AFFLIATED HOSPITALS PLANS
Beverly Hospital--Montebello
California Hospital Medical Center*
Centinela Hospital Medical Center
Children’s Hospital of Los Angeles (Tertiary)
East LA Doctor’s Hospital
Hollywood Presbyterian Medical Center*
Huntington Memorial Hospital (Tertiary)
L.A. Community Hospital – Los Angeles & Norwalk
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
Southern CA Hospital—Culver City & Hollywood
St. Francis Medical Center
St. Mary Medical Center
St. Vincent Medical Center
White Memorial Medical Group
Legend: * Full Risk Partners for Medi-Cal Enrollees

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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.