Yes! You can use AI to fill out L.A. Care Behavioral Health Treatment Applied Behavioral Analysis Authorization Request Form
The L.A. Care Behavioral Health Treatment Applied Behavioral Analysis Authorization Request Form (LA5480) is an official document submitted to L.A. Care's BH ASD Program Department to obtain prior authorization for ABA services, including Comprehensive Diagnostic Evaluations, Functional Behavioral Assessments, Direct ABA Services, Case Supervision, Parent Education Training, and Social Skills Groups for eligible Medi-Cal members. The form requires detailed member information, provider details, DSM-V/ICD-10 diagnosis codes, and clinical justification to ensure services are medically necessary and meet all approval criteria. It is a critical step in the authorization process, as services cannot be scheduled until approval is granted. Today, this form can be filled out quickly and accurately using AI-powered services like Instafill.ai, which can also convert non-fillable PDF versions into interactive fillable forms.
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Form specifications
| Form name: | L.A. Care Behavioral Health Treatment Applied Behavioral Analysis Authorization Request Form |
| Number of pages: | 1 |
| Language: | English |
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How to Fill Out LA Care BHT ABA Authorization Request (LA5480) Online for Free in 2026
Are you looking to fill out a LA CARE BHT ABA AUTHORIZATION REQUEST (LA5480) form online quickly and accurately? Instafill.ai offers the #1 AI-powered PDF filling software of 2026, allowing you to complete your LA CARE BHT ABA AUTHORIZATION REQUEST (LA5480) form in just 37 seconds or less.
Follow these steps to fill out your LA CARE BHT ABA AUTHORIZATION REQUEST (LA5480) form online using Instafill.ai:
- 1 Navigate to Instafill.ai and upload the LA5480 L.A. Care BHT ABA Authorization Request Form or select it from the available form library.
- 2 Complete the Member Information section by entering the member's full name, date of birth, Medi-Cal ID (CIN), mailing address, caregiver name, primary phone number, preferred language, and applicable DSM-V/ICD-10 diagnosis code(s).
- 3 Fill in the Requesting Provider Information section with the request date, requested date of services, referring organization name, referring individual name, organization address, phone number, fax number, and email address.
- 4 If applicable, complete the Servicing Provider Information section with the date of referral, requested date of services, and all relevant contact and organization details for the servicing provider.
- 5 Select the appropriate Service Type Request(s) by checking the relevant boxes for Comprehensive Diagnostic Evaluation, Functional Behavioral Assessment (verifying all 4 eligibility criteria), Direct ABA Services, Case Supervision, Parent Education Training, and/or Social Skills Group, and enter the requested hours for each selected service.
- 6 Provide the clinical indication and any additional information supporting the authorization request in the designated text area.
- 7 Enter the provider's name, credentials, and signature date, then review the completed form for accuracy before submitting it via fax to L.A. Care BH ASD Program Department at (213) 438-5054 along with all required supporting documentation.
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Frequently Asked Questions About Form LA Care BHT ABA Authorization Request (LA5480)
This is the L.A. Care Behavioral Health Treatment / Applied Behavioral Analysis (ABA) Authorization Request Form. It is used by providers to request prior authorization for ABA-related services for members diagnosed with Autism Spectrum Disorder (ASD), including assessments, direct therapy, case supervision, parent education training, and social skills groups.
This form must be completed by a licensed healthcare provider or authorized referring organization requesting ABA or behavioral health treatment services on behalf of an L.A. Care member. The member's caregiver information is also required, but the provider is responsible for submitting the form.
The completed form, along with all required supporting documentation, must be faxed to the L.A. Care BH ASD Program Department at (213) 438-5054. Do not schedule any services until authorization has been officially obtained.
If a provider would like to discuss the authorization request, they can call L.A. Care at 1-888-347-2264 or (213) 438-5631. These lines are available for provider inquiries related to the ABA authorization process.
All four of the following criteria must be met: (1) The member must be under 21 years old; (2) A licensed physician, surgeon, or psychologist must recommend that evidence-based BHT services are medically necessary, with documentation attached; (3) The member must be medically stable, with supporting documentation such as a physician's note; and (4) The member must not require 24-hour medical/nursing monitoring or procedures in a hospital or ICF/ID facility.
The form includes checkboxes for DSM-V code 299.00 (Autism Spectrum Disorder) and ICD-10 code F84.0 (Childhood Autism). If the member has a different applicable code, providers can check the 'Other' box and enter the relevant code and description manually.
Providers can request authorization for several service types, including: Comprehensive Diagnostic Evaluation (CDE) or 2nd Opinion (code 90791), Functional Behavioral Assessment (FBA, code H0032), Direct ABA Services (H2019), Case Supervision (H0031), Parent Education Training (S5111), and Social Skills Group (H2014).
The FBA (H0032) is limited to up to 12 hours total (48 units) across all modifiers. The H0032: HP modifier (BCBA-D, BCBA, or Licensed MA/MS) is required, and a second service code (H0032: HP, HC for BCaBA or MA/MS) may also be approved across modifiers.
When requesting services under the *HN (BA/BS) modifier for Case Supervision (H0031) or Parent Education Training (S5111), providers must submit supporting documents including a transcript and an attestation. Without these documents, the *HN modifier cannot be approved.
No, the Servicing Provider Information section only needs to be completed if the servicing provider is different from the requesting provider. If they are the same, this section can be left blank.
No. The form clearly states that services must not be scheduled until authorization is obtained, and that authorization is contingent upon the member's eligibility on the date of service. Starting services before authorization may result in non-payment.
Yes, AI-powered services like Instafill.ai can help providers accurately auto-fill form fields, reducing manual data entry errors and saving significant time. These tools are especially useful for complex forms with multiple sections like this ABA Authorization Request Form.
You can visit Instafill.ai, upload the L.A. Care ABA Authorization Request Form, and use the AI-powered tool to fill in all required fields digitally. Once completed, you can download the filled form and fax it to L.A. Care at (213) 438-5054 with the required supporting documentation.
If you have a flat, non-fillable PDF version of this form, Instafill.ai can convert it into an interactive fillable form, allowing you to type directly into the fields digitally rather than printing and handwriting the information.
This section should include a detailed clinical justification for the requested services, such as the member's diagnosis, behavioral challenges, treatment goals, and any other relevant clinical information that supports the medical necessity of the requested ABA services. Thorough documentation in this section can help facilitate faster approval.
Compliance LA Care BHT ABA Authorization Request (LA5480)
Validation Checks by Instafill.ai
1
Ensures Member Date of Birth is a Valid Date in the Past
This check verifies that the Member Date of Birth field contains a properly formatted date (MM/DD/YYYY) and that the date falls in the past, not in the future. It is critical for confirming the member's identity and determining eligibility criteria such as the FBA age requirement (under 21 years old). If the date is missing, improperly formatted, or in the future, the form cannot be processed and the authorization request will be rejected.
2
Ensures Medi-Cal ID (CIN) Follows the Required Format
This check validates that the Member's Medi-Cal ID (CIN) is present and conforms to the standard California Medi-Cal Client Identification Number format, which typically consists of a letter followed by eight digits (e.g., A12345678). The CIN is the primary identifier used to verify member eligibility on the date of service, as stated in the form's header. A missing or incorrectly formatted CIN will prevent eligibility verification and result in the authorization request being denied or delayed.
3
Ensures at Least One DSM-V/ICD-10 Diagnosis Code is Selected or Specified
This check confirms that at least one of the three diagnosis code options is selected: checkbox 299.00, checkbox F84.0, or the 'Other' checkbox with a corresponding code entered in the adjacent text field. A valid diagnosis code is required to establish medical necessity for Applied Behavioral Analysis services. If no diagnosis code is selected or if 'Other' is checked but the code field is left blank, the form is incomplete and the authorization request cannot be evaluated.
4
Ensures 'Other' DSM-V/ICD-10 Code Field is Populated When 'Other' Checkbox is Selected
This check verifies that when the 'Other' checkbox is selected in the DSM-V/ICD-10 Code(s)/Description section, the adjacent text field contains a valid diagnosis code or description. Selecting 'Other' without specifying the code provides no clinical information to support the authorization request. If the 'Other' box is checked but the text field is empty, the submission is incomplete and must be returned to the provider for correction.
5
Ensures Request Date is Present and Not a Future Date
This check validates that the Request Date in the Requesting Provider Information section is populated with a valid date and that it is not set in the future. The request date establishes the timeline for the authorization process and is used to track processing deadlines. A missing or future-dated request date creates an invalid submission record and may affect compliance with required authorization turnaround times.
6
Ensures Requested Date of Services is On or After the Request Date
This check verifies that the Requested Date of Services is not earlier than the Request Date, as services cannot logically be requested before the request itself is submitted. This logical consistency check applies to both the Requesting Provider and Servicing Provider sections. If the Requested Date of Services precedes the Request Date, it indicates a data entry error that must be corrected before the authorization can be processed.
7
Ensures All Four FBA Eligibility Criteria Are Answered When FBA is Requested
This check confirms that when the Functional Behavioral Assessment (FBA) service type is being requested, all four eligibility criteria checkboxes are answered: (1) member under 21, (2) physician/psychologist recommendation with documentation, (3) medical stability with documentation, and (4) no need for 24-hour medical monitoring. The form explicitly states that all four criteria must be met for approval, so any unanswered criterion renders the FBA request incomplete. If any criterion is left blank, the request will be flagged as insufficient for review.
8
Ensures FBA Age Criterion Confirms Member is Under 21 Years Old
This check cross-references the FBA Age Criterion answer ('Yes' for under 21) against the Member Date of Birth to confirm consistency. If the member's date of birth indicates they are 21 or older but 'Yes' is selected for the age criterion, or vice versa, there is a data conflict that must be resolved. Since being under 21 is a mandatory eligibility requirement for FBA approval, any inconsistency between the stated age criterion and the calculated age from the date of birth will result in the request being flagged for review or denial.
9
Ensures FBA Total Hours Do Not Exceed the 12-Hour (48-Unit) Maximum
This check validates that the combined total hours entered across both FBA service codes (H0032: HP and H0032: HP, HC) do not exceed the 12-hour (48-unit) maximum specified on the form. The form explicitly states that requested services are 'up to 12 hours total (48 units) across modifiers.' If the combined hours exceed this limit, the request is non-compliant with program policy and must be corrected before it can be approved.
10
Ensures H0032 HP Primary Service Code is Selected When FBA is Requested
This check verifies that the primary FBA service code H0032: HP (BCBA-D, BCBA, Licensed MA/MS) checkbox is selected whenever an FBA is being requested, as the form designates this code as 'Required.' The second service code (H0032: HP, HC) is optional and can only be approved in addition to the primary code. If the primary H0032: HP code is not selected but the secondary code is, the submission is invalid and must be corrected.
11
Ensures H0031 HP Primary Service Code is Selected When Case Supervision is Requested
This check confirms that the primary Case Supervision service code H0031: HP (BCBA-D, BCBA, Licensed MA/MS) is selected whenever Case Supervision services are being requested, as it is marked 'Required' on the form. The secondary service codes (H0031: HP, HC or H0031: HP, HC, *HN) are only approvable as supplemental codes alongside the primary. If a secondary Case Supervision code is selected without the primary code, the request is structurally invalid and will be returned.
12
Ensures Supporting Documents Are Indicated When HN Modifier is Used for Case Supervision or Parent Education Training
This check flags submissions that include the *HN (BA/BS) modifier for Case Supervision (H0031) or Parent Education Training (S5111) to ensure that the provider has acknowledged the requirement for supporting documents, specifically a transcript and attestation. The form notes that '*HN- Supporting documents required: transcript & attestation.' If the HN modifier is selected but no supporting documentation is referenced or attached, the request is incomplete and cannot be approved for those service lines.
13
Ensures Phone Numbers Are in a Valid Format for All Provider and Member Fields
This check validates that all phone number fields ā including the Member Primary Phone Number, Requesting Provider Phone Number, and Servicing Provider Phone Number ā contain a properly formatted 10-digit U.S. phone number (e.g., (XXX) XXX-XXXX or XXX-XXX-XXXX). Valid contact information is essential for L.A. Care to reach the provider or member if additional information is needed during the authorization review. Phone numbers with fewer than 10 digits, non-numeric characters, or placeholder values will cause the submission to be flagged as incomplete.
14
Ensures Email Addresses Are in a Valid Format for Requesting and Servicing Provider Sections
This check verifies that any email address entered in the Requesting Provider or Servicing Provider sections follows a valid email format, containing a local part, an '@' symbol, and a domain (e.g., [email protected]). A valid email address ensures that electronic communications regarding the authorization request can be delivered successfully. An improperly formatted email address will prevent follow-up communication and may delay the authorization process.
15
Ensures Provider Name, Credentials, and Attestation Date Are All Completed
This check confirms that the Provider Name and Credentials field, the Provider Signature field, and the Attestation Date field at the bottom of the form are all populated. The provider attestation section serves as the legal certification that the information submitted is accurate and complete, and it is required for the form to be considered a valid authorization request. If any of these three fields are missing, the form lacks proper authorization and must be returned to the provider for completion before processing can begin.
16
Ensures at Least One Service Type is Selected on the Form
This check verifies that at least one service type section has been completed ā whether Comprehensive Diagnostic Evaluation, Functional Behavioral Assessment, Direct ABA Services, Case Supervision, Parent Education Training, or Social Skills Group ā with the corresponding checkbox selected and hours entered. An authorization request form with no service type selected provides no actionable information for the review team. If no service type is indicated, the form is considered blank with respect to the clinical request and will be rejected as incomplete.
Common Mistakes in Completing LA Care BHT ABA Authorization Request (LA5480)
Providers sometimes schedule or begin ABA services immediately after submitting the form, without waiting for authorization approval. The form explicitly states 'Do not schedule services until authorization is obtained,' and authorization is contingent upon member eligibility on the date of service. Starting services prematurely can result in denied claims and non-reimbursable costs. Always wait for written authorization confirmation before scheduling any appointments.
The Medi-Cal Client Identification Number (CIN) is a unique identifier that must be entered exactly as it appears on the member's Medi-Cal card. Providers often transpose digits, omit characters, or confuse the CIN with other ID numbers such as a Social Security Number or insurance member ID. An incorrect CIN will cause the authorization request to be rejected or matched to the wrong member. Always verify the CIN directly from the member's current Medi-Cal Benefits Identification Card before submitting. Tools like Instafill.ai can help validate ID formats to reduce transcription errors.
The Functional Behavioral Assessment (FBA) section requires that all four criteria be met and checked for approval, yet submitters frequently leave one or more criteria unanswered or check 'No' without realizing this disqualifies the request. A common error is misunderstanding criterion 4āchecking 'Does have a need' for 24-hour medical monitoring, which actually indicates the member does NOT qualify. Review each criterion carefully, ensure all four are answered 'Yes' (or 'Does not have a need' for criterion 4), and confirm supporting documentation is attached before submitting.
Multiple sections of the form require attached documentationāsuch as a licensed physician's recommendation for medical necessity (criterion 2), a physician note confirming medical stability (criterion 3), and transcripts and attestation for *HN (BA/BS) providers. Submitters frequently check 'Yes' on these criteria but forget to attach the corresponding documents, leading to automatic denial or delays. Create a documentation checklist before faxing to ensure every required attachment is included with the completed form.
The FBA section specifies a maximum of 12 hours total (48 units) across modifiers, but providers sometimes request more hours than allowed or fail to distribute hours correctly across the H0032 HP and H0032 HP, HC service codes. Exceeding the cap will result in partial or full denial of the FBA request. Carefully calculate the combined total hours across both FBA service codes to ensure they do not exceed 12 hours before submitting.
The form provides checkboxes for DSM-V code 299.00 and ICD-10 code F84.0 (both representing Autism Spectrum Disorder), but providers sometimes check neither box, check both, or fail to complete the 'Other' field when a different code applies. Using an incorrect or missing diagnosis code can result in a mismatch with clinical records and cause the authorization to be denied. Verify the member's current diagnosis code in their clinical file and select only the applicable code, completing the 'Other' field with the full code and description if neither standard option applies.
When the servicing provider is different from the requesting provider, the entire Servicing Provider Information section must be completed separately. Many submitters leave this section blank, assuming the requesting provider information applies to both, which causes processing delays and potential denial. If the servicing provider is the same as the requesting provider, note that explicitly; if different, provide all required fields including organization name, address, phone, fax, email, and referral date.
For Case Supervision (H0031) and Parent Education Training (S5111), the HP (BCBA-D, BCBA, Licensed MA/MS) service code is marked as 'Required,' and the second service code can only be approved across modifiers if the first is also requested. Providers sometimes request only the second-tier code (e.g., BCaBA or BA/BS level) without checking the required primary code, which will result in denial of the secondary code. Always check and complete the required primary service code first before adding any secondary codes.
The Social Skills Group service code H2014 is only approvable if the provider is listed under contract for this service, yet providers frequently request it without verifying their contract status. Submitting this request without contract authorization will result in an automatic denial. Confirm with your organization's contracting department that H2014 is explicitly listed in your L.A. Care contract before checking this box on the form.
The 'Clinical indication for request/additional information' field is often completed with generic statements like 'member has ASD' or left nearly blank, which does not provide sufficient clinical justification for the requested services and hours. Reviewers need specific behavioral data, functional impairments, treatment goals, and rationale for the number of hours requested to make an informed authorization decision. Include measurable behavioral targets, frequency/intensity of behaviors, prior treatment history, and a clear explanation of why the requested service type and hours are medically necessary. AI-powered tools like Instafill.ai can prompt users to include all required clinical details.
The form requires the provider's full name, credentials, and signature, but submitters sometimes omit credentials (e.g., BCBA, BCBA-D, PhD), leave the signature blank, or forget to date the attestation. An unsigned or undated form is considered incomplete and will not be processed. Ensure the provider signs the form, prints their full name with all applicable credentials, and enters the current date before faxing to L.A. Care.
The completed form must be faxed specifically to the L.A. Care BH ASD Program Department at (213) 438-5054, but providers sometimes use a general L.A. Care fax number or a previously used number from an older version of the form. Sending to the wrong fax number means the request is never received or processed, causing significant delays in authorization. Always confirm the fax number directly from the current form version before transmitting, and retain a fax confirmation receipt as proof of submission.
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