In May of 2017, DHCS released All Plan Letter 17-009 (APL 17-009), superseding APL-16-011, along with updated guidance for no longer allowing paper submissions of form 7107 and requiring the submission of Provider Preventable Conditions (PPC) reporting through DHCS's secure online system.
DHCS also re-released encounter and claims data related to Provider Preventable Conditions (PPCs), Hospital Acquired Conditions (HCACs) and Other Provider Preventable Conditions (OPPCs). APL 17-011 supersedes and incorporates previous guidance related to the above.
The data screening and reporting process, which is to be instituted as an ongoing, continual monthly screening process within health plan or medical practice operations, is summarized below:
Welfare and Institutions Code 14131.11, as well Title 42 of the Code of Federal Regulations, sections 447, 434 and 438, require all Medi-Cal providers to report provider-preventable conditions (PPCs) that are associated with claims for Medi-Cal payment or with courses of treatment prescribed to a Medi-Cal patient for which payment would otherwise be available. States are prohibited from permitting payment to providers for treatment of PPCs. PPCs include both the "Health Care Acquired Conditions" (HCACs) defined in section 1886(d)(4)(D)(ii) and (iv) of the Social Security Act and "Other Provider Preventable Conditions" (OPPCs).
Further information is available on the following pages:
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Medi-Cal Guidance on Reporting Provider-Preventable Conditions
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Provider-Preventable Conditions - Frequently Asked Questions
L.A. Care and its delegates must report PPC related encounters "in a form and frequency as specified by the State" per Title 42 CFR Section 438.3(g). In addition to receiving copies of any submitted online PPC reports from providers, L.A. Care and its delegates must screen claims encounter data, including data received from network providers, for the presence of the PPCs to be included in any mandated online reporting on a monthly basis.
L.A. Care and its delegates must:
- Monthly - review encounter data submitted by network providers for evidence of PPCs that must be reported using the online PPC reporting system on DHCS's website.
- When a PPC is confirmed, L.A. Care or its delegate must complete the online form for each PPC. L.A. Care must:
- remind all network providers that they must report PPCs to DHCS using the online reporting system;
- require all network providers to also send L.A. Care a copy of the online form submission when a network provider self-reports and
- retain copies of all submissions.
L.A. Care and delegates of L.A. Care must all utilize the PPC process that is outlined above and on the secure online form.