LEA Annual Report
Page Updated: September 30, 2010
LEA MEDI-CAL BILLING OPTION PROGRAM ANNUAL REPORT
SUBMISSION DEADLINE:
OCTOBER 30, 2010*
*Note: Since the availability of the forms and information was delayed, LEA’s will be given a ‘grace period’ to submit the FY 2009/2010 LEA Annual Report. The
FY 2009/2010 LEA Annual Report must be received by December 31, 2010 to be exempt from the ‘late submissions’ penalty process. Any submission received after December 31, 2010 will be subject to the penalty process.
Mandatory LEA Annual Report Requirement:
As specified in the Local Educational Agency (LEA) Medi-Cal Billing Option (LBO) Program Provider Participation Agreement (PPA), LEAs participating in the LBO Program must submit an LEA Annual Report describing their collaborative, service priorities, and reinvestment expenditures each Fiscal Year (FY).
New LBO Program participants with a provider enrollment effective date prior to July 1 of any given Fiscal Year must submit an LEA Annual Report to the Department of Health Care Services (DHCS) on or before October 30 of the same Fiscal Year. Current LBO Program participants are required to submit an LEA Annual Report by October 30 every year whether or not the LEA has submitted Medi-Cal claims during the Fiscal Year.
Continued enrollment in the LBO Program is contingent upon timely submission of the LEA Annual Report each fiscal year.
Non-submission of the LEA Annual Report will result in expulsion from the LBO Program.
FY 2009-10 LEA ANNUAL REPORT FORM:
(PDF)
(Excel)
LEA ANNUAL REPORT FORM SUBMISSION INSTRUCTIONS:
1. Download and save the Excel version of the LEA Annual Report Forms to your computer
a. Use the following information to comply with the required file naming convention
i. Fiscal Year with the letters ‘AR’ to identify it as an Annual Report submission
1. Example: FY0910AR
ii. National Provider Identifier (NPI) number
1. Example: 1234567890
iii. Official LEA Name
1. Example: Official LEA Name Unified School District
iv. Submission Date (MM.DD.YYYY) format
1. Example: 11.30.2010
b. Full file naming convention sample:
i. FY0910AR.1234567890.OfficialLEANameUSD.11.30.2010.xls
1. Each piece of information included above is separated by a period
2. There are no spaces between words (i.e. OfficialLEANameUSD)
2. Once completed, print the LEA Annual Report Forms
3. Ensure all required signatures are obtained and signed in
BLUE ink
4. Scan the printed and signed copies of the LEA Annual Report Forms and save them in the Adobe PDF format
a. Use the previous file naming convention for the PDF version
i. Example: FY0910AR.1234567890.OfficialLEANameUSD.11.30.2010.pdf
5. Submit your LEA Annual Report Forms to DHCS by sending an email to:
LEA.ANNUALREPORT@DHCS.CA.GOV
a. The Excel and PDF versions MUST BE included as attachments
b. Maintain the original, signed hard copies of the LEA Annual Report on site for DHCS Audits and Investigations staff, if necessary
i. You are not required to submit a hard copy to DHCS; the PDF version will serve as the original hard copy submission
Note: LEAs will receive an email confirming receipt of a properly submitted LEA Annual Report. The confirmation of receipt indicates that the LEA Annual Report has been received by DHCS; however, it will not confirm accuracy of the information contained therein.
LEA ANNUAL REPORT QUESTIONS/CONTACTS:
LEA Annual Report Forms Submissions: LEA.ANNUALREPORT@DHCS.CA.GOV
LEA Annual Report Forms Questions: 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 ANNUAL REPORTS:
To obtain a copy of your prior year LEA Annual Report(s), you must use the following instructions:
1. Send your request to:
LEA.ANNUALREPORT@DHCS.CA.GOV
a. Your email request MUST meet the following guidelines:
i. Subject Line: “(FY) LEA Annual Report Request – (NPI Number)”
1. Example: 2008-2009 LEA Annual Report Request – 1234567890
ii. Copy (CC): All LEA staff members who will also need a copy of the prior LEA Annual Report
iii. Body: (NPI Number), (Official LEA Name), (Contact Name and Phone Number)
1. Example:
1234567890
Official LEA Name USD
Terry Administrator
(817) 980-0987
The following link will take you to previous Annual Report forms:
