Long-Term Services and Supports

Long-Term Services and Supports Forms

Documents for long-term care providers

We want to make it easy for you to find the forms you need. If you don't see the form you are looking for, or if you aren't sure which one you need, please call our Long-Term Care Department at 1-714-246-8444. We are here to help you.

B

Benefit Inquiry for Community-Based Adult Services (CBAS) Download PDF Icon Submit form for benefit information of CBAS participants.

C

CalOptima Direct Claims Instructions/Claims Resubmission Form Download PDF Icon Use this form for all claim inquiries and resubmissions.

Community-Based Adult Services (CBAS) Authorization Request Form (ARF) Download PDF Icon Submit along with clinical documentation to request a review to authorize CBAS participant’s treatment plan.

CBAS Incident Report Form Download PDF Icon Used to provide a summary of adverse events that occur at or in transit to a CBAS center.

CBAS Member Discharge Plan and Reason Download PDF Icon Complete form to provide reason for CBAS discharge of member and continued treatment plan.

D

Deferral Extension Notification Form Download PDF Icon Use this form to request an extension or deferral of an authorization request.

Discharge Disposition Form Download PDF Icon Use this form when discharging a CalOptima member from a long-term care facility.

E

Electronic Funds Transfer Authorization Form (External Link to InstaMed Website)  Download PDF Icon Submit this form and get claims information and payments faster and easier.

H

Hospice Care Inpatient Information Sheet and Instructions Download PDF Icon Use this form when transferring a Medi-Cal hospice patient to a general inpatient level of care.

Hospice Notification/Validation Form Download PDF Icon Complete this form when requesting claim payment for hospice care.

I

ICF/DD, ICF/DD-H and ICF/DD-N Notification Form Download PDF Icon Use this form to notify CalOptima when our members utilize intermediate-care facilities for the developmentally disabled (ICF/DD), habilitative (ICF/DD-H) and nursing (ICF/DD-N).

L

Long-Term Care Authorization Processing Guidelines Download PDF Icon Learn the processing guidelines for long-term care authorizations.

Long-Term Care Authorization Request Form Download PDF Icon Use this form to request long-term care authorization for our members.

Long-Term Care Treatment in Place Notification Form Download PDF Icon Use this form to notify CalOptima of long-term care treatment in place services provided to our members.

Long-Term Services and Supports Assessments Request Form Download PDF Icon Use this form -when requesting completed long-term services and supports assessments of CalOptima members.

M

MSSP LTC/SNF Incident Reporting Form Download PDF Icon Submit when notifying CalOptima of a critical incident involving member.

Multipurpose Senior Services Program (MSSP) — Referral Download PDF Icon Complete with evaluating and referring member for MSSP services.

N

Notification of Change of Address/Tax ID Form Download PDF Icon Use this form when requesting a change of your address or tax identification number.

Notification of Change of "Pay To" Address Form Download PDF Icon Use this form when requesting a change of your payment address.

O

On-Site Visit/21-Day List Download PDF Icon This log tracks your on-site visit/21-day list for CalOptima members.

P

Provider Complaint Form And Instructions Download PDF Icon Review instructions for filing a provider complaint.

Provider Dispute Resolution Request Form  Download PDF Icon Use this form when you are requesting a resolution to a provider dispute.

Q

Quality Improvement Critical Incident and Abuse Report Download PDF Icon Use this form to alert CalOptima to any actual or alleged event or situation that creates risk or serious harm to the physical or mental health or safety of a CalOptima member.

Contact Us
Provider Directory
  • Find a Provider
    CalOptima works with over 3,700 Orange County physicians, making it easy for our members to get the care they need.

    Check here for our extensive list of providers, health networks, medical groups, hospitals and pharmacies.
Claims
Provider Trainings
  • Trainings by Topic
    View the latest model of care and other educational materials designed to help you and your staff provide care for CalOptima members.

Download the free Adobe Reader.

Materials available on this Website in PDF format may require the free Adobe Reader to view. To download Adobe Reader for free from the Adobe Website, click here.