Claims Information
Once you have registered for EZ-NET access, you can log in to conduct highly secure functions such as check claim status, verify member eligibility and submit claims.
The Claims and Eligibility section of the EZ-NET site contains related features as well as information about current patient status, physicians of record, and more. To view claim status by member, claim number, date of service or provider Tax ID, simply log in and follow the prompts within the Claims and Eligibility section. Each claim summary includes the claim number, date of claim, patient ID, patient’s name, billed amount, paid amount, claim status and other details.
In order to obtain EZ-NET access, contracted providers and specialist need to fill out the Provider Web Services (PWS) form and fax it to the number listed on the form. Please when filling out this form provide us with your contact information.
Note: La Vida Medical Group Central Valley contract was terminated 1/31/10. Any questions regarding service prior to termination date refer to the contact information here.
Eligibility Verification
La Vida Medical Group & IPA requires that both contracted and non-contracted providers and specialists re-verify eligibility as close to the date of the scheduled service as possible. For current eligibility verification, providers and specialist need to call the Health Plan that the patient belongs to directly. Due to ongoing changes in eligibility, the best practice is to re-verify eligibility no more than a day prior to providing a prior authorized service. The links to the different health plans can be found on our home page.
To verify noncurrent eligibility, please contact La Vida’s Eligibility desk at: (310) 214-8677 x431
Submitting Claims to La Vida Medical Group
Left Click on Sections Below
| All paper claims and supporting information must be submitted to:
Los Angeles Area La Vida Medical Group & IPA (Los Angeles)
4161 W. Redondo Beach Blvd. Lawndale, California 90260 |
| La Vida Medical Group is working hard to make claims procedures easier for providers and specialist. La Vida’s Electronic Data Interchange (EDI) solutions make it easy for our contracted provider and specialist network to submit claims electronically. Whether on-line, through our EZ-NET website or clearinghouse or direct using 837P or CMS1500 formats, EDI ensures that your claims get submitted quickly.La Vida Medical Group has contracted with Gateway & Office Ally to provide claims clearinghouse services for claim submission. |
La Vida Los Angeles Offices
| La Vida Los Angeles (Option # 1) | (310) 214-8677 |
| Claims Provider Inquiry Fax: | (310) 896-2325 |
| Claims Submissions Fax | (310) 896-2323 |
As required by Assembly Bill 1455, the California Department of Managed Health Care has set forth regulations establishing certain claim settlement practices and the process for resolving claims disputes for managed care products regulated by the Department of Managed Health Care. This information notice is intended to inform you of your rights, responsibilities, and related procedures as they relate to claim settlement practices and claim disputes for commercial HMO, POS, and, where applicable, PPO products where La Vida Medical Group delegated to perform claims payment and provider dispute resolution processes. Unless otherwise provided herein, capitalized terms have the same meaning as set forth in Sections 1300.71 and 1300.71.38 of Title 28 of the California Code of Regulations.
Dispute Resolution Process for Contracted Providers
Definition of Contracted Provider Dispute.
A contracted provider dispute is a provider’s written notice to La Vida Medical Group and/or the member’s applicable health plan challenging, appealing or requesting reconsideration of a claim (or a bundled group of substantially similar multiple claims that are individually numbered) that has been denied, adjusted or contested or seeking resolution of a billing determination or other contract dispute (or bundled group of substantially similar multiple billing or other contractual disputes that are individually numbered) or disputing a request for reimbursement of an overpayment of a claim. Each contracted provider dispute must contain, at a minimum the following information: provider’s name; provider’s identification number, provider’s contact information, and:
If the contracted provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from La Vida Medical Group
i. to a contracted provider the following must be provided: a clear identification of the disputed item, the Date of Service and a clear explanation of the basis upon which the provider believes the payment amount, request for additional information, request for reimbursement for the overpayment of a claim, contest, denial, adjustment or other action is incorrect;
ii. If the contracted provider dispute is not about a claim, a clear explanation of the issue and the provider’s position on such issue; and
iii. If the contracted provider dispute involves an enrollee or group of enrollees, the name and identification number(s) of the enrollee or enrollees, a clear explanation of the disputed item, including the Date of Service and provider’s position on the dispute, and an enrollee’s written authorization for provider to represent said enrollees.
Sending a Contracted Provider Dispute to La Vida Medical Group
Contracted provider disputes submitted to La Vida Medical Group must include the information listed in the above section, for each contracted provider dispute. All contracted provider disputes must be sent to the attention of:
Via Mail:
Lawndale, California 90260
Via e-mail: Claims Submissions
Via Fax: (310) 896-2323
For the Los Angeles Area:
La Vida Medical Group & IPA.- Claims Department at the following:
Via Fax: (310) 896-2323
Time Period for Submission of Provider Disputes.
Contracted provider disputes must be received at La Vida Medical Group within 365 days.
In the case of La Vida Medical Group inaction, contracted provider disputes must be received by La Vida Medical Group within 365 days. Contracted provider disputes that do not include all required information as set forth above may be returned to the submitter for completion. An amended contracted provider dispute which includes the missing information may be submitted to La Vida Medical Group within thirty (30) working days of your receipt of a returned contracted provider dispute.
Acknowledgment of Contracted Provider Disputes
La Vida Medical Group will acknowledge receipt of all contracted provider disputes as follows:
- Electronic contracted provider disputes will be acknowledged by La Vida Medical Group within two (2) working days of the date of receipt.
- Paper contracted provider disputes will be acknowledged by La Vida Medical Group within fifteen (15) working days of the date of receipt.
B. Claim Timeliness for Medical Members is 6 months for Non Contracted providers that Section 1300.71(a)(10) of title 28 of the California Code of Regulations states that IPAs/Medical Groups may request only “reasonably relevant information” to determine the nature, cost and extent of the liability for the adjudication of claims.
Regarding Contracted Provider Disputes. All inquiries regarding the status of a contracted provider dispute or about filing a contracted provider dispute must be directed to:
For the Los Angeles Area:
La Vida Medical Group & IPA at: (310) 214-8677 option #1
Instructions for Filing Substantially Similar Contracted Provider Disputes
Substantially similar multiple claims, billing or contractual disputes, may be filed in batches as a single dispute, provided that such disputes are submitted in the following format:
i. Sort provider disputes by similar issue
ii. Provide cover sheet for each batch
iii. Number each cover sheet
iv. Provide a cover letter for the entire submission describing each provider dispute with references to the numbered coversheets
Time Period for Resolution and Written Determination of Contracted Provider Dispute
La Vida Medical Group will issue a written determination stating the pertinent facts and explaining the reasons for its determination within forty-five (45) working days after the date of receipt of the contracted provider dispute or the amended contracted provider dispute.
Past Due Payments
If the contracted provider dispute or amended contracted provider dispute involves a claim and is determined in whole or in part in favor of the provider, La Vida Medical Group will pay any outstanding monies determined to be due, and all interest and penalties required by law or regulation, within five (5) Working Days of the issuance of the written determination.
Dispute Resolution Process for Non-Contracted Providers
- Definition of Non-Contracted Provider Dispute
A non-contracted provider dispute is a non-contracted provider’s written notice to La Vida Medical Group challenging, appealing or requesting reconsideration of a claim (or a bundled group of substantially similar claims that are individually numbered) that has been denied, adjusted or contested or disputing a request for reimbursement of an overpayment of a claim. Each non-contracted provider dispute must contain, at a minimum, the following information: the provider’s name, the provider’s identification number, contact information, and:
- If the non-contracted provider’s dispute concerns a claim or a request for reimbursement of an of an overpayment of claim from La Vida Medical Group the following must be provided: a clear identification of the disputed item, the date of service and a clear explanation of the basis upon which the provider believes the payment amount, request for additional information, contest, denial, request for reimbursement for the overpayment of a claim, or other action is incorrect;
- If the non-contracted provider dispute involves an enrollee or group of enrollees, the name and dentification number(s) of the enrollee or enrollees, a clear explanation of the disputed item, including the date of service, provider’s position on the dispute, and an enrollee’s written authorization for provider to represent said enrollees.
Dispute Resolution Process
The dispute resolution process for non-contracted Providers is the same as the process for contracted Providers above.
Notice of Overpayment of a Claim
If La Vida Medical determines that it has overpaid a claim, La Vida Medical Group will notify the provider in writing through a separate notice clearly identifying the claim, the name of the patient, the date of service(s) and a clear explanation of the basis upon which La Vida Medical Group believes the amount paid on the claim was in excess of the amount due, including interest and penalties on the claim.
Contested Notice
If the non-contracted provider wishes to contests the La Vida Medical Group’s notice of overpayment of a claim, the non-contracted provider must within thirty (30) working days of the receipt of the notice of overpayment of a claim send a written notice to La Vida Medical Group stating the basis upon which the provider believes that the claim was not overpaid. The time process is similar to the contracted provider dispute resolution process described in the contracted provider section above.
No Contest
If the provider does not contest La Vida Medical Group’s notice of overpayment of a claim, the provider must reimburse La Vida Medical Group within thirty (30) working days of the provider’s receipt of the notice of overpayment of a claim.
Offsets to payments
La Vida Medical Group may only offset an uncontested notice of overpayment of a claim against a provider’s current claim submission when; the provider fails to reimburse La Vida Medical Group within the timeframe set forth above. In the event that an overpayment of a claim or claims is offset against the provider’s current claim or claims pursuant to this section, La Vida Medical Group will provide the provider with a detailed written explanation identifying the specific overpayment or payments that have been offset against the specific current claim or claims.
Submissions of PDR Via Mail:
Lawndale, CA 90260
Downstream Provider Notice
CLAIMS SETTLEMENT PRACTICES & DISPUTE RESOLUTION MECHANISM
As required by Assembly Bill 1455, the California Department of Managed Health Care has set forth regulations establishing certain claim settlement practices and the process for resolving claims disputes for managed care products regulated by the Department of Managed Health Care. This information notice is intended to inform you of your rights, responsibilities, and related procedures as they relate to claim settlement practices and claim disputes for commercial HMO, POS, and, where applicable, PPO products where La Vida Medical Group & IPA.delegated to perform claims payment and provider dispute resolution processes. Unless otherwise provided herein, capitalized terms have the same meaning as set forth in Sections 1300.71 and 1300.71.38 of Title 28 of the California Code of Regulations.
- Claim submission instructions.
Sending Claims to La Vida Medical Group & IPA Claims for services provided to members assigned to La Vida Medical Group & IPA must be sent to the following:
Via Mail: 4161 Redondo Beach Blvd,#201,Lawndale, CA,90260
Via Physical Delivery: 4161 Redondo Beach Blvd,#201,Lawndale CA,
Via e-mail: Claims Submissions
Via Fax: (310) 896-2323
Via Physical Delivery:
Via e-mail:Lavidamed.com
Via Fax: 310 921-1216
Via Clearinghouse: Office Ally
Calling La Vida Medical Group & IPA.
Regarding Claims. For claim filing requirements or status inquiries, you may contact La Vida Medical Group & IPA. by calling: 310 214-8677 X425
Claim Submission Requirements. The following is a list of claim timeliness requirements, claims supplemental information and claims documentation required by La Vida Medical Group & IPA Claim Receipt Verification. For verification of claim receipt by La Vida Medical Group & IPA., please do the following:
Electronic means
Phone
Website
Other mutually agreeable accessible method of notification by which provider readily confirms receipt of claim and recorded Date of Receipt]
- Dispute Resolution Process for Contracted Providers
Definition of Contracted Provider Dispute. A contracted provider dispute is a provider’s written notice to La Vida Medical Group & IPA and/or the member’s applicable health plan challenging, appealing or requesting reconsideration of a claim (or a bundled group of substantially similar multiple claims that are individually numbered) that has been denied, adjusted or contested or seeking resolution of a billing determination or other contract dispute (or bundled group of substantially similar multiple billing or other contractual disputes that are individually numbered) or disputing a request for reimbursement of an overpayment of a claim. Each contracted provider dispute must contain, at a minimum the following information: provider’s name; provider’s identification number, provider’s contact information, and:
If the contracted provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from La Vida Medical Group & IPA
i. to a contracted provider the following must be provided: a clear identification of the disputed item, the Date of Service and a clear explanation of the basis upon which the provider believes the payment amount, request for additional information, request for reimbursement for the overpayment of a claim, contest, denial, adjustment or other action is incorrect;
ii. If the contracted provider dispute is not about a claim, a clear explanation of the issue and the provider’s position on such issue; and
iii. If the contracted provider dispute involves an enrollee or group of enrollees, the name and identification number(s) of the enrollee or enrollees, a clear explanation of the disputed item, including the Date of Service and provider’s position on the dispute, and an enrollee’s written authorization for provider to represent said enrollees.
Sending a Contracted Provider Dispute to La Vida Medical Group & IPA Contracted provider disputes submitted La Vida Medical Group & IPA must include the information listed in Section II.A., above, for each contracted provider dispute. All contracted provider disputes must be sent to the attention of La Vida Medical Group & IPA .-Claims Department at the following:
Via Mail:4161 Redondo Beach Blvd,#201,Lawndale, CA,90260
Via Physical Delivery: 4161RedondoBeachBlvd,#201,Lawndale, 90260
Via e-mail: lavidamed.com
Via Fax: 310 921-1216
Time Period for Submission of Provider Disputes.
Contracted provider disputes must be received La Vida Medical Group & IPA within 365 days. In the case of La Vida Medical Group & IPA . inaction, contracted provider disputes must be received by La Vida Medical Group & IPA.within 365 days. Contracted provider disputes that do not include all required information as set forth above in Section II.A. may be returned to the submitter for completion. An amended contracted provider dispute which includes the missing information may be submitted to La Vida Medical Group & IPA within thirty (30) working days of your receipt of a returned contracted provider dispute.
Acknowledgment of Contracted Provider Disputes. La Vida Medical Group & IPA will acknowledge receipt of all contracted provider disputes as follows:
Electronic contracted provider disputes will be acknowledged by La Vida Medical Group & IPA. within two (2) Working Days of the Date of Receipt by La Vida Medical Group & IPA .Paper contracted provider disputes will be acknowledged by La Vida Medical Group & IPA . within fifteen (15) Working Days of the Date of Receipt by La Vida Medical Group & IPA
- Claim Timeliness for Medical Members is 6 months for Non Contracted providers that Section 1300.71(a)(10) of title 28 of the California Code of Regulations states that IPAs/Medical Groups may request only “reasonably relevant information” to determine the nature, cost and extent of the liability for the adjudication of claims.
Contact La Vida Medical Group & IPA. Regarding Contracted Provider Disputes. All inquiries regarding the status of a contracted provider dispute or about filing a contracted provider dispute must be directed to La Vida Medical Group & IPA .
at: 310 214-8677 x425
Instructions for Filing Substantially Similar Contracted Provider Disputes. Substantially similar multiple claims, billing or contractual disputes, may be filed in batches as a single dispute, provided that such disputes are submitted in the following format:
i. Sort provider disputes by similar issue
ii. Provide cover sheet for each batch
iii. Number each cover sheet
iv. Provide a cover letter for the entire submission describing each provider dispute with references to the numbered coversheets]
Time Period for Resolution and Written Determination of Contracted Provider Dispute. La Vida Medical Group & IPA. will issue a written determination stating the pertinent facts and explaining the reasons for its determination within forty-five (45) Working Days after the Date of Receipt of the contracted provider dispute or the amended contracted provider dispute.
Past Due Payments. If the contracted provider dispute or amended contracted provider dispute involves a claim and is determined in whole or in part in favor of the provider, La Vida Medical Group & IPA.will pay any outstanding monies determined to be due, and all interest and penalties required by law or regulation, within five (5) Working Days of the issuance of the written determination.
III. Dispute Resolution Process for Non-Contracted Providers
Definition of Non-Contracted Provider Dispute. A non-contracted provider dispute is a non-contracted provider’s written notice to La Vida Medical Group & IPA challenging, appealing or requesting reconsideration of a claim (or a bundled group of substantially similar claims that are individually numbered) that has been denied, adjusted or contested or disputing a request for reimbursement of an overpayment of a claim. Each non-contracted provider dispute must contain, at a minimum, the following information: the provider’s name, the provider’s identification number, contact information, and:
i. If the non-contracted provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from La Vida Medical Group & IPA to provider the following must be provided: a clear identification of the disputed item, the Date of Service and a clear explanation of the basis upon which the provider believes the payment amount, request for additional information, contest, denial, request for reimbursement for the overpayment of a claim, or other action is incorrect; If the non-contracted provider dispute involves an enrollee or group of enrollees, the name and identification number(s) of the enrollee or enrollees, a clear explanation of the disputed item, including the Date of Service, provider’s position on the dispute, and an enrollee’s written authorization for provider to represent said enrollees.
Dispute Resolution Process. The dispute resolution process for non-contracted Providers is the same as the process for contracted Providers as set forth in sections II.B., II.C., II.D., II.E., II.F., II.G., and II.H. above.
Claim Overpayments La Vida Medical Group & IPA may want to add these provisions to provider’s contract.]
Notice of Overpayment of a Claim. If La Vida Medical Group & IPA determines that it has overpaid a claim La Vida Medical Group & IPA will notify the provider in writing through a separate notice clearly identifying the claim, the name of the patient, the Date of Service(s) and a clear explanation of the basis upon which La Vida Medical Group & IPA believes the amount paid on the claim was in excess of the amount due, including interest and penalties on the claim.
Contested Notice. If the provider contests La Vida Medical Group & IPA notice of overpayment of a claim, the provider, within 30 Working Days of the receipt of the notice of overpayment of a claim, must send written notice La Vida Medical Group & IPA stating the basis upon which the provider believes that the claim was not overpaid. will process the contested La Vida Medical Group & IPA notice in accordance with La Vida Medical Group & IPA contracted provider dispute resolution process described in Section II above.
No Contest. If the provider does not contest ’s La Vida Medical Group & IPA notice of overpayment of a claim, the provider must reimburse La Vida Medical Group & IPA.within thirty (30) Working Days of the provider’s receipt of the notice of overpayment of a claim.
Offsets to payments. La Vida Medical Group & IPA may only offset an uncontested notice of overpayment of a claim against provider’s current claim submission when; the provider fails to reimburse La Vida Medical Group & IPA.within the timeframe set forth in Section IV.C., above, and La Vida Medical Group & IPA contract with the provider specifically authorizes La Vida Medical Group & IPA to offset an uncontested notice of overpayment of a claim from the provider’s current claims submissions. In the event that an overpayment of a claim or claims is offset against the provider’s current claim or claims pursuant to this section, La Vida Medical Group & IPA will provide the provider with a detailed written explanation identifying the specific overpayment or payments that have been offset against the specific current claim or claims
Regarding Contracted Provider Disputes. All inquiries regarding the status of a contracted provider dispute or about filing a contracted provider dispute must be directed to La Vida Medical Group & IPA at: 4161 Redondo Beach Blvd, Lawndale, CA 90260.
- Instructions for Filing Substantially Similar Contracted Provider Disputes. Substantially similar multiple claims, billing or contractual disputes, may be filed in batches as a single dispute, provided that such disputes are submitted in the following format:
i. Sort provider disputes by similar issue
ii. Provide cover sheet for each batch
iii. Number each cover sheet
iv. Provide a cover letter for the entire submission describing each provider dispute with references to the numbered coversheets
Time Period for Resolution and Written Determination of Contracted Provider Dispute. La Vida Medical Group & IPA will issue a written determination stating the pertinent facts and explaining the reasons for its determination within forty-five (45) Working Days after the Date of Receipt of the contracted provider dispute or the amended contracted provider dispute.
Past Due Payments. If the contracted provider dispute or amended contracted provider dispute involves a claim and is determined in whole or in part in favor of the provider, La Vida Medical Group & IPA will pay any outstanding monies determined to be due, and all interest and penalties required by law or regulation, within five (5) Working Days of the issuance of the written determination.
IV. Dispute Resolution Process for Non-Contracted Providers
Definition of Non-Contracted Provider Dispute. A non-contracted provider dispute is a non-contracted provider’s written notice to La Vida Medical Group & IPA challenging, appealing or requesting reconsideration of a claim (or a bundled group of substantially similar claims that are individually numbered) that has been denied, adjusted or contested or disputing a request for reimbursement of an overpayment of a claim. Each non-contracted provider dispute must contain, at a minimum, the following information: the provider’s name, the provider’s identification number, contact information, and: If the non-contracted provider dispute concerns a claim or a request for reimbursement of an overpayment of a claim from La Vida Medical Group & IPA. to provider the following must be provided: a clear identification of the disputed item, the Date of Service and a clear explanation of the basis upon which the provider believes the payment amount, request for additional information, contest, denial, request for reimbursement for the overpayment of a claim, or other action is incorrect; If the non-contracted provider dispute involves an enrollee or group of enrollees, the name and identification number(s) of the enrollee or enrollees, a clear explanation of the disputed item, including the Date of Service, provider’s position on the dispute, and an enrollee’s written authorization for provider to represent said enrollees.
Dispute Resolution Process. The dispute resolution process for non-contracted Providers is the same as the process for contracted Providers as set forth in sections II.B., II.C., II.D., II.E., II.F., II.G., and II.H. above.
Claim Overpayments La Vida Medical Group & IPA may want to add these provisions to provider’s contract.]
Notice of Overpayment of a Claim. If La Vida Medical Group & IPA determines that it has overpaid a claim La Vida Medical Group & IPA will notify the provider in writing through a separate notice clearly identifying the claim, the name of the patient, the Date of Service(s) and a clear explanation of the basis upon which La Vida Medical Group & IPA believes the amount paid on the claim was in excess of the amount due, including interest and penalties on the claim.
Contested Notice. If the provider contests La Vida Medical Group & IPA notice of overpayment of a claim, the provider, within 30 Working Days of the receipt of the notice of overpayment of a claim, must send written notice to La Vida Medical Group & IPA stating the basis upon which the provider believes that the claim was not overpaid. will process the contested La Vida Medical Group & IPA notice in accordance with La Vida Medical Group & IPA contracted provider dispute resolution process described in Section II above.
No Contest. If the provider does not contest ’s La Vida Medical Group & IPA notice of overpayment of a claim, the provider must reimburse La Vida Medical Group & IPA within thirty (30) Working Days of the provider’s receipt of the notice of overpayment of a claim.
Offsets to payments. La Vida Medical Group & IPA may only offset an uncontested notice of overpayment of a claim against provider’s current claim submission when; (i) the provider fails to reimburse La Vida Medical Group & IPA within the timeframe set forth in Section IV.C., above, and (ii) La Vida Medical Group & IPA contract with the provider specifically authorizes La Vida Medical Group & IPA to offset an uncontested notice of overpayment of a claim from the provider’s current claims submissions. In the event that an overpayment of a claim or claims is offset against the provider’s current claim or claims pursuant to this section, La Vida Medical Group & IPA will provide the provider with a detailed written explanation identifying the specific overpayment or payments that have been offset against the specific current claim or claims
Dispute Resolution Form 1 – Provider Inquiry Request Excel Spread Sheet
Disput Resolution Form 2 – Provider Inquiry Request List
Dispute Resolution Form 3 – Provider Dispute Resolution Request
Dispute Resolution Form 4 – Provider Dispute Resolution List