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:

  Letter of Interest that outlines the following:
    1. What Specialty/Services your interested in contracting for
    2. Facility location(s)
    3. National Provider Identifier (NPI) for each facility

  DME Provider Network Participation Form

  W-9 Form
    1. A current Taxpayer Identification Number and Certification form

  Liability Insurance Certificate
    1. Professional general liability in the minimum amount of One Million Dollars ($1,000,000) per occurrence; and
    2. Three Million Dollars ($3,000,000) aggregate per year for professional liability.

  Facility Business License - Facility

  Ownership Information
(Name/Title/% of Ownership)

  Documentation required to provide services to Medicare Members for DME providers:
    1. Accreditation certificate and/or approval letter from the Centers from Medicare and Medicaid (CMS)
    2. Copy of surety bond for each facility as required by CMS

Any delay in receiving the above stated documents will affect the effective date of the contract that will be mailed to you.  If you have any questions or concerns please feel free to contact the IEHP Contracting Department at (909) 890-2954. Fax your completed information to (909) 890-2997.