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Thank you for your initial interest in becoming an Inland Empire Health Plan (IEHP) directly contracted provider. Prior to extending a contract, we must receive the following documents. 

 

PLEASE NOTE, IEHP is only accepting Vision Providers who meet the following exceptions through October 31, 2022:

  • Providers practicing in any of the CalAIM service area expansion territories effective January 1, 2022 (including formerly voluntary and excluded zip codes)
  • Providers filling positions that have been vacated in an existing practice
  • Providers transitioning from an existing group agreement to their own individual agreement
  • Providers being added to existing Vision groups

 

Please completely fill out all required documents and submit to contract@iehp.org.

 

Any delay in receiving the below stated documents will affect the effective date of the contract that will be mailed to you. 

 

Contracting Requirements

1. Vision Provider Network Participation Form

 

2. W-9 Form (current Taxpayer Identificaiton Number and Certification Form)

 

3. Ownership Information Form (Name, Title and Percentage of Ownership)

 

4. Facility Business License – Faculty

 

5. California Participating Physician Application

 

6. Letter of Interest that outlines the following:

  • What Specialty/Services you are interested in contracting for
  • Facility locations (s)
  • National Provider Indentifier (NPI) for each facility
  • Medi-Cal Provider information (PIN)

7. Liability Insurance Certificate

  • Professional general liability in the minimum amount of One Million Dollars ($1,000,000) per occurrence.
  • Three Million Dollars ($3,000,000) aggregate per year for professional liability.

Contracting Requirement Forms

Additional Resources:

 

You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.