Central California Alliance For Health

Care Based Incentives Resources

Please click on the links below to access information and resources to help you understand and successfully implement the Care Based Incentives (CBI) program.


General Resources

2017 Incentive Summary

2017 Technical Specifications

2017 Quick Reference Guide

2017 CBI Provider Training Workshop


Programmatic Measures

2017 Programmatic Measure Benchmarks

2017 Performance Improvement Plan Goals


Fee for Service Measures

Fee for Service Form Required Data Fields

Fee for Service Form Tips for Approval


Initial Health Assessment Information

Initial Health Assessment Checklist

Initial Health Assessment Billing Codes

Initial Health Assessment and Staying Healthy Assessment Resources

Measure Specific Resources

Advance Care Planning Tip Sheet

Advance Directive Form- English

Advance Directive Form- Spanish

Cervical Cancer Screening Tip Sheet

Extended Hours Attestation Form

Post Partum Visit Tip Sheet

SBIRT Tip Sheet

SHA Form Periodicity Schedule

Vision Services Providers for Retinal Eye Exams


 

Care Based Incentives Forms


2017 Care Based Incentive Forms

Provider 2017 Care Based Incentive Forms

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


•  2017 Fee For Service (FFS) Forms


Forms for Specific Health Education Programs

Healthy Breathing for Life


•  Asthma Action Plan (AAP) - PCPs may use the form to create an Asthma Action Plan for members ages 5-64 with a diagnosis of asthma. The AAP provides instruction and information on how to self-manage asthma daily, including taking medications appropriately, and how to recognize and handle worsening asthma. The PCP and member complete the AAP shortly after an asthma diagnosis, an asthma exacerbation, or with change in asthma severity classification or medication change. Review the AAP at each visit and make adjustments as needed to achieve asthma control. PCPs that complete and fax the AAP to the Alliance may be eligible for payment through our Care Based Incentive (CBI) program.


There are two versions of the AAP for your convenience. The fillable AAP allows you to pick medications from a drop down list and type in the member's information and your instructions to the member. The printable AAP allows you to print out the document and check the box that corresponds to the medication you have prescribed.


•  Fillable AAP in English or Spanish or Hmong.


•  Printable AAP in English or Spanish or Hmong.



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.

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

Fax this form to the Alliance at 1 (877) 793-8504.


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 and 6-Month and 12-Month Follow Up Referral - PCPs must use the form to refer members to the Healthy Weight for Life program and report members' Body Mass Index (BMI) to the Alliance. This program is for members ages 2-18 with a BMI at or above the 85th percentile. PCPs that complete and fax these forms to the Alliance may be eligible for payment through our CBI program; however, PCPs will only receive reimbursement of subsequent HWL follow up referral forms for up to two years per linked member.


Please fax only the completed referral form to the Alliance, not the Rx form. Give the completed Rx 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 2017 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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