AFFLIATED HOSPITALS PLANS
*Southern California Hospital at Culver City
*Southern California Hospital at Hollywood
*Los Angeles Community Hospital at Los Angeles
*Los Angeles Community Hospital at Norwalk
*Southern California Hospital at Van Nuys (behavioral health)
*Los Angeles Community Hospital at Bellflower (behavioral health)
Beverly Hospital--Montebello
California Hospital Medical Center*
Centinela Hospital Medical Center
Children’s Hospital of Los Angeles (Tertiary)
East LA Doctor’s Hospital
Glendale Adventist Medical Center
Hollywood Presbyterian Medical Center*
Huntington Memorial Hospital (Tertiary)
Long Beach Memorial Medical Center
Martin Luther King Jr. Community Hospital
Memorial Hospital of Gardena
Miller Children’s Hospital (Tertiary)
Providence Little Company of Mary – San Pedro & Torrance
San Gabriel Valley Medical Center
St. Francis Medical Center
St. Mary Medical Center
White Memorial Medical Group
Legend: * Full Risk Partners for Medi-Cal Enrollees

more info
HEALTH PLAN HEALTH PLAN CMS 150 HEALTH PLAN PM 160 IPA 1500 Vaccines VFC Notes
ANTHEM/ BLUE CROSS ✅ ✅ ✅ ✅ Submit Plan PM 160 and CMS 1500 to:
P.O. Box 60007
Los Angeles, CA 90060‐0007
In addition, CMS 1500 encounter must
be submitted to the IPA.
CHDP is Plan financial responsibility.
*PM 160 not required if clinic is certified
by Blue Cross*
CARE 1st
✅ ✅ CHDP is IPA financial responsibility. $9.00
flat rate admin fee paid by IPA in
conjunction with vaccine CPT. No
additional Care 1st incentive.
Health Net ✅ ✅ ✅ Submit Health Plan PM 160
electronically via the Health Net web
portal. In addition, CMS 1500 encounter
must be submitted to the IPA.
CHDP is IPA financial responsibility. $9.00
flat rate admin fee paid by IPA in
conjunction with vaccine CPT. Health Net
offers additional $30 incentive through
the Incentive Reward Program based on
encounter to Plan as well as IPA.
Member enrollment must be over 250.
PCP must be enrolled in the program.
L.A. CARE ✅ ✅ ✅ Submit Health Plan forms to:
PO Box 811580
Los Angeles, CA 90081
CHDP is Plan financial responsibility.
*PM 160 form will phase out effective
7/1/18 dates of services*
MOLINA You must preregister for the program. Contact Molina: (562) 435‐3666 ✅ ✅ *PM 160 form and dual IPA/Health Plan
submission is phased out for 2018 dates
of services*
CHDP is Plan financial responsibility.
Molina offers additional incentive based
on electronic encounter to IPA. Member
enrollment must be over 200. PCP must
be enrolled in the program.