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- Data Sharing Incentive
- Specialty Care Incentive Measures
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- Member Incentives
Specialty Care Incentive Measures
Effective date: Jan. 1–Dec. 31, 2025
Introduction
This page sets forth terms of the Specialty Care Incentive Program (“SCI Program”) offered by the Alliance, as described herein. The SCI Program compensates SCI Eligible Providers for providing access to specialty care services for Alliance Eligible Members and encourages specialty care physician participation in the Alliance Medi-Cal program.
Definitions
The following terms shall have the definitions contained in the section below. Capitalized terms used in this document and not otherwise defined herein shall have the meanings assigned to them in the Agreement.
An SCI Eligible Provider is an Alliance Participating Provider who has entered into a Referral Physician Services Agreement (“Agreement”), or a physician or Non-Physician Medical Practitioner of a group that has entered into a Referral Physician Services Agreement, with the Alliance, that is in effect at the end of the SCI Term. SCI Eligible Providers exclude emergency department physicians, hospitalists, pathologists and radiologists.
The term of the SCI Program shall begin on later of the Commencement Date of the Agreement or January 1, 2025 and end on December 31, 2025.
An SCI Eligible Member is an Alliance Medi-Cal member, excluding members with other medical health care coverage, except that members enrolled in the CCS program shall be considered SCI Eligible Members for purposes of the SCI Program.
Non-Physician Medical Practitioner is a nurse practitioner, physician assistant, certified nurse midwife, or certified registered nurse anesthetist.
Participating Provider(s) are physicians, medical groups, IPAs, health care professionals, hospitals, facilities and other providers of health care services or supplies that have entered into written contracts directly or indirectly with the Alliance to provide covered services to members pursuant to a program.
General Terms
Policies regarding actual and proposed budget and cost allocations are subject to the approval of the Alliance. The Alliance shall have the sole discretion to establish binding policies regarding determination of incentive payments. The Alliance, in its sole and absolute discretion, may implement Specialty Care Incentive Programs for periods after completion of the SCI Term. Any such programs shall be on terms determined by the Alliance. The SCI Program does not contain any financial incentive or make any payment that acts directly or indirectly as an inducement to reduce or limit medically necessary covered services provided to a member.
Effect of Termination
In the event of the termination of the SCI Eligible Provider’s Agreement for any reason prior to the expiration of the SCI Term, the SCI Eligible Provider will only be eligible for payment of measures that are payable via claims for any services provided prior to the termination date.
SCI Program Measure Overview
The following table includes the names of the nine measures included in the SCI Program and a description of each measure's goal.
Measure | Goal | |
1 | Reduce OB C-Section Rate | Encourage appropriate delivery method that drives better outcomes for members. |
2 | Increase OB Referrals to Doulas | Encourage obstetrics and gynecology (OB) providers to refer patients to doulas. |
3 | Increase California Children Services (CCS) Referral Rate | Timely diagnostics and treatment for children with eligible medical conditions (such as cystic fibrosis, cerebral palsy, heart diseases) through referrals. |
4 | Increase Palliative Care Referrals | Reduce emergency visits and inpatient care through increase of referrals to a palliative care program. |
5 | Coordination with Primary Care Provider (PCP) | Increase data sharing and PCP collaboration. |
6 | Provider Completion of Activities to Support Regulatory Requirements | Improve Provider Satisfaction Survey responsiveness. |
7 | Provider Completion of Activities to Support DHCS | Demonstrate support of health equity initiatives through provider training to clinically integrate DEIB principles as required by DHCS. |
8 | Increase New Members Seen | Increase access to care for Alliance members and increase the number of members seen with timely access to care standards. |
9 | Emergency Department Follow-Up Visit | Reduce emergency department utilization and inpatient admissions. Encourage providers to see members within 14 days of an emergency room discharge. |
SCI Measure Specifications
This section includes specifications for the 2025 SCI Program measures.
Measure Description |
Providers will receive payment for a reduction in cesarean deliveries for Eligible Members as compared to the baseline year and targets. |
Related Documentation and Deadline |
Provider must submit a report to the Alliance of all births for Eligible Members for the baseline calendar year of 2023 and measurement calendar year of 2025 no later than February 14, 2026. Reports must be provided using the Alliance’s report template and sent to the Alliance’s Finance Department via email to SCI@ccah-alliance.org. |
Calculation Specification |
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Payment Frequency |
Payment for this measure shall be made to Provider no later than March 31, 2026. |
Measure Description |
Providers will receive $100 for each referral provided to an Eligible Member for an Alliance contracted doula provider. |
Related Documentation and Deadline |
This measure is based on claims data. Providers are required to bill with code G9968 and modifier U1 to indicate that a referral to a doula provider was issued to an Eligible Member. All applicable claims must be received by the Alliance no later than January 31, 2026 and must be Complete Claims that are in a paid status to be counted toward this measure. |
Calculation Specification |
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Payment Frequency |
Payment for this measure will be made to Provider no later than 45 days after the end of quarters 1-3 of calendar year 2025 and 90 days after the end of quarter 4 of calendar year 2025. |
Measure Description |
Providers contracted with the Alliance will receive $1,000 for each Eligible Member referred by the Eligible Provider to the California Children’s Services (CCS) program. |
Related Documentation and Deadline |
This measure is based on claims data. Providers are required to bill with code G9968 and modifier U2 to indicate that a referral to the applicable local county CCS office was issued for an Eligible Member. All applicable claims must be received by the Alliance no later than January 31, 2026 and must be Complete Claims that are in a paid status to be counted toward this measure. |
Calculation Specification |
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Payment Frequency |
Payment for this measure will be made to the Provider no later than 45 days after the end of quarters 1-3 of calendar year 2025 and 90 days after the end of quarter 4 of calendar year 2025. |
Measure Description |
Providers will receive $100 for each Eligible Member referred to an Alliance contracted palliative care provider. |
Related Documentation and Deadline |
Eligible Providers must submit a referral to the Alliance to a palliative care provider. Only referrals with an effective date in 2025 will count toward this measure. |
Calculation Specification |
Payment Amount: $100 for every eligible palliative care referral provided to an Eligible Member (limited to one referral per Eligible Member). |
Payment Frequency |
Payment for this measure shall be made to the Provider by no later than 45 days after the end of quarters 1-3 of calendar year 2025 and 90 days after the end of quarter 4 of calendar year 2025. |
Measure Description |
Providers will receive $25 for each Eligible Member where Eligible Provider communicates with the member’s PCP to share information relevant to the member’s care (e.g. treatment notes, care plan notes, etc.) within 30 days of Eligible Provider’s visit with Eligible Member. |
Related Documentation and Deadline |
This measure is based on claims data. Eligible Providers are required to bill with code G9968 and modifier U3 to signify that provider communicated with the Eligible Member’s PCP within 30 days of Eligible Provider’s visit with Eligible Member. All applicable claims must be received by the Alliance no later than January 31, 2026 and must be Complete Claims that are in a paid status to be counted toward this measure. |
Calculation Specification |
Payment Amount: $25 for every eligible PCP Coordination provided for an Eligible Member. |
Payment Frequency |
Payment for this measure shall be made to Provider no later than 45 days after the end of quarters 1-3 of calendar year 2025 and 90 days after the end of quarter 4 of calendar year 2025. |
Measure Description |
Providers will receive $100 for each Provider Satisfaction Survey submitted. |
Related Documentation and Deadline |
This measure is based on submission of completed Provider Satisfaction Surveys that have been completed by the Alliance’s survey vendor’s deadline. The Alliance’s Provider Satisfaction Survey vendor will only share the identity of the providers who complete the survey. The rest of the survey is anonymous. |
Calculation Specification |
Payment Amount: $100 for every eligible Provider Satisfaction Survey completed as verified by the Alliance’s vendor. |
Payment Frequency |
Payment for this measure shall be made to Providers by no later than March 31, 2026. |
Measure Description |
Providers will receive $200 for each completed health equity training provided by the Alliance per DHCS requirements as noted in All Plan Letter (APL) 23-025. Providers who participate in the Alliance DEIB training must complete one of the following trainings: the online learning management system training (log in with name, email and attestation) or an in-person Alliance specific DEIB training (sign in sheet attendance required). |
Related Documentation and Deadline |
Eligible Provider must ensure that all documentation requirements specified by DHCS for health equity trainings are completed prior to the end of calendar year 2025. |
Calculation Specification |
Payment Amount: $200 for every eligible health equity training completed. |
Payment Frequency |
Payment for this measure shall be made to Providers by no later than March 31, 2026. |
Measure Description | Providers will receive payment for an increase in New Member Visits in the Measurement Quarter as compared to the Baseline Quarter. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Related Documentation and Deadline | Eligible Provider must submit claim no later than February 14, 2026. Claims must be Complete Claims that are in a paid status in order to count for this measure for each Measurement Quarter. | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Calculation Specification |
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Payment Frequency | The Alliance will pay the Provider no later than 45 days after the end of quarters 1-3 of calendar year 2025 and 90 days after the end of quarter 4 of calendar year 2025. |
Measure Description |
Providers will receive $50 for each applicable claim for an Eligible Member who was seen by an Eligible Provider within 14 days after being discharged from an emergency department (ED) visit. |
Related Documentation and Deadline |
This measure is based on claims data. All applicable claims must be received by the Alliance no later than February 14, 2026 to be counted toward this measure and must be Complete Claims that are in a paid status. |
Calculation Specification |
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Payment Frequency |
Payment shall be made to Providers for this measure no later than March 31, 2026. |
Contact Provider Services
Provider Relations Representative | 800-700-3874, ext. 5504 |
Practice Coaching | |
performanceimprovement@thealliance.health | |
CBI Team | |
cbi@thealliance.health |
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