LEA Provider Participation Agreement (PPA)/Annual Report (AR) for Returning Providers
Last Updated: August 15, 2013
LEA MEDI-CAL BILLING OPTION PROGRAM
PROVIDER PARTICIPATION AGREEMENT/ANNUAL REPORT
SUBMISSION DEADLINE: OCTOBER 10, 2013*
Note: The submission date for the Provider Participation Agreement/Annual Report has changed to October 10th. LEAs who submit the PPA/AR after the due date may be suspended from the LEA program.
MANDATORY LEA ANNUAL REPORT REQUIREMENT:
As specified in the Local Educational Agency (LEA) Medi-Cal Billing Option Program Provider Participation Agreement
(PPA), LEAs participating in the Program must submit an LEA Annual Report describing their collaborative, service priorities, and reinvestment expenditures each Fiscal Year (FY). All Program participants must submit an LEA Annual Report to the Department of Health Care Services (DHCS) on or before October 10th of the same Fiscal Year whether or not the LEA has submitted Medi-Cal claims during the Fiscal Year.
Continued enrollment in the Program is contingent upon timely submission of the LEA Annual Report each fiscal year. Non-submission of the LEA PPA/Annual Report may result in suspension from the Program.
FY 2012-13 LEA ANNUAL REPORT FORM:
(Excel)
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(PDF) completed correctly.
LEA ANNUAL REPORT/PPA QUESTIONS/CONTACTS:
Please direct any questions regarding the LEA PPA/Annual Report to:LEA@DHCS.CA.GOV
ANNUAL REPORT SUBMISSION PROCESS FOR RETURNING PROVIDERS
For the 13-14 FY, LEAs that are currently participating in the LEA Medi-Cal Billing Option Program may mail a hard copy OR email the annual report no later than October 10, 2013.
* DO NOT send the annual report by BOTH mail and email .
You may mail the Annual Report package, with original signatures, to the Department of Health Care Services to the address below:
Department of Health Care Services
Safety Net Financing Division
LEA Medi-Cal Billing Option Program
Attn: Angelia Johnson
1501 Capitol Avenue, MS 4603, P.O. Box 997436
Sacramento, CA 95899-7436
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The email file MUST include the following:
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Excel version of the completed AR form (all worksheets)
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Scanned version of the original signed AR forms (i.e., PDF, JPEG, etc.)
AR electronic files must follow this naming convention: Fiscal YearAR.NPI Number.Business LEA Name.Submission Date
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Example: 12-13AR.1234567890.DHCS Unified School District.6/14/2013.xls (or PDF)
Use this naming convention to save your AR and in the subject line of the email submission.
**** Reports without the correct naming convention will be returned*****
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, you must use the following instructions:
1. Send your request to:
PEDCorr@dhcs.ca.gov . Your email request MUST meet the following guidelines:
A. Subject Line: “(FY) LEA Annual Report Request – (NPI Number)”
a. 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)
a. 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, you must use the following instructions:
1. Send your request to:
LEA@dhcs.ca.gov . Your email request MUST meet the following guidelines:
A. Subject Line: “(FY) LEA Annual Report Request – (NPI Number)”
a. 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)
a. Example:1234567890, Official LEA Name USD, Terry Administrator (817) 980-0987
