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)
Adventist Health White Memorial
Los Angeles Community Hospital at Norwalk ^
Adventist Health White Memorial Montebello (Beverly Hospital)
Martin Luther King Jr. Community Hospital
Adventist Health Glendale
Memorial Hospital of Gardena
Alhambra Hospital Medical Center
Monterey Park Hospital
California Hospital Medical Center *
Pacifica Hospital of the Valley
Centinela Hospital Medical Center
PIH Health Downey Hospital
East Los Angeles Doctors Hospital
Providence Little Company of Mary – San Pedro & Torrance
Garfield Medical Center
San Gabriel Valley Medical Center
Greater El Monte Community Hospital
Southern California Hospital at Culver City *^
Hollywood Presbyterian Medical Center *
Southern California Hospital at Hollywood ^
Lakewood Regional Medical Center
St. Francis Medical Center
Long Beach Memorial Medial Center / Miller Children’s Hospital
St. Mary Medical Center
Los Angeles Community Hospital at Los Angeles ^
Valley Presbyterian Hospital
Legend: * - Dual Risk for Medi-Cal Health Net
^ - Dual Risk for Medi-Cal Blue Shield Promise & LA Care with Alta Hospital Systems

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.