L.A. Care's policy relating to Government Claims (LS-009).
L.A. Care's policy on Fair Hearing for Administrative/Business Decisions (LS-011).
As a managed care health plan, L.A. Care participates in conducting facility site reviews and medical record reviews.
This DHCS policy defines how these reviews are conducted and includes related guidelines and tools. (PL-14-004).
Enforcement of Disciplinary Standards
It is L.A. Care's expectation that PPG immediately report to L.A. Care any suspected compliance issues, such as noncompliant, unethical, or illegal behavior. Such behavior may include, but is not limited to, falsifying diagnoses, claims, or other documents; refusal to cooperate with state or federal audits or investigations; and other behavior. Such reports can be made directly to L.A. Care's Compliance Officer at (213) 694-1250, x4292. Anonymous complaints of noncompliant, unethical, or illegal conduct may also be reported by calling L.A. Care's Compliance Helpline at 1-800-400-4889 or via the internet at www.lacare.ethicspoint.com. The Compliance Helpline is available 24 hours a day, 7 days a week. PPG shall also assist in the resolution of reported compliance issues.
L.A. Care will timely, consistently, and effectively act when noncompliant or unethical behavior is found. Such action will be appropriate to the seriousness of the violation and may include de-delegation of a function, restriction of enrollment or assignment of members, withholding capitation, instituting monetary sanctions, or terminating a contract. Refer to the Participating Provider Group Services Agreement (PPGSA) for further details on these measures.
PPG shall ensure that it has established, implemented, and enforced disciplinary standards that are publicized to those entities with which it contracts.
It is L.A. Care's expectation that PPG will cooperate with L.A. Care's efforts to monitor compliance.
Subcontractor Network Certification (SNC)
The Department of Health Care Services (DHCS) requires Medi-Cal Managed Care Health Plans (MCPs) to conduct Subcontractor Network Certifications (SNC) to validate network adequacy and access to care gaps pursuant to 42 CFR § 438.66(e) and APL 23-006 (ca.gov).