Pay for Performance (P4P) Program - DualChoice Annual Visit
Welcome to the Inland Empire Health Plan (IEHP) Pay for Performance program, also known as P4P. IEHP’s P4P was designed to increase the provision of preventive health services to IEHP Members as well as improve HEDIS® results to ensure that all IEHP Direct DualChoice Members receive timely annual assessment visits with an emphasis on review and management of chronic illnesses.
IEHP Direct PCPs will be reimbursed directly by IEHP through the DualChoice Annual Visit program. PCPs participating in IEHP's network through an IPA only are not eligible for this program:
To learn more about P4P IEHP DualChoice Annual Visit, contact a Provider Services Representative at (909) 890-2054.
Click on the following links to jump to that specific section:
Provider Quality Incentives Brochure
Inland Empire Health Plan (IEHP) is pleased to announce the 2022 Provider Quality Incentive Brochure.
- 2022 Provider Quality Incentive Brochure (PDF) | June 22, 2022
Medicare P4P IEHP Direct Program
Inland Empire Health Plan (IEHP) is pleased to announce the Medicare P4P IEHP Direct Program. The goal of the program is designed to reward IEHP Direct Primary Care Providers (PCPs) for providing quality care to IEHP DualChoice Members.
- Medicare P4P IEHP Direct Program Guide (PDF) Published: February 16, 2023
IEHP Direct Stars Incentive Program
Inland Empire Health Plan (IEHP) is pleased to announce the IEHP Direct Stars Incentive Program for Primary Care Physicians (PCPs). The goal of the program is to reward PCPs who provide high-quality care to IEHP DualChoice (HMO D-SNP) members.
- IEHP Direct Stars Incentive Program Guide (PDF) Updated: March 23, 2023
D-SNP Model of Care Incentive Program
Inland Empire Health Plan (IEHP) is pleased to announce the D-SNP Model of Care Incentive Program for Independent Physicians Associations (IPAs). The goal of the program is to reward IPAs who provide high-quality care to IEHP DualChoice (HMO D-SNP) members.
- D-SNP Model of Care Incentive Program (PDF) Published: March 24, 2023
Chronic Care Improvement Program Planning and Reporting Document
The Chronic Care Improvement Program (CCIP) Planning and Reporting document can be used for the following D-SNP Model of Care Incentive Program activity: Chronic Care Improvement Program (CCIP) Activity.
- CCIP Planning and Reporting Document (Word Document)
- CCIP Planning and Reporting Document - Reference Guide (PDF)
Global Quality P4P Program
If you would like more information about IEHP’s GQ P4P Program or best practices to help improve quality scores and outcomes, visit our Secure Provider Portal, email the Quality Team at QualityPrograms@iehp.org or call the IEHP Provider Relations Team at (909) 890-2054.- 2023 IEHP Global Quality P4P Program Guide PCP (PDF) Published: March 14, 2023
- 2023 IEHP Global Quality P4P Program Guide IPA (PDF) Published: March 14, 2023
- 2022 IEHP Global Quality P4P Program Guide PCP (PDF) Published: December 21, 2022
- 2022 IEHP Global Quality P4P Program Guide IPA (PDF) Published: December 16, 2022
- 2022 Provider Quality Resource Guide (PDF) Published: July 14, 2022
Quality Improvement Activity Strategy Forms
The Quality Improvement Activity (QIA) Strategy Forms can be used for the following 2023 and 2022 Global Quality P4P QIA Activities: Reducing Health Disparities and Potentially Avoidable Emergency Department Visits or Potentially Preventable Admissions.- 2023 Equity Quality Improvement Activity #1 - Strategy Form (PDF)
- 2023 Quality Improvement Activity #2 - Strategy Form (PDF)
- 2022 Equity Quality Improvement Activity #1 - Strategy Form (PDF)
- 2022 Quality Improvement Activity #2 - Strategy Form (PDF)
Potentially Avoidable Emergency Department (ED) Visits: Potentially Preventable Diagnosis Codes
The Potentially Preventable Diagnosis Code List includes diagnosis codes for visits to an ED in which the condition could be treated by a Physician or other health care Provider in a non-emergency setting or conditions that are potentially preventable or are ambulatory care sensitive.
- Potentially Preventable Diagnosis List (PDF) Published: February 04, 2022
Patient Experience
This toolkit is full of proven tips and successful strategies based on the kinds of questions your IEHP Members could be asked to answer regarding their Provider's service. Your Provider Relations Team has targeted nine specific topics in this toolkit to help Providers and their staff continue to achieve the highest marks in Patient experience from their IEHP Members.
Well Child
Immunizations
IEHP provides vaccine coverage based on the latest ACIP recommendation and guidelines. Please refer to the Immunization Update and "Summary of Recommendations" for both Child and Adolescents AND Adult Vaccines as follows:
- 2022 Immunization Timing Chart - English (PDF)
- 2022 Immunization Timing Chart - Spanish (PDF)
- 2022 Immunization Timing Chart - Chinese (PDF)
- 2022 Immunization Timing Chart - Vietnamese (PDF)
- Immunization Updates (PDF)
- 2021 Recommended Child and Adolescent Immunization Schedule (0-18 years) (PDF)
- 2021 Recommended Adult Immunization Schedule (19+ years) (PDF)
- OB/GYN P4P Program Guide (PDF) Published: January 01, 2023
- OB P4P Frequently Asked Questions FAQs (PDF) Published: February 13, 2023
- Postpartum Depression Screening (PDF)
- 2023 Hospital P4P Program Guide (PDF) Published: March 23, 2023
- P4P 2023 MX Data Contributions (PDF) Published: February 02, 2023
- IEHP P4P 2023 Data Guidelines (PDF) Published: February 02, 2023
- 2022 Hospital P4P Program Guide (PDF) Published: March 20, 2023
- P4P 2022 MX Data Contribution (PDF) Published: April 18, 2022
- P4P 2022 MX Data Guidelines (PDF) Published: April 18, 2022
- Potentially Preventable Diagnosis List (PDF) Published: February 04, 2022
- Mental Health Diagnosis List (PDF) Published: February 02, 2022
- Substance Use Disorders Diagnosis List (PDF) Published: February 02, 2022
Adult Vaccines are a covered benefit and do not require prior authorization (must adhere to CDC/ACIP Immunization Recommendation and/or FDA approved indication).
This toolkit contains commonly used immunization codes, best practices for reporting immunizations including information on registering with CAIR, tips on talking with parents and information on understanding vaccination hesitancy.
This guide contains helpful links and contact information for locations to register for CAIR2 or current users.
Reimbursement process:
Complete a CMS1500 form by including the appropriate CPT codes, quantity dispensed and billed amount.
Mail:
IEHP Claims Department
P.O. Box 4349
Rancho Cucamonga, CA 91729-4349.
For the latest updates and news regarding the vaccines, please visit CDC's ACIP website at https://www.cdc.gov/vaccines/hcp/acip-recs/index.html. By clicking on this link, you will be leaving the IEHP website.
Quality Bonus Services Dispute Form
Please e-mail completed forms to QualityPrograms@iehp.org
OB/GYN P4P Program
Inland Empire Health Plan (IEHP) has released the OB/GYN P4P Program Guide which details the program requirements, performance measures, updated code sets, and payment timelines.
Hospital P4P Program
Inland Empire Health Plan (IEHP) is pleased to announce the Hospital Pay For Performance Program (Hospital P4P) for IEHP Medi-Cal contracted Hospitals servicing Riverside and San Bernardino Counties. The goal of the Hospital P4P Program is to provide substantial financial rewards to Hospitals that meet quality performance targets and demonstrate high-quality care to IEHP Members.
Potentially Avoidable Emergency Department (ED) Visits: Potentially Preventable Diagnosis Codes
The Potentially Preventable Diagnosis Code List includes diagnosis codes for visits to an ED in which the condition could be treated by a Physician or other health care Provider in a non-emergency setting or conditions that are potentially preventable or are ambulatory care sensitive.
Substance Use Disorders and Mental Health Diagnosis Lists
The Substance Use Disorders and Mental Health Diagnosis Lists includes diagnosis codes to identify substance use disorders, drug overdose, mental health or intentional self-harm diagnoses.
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here
Proposition 56
Proposition 56, the California Healthcare, Research and Prevention Tobacco Tax Act of 2016, now includes proposed supplemental payments for physicians participating in Medi-Cal Fee-For-Service (FFS) and Medi-Cal Managed Care.
- Proposition 56 FAQs SFY 19/20 (PDF) Published: February 18, 2020
Click on the following links to jump to that specific section:
Electronic Payments
With the current public health situation that our country is experiencing, it is necessary for IEHP to take additional precautions to ensure the health and well-being of our community. These precautions are being reviewed, and discussed daily, by our Executive leadership team and will be implemented as deemed necessary. Future COVID-19 precautions may include reduced on-site staffing and prioritization of electronic payments over printed checks.
To minimize any disruption or delay in payment, we recommend that you sign up for electronic payments as soon as possible if you have not done so already. Our team is available to assist you with the necessary paperwork required to make this change or to answer any questions you may have. The team can be reached by e-mailing vendormaintenance@iehp.org or by calling (909) 294-3928 and selecting Option 1.
Our priority remains keeping our Members, Providers, Vendors, and Team Members safe while doing what we can to minimize the potential spread of the virus. We will continue to work hard to provide you with the level of service you have come to expect during this uncertain time.
Adverse Childhood Experiences Screening (ACES) Services
- Proposition 56 Adverse Childhood Experience Screening (ACES) Services (PDF) Published: May 15, 2020
- FAQs on Proposition 56 Payment - Adverse Childhood Experience Screening (ACES) Services (PDF) Published: October 14, 2021
PSA Videos:
Developmental Screening Services
- Proposition 56 Developmental Screening Services (PDF) Published: March 19, 2020
- FAQs on Proposition 56 - Developmental Screening Services (PDF) Published: October 14, 2021
Family Planning Services
- Proposition 56 - Family Planning Services (PDF) Published: June 1, 2022
- FAQs on Proposition 56 - Family Planning Screening Services (PDF) Published: October 13, 2022
Ground Emergency Medical Transport (GEMT) Payment
The Department of Health Care Services (DHCS) has established a Ground Emergency Medical Transport (GEMT) Quality Assurance Fee (QAF) program. In accordance with 42 USC Section 1396u-2(b)(2)(D), Title 42 of the Code of Federal Regulations part 438.114(c), and WIC Sections 14129-14129.7, Medi-Cal Managed Care Health Plans must provide increased reimbursement rates for specified GEMT services to non-contracted GEMT providers. SPA 18-004 implements a one-year QAF program and reimbursement add-on for GEMT provided by emergency medical transportation providers effective for State Fiscal Year (SFY) 2018-19 from July 1, 2018, to June 30, 2019.
Please email completed forms to Prop56Inquiry@iehp.org or fax to (909) 296-3550.
HYDE
- Proposition 56 HYDE Services (PDF) Published: May 15, 2020
- FAQs on Proposition 56 - HYDE Services (PDF) Published: October 14, 2021
Proposition 56 and GEMT Payment Schedule
- Proposition 56 and GEMT Supplemental Payment Schedule CY2023 Updated: January 6, 2023
Proposition 56 Payment Dispute Process
- Proposition 56 - Paid Claims Dispute Request Form (PDF)
- Proposition 56 - Encounter Dispute Request Form (PDF)
Please email completed forms to Prop56Inquiry@iehp.org or fax to (909) 296-3550.
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.
Proposition 56 - Value Based Payments (VBP) Program*
*UPDATE: Although the VBP program ended as of DOS June 30, 2022, payments will run out through June 2023.
The Proposition 56 VBP Program provided direct payments incentivizing Providers to meet specific measures aimed at delivering key quality healthcare services that improve the quality of care to Medi-Cal beneficiaries. Targeted areas were behavioral health integration, chronic disease management, prenatal/post-partum care and early childhood prevention. For more information about the VBP Program, please visit the DHCS website at https://www.dhcs.ca.gov/provgovpart/Pages/VBP_Measures_19.aspx. By clicking on this link, you will be leaving the IEHP website.
Value Based Payments Program Guide
- Value Based Payments (VBP) Program Guide (PDF) - Published: January 01, 2022
Value Based Payments Dispute Forms
- Value Based Payments Program - Paid Claims Dispute Request (PDF) Published: January 19, 2022
- Value Based Payments Program - Encounter Dispute Request (PDF) Published: January 19, 2022
Please e-mail completed forms to ValueBasedPaymentsProgram@iehp.org
At-Risk Condition Codes
The At-Risk Condition Codes list includes diagnosis codes to identify Serious Mental Illness, Substance Use Disorder or Homelessness Conditions for the VBP Program. These conditions qualify Providers for an additional payment amount for VBP services. Please refer to page 4 of the VBP Program Guide for additional details.
- At-Risk Condition Codes (PDF) Published: March 25, 2020
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.
Private Hospital Directed Payment Program (PHDP)
PHDP provides supplemental reimbursement to participating Network Provider private hospitals through uniform dollar increases for select inpatient and outpatient services based on actual utilization of qualifying services as reflected in encounter data reported to DHCS. PHDP utilization-based payments will be calculated by DHCS in accordance with the CMS approved preprint, and must be issued by IEHP to private hospitals, in six-month increments: January through June, and July through December
Enhanced Payment Program (EPP)
EPP provides supplemental reimbursement to Network Provider DPHs through uniform dollar increases for select inpatient and non-inpatient services, based on the actual utilization of qualifying services as reflected in encounter data reported to DHCS. In addition, for Network Provider DPHs that are primarily reimbursed on a capitated basis, DPH EPP provides supplemental reimbursement through uniform percentage increases to their contracted capitation rates. EPP utilization-based payments and Capitation based payments will be calculated by DHCS in accordance with the CMS-approved preprint and must be issued by to DPHs, in six-month increments: January through June, and July through December
For more information about PHDP and EPP Programs, please visit the DHCS website at https://www.dhcs.ca.gov/services/Pages/DirectedPymts.aspx.
District and Municipal Public Hospital Quality Incentive Pool and Designated Public Hospital Quality Incentive Pool
QIP provides supplemental incentive payments to participating DPH and DMPH systems based on their performance on specified quality measures that address primary, specialty, and inpatient care, including measures of appropriate resource utilization. QIP payments are linked to delivery of services under MCP contracts. For additional details on QIP incentive program please visit DHCS website at https://www.dhcs.ca.gov/services/Pages/DP-DPH-QIP.aspx or contact DHCS at qip@dhcs.ca.gov.
For disputes of payments issued under Private Hospital Directed Payment Program (PHDP) and or Enhanced Payment Program (EPP)- Hospital is to send email to PHDP-EPP@iehp.org stating the service period and dispute reason in detail. Hospital has six months from IEHP’s payment check date to dispute payment.
Please e-mail any inquiries related to the PHDP or EPP Program to PHDP-EPP@iehp.org.
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.