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

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)


Early Prenatal Care Form - PCPs who use the form to indicate members have received an initial prenatal consultation may be eligible for 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 in Early Prenatal Care Form in English or Spanish or Hmong.


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.


2016 Care Based Incentive Forms

For all dates of service after 12/31/16, please use the 2017 forms linked above.


Provider 2016 Care Based Incentive Forms

•  2016 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 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 with English Rx Form
• Initial Referral with Spanish Rx Form
• Initial Referral with Hmong Rx Form
• 6-Month and 12-Month Follow Up Referral with English Rx Form
• 6-Month and 12-Month Follow Up Referral with Spanish Rx Form
• 6-Month and 12-Month Follow Up Referral with Hmong Rx Form
• Instructions for Calculating BMI
• CDC BMI Percentile Calculator for Child and Teen


Other Provider CBI Forms

Medication Management Agreement (MMA) - PCPs may use this form to create a Medication Management Agreement for their members. PCPs who complete and fax this form to the Alliance may be eligible for payment through our CBI program.
  •  MMA in English, Spanish, or Hmong.

Physician Orders for Life-Sustaining Treatment (POLST) - This incentive is designed to ensure that conversations on end-of-life planning occur with seriously ill patients, allowing them to choose the treatments they want and helping ensure that their wishes are honored by medical providers. Providers who complete and fax the cover sheet and English version of this form to the Alliance may be eligible for payment through our CBI program.
  •  POLST in English (with cover sheet)
  •  POLST in Spanish (with cover sheet)
  •  POLST in Hmong (with cover sheet)
  •  POLST forms in additional languages

Attestation Regarding Extended Office Hours - The Alliance provides an incentive for qualifying Primary Care Providers who offer their linked members access to primary care services outside of standard business hours. In order to be eligible for this incentive, providers must complete the Attestation Form below and fax it to their Provider Services Representative at (831) 430-5857.

Member 2016 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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