Ancillary

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:

  1. Ancillary Provider Network Participation Request Form
  2. Letter of Interest that outlines the following:
    • What Specialty/Services your interested in contracting for Facility location(s)
    • National Provider Identifier (for each facility)
  3. W-9 Form
    • A current Taxpayer Identification Number and Certification Form
  4. 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.
  5. Ownership Information
    • Name, Title and Percent of Ownership
    • Articles of Incorporation 
      • Certified, stamped copy issued by the Secretary of State
      • Applies to Corporations, LLC and Non-Profits only
    • Fictitious Business Name Receipt           
      • Certified, stamped copy issued by the County
      • Applies to Sole Proprietors only
  6. Provider Accreditation Certificate
  7. CMS/DHCS Passing Site Survey (Approval Letter)
    • Required for each facility
  8. California State License (if applicable)
    • Required for each facility
  9. Urgent Care Minimum Qualifications (if applicable)

Any delay in receiving the above stated 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  The credentialing application and relevant document should be e-mailed to credentialing@iehp.org