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Thank you for your initial interest in becoming an Inland Empire Health Plan (IEHP) directly contracted provider.

 

PLEASE NOTE, IEHP is currently not accepting new:

  • DME
  • Hospice
  • Specialty Pharmacy
  • Clinical Laboratories
  • Non-Emergent Medical Transportation (NEMT)
  • Community Based Adult Services (CBAS) outside of the Inland Empire

 

Please check monthly for updates on Network Availability.

 

Prior to extending a contract, we must receive the following items listed below. Any delay in receiving the applicable documents will affect the effective date of the contract that will be mailed to you. 

 

The contract collateral and other supporting contract documents should be e-mailed to contract@iehp.org.

 

Ancillary Providers must also successfully enroll in the state’s Medi-Cal Program to be issued a Medi-Cal number.

Medi-Cal Screening and Enrollment

 

Visit the following page for more information on the Medi-Cal Program.

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Provider Acknowledgement of Receipt (AOR)

 

All Providers must also annually submit the Provider Acknowledgment of Receipt (AOR). IEHP is required by State and Federal regulators to maintain an AOR form on file for our Providers signifying your receipt and review of the Policy & Procedure manuals, including annual updates.

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Contracting Requirements

1. Ancillary Provider Network Participation Request Form

 

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

 

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

 

4. Provider Accreditation Certificate

 

5. Medi-Cal Number

 

6. California State License (if applicable – required for each facility)

 

7. CMS/DHCS Passing Site Survey (Approval Letter – required for each facility)

 

8. Urgent Care Minimum Qualifications Forms (if applicable – All Ages and/or Pediatrics)

 

9. Electronic Remittance Advice (ERA) Form (Ancillary Providers must complete ERA form)

 

10. Provider Acknowledgement of Receipt (AOR)

 

11. 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.