L.A. Care Health Plan Claims Quick Reference Guide

Instructions on how to complete and submit claims using the UB-04 form which L.A. Care uses to process payments for

ALL lines of business may be found by accessing the link below:

Accommodation Codes

Facilities must bill indicating the Accommodation Code that is applicable to the custodial claim, as this drives the

appropriate payment rate for a facility based on the California Medi-Cal rate for the facility. Accommodation Codes

should be billed with a Value Code 24 and billed as a cent amount. If billing a single Accommodation Code on row 1 of

the claim, the dollar amount should be 0. If billing multiple Accommodation Codes on a single claim, in order to associate

the Accommodation Code with the applicable revenue code the Line Number for the associated revenue code should be

billed as the dollar amount.

Example:

0160 on line 2 of the claim detail, then you would bill the Value Code 24 with $2.01 as the amount. If the

Accommodation Code is 02 and the associated revenue code is 0185 on line 1 of the claim detail, then you would bill the

Value Code 24 with $1.02 as the amount. Please indicate the value code and amount in boxes 39 – 41 of the UB04 form

(refer to UB-04 form on the last page of this document).

Following is a list of Revenue and Accommodation Codes:

Type/Level of Care: Skilled Nursing Care

The following is a list of acronyms used to describe the SNF Accommodation Codes listed below:

DD - Developmentally Disabled

DD-CN - Developmentally Disabled/Continuous Nursing

DD-H - Developmentally Disabled/Habilitative

DD-N - Developmentally Disabled/Nursing

DP - Distinct Part

ICF - Intermediate Care Facility

Type/Level of Care: Sub-Acute Facility Care (Adult)

Type/Level of Care: Long Term Care (Custodial Care)

Special Reimbursement Provisions: Bed Hold (Adult) (Admit to acute inpatient or skilled level of care up to 7 days)

Special Reimbursement Provisions: Bed Hold (Pediatric) (Admit to acute inpatient or skilled level of care up to 7 days)

Special Reimbursement Provisions: Leave of Absence (Adult)

Special Reimbursement Provisions: Leave Days Non-DD Patient

Special Reimbursement Provisions: