Central California Alliance For Health

2018 Care Based Incentives Resources

PCPs must submit all Fee-for-Service Incentive forms within 21 business days from the date of service.

2018 Incentive Summary

2018 Programmatic Measures Resources

Programmatic Measure Benchmarks

Performance Improvement Plan Goals

2018 CBI Tip Sheets

Adolescent Immunizations

Annual Monitoring for Patients on Persistent Medications: ACE/ARB

Asthma Medication Ratio

Cervical Cancer Screening

Childhood Immunizations

Clinical Depression Screening and Follow-up

Diabetic Retinal Exam

Diabetic HbA1c Good Control and Data Submissions

Fee for Service Form Required Data Fields

Fee for Service Form Tips for Approval

Initial Health Assessment Checklist

Maternity Care: Post Partum Visit Tip Sheet

SBIRT Tip Sheet

2018 Quick Reference Guide

2018 CBI Technical Specifications

Complete Technical specifications

Please click on the links below to view individual sections of the CBI Technical Specifications.

CBI Program Overview

CBI Key Terms and Definitions

CBI Program Support

Programmatic Measures Overview

Care Coordination – Access Measures

Care Coordination – Access Measures

   – Initial Health Assessment (IHA)

   – Post-Discharge Care

   – Screening, Brief Intervention, And Referral To Treatment

Care Coordination – Hospital Measures

Care Coordination – Hospital Measures

   – Ambulatory Care Sensitive Admissions (ACSA)

   – Preventable Emergency Visits

   – 30 Day Readmissions

Quality of Care Measures

Quality of Care Measures

   – Annual Monitoring For Patients On Persistent Medications (MPM):


   – Asthma Medication Ratio (AMR)

   – Cervical Cancer Screening (CCS)

   – Childhood Immunization Combo 3 (CIS)

   – Diabetic HbA1c Good Control <8%

   – Diabetic Retinal Exam (CDC)

   – Diabetic Testing For Hba1c (CDC)

   – Maternity Care: Post-Partum Care (PPC)

   – Well Adolescent Visit 12-21 Years (AWC)

   – Well Child Visit 3-6 Years (W34)

Performance Target Measures

Performance Target Measures

   – Formulary Adherence

   – Performance Improvement Measure

   – Member Reassignment Threshold

Provisionary Measures

Provisionary Measures

   – Clinical Depression: Screening

   – Clinical Depression: Follow-up Plan

   – Immunizations for Adolescents (IMA)

   – Formulary Medication Utilization: Basaglar

   – Formulary Medication Utilization: AirDuo

Fee for Service Measures Overview

Fee for Service Measures Overview

   Preventive Care

   – Healthy Weight For Life (HWL) Form

   – Maternity Care: Early Prenatal Care

   Practice Management

   – Buprenorphine License

   – Patient Centered Medical Home (PCMH) Recognition

2018 CBI Training Resources

CBI Provider Training Workshop

CBI Webinars

General Resources

Ambulatory Sensitive Care Admissions (ACSA) Diagnosis

Emergency Care Visit Diagnosis

CAIR Immunization Registry

RIDE (Healthy Futures) Immunization Registry

Initial Health Assessment Billing Codes

Initial Health Assessment and Staying Healthy Assessment Resources

SHA Form Periodicity Schedule

U.S. Preventive Services Task Force (USPSTF) Recommendations for Primary Care Practice

Vision Services Providers for Retinal Eye Exams


Care Based Incentives (CBI) Forms

2018 Care Based Incentive Forms

Provider 2018 Care Based Incentive Forms

PCPs must submit all Fee-for-Service CBI forms within 21 business days of the date of service.

•  2018 Fee For Service (FFS) Form Tips

Forms for Preventive Care Incentives

Healthy Breathing for Life

Asthma Action Plans (AAP) are no longer a part of CBI 2018 program, but we encourage providers to continue providing the action plans to your patients. The AAP forms are now located in the Forms Library.

Healthy Moms and Healthy Babies (HMHB)

The Alliance's HMHB program is designed to encourage pregnant women to seek early prenatal and postpartum care. These members can earn up to $50 in gift cards.

Early Prenatal Care - Pregnant members who have a prenatal visit (Early Prenatal Care) within their first 13 weeks of their pregnancy or within 42 days of becoming an Alliance member can receive a gift card. PCPs who submit the form to the Plan within 21 business days from the date of services to indicate members have received an initial prenatal consultation will receive payment through our CBI program. The prenatal visit does not need to be a comprehensive official prenatal exam and can simply be a diagnosis of pregnancy and referral to relevant specialist or PCP for continued prenatal services.

Early Prenatal Care Form

• Fillable Early Prenatal Care Form in English or Spanish or Hmong

Postpartum Care - New moms can also receive a gift card for their postpartum visit (Postpartum Care) if they see their PCP within 21-56 days of the birth of their child. The member will receive this incentive once the PCP has billed the Plan for the encounter and no form is required. The provider to which the member is linked at the time of the visit will receive payment for either 1) performing the visit or 2) the visit being performed by a referral specialist.

Healthy Weight for Life

Initial Referral, 6-Month and 12-Month Follow Up Referrals - PCPs may use the form below or their own form to refer members to the Healthy Weight for Life (HWL) program and report members' Body Mass Indexes (BMI) to the Alliance. This program is for members age 2-18 with a BMI at or above the 85th percentile. PCPs that complete and fax these forms to the Alliance at (877) 793-8504 may be eligible for payment through our CBI program. Forms must be completed by the linked PCP site to receive credit.

Please fax only the completed referral form to the Alliance, not the prescription form. Give the completed prescription form to the patient and keep a copy in the patient's file.

Initial Referral, 6-Month and 12-Month Follow Up Referral Form
   - English
Initial Referral, 6-Month and 12-Month Follow Up Referral Form
   - Spanish
Initial Referral, 6-Month and 12-Month Follow Up Referral Form
   - Hmong

Member 2018 Care Based Incentive Forms

The following CBI forms are intended for member use. Providers may view and download these forms if they receive questions from members.

Forms for Specific Health Education Programs

Healthy Moms And Healthy Babies (HMHB)

Early Prenatal Care Form - Providers may be asked to complete this form after their member's first prenatal visit. Members who have a prenatal visit within their first twelve weeks of pregnancy can complete and submit this form to the Alliance to receive a $25 gift card. Members can also qualify for the gift card if they are pregnant and get a prenatal visit within 42 days of becoming an Alliance member.

  •  Early Prenatal Care Form in English or Spanish or Hmong.


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