​​​​LEA Program Enrollment and Compliance Documents

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Updated: November 25, 2019       

Mandatory LEA Program Provider Participation Agreement & Annual Report Requirements

The Provider Participation Agreement (PPA) and Annual Report (AR) are required for participation in the LEA Program. The PPA contains two exhibits: Exhibit A - Health Insurance Portability and Accountability Act (HIPAA) Business Associate Addendum (BAA), and Exhibit B - Data File Description. In addition to complying with the terms listed in the PPA, all LEA providers 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 the Department of Health Care Services (DHCS).

Data Use Agreement Requirement

LEA providers that designate a third-party billing vendor as their 'Custodian of the Files' must also submit a DUA, which is signed by representatives of DHCS, the LEA provider 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 provider. If a LEA provider 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.

Provider Participation Agreement, Annual Report, and Data Use Agreement and Instructions

(Email LEA.AnnualReport@dhcs.ca.gov to request the PPA, AR, and DUA packets)

Please use Adobe Acrobat or Reader to complete the forms.
Please direct any questions regarding the LEA Provider Participation Agreement & Annual Report to: LEA@dhcs.ca.gov

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. 

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 Reporting Year's PPA or AR

To obtain a copy of a prior year's PPA or AR, please send your request to LEA.AnnualReport@dhcs.ca.gov
Last modified date: 4/11/2022 8:39 AM