LEA Provider Participation Agreement (PPA)/Annual Report (AR)

Last Updated: August 21, 201 

LEA MEDI-CAL BILLING OPTION PROGRAM 

PROVIDER PARTICIPATION AGREEMENT/ANNUAL REPORT

SUBMISSION DEADLINE: OCTOBER 10, 2012*

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 (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).  All LBO 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 LBO 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 LBO Program.

FY 2011-12 LEA ANNUAL REPORT FORM:

(EXCEL)

Please click on the tabs on the bottom of the document to access the forms outlined in the instructions.

(PDF) completed correctly.

LEA ANNUAL REPORT/PPA QUESTIONS/CONTACTS:   

Please mail a hard copy of your Annual Report/PPA with original signatures to: 

California Department of Education

Coordinated School Health & Safety Office

Attn: Shalonn Woodard

1430 N Street, Suite 6408

Sacramento, CA  95814

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

.     Example:1234567890, Official LEA Name USD, Terry Administrator (817) 980-098

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