How to Fill Out the L.A. Care PDR Form: Deadlines and Submission

The L.A. Care PDR form is the Provider Dispute Resolution Request Form that contracted and non-contracted providers use to formally challenge a claim denial, underpayment, overpayment recovery, or other final billing decision by L.A. Care Health Plan. Download the PDF from L.A. Care’s Manuals and Forms page under Claims Forms,¹ complete every field marked with an asterisk, attach your supporting documentation, and send the package by mail to L.A. Care Provider Dispute Resolution Unit, P.O. Box 811610, Los Angeles, CA 90081, or by fax to (213) 438-5057.² You have at least 365 days from L.A. Care’s action on the claim to file, and the plan then has 45 working days to issue a written decision.

When the PDR Form Is the Right Tool

Use the PDR form to contest a decision L.A. Care has already made on a claim. Typical situations include partial payments that fall short of your contracted rate, denials based on medical necessity or coding, timely-filing denials, and overpayment recovery notices you believe are wrong. The first question on the form asks whether you are disputing a previously processed claim or dispute; if the answer is no, the form directs you elsewhere.²

The form is not for claims follow-up or checking payment status. Those requests get rejected outright.² If you just need to know where a claim stands, contact L.A. Care’s provider services line.

If your claims run through a delegated entity such as an IPA or medical group, work through that entity’s dispute process first. When you then file the PDR with L.A. Care, the form requires you to include the delegated entity’s first-level review decision along with their Explanation of Benefits or Remittance Advice.² Skipping that step usually results in rejection or delay.

How Long You Have To File

California regulation prohibits health plans from setting a PDR submission deadline shorter than 365 days from the plan’s action on the claim. If the dispute is about the plan’s failure to act at all, the 365-day clock starts once the regulatory time for contesting or denying the claim has expired.³

A year sounds generous. It isn’t, if you wait. Evidence gets harder to assemble, and any interest you’re owed on a resolved dispute doesn’t accrue until the plan processes it.

Completing the Form Section by Section

Fields marked with an asterisk are required, and leaving any of them blank is one of the fastest ways to get your dispute bounced back.

Provider Information

Enter your provider or group name, Tax ID (TIN), National Provider Identifier (NPI), and both your billing and physical addresses.² The TIN and NPI must match exactly what appeared on the original claim. Mismatches create confusion and delay processing.

Member and Claim Information

Enter the patient’s name, date of birth, Health Plan ID number, and patient account number, then fill in the original claim number and the service from/to dates.² If your dispute covers multiple claims, use page three of the form, which is set up for listing additional claim numbers rather than cramming them into a single field.

Description of Dispute and Expected Outcome

This is where most PDRs succeed or fail. The form instructs you to be specific and include all relevant information in both the Description of Dispute and the Expected Outcome sections.² Vague language like “claim was underpaid” won’t hold up. Identify the specific error: cite the CPT or HCPCS code, reference the contracted rate or applicable fee schedule, and show the dollar difference between what you billed, what you expected, and what the plan paid.

In the Expected Outcome field, state plainly what you want: full payment of the remaining balance, reversal of the denial, withdrawal of an overpayment notice, or whatever resolution applies.

Overpayment Disputes

If you’re contesting an overpayment recovery notice, attach the notice itself, explain why you believe the recovery is incorrect, list the claims affected, and include any supporting documentation that backs your position.²

What To Attach

The form warns that failing to submit supporting documentation may result in rejection or delayed resolution.² At minimum, include a copy of the Explanation of Benefits (EOB) or Remittance Advice (RA) showing the original adjudication.

What else you attach depends on the type of dispute:

Medical necessity denials: clinical records, progress notes, or physician documentation supporting why the service was appropriate for the patient’s condition.
Timely filing denials: a clearinghouse transmission report with an electronic timestamp, or other dated proof that the claim was submitted before the filing deadline.
Coding disputes: operative reports, pathology results, or other records that support the billed procedure or diagnosis code.
Delegated entity disputes: the first-level review determination letter and the EOB or RA from the delegated entity.
Overpayment disputes: the overpayment notice and a list of the specific claims affected.

Keep copies of everything. If the dispute later moves to external review, you’ll need those records again.

Submitting the Form

L.A. Care accepts PDR submissions two ways:

Mail: L.A. Care Provider Dispute Resolution Unit, P.O. Box 811610, Los Angeles, CA 90081
Fax: (213) 438-5057

If you fax, save the confirmation page with its date and time stamp. For mail, use certified mail with a return receipt so you have a verifiable delivery date. Every regulatory clock runs from the date L.A. Care receives the dispute, not the date you sent it.²

What Happens After You Submit

L.A. Care must acknowledge receipt within two working days if you submitted electronically (by fax), or within 15 working days if you mailed a paper submission.³ If you don’t get an acknowledgment in those windows, follow up. Silence doesn’t mean receipt.

From the date of receipt, L.A. Care has 45 working days to resolve the dispute and issue a written determination explaining the facts considered and the reasons for the decision.³ Working days, not calendar days.

If Your Submission Is Returned as Incomplete

If L.A. Care finds your dispute is missing information you have access to, they can return it with a written explanation of what’s needed. You then have 30 working days from receiving the returned dispute to submit an amended version. Once L.A. Care receives the amended dispute, a fresh 45-working-day resolution clock begins.³ The plan cannot ask you to resubmit claim information or supporting documents you already provided during the original claims adjudication.

If the Plan Rules in Your Favor

Health plans that fail to pay past due amounts, including any interest and penalties owed, within five working days of a favorable written decision face regulatory consequences.⁴ Under California Health and Safety Code Section 1371.35, plans that fail to reimburse complete claims within the statutory window must automatically pay the greater of $15 per year or interest at 15 percent per annum on the overdue amount.⁵ That interest is supposed to be included automatically.

If L.A. Care Rules Against You

An unfavorable PDR decision isn’t the last word. Once you’ve exhausted the internal process, either by receiving a written denial or by waiting at least 45 working days without a determination, you can file a provider complaint with the California Department of Managed Health Care (DMHC).⁶ Include:

The PDR letter you sent to L.A. Care.
L.A. Care’s acknowledgment and determination letters.
The original claim form.
The EOB or Remittance Advice showing the plan’s payment decision.

All documentation must be free of protected health information for patients not associated with the complaint. If your submission is incomplete, the DMHC closes the complaint without follow-up requests, though you can resubmit after fixing the deficiencies. Effective July 1, 2026, the DMHC will not accept complaints on claims whose last date of service is older than 30 months.⁶

Non-contracted providers who have completed the PDR process within the past 365 days have a second route: the DMHC’s Independent Dispute Resolution Process (IDRP). An IDRP application requires the claim forms and L.A. Care’s PDR determination letter. If you attempted the PDR but never received a determination and at least 45 business days have passed, dated proof of the attempt can substitute.⁷

Whichever path you take, document every date. When you submitted, whether and when the acknowledgment arrived, and when the determination came back. That record is what turns a missed L.A. Care deadline into leverage at the DMHC.

1
L.A. Care Health Plan. Manuals and Forms
2
L.A. Care Health Plan. Provider Dispute Resolution Request Form
3
Cornell Law Institute. 28 CCR 1300.71.38 – Fast, Fair and Cost-Effective Dispute Resolution Mechanism
4
Department of Managed Health Care. DMHC Fines Health Net Health Plans $1.3 Million for Mishandling Provider Payment Disputes
5
California Legislative Information. California Code Health and Safety Code HSC 1371.35
6
Department of Managed Health Care. Submit a Provider Complaint
7
Department of Managed Health Care. Non Emergency Services Independent Dispute Resolution Process