LEA Program Provider Participation Agreement & Annual Report

Submission Deadline

Updated: July 1, 2017

LEA Medi-Cal Billing Option Program Provider Participation Agreement & Annual Report Submission Deadline: November 30, 2017

Mandatory LEA Program Provider Participation Agreement & Annual Report Requirements

A Provider Participation Agreement (PPA) is required for participation in the LEA Medi-Cal Billing Option Program. Effective July 1, 2016, the PPA contains two exhibits: Exhibit A - HIPAA Business Associate Addendum (BAA), and Exhibit B - Data File Description. In addition to complying with the terms listed in the PPA, all LEAs must abide by the terms listed in the BAA. The purpose of the BAA is to guard the privacy and security of protected health information and personal information that may be created, received, maintained, transmitted, used or disclosed pursuant to the PPA, and to comply with certain standards and requirements of HIPAA regulations. Exhibit B is a description of the data provided to the LEA via data tape match. LEAs do not need to sign or return Exhibits A and B to DHCS.

LEAs that designate a third-party billing vendor as their 'Custodian of the Files' must also submit a Data Use Agreement (DUA), which is signed by representatives of DHCS, the LEA and the vendor. A DUA is required for non-providers (provider representatives, such as a billing vendor) to order and receive Medi-Cal eligibility information on behalf of the LEA. If a LEA does not utilize services of a third-party billing vendor and performs its own in-house billing, the submission of the DUA is not required.

For Fiscal Year 2017-18, all participating LEAs must submit the FY 2016-17 Annual Report (AR) by November 30, 2017.
Currently enrolled LEAs are not required to resubmit the PPA or the DUA.
All newly enrolling LEAs must submit the PPA, AR, and the DUA (if applicable) to begin participation in the LEA Medi-Cal Billing Option Program.

Provider Participation Agreement & Annual Report Materials and Instructions

For newly enrolling LEAs only

For newly enrolling LEAs that are a Community College District, California State University, or University of California

PPA Exhibit A: Business Associate Addendum (BAA)

PPA Exhibit B: Data File Description

Instructions for completing and submitting the PPA

For new and returning LEAs - DUE NOVEMBER 30, 2017

Includes Medi-Cal Provider Enrollment Information Sheet
Includes Consortium Billing (if applicable)
In order to limit software compatibility issues, save the Annual Report to your computer prior to completing it. Right click the above link and select 'Save target as.' Please use Adobe Acrobat or Reader to complete the form.

Instructions for completing and submitting the Annual Report

LEA PPA & AR Questions

Please direct any questions regarding the LEA PPA / Annual Report to: LEA@dhcs.ca.gov

Documentation Retention Requirements

The LEA Annual Report and supporting documentation must be maintained by each LEA for a minimum of three years from the date of submission to DHCS and the information contained therein must be verifiable by DHCS Audits and Investigations staff, if necessary.

Copies of Prior FY LEA PPA

To obtain a copy of your prior year LEA PPA, please use the following instructions:

Send your request to: LEA.AnnualReport@dhcs.ca.gov

Your email request MUST meet the following guidelines:

A) Subject Line: “(FY) LEA Annual Report Request – (NPI Number)”

Example: 2008-2009 LEA Annual Report Request – 1234567890

B) Copy (CC): All LEA staff members who will also need a copy of the prior LEA Annual Report

C) Body: (NPI Number), (Official LEA Name), (Contact Name and Phone Number)

Example:1234567890, Official LEA Name USD, Terry Administrator (817) 980-0987

Copies of Prior FY LEA Annual Report

To obtain a copy of your prior year LEA Annual Report, please use the following instructions: