main content

Search Results For : " BUSINESS DEGREE CERTIFICATEWE "

Pages 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

IEHP DualChoice - Problems with Part C

ng appeals with problems related to your benefits and coverage. It also includes problems with payment. You are not responsible for Medicare costs except for Part D copays. How to ask for coverage decision coverage decision to get medical, behavioral health, or certain long-term services and supports (CBAS, or NF services)  To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for an coverage decision.  You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY (800) 718-4347.  You can fax us at: (909) 890-5877  You can to write us at: IEHP DualChoice P.O. Box 1800 Rancho Cucamonga, CA 91729-1800. How long does it take to get a coverage decision coverage decision for Part C services? It usually takes up to 14 calendar days after you asked. If we don’t give you our decision within 14 calendar days, you can appeal. Sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 calendar more days. The letter will explain why more time is needed. Can I get a coverage decision faster for Part C services? Yes. If you need a response faster because of your health, you should ask us to make a “fast coverage decision.”  If we approve the request, we will notify you of our coverage decision coverage decision within 72 hours. However, sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 more calendar days. Asking for a fast coverage decision coverage decision: If you request a fast coverage decision coverage decision, start by calling or faxing our plan to ask us to cover the care you want.  You can call IEHP DualChoice at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call (800) 718-4347 or fax us at (909) 890-5877. You can also have your doctor or your representative call us. Here are the rules for asking for a fast coverage decision coverage decision:  You must meet the following two requirements to get a fast coverage decision coverage decision:  You can get a fast coverage decision coverage decision only if you are asking for coverage for care or an item you have not yet received. (You cannot get a fast coverage decision coverage decision if your request is about payment for care or an item you have already received.) You can get a fast coverage decision only if the standard 14 calendar day deadline could cause serious harm to your health or hurt your ability to function.  If your doctor says that you need a fast coverage decision, we will automatically give you one. If you ask for a fast coverage decision, without your doctor’s support, we will decide if you get a fast coverage decision.  If we decide that your health does not meet the requirements for a fast coverage decision, we will send you a letter. We will also use the standard 14 calendar day deadline instead. This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision. The letter will also tell how you can file a “fast appeal” about our decision to give you a fast coverage decision instead of the fast coverage decision you requested. If the coverage decision is Yes, when will I get the service or item? You will be able to get the service or item within 14 calendar days (for a standard coverage decision) or 72 hours (for a fast coverage decision) of when you asked. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period. If the coverage decision is No, how will I find out?  If the answer is No, we will send you a letter telling you our reasons for saying No. If we say no, you have the right to ask us to change this decision by making an appeal. Making an appeal means asking us to review our decision to deny coverage. If you decide to make an appeal, it means you are going on to Level 1 of the appeals process. Appeals What is an Appeal? An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. For example, we might decide that a service, item, or drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. If you or your doctor disagree with our decision, you can appeal. In most cases, you must start your appeal at Level 1. If you do not want to first appeal to the plan for a Medi-Cal service, in special cases you can ask for an Independent Medical Review. If you need help during the appeals process, you can call the Office of the Ombudsman at 1-888-452-8609. The Office of Ombudsman is not connected with us or with any insurance company or health plan. What is a Level 1 Appeal for Part C services? A Level 1 Appeal is the first appeal to our plan. We will review our coverage decision to see if it is correct. The reviewer will be someone who did not make the original coverage decision. When we complete the review, we will give you our decision in writing. If we tell you after our review that the service or item is not covered, your case can go to a Level 2 Appeal.  Can someone else make the appeal for me for Part C services? Yes. Your doctor or other provider can make the appeal for you. Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative Form. The form gives the other person permission to act for you. If the appeal comes from someone besides you or your doctor or other provider, we must receive the completed Appointment of Representative form before we can review the appeal. How do I make a Level 1 Appeal for Part C services? To start your appeal, you, your doctor or other provider, or your representative must contact us. You can call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY should call (800) 718-4347. For additional details on how to reach us for appeals, see Chapter 9 of the IEHP DualChoice Member Handbook. You can ask us for a “standard appeal” or a “fast appeal.” If you are asking for a standard appeal or fast appeal, make your appeal in writing: IEHP DualChoice P.O. Box 1800 Rancho Cucamonga, CA 91729-1800 Fax: (909) 890-5748 You may also ask for an appeal by calling IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY should call (800) 718-4347. We will send you a letter within 5 calendar days of receiving your appeal letting you know that we received it. How much time do I have to make an appeal for Part C services? You must ask for an appeal within 60 calendar days from the date on the letter we sent to tell you our decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make your appeal. Examples of a good reason are: you had a serious illness, or we gave you the wrong information about the deadline for requesting an appeal. Can I get a copy of my case file? Yes. Ask us for a copy by calling Member Services at (877) 273-IEHP (4347). TTY (800) 718-4347. Can my doctor give you more information about my appeal for Part C services? Yes, you and your doctor may give us more information to support your appeal. How will the plan make the appeal decision?  We take a careful look at all of the information about your request for coverage of medical care. Then, we check to see if we were following all the rules when we said No to your request. The reviewer will be someone who did not make the original decision. If we need more information, we may ask you or your doctor for it.  When will I hear about a “standard” appeal decision for Part C services? We must give you our answer within 30 calendar days after we get your appeal. We will give you our decision sooner if your health condition requires us to. However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you by letter. If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will give you an answer to your appeal within 24 hours. If we do not give you an answer within 30 calendar days or by the end of the extra days (if we took them), we will automatically send your case to Level 2 of the appeals process if your problem is about a Medicare service or item. You will be notified when this happens. If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. Please see below for more information.  If our answer is Yes to part or all of what you asked for, we must approve or give the coverage within 30 calendar days after we get your appeal. If our answer is No to part or all of what you asked for, we will send you a letter. If your problem is about a Medicare service or item, the letter will tell you that we sent your case to the Independent Review Entity for a Level 2 Appeal. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. Please see below for more information. What happens if I ask for a fast appeal? If you ask for a fast appeal, we will give you your answer within 72 hours after we get your appeal. We will give you our answer sooner if your health requires us to do so. However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. If we decide to take extra days to make the decision, we will tell you by letter. If you believe we should not take extra days, you can file a “fast complaint” about our decision to take extra days. When you file a fast complaint, we will give you an answer to your appeal within 24 hours. If we do not give you an answer within 72 hours or by the end of the extra days (if we took them), we will automatically send your case to Level 2 of the appeals process if your problem is about a Medicare service or item. You will be notified when this happens. If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. Please see below for more information. If our answer is Yes to part or all of what you asked for, we must authorize or provide the coverage within 72 hours after we get your appeal.  If our answer is No to part or all of what you asked for, we will send you a letter. If your problem is about a Medicare service or item, the letter will tell you that we sent your case to the Independent Review Entity for a Level 2 Appeal. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. Please see below for more information. Will my benefits continue during Level 1 appeals? If we decide to change or stop coverage for a service or item that was previously approved, we will send you a notice before taking the action. If you disagree with the action, you can file a Level 1 Appeal and ask that we continue your benefits for the service or item. You must make the request on or before the later of the following in order to continue your benefits: Within 10 days of the mailing date of our notice of action; or The intended effective date of the action. If you meet this deadline, you can keep getting the disputed service or item while your appeal is processing. Level 2 Appeal If the plan says No at Level 1, what happens next? If we say no to part or all of your Level 1 Appeal, we will send you a letter. This letter will tell you if the service or item is usually covered by Medicare or Medi-Cal. If your problem is about a Medicare service or item, we will automatically send your case to Level 2 of the appeals process as soon as the Level 1 Appeal is complete. If your problem is about a Medi-Cal service or item, you can file a Level 2 Appeal yourself. The letter will tell you how to do this. Information is also below. What is a Level 2 Appeal? A Level 2 Appeal is the second appeal, which is done by an independent organization that is not connected to the plan.   My problem is about a Medi-Cal service or item. How can I make a Level 2 Appeal? There are two ways to make a Level 2 appeal for Medi-Cal services and items: 1) Independent Medical Review or 2) State Hearing. 1)    Independent Medical Review You can ask for an Independent Medical Review (IMR) from the Help Center at the California Department of Managed Health Care (DMHC). An IMR is available for any Medi-Cal covered service or item that is medical in nature. An IMR is a review of your case by doctors who are not part of our plan. If the IMR is decided in your favor, we must give you the service or item you requested. You pay no costs for an IMR. You can apply for an IMR if our plan: Denies, changes, or delays a Medi-Cal service or treatment (not including IHSS) because our plan determines it is not medically necessary. Will not cover an experimental or investigational Medi-Cal treatment for a serious medical condition. Will not pay for emergency or urgent Medi-Cal services that you already received. Has not resolved your Level 1 Appeal on a Medi-Cal service within 30 calendar days for a standard appeal or 72 hours for a fast appeal. You can ask for an IMR if you have also asked for a State Hearing, but not if you have already had a State Hearing, on the same issue. In most cases, you must file an appeal with us before requesting an IMR. If you disagree with our decision, you can ask the DMHC Help Center for an IMR. If your treatment was denied because it was experimental or investigational, you do not have to take part in our appeal process before you apply for an IMR. If your problem is urgent and involves an immediate and serious threat to your health, you may bring it immediately to the DMHC’s attention. The DMHC may waive the requirement that you first follow our appeal process in extraordinary and compelling cases. You must apply for an IMR within 6 months after we send you a written decision about your appeal. The DMHC may accept your application after 6 months if it determines that circumstances kept you from submitting your application in time. To ask for an IMR: Fill out the Independent Medical Review/Complaint Form available at: http://www.dmhc.ca.gov/FileaComplaint/SubmitanIndependentMedicalReviewComplaintForm.aspx or call the DMHC Help Center at (888) 466-2219. TDD users should call (877) 688-9891. If you have them, attach copies of letters or other documents about the service or item that we denied. This can speed up the IMR process. Send copies of documents, not originals. The Help Center cannot return any documents. Fill out the Authorized Assistant Form if someone is helping you with your IMR. You can get the form at http://www.dmhc.ca.gov/FileaComplaint/SubmitanIndependentMedicalReviewComplaintForm.aspx Or call the DMHC Help Center at (888) 466-2219. TDD users should call (877) 688-9891. Mail or fax your forms and any attachments to:  Help Center Department of Managed Health Care 980 Ninth Street, Suite 500 Sacramento, CA 95814-2725 FAX: 916-255-5241 If you qualify for an IMR, the DMHC will review your case and send you a letter within 7 calendar days telling you that you qualify for an IMR. After your application and supporting documents are received from your plan, the IMR decision will be made within 30 calendar days. You should receive the IMR decision within 45 calendar days of the submission of the completed application. If your case is urgent and you qualify for an IMR, the DMHC will review your case and send you a letter within 2 calendar days telling you that you qualify for an IMR. After your application and supporting documents are received from your plan, the IMR decision will be made within 3 calendar days. You should receive the IMR decision within 7 calendar days of the submission of the completed application. If you are not satisfied with the result of the IMR, you can still ask for a State Hearing.  If the DMHC decides that your case is not eligible for IMR, the DMHC will review your case through its regular consumer complaint process. 2)    State Hearing You can ask for a State Hearing for Medi-Cal covered services and items. If your doctor or other provider asks for a service or item that we will not approve, or we will not continue to pay for a service or item you already have and we said no to your Level 1 appeal, you have the right to ask for a State Hearing. In most cases you have 120 days to ask for a State Hearing after the “Your Hearing Rights” notice is mailed to you.  NOTE: If you ask for a State Hearing because we told you that a service you currently get will be changed or stopped, you have fewer days to submit your request if you want to keep getting that service while your State Hearing is pending. Read “Will my benefits continue during Level 2 appeals” in Chapter 9 of the Member Handbook for more information. There are two ways to ask for a State Hearing: You may complete the "Request for State Hearing" on the back of the notice of action. You should provide all requested information such as your full name, address, telephone number, the name of the plan or county that took the action against you, the aid program(s) involved, and a detailed reason why you want a hearing. Then you may submit your request one of these ways: To the county welfare department at the address shown on the notice. To the California Department of Social Services: State Hearings Division P.O. Box 944243, Mail Station 9-17-37 Sacramento, California 94244-2430 To the State Hearings Division at fax number 916-651-5210 or 916-651-2789. You can call the California Department of Social Services at (800) 952-5253. TDD users should call (800) 952-8349. If you decide to ask for a State Hearing by phone, you should be aware that the phone lines are very busy. Will my benefits continue during Level 2 appeals? If your problem is about a service or item covered by Medicare, your benefits for that service or item will not continue during the Level 2 appeals process with the Independent Review Entity. If your problem is about a service or item covered by Medi-Cal and you ask for a State Fair Hearing, your Medi-Cal benefits for that service or item will continue until a hearing decision is made. You must ask for a hearing on or before the later of the following in order to continue your benefits: Within 10 days of the mailing date of our notice to you that the adverse benefit determination (Level 1 appeal decision) has been upheld; or The intended effective date of the action. If you meet this deadline, you can keep getting the disputed service or item until the hearing decision is made. How will I find out about the decision? If your Level 2 Appeal was a State Hearing, the California Department of Social Services will send you a letter explaining its decision.  If the State Hearing decision is Yes to part or all of what you asked for, we must comply with the decision. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision. If the State Hearing decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. We may stop any aid paid pending you are receiving.  If your Level 2 Appeal was an Independent Medical Review, the Department of Managed Health Care will send you a letter explaining its decision.  If the Independent Medical Review decision is Yes to part or all of what you asked for, we must provide the service or treatment. If the Independent Medical Review decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. You can still get a State Hearing. If your Level 2 Appeal went to the Medicare Independent Review Entity, it will send you a letter explaining its decision. If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize the medical care coverage within 72 hours or give you the service or item within 14 calendar days from the date we receive the IRE’s decision.  If the Independent Review Entity says No to part or all of what you asked for, it means they agree with the Level 1 decision. This is called “upholding the decision.” It is also called “turning down your appeal.” If the decision is No for all or part of what I asked for, can I make another appeal? If your Level 2 Appeal was a State Hearing, you may ask for a rehearing within 30 days after you receive the decision. You may also ask for judicial review of a State Hearing denial by filing a petition in Superior Court (under Code of Civil Procedure Section 1094.5) within one year after you receive the decision.  If your Level 2 Appeal was an Independent Medical Review, you can request a State Hearing.  If your Level 2 Appeal went to the Medicare Independent Review Entity, you can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. The letter you get from the IRE will explain additional appeal rights you may have. Payment Problems We do not allow our network providers to bill you for covered services and items. This is true even if we pay the provider less than the provider charges for a covered service or item. You are never required to pay the balance of any bill. The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. If you get a bill that is more than your copay for covered services and items, send the bill to us. You should not pay the bill yourself. We will contact the provider directly and take care of the problem. How do I ask the plan to pay me back for the plan’s share of medical services or items I paid for? Remember, if you get a bill that is more than your copay for covered services and items, you should not pay the bill yourself. But if you do pay the bill, you can get a refund if you followed the rules for getting services and items.  If you are asking to be paid back, you are asking for a coverage decision. We will see if the service or item you paid for is a covered service or item, and we will check to see if you followed all the rules for using your coverage. If the service or item you paid for is covered and you followed all the rules, we will send you the payment for our share of the cost of the service or item within 60 calendar days after we get your request. Or, if you haven’t paid for the service or item yet, we will send the payment directly to the provider. When we send the payment, it’s the same as saying Yes to your request for a coverage decision. If the service or item is not covered, or you did not follow all the rules, we will send you a letter telling you we will not pay for the service or item and explaining why. What if the plan says they will not pay? If you do not agree with our decision, you can make an appeal. Follow the appeals process. When you are following these instructions, please note: If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we get your appeal. If you are asking us to pay you back for medical care you have already received and paid for yourself, you are not allowed to ask for a fast appeal.  If we answer “no” to your appeal and the service or item is usually covered by Medicare, we will automatically send your case to the Independent Review Entity. We will notify you by letter if this happens. If the IRE reverses our decision and says we should pay you, we must send the payment to you or to the provider within 30 calendar days. If the answer to your appeal is Yes at any stage of the appeals process after Level 2, we must send the payment you asked for to you or to the provider within 60 calendar days. If the IRE says No to your appeal, it means they agree with our decision not to approve your request. (This is called “upholding the decision.” It is also called “turning down your appeal.”) The letter you get will explain additional appeal rights you may have. You can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. If we answer “no” to your appeal and the service or item is usually covered by Medi-Cal, you can file a Level 2 Appeal yourself (see above). IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. Information on this page is current as of October 01, 2022. H8894_DSNP_23_3241532_M

IEHP DualChoice - New to IEHP DualChoice

e important phone numbers including your Doctor, IEHP DualChoice Member Services, and IEHP’s 24-Hour Nurse Advice Line. Be sure to complete your health risk assessment (HRA). When you first join our plan, you get a health risk assessment (HRA) within 90 days before or after your effective enrollment date.  We must complete an HRA for you. This HRA is the basis for developing your care plan. The HRA include questions to identify your medical, LTSS, and behavioral health and functional needs.  We reach out to you to complete the HRA. We can complete the HRA by an in-person visit, telephone call, or mail. We’ll send you more information about this HRA upon your enrollment with the plan.  If our plan is new for you, you can keep using the doctors you use now for a certain amount of time, if they are not in our network. We call this continuity of care. If they are not in our network, you can keep your current providers and service authorizations at the time you enroll for up to 12 months if all of the following conditions are met:  You, your representative, or your provider asks us to let you keep using your current provider.  We establish that you had an existing relationship with a primary or specialty care provider, with some exceptions. When we say “existing relationship,” it means that you saw an out-of-network provider at least once for a non-emergency visit during the 12 months before the date of your initial enrollment in our plan. We determine an existing relationship by reviewing your available health information available or information you give us. We have 30 days to respond to your request. You can ask us to make a faster decision, and we must respond in 15 days. You or your provider must show documentation of an existing relationship and agree to certain terms when you make the request. Note: You can only make this request for services of Durable Medical Equipment (DME), transportation, or other ancillary services not included in our plan. You cannot make this request for providers of DME, transportation or other ancillary providers. After the continuity of care period ends, you will need to use doctors and other providers in the IEHP DualChoice network that are affiliated with your primary care provider’s medical group, unless we make an agreement with your out-of-network doctor. A network provider is a provider who works with the health plan. Our plan’s PCPs are affiliated with medical groups or Independent Physicians Associations (IPA). When you choose your PCP, you are also choosing the affiliated medical group. This means that your PCP will be referring you to specialists and services that are affiliated with their medical group. A medical group or IPA is a group of physicians, specialists, and other providers of health services that see IEHP Members. Your PCP, along with the medical group or IPA, provides your medical care. This includes getting authorization to see specialists or medical services such as lab tests, x-rays, and/or hospital admittance. In some cases, IEHP is your medical group or IPA. Refer to Chapter 3 of your Member Handbook for more information on getting care. Be prepared for important health decisions Get the My Life. My Choice. app today. It stores all your advance care planning documents in one place online. Advance care planning (ACP) involves shared decision making to write down-in an advance care directive-a person’s wishes about their future medical care. ACP and the advance health care directive can bridge the gap between the care someone wants and the care they receive if they lose the capacity to make their own decisions. With this app, you or a designated person with Power of Attorney can access your advance health care directives at any time from a home computer or smartphone. Sign up for the free app through our secure Member portal. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. This is not a complete list. Information on this page is current as of October 01, 2022. H8894_DSNP_23_3241532_M  

IEHP DualChoice - Grievances, Coverage Determination and Appeals Process

Member Services at (877) 273-IEHP (4347) and ask for a Member Complaint Form. If you need help to fill out the form, IEHP Member Services can assist you. You can complete the Member Complaint Form online. You can give the completed form to any IEHP Provider or mail it to: P.O Box 1800, Rancho Cucamonga, CA 91729-1800 You can fax the completed form to (909) 890-5877. You can file a grievance online. This form is for IEHP DualChoice as well as other IEHP programs.  For some types of problems, you need to use the process for coverage decisions and making appeals. For other types of problems you need to use the process for making complaints. Both of these processes have been approved by Medicare. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you. Long-Term Services and Supports: If you are having a problem with your care, you can call the Office of Ombudsman at 1-888-452-8609 for help. For problems and concerns regarding eligibility determinations, assessments, and care delivered by our contracted Community Based Adult Services (CBAS) centers,  or Nursing Facilities/Sub-Acute Care Facilities, you should follow the process outlined below. Community Based Adult Services (CBAS) You can call IEHP Member Services at (877) 273-IEHP (4347) and ask for a Member Complaint Form. If you need help to fill out the form, IEHP Member Services can assist you. You can give the completed form to any IEHP Provider or mail it to: P.O Box 1800 Rancho Cucamonga, CA 91729-1800 You can fax the completed form to (909) 890-5877. You can file a grievance online. This form is for IEHP DualChoice as well as other IEHP programs. Help in Handling a Problem You can contact Medicare. Here are two ways to get information directly from Medicare: You can call (800) MEDICARE (800) 633-4227, 24 hours a day, 7 days a week, TTY (877) 486-2048. You can visit the Medicare website By clicking on this link, you will be leaving the IEHP DualChoice website. Get Help from an Independent Government Organization We are always available to help you. But in some situations, you may also want help or guidance from someone who is not connected with us. You can always contact your State Health Insurance Assistance Program (SHIP). This government program has trained counselors in every state. The program is not connected with us or with any insurance company or health plan. The counselors at this program can help you understand which process you should use to handle a problem you are having. They can also answer your questions, give you more information, and offer guidance on what to do. The services of SHIP counselors are free. You can call SHIP at 1-800-434-0222. Get Help and Information from DHCS Call: (916) 445-4171 MCI from TDD at (800) 735-2929 MCI from Voice Telephone: (800) 735-2922 Sprint from TDD at (800) 877-5378 Sprint from Voice Telephone: (800) 877-5379 Write to: Department of Health Care Services 1501 Capitol Ave., P.O. Box 997413 Sacramento, CA 95899-7413 Website:www.dhcs.ca.gov By clicking on this link, you will be leaving the IEHP DualChoice website. Get Help and Information from Medi-Cal The Office of the Ombudsman Program can answer your questions and help you understand what to do to handle your problem. The Office of the Ombudsman is not connected with us or with any insurance company or health plan. They can help you understand which process to use. Call: 1-888-452-8609 (TTY 711) Monday through Friday, 9 a.m. to 5 p.m. Visit their website at: www.healthconsumer.org/ By clicking on this link, you will be leaving the IEHP DualChoice website. Get Help and Information from Livanta Our state has an organization called Livanta Beneficiary & Family Centered Care (BFCC) Quality Improvement Organization (QIO). This is a group of doctors and other health care professionals who help improve the quality of care for people with Medicare. Livanta is not connect with our plan. Call: (877) 588-1123, TTY (855) 887-6668 For appeals: (855) 694-2929 For all other reviews: (844) 420-6672 Write to: Livanta BFCC-QIO Program 10820 Guilford Road, Suite 202 Annapolis Junction, Maryland 20701 Website: www.livanta.com By clicking on this link, you will be leaving the IEHP DualChoice website. How to obtain an aggregate number of grievances, appeals, and exceptions filed with IEHP DualChoice (HMO D-SNP)? Please call or write to IEHP DualChoice Member Services. Call: (877) 273-IEHP (4347). Calls to this number are free. 8am - 8pm (PST), 7 days a week, including holidays, TTY: (800) 718-4347. This number requires special telephone equipment. Calls to this number are free. Fax: (909) 890-5877 Write: IEHP DualChoice, P.O. Box 1800 Rancho Cucamonga, CA 91729-1800 Email: memberservices@iehp.org Visit: 10801 Sixth Street, Suite 120, Rancho Cucamonga, CA 91730 IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. This is not a complete list.  Information on this page is current as of October 01, 2022. H8894_DSNP_23_3241532_M

P4P - Proposition 56 - GEMT - Prop 56 - Value Based Payment

OS June 30, 2022, payments will run out through June 2023. The Proposition 56 VBP Program provided direct payments incentivizing Providers to meet specific measures aimed at delivering key quality healthcare services that improve the quality of care to Medi-Cal beneficiaries. Targeted areas were behavioral health integration, chronic disease management, prenatal/post-partum care and early childhood prevention. For more information about the VBP Program, please visit the DHCS website at https://www.dhcs.ca.gov/provgovpart/Pages/VBP_Measures_19.aspx. By clicking on this link, you will be leaving the IEHP website.  Value Based Payments Program Guide Value Based Payments (VBP) Program Guide (PDF) - Published: January 01, 2022 Value Based Payments Dispute Forms Value Based Payments Program - Paid Claims Dispute Request (PDF) Published: January 19, 2022 Value Based Payments Program - Encounter Dispute Request (PDF) Published: January 19, 2022 Please e-mail completed forms to ValueBasedPaymentsProgram@iehp.org At-Risk Condition Codes The At-Risk Condition Codes list includes diagnosis codes to identify Serious Mental Illness, Substance Use Disorder or Homelessness Conditions for the VBP Program. These conditions qualify Providers for an additional payment amount for VBP services. Please refer to page 4 of the VBP Program Guide for additional details. At-Risk Condition Codes (PDF) Published: March 25, 2020 You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

Governing Board Meetings - 2023 Meeting Schedule and Locations

n to the public. We invite you to join us at the next board meeting. You can also download a copy of our most current monthly board report. Dr. Bradley P. Gilbert Center for Learning and Innovation 9500 Cleveland Avenue Rancho Cucamonga, CA 91730 Click here to view the meeting room map.  Inland Empire Health Plan Dates & Times Monday, January 30, 2023 9:00 a.m. February - NO MEETING Monday,  March 6, 2023 9:00 a.m. Monday, April 10, 2023 9:00 a.m. Monday, May 8, 2023 9:00 a.m.  Monday, June 5, 2023 9:00 a.m.  Monday, July 10, 2023 9:00 a.m.  Monday, August 14, 2023 9:00 a.m.  Monday, September 11, 2023 9:00 a.m.  Tuesday, October 17, 2023 9:00 a.m. Monday, November 13, 2023 9:00 a.m.  Monday, December 11, 2023 9:00 a.m. 

IEHP DualChoice - NCD

d the following services to be necessary for the treatment of an illness or injury. National Coverage determinations (NCDs) are made through an evidence-based process. See below for a brief description of each NCD. There may be qualifications or restrictions on the procedures below. For more detailed information on each of the NCDs including restrictions and qualifications click on the link after each NCD or call IEHP DualChoice Member Services at (877) 273-IEHP (4347) 8am-8pm (PST), 7 days a week, including holidays, or. TTY/TDD (800) 718-4347 1. Screening for Hepatitis B Virus (HBV) Infection (Effective: September 28, 2016)  (Implementation date: October 2, 2017 – for design and coding; January 1, 2018 – for testing and implementation) Per the recommendation of the United States Preventive Services Task Force (USPSTF), CMS has issued a National Coverage Determination (NCD) which expands coverage to include screening for HBV infection. Previously, HBV screening and re-screening was only covered for pregnant women.  Hepatitis B Virus (HBV) is transmitted by exposure to bodily fluids. It attacks the liver, causing inflammation. Infected individuals may develop symptoms such as nausea, anorexia, fatigue, fever, and abdominal pain, or may be asymptomatic. An acute HBV infection could progress and lead to life-threatening complications. The USPTF has found that screening for HBV allows for early intervention which can help decrease disease acquisition, transmission and, through treatment, improve intermediate outcomes for those infected. What is covered? Effective for claims with dates of service on or after 09/28/2016, CMS covers screening for HBV infection. Who is covered? Medicare beneficiaries who meet either of the following criteria: They are considered to be at high-risk for infection; or They are pregnant. Click here for more information on HBV Screenings. 2. Percutaneous Image-guided Lumbar Decompression (PILD) for Lumbar Spinal Stenosis (LSS) ((Effective: December 7, 2016)  (Implementation date: June 27, 2017) CMS has expanded the PILD for LSS National Coverage Determination (NCD) to now cover beneficiaries that are enrolled in a CMS-approved prospective longitudinal study. Previously, PILD for LSS was covered for beneficiaries enrolled only in a CMS-approved prospective, randomized, controlled clinical trial (RCT) under the Coverage with Evidence Development (CED) paradigm. Now, the NCD will cover PILD for LSS under both RCT and longitudinal studies. LSS is a narrowing of the spinal canal in the lower back. PILD is a posterior decompression of the lumbar spine performed under indirect image guidance without any direct visualization of the surgical area. The procedure removes a portion of the lamina in order to debulk the ligamentum flavum, essentially widening the spinal canal in the affected area. What is covered? Effective for claims with dates of service on or after 12/07/16, Medicare will cover PILD under CED for beneficiaries with LSS when provided in an approved clinical study. Who is covered? Medicare beneficiaries with LSS who are participating in an approved clinical study. Click here for more information on PILD for LSS Screenings. 3. Leadless Pacemakers   (Effective: January 18, 2017)  (Implementation date: August 29, 2017 – for MAC local edits; January 2, 2018 – for MCS shared edits) CMS has issued a National Coverage Determination (NCD) which expands coverage to include leadless pacemakers when procedures are performed in CMS-approved Coverage with Evidence Development (CED) studies.  Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. The leadless pacemaker eliminates the need for a device pocket and insertion of a pacing lead which are integral elements of traditional pacing systems. The removal of these elements eliminates an important source of complications associated with traditional pacing systems while providing similar benefits. Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. Prior to January 18, 2017, there was no national coverage determination (NCD) in effect. What is covered? Effective for claims with dates of service on or after 01/18/17, Medicare will cover leadless pacemakers under CED when procedures are performed in CMS-approved studies. Who is covered? Medicare beneficiaries in need of a pacemaker who are participating in an approved clinical study. Click here for more information on Leadless Pacemakers. 4. Hyperbaric Oxygen (HBO) Therapy (Section C, Topical Application of Oxygen)  (Effective: April 3, 2017)  (Implementation date: December 18, 2017) CMS has revised Chapter 1, Section 20.29, Subsection C Topical Application of Oxygen to remove the exclusion of this treatment.  It has been updated that coverage determinations for providing Topical Application of Oxygen for the treatment of chronic wounds can be made by the local Contractors.     What is covered? Topical Application of Oxygen for Chronic Wound Care. Who is covered? Medicare beneficiaries may be covered with an affirmative Coverage Determination. Click here for more information on Topical Applications of Oxygen. 5. Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) (Effective: May 25, 2017) (Implementation Date: July 2, 2018) CMS has added a new section, Section 20.35, to Chapter 1 entitled Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD).  It has been concluded that high-quality research illustrates the effectiveness of SET over more invasive treatment options and beneficiaries who are suffering from Intermittent Claudication (a common symptom of PAD) are now entitled to an initial treatment. What is covered? Eligible beneficiaries are entitled to 36 sessions over a 12-week period after meeting with the physician responsible for PAD treatment and receiving a referral.  The SET program must: Consist of 30-60 minute sessions comprising of therapeutic exercise-training program for PAD; Be conducted in a hospital outpatient setting or physician’s office; Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD; and, Be under the direct supervision of a physician. Who is covered? Medicare beneficiaries who are diagnosed with Symptomatic Peripheral Artery Disease who would benefit from this therapy. Click here for more information on Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). 6. Magnetic Resonance Imaging (MRI) (Effective: April 10, 2017) (Implementation Date: December 10, 2018) CMS has added a new section, Section 220.2, to Chapter 1, Part 4 of the Medicare National Coverage Determinations Manual entitled Magnetic Resonance Imaging (MRI). According to the FDA labeling in an MRI environment, MRI coverage will be provided for beneficiaries under certain conditions. What is covered? Effective on or after April 10, 2018, MRI coverage will be provided when used in accordance to the FDA labeling in an MRI environment. In the instance where there is not FDA labeling specific to use in an MRI environment, coverage is only provided under specific conditions including the following: MRI field strength of 1.5 Tesla using Normal Operating Mode The Implanted pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy defibrillator (CRT-D) system has no fractured, epicardial, or abandoned leads The facility has implemented a specific checklist Who is covered? Medicare beneficiaries with an Implanted pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy defibrillator (CRT-D). Click here for more information on MRI Coverage. 7. Implantable Cardiac Defibrillators (ICDs) (Effective: February 15, 2018) (Implementation Date: March 26, 2019) CMS has updated Chapter 1, Part 1, Section 20.4 of the Medicare National Coverage Determinations Manual providing additional coverage criteria for Implantable Cardiac Defibrillators (ICD) for Ventricular Tachyarrhythmias (VTs). What is covered? An ICD is an electronic device to diagnose and treat life threating Ventricular Tachyarrhythmias (VTs) that has demonstrated improvement in survival rates and reduced cardiac death for certain patients. The Centers of Medicare and Medicaid Services (CMS) will cover claims for effective dates of service on or after February 15, 2018. Who is covered: Beneficiaries who meet the coverage criteria, if determined eligible. ICDs will be covered for the following patient indications: Personal history of sustained VT or cardiac arrest due to Ventricular Fibrillation (VF) Prior Myocardial Infarction (MI) and measured Left Ventricular Ejection Fraction (LVEF) less than or equal to .03 Severe, ischemic, dilated cardiomyopathy without history of sustained VT or cardiac arrest due to VF, and have New York Heart Association (NYHA) Class II or III heart failure with a LVEF less than or equal to 35% Severe, non-ischemic, dilated cardiomyopathy without history of cardiac arrest or sustained VT, NYHA Class II or II heart failure, LVEF less than or equal for 35%, and utilization of optimal medical therapy for at a minimum of three (3) months Documented, familial or genetic disorders with a high risk of life-threating tachyarrhythmias, but not limited to long QT syndrome or hypertrophic cardiomyopathy Existing ICD requiring replacement due to battery life, Elective Replacement Indicator (ERI), or malfunction Please refer to section 20.4 of the NCD Manual for additional coverage criteria. Click here for more information on ICD Coverage. 8. Next Generation Sequencing (NGS) for Medicare Beneficiaries with Germline (Inherited) Cancer (Effective: January 27, 20)  (Implementation Date: November 13, 2020) CMS has updated Chapter 1, Part 2, Section 90.2 of the Medicare National Coverage Determinations Manual to include NGS testing for Germline (inherited) cancer when specific requirements are met and updated criteria for coverage of Somatic (acquired) cancer. What is covered: Effective for dates of service on or after January 27, 2020, CMS has determined that NGS, as a diagnostic laboratory test, is reasonable and necessary and covered nationally for patients with germline (inherited) cancer when performed in a CLIA-certified laboratory, when ordered by a treating physician and when specific requirements are met. Who is covered: Beneficiaries with Somatic (acquired) cancer or Germline (inherited) cancer when performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all the following requirements are met: For Somatic (acquired) cancer: Beneficiary has: either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer and; has not been previously tested with the same test using NGS for the same cancer genetic content and; has decided to seek further cancer treatment (e.g., therapeutic chemotherapy). The diagnostic laboratory test using NGS must have: Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic and; FDA-approved or cleared indication for use in that patient’s cancer and; results provided to the treating physician for management of the patient using a report template to specify treatment options. For Germline (inherited) Cancer Beneficiary has: -ovarian or breast cancer and; a clinical indication for germline (inherited) testing for hereditary breast or ovarian cancer and; a risk factor for germline (inherited) breast or ovarian cancer and; -not been previously tested with the same germline test using NGS for the same germline genetic content. The diagnostic laboratory test using NGS must have: FDA-approval or clearance; and, results provided to the treating physician for management of the patient using a report template to specify treatment options. Medicare Administrative Contractors (MACs) may determine coverage of NGS as a diagnostic test when additional specific criteria are met. Click here for information on Next Generation Sequencing coverage. 9. Percutaneous Transluminal Angioplasty (PTA)    (Effective: February 19, 2019)  (Implementation Date: February 19, 2019)  CMS has updated Chapter 1, Part 1, Section 20.7 of the Medicare National Coverage Determinations Manual providing additional information regarding PTA.  What is covered: Percutaneous Transluminal Angioplasty (PTA) is covered in the below instances in order to improve blood flow through the diseased segment of a vessel in order to dilate lesions of peripheral, renal and coronary arteries.  Who is covered: The PTA is covered under the following conditions:  1. Treatment of Atherosclerotic Obstructive Lesions  2. Concurrent with Carotid Stent Placement in Food and Drug Administration (FDA) – Approved Category B Investigational Device Exemption (IDE) Clinical Trials  3. Concurrent with Carotid Stent Placement in FDA-Approved Post-Approvals Studies  4. Concurrent with Carotid Stent Placement in Patients at High Risk for Carotid Endarterectomy (CEA) 5. Concurrent with Intracranial Stent Placement in FDA-Approved Category B IDE Clinical Trials Click here for more detailed information on PTA coverage. 10. Transcatheter Aortic Valve Replacement (TAVR) (Effective: June 21, 2019) (Implementation Date: June 12, 2020) CMS has updated Chapter 1, section 20.32 of the Medicare National Coverage Determinations Manual. The Centers of Medicare and Medicaid Services (CMS) will cover transcatheter aortic valve replacement (TAVR) under Coverage with Evidence Development (CED) when specific requirements are met. What is covered: Effective June 21, 2019, CMS will cover TAVR under CED when the procedure is related to the treatment of symptomatic aortic stenosis and according to the Food and Drug Administration (FDA) approved indication for use with an approved device, or in clinical studies when criteria are met, in addition to the coverage criteria outlined in the NCD Manual. Who is covered: This service will be covered when the TAVR is used for the treatment of symptomatic aortic valve stenosis according to the FDA-approved indications and the following conditions are met: The procedure and implantation system received FDA premarket approval (PMA) for that system's FDA approved indication The patient is under the care of a heart team, which consists of a cardiac surgeon, interventional cardiologist, and various Providers, nurses, and research personnel The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the related aspects of TAVR The hospital where the TAVR is complete must have various qualifications and implemented programs The registry shall collect necessary data and have a written analysis plan to address various questions. This service will be covered when the TAVR is not expressly listed as an FDA-approved indication, but when performed within a clinical study and the following conditions are met: The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the related aspects of TAVR The clinical research study must critically evaluate each patient's quality of life pre- and post-TAVR for a minimum of 1 year, but must also address other various questions The clinical study must adhere to all the standards of scientific integrity and relevance to the Medicare population. Click here for more information on NGS coverage. 11. Ambulatory Blood Pressure Monitoring (ABPM) (Effective: July 2, 2019) (Implementation Date: June 16, 2020) CMS has updated Chapter 1, section 20.19 of the Medicare National Coverage Determinations Manual. The Centers of Medicare and Medicaid Services (CMS) will cover Ambulatory Blood Pressure Monitoring (ABPM) when specific requirements are met. What is covered: Effective July 2, 2019, CMS will cover Ambulatory Blood Pressure Monitoring (ABPM) when beneficiaries are suspected of having white coat hypertension or masked hypertension in addition to the coverage criteria outlined in the NCD Manual. Who is covered: This service will be covered when the Ambulatory Blood Pressure Monitoring (ABPM) is used for the diagnosis of hypertension when either there is suspected white coat or masked hypertension and the following conditions are met: The ABPM device must be: Capable of producing standardized plots of BP measurements for 24 hours with daytime and nighttime windows and normal BP bands demarcated; Provided to patients with oral and written instructions, and a test run in the physician’s office must be performed; and, Interpreted by the treating physician or treating non-physician practitioner. Coverage of other indications for ABPM is at the discretion of the Medicare Administrative Contractors. Click here for more information on ambulatory blood pressure monitoring coverage. 12. Acupuncture for Chronic Low Back Pain (cLBP) (Effective: January 21, 2020) (Implementation Date: October 5, 2020) CMS has updated Chapter 1, section 30.3.3 of the Medicare National Coverage Determinations Manual. The Centers of Medicare and Medicaid Services (CMS) will cover acupuncture for chronic low back pain (cLBP) when specific requirements are met. What is covered: Effective January 21, 2020, CMS will cover acupuncture for chronic low back pain (cLBP) for up to 12 visits in 90 days and an additional 8 sessions for those beneficiaries that demonstrate improvement, in addition to the coverage criteria outlined in the NCD Manual. Who is covered: This service will be covered only for beneficiaries diagnosed with chronic Lower Back Pain (cLBP) when the following conditions are met: For the purpose of this decision, cLBP is defined as: Lasting 12 weeks or longer; nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease); not associated with surgery; and, not associated with pregnancy. An additional 8 sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually. Treatments must be discontinued if the patient is not improving or is regressing. All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare. Click here for more information on acupuncture for chronic low back pain coverage. 13. Vagus Nerve Stimulation (VNS) (Effective: February 15. 2020) (Implementation Date: July 22, 2020) CMS has updated Chapter 1, section 160.18 of the Medicare National Coverage Determinations Manual. The Centers of Medicare and Medicaid Services (CMS) will cover Vagus Nerve Stimulation (VNS) for treatment-resistant depression when specific requirements are met. What is covered:  Effective February 15, 2020, CMS will cover FDA approved Vagus Nerve Stimulation (VNS) devices for treatment-resistant depression through Coverage with Evidence Development (CED) in a CMS approved clinical trial in addition to the coverage criteria outlined in the National Coverage Determination Manual. Who is covered: Beneficiaries participating in a CMS approved clinical study undergoing Vagus Nerve Stimulation (VNS) for treatment resistant depression and the following requirements are met: Treatment is furnished as part of a CMS approved trial through Coverage with Evidence Development (CED).Detailed clinical trial criteria can be found in section 160.18 of the National Coverage Determination Manual. The clinical study must address whether VNS treatment improves health outcomes for treatment resistant depression compared to a control group, by answering all research questions listed in 160.18 of the National Coverage Determination Manual. Patient Criteria:      The following criteria must be used to identify a beneficiary demonstrating treatment resistant depression: Beneficiary must be in a major depressive disorder episode for at least two years or have had at least four episodes, including the current episode. Patient’s depressive illness meets a minimum criterion of four prior failed treatments of adequate dose and duration as measured by a tool designed for this purpose. The patient is experiencing a major depressive episode, as measured by a guideline recommended depression scale assessment tool on two visits, within a 45-day span prior to implantation of the VNS device. Patients must maintain a stable medication regimen for at least four weeks before device implantation. If patients with bipolar disorder are included, the condition must be carefully characterized. Patients must not have: Current or lifetime history of psychotic features in any MDE; Current or lifetime history of schizophrenia or schizoaffective disorder; Current or lifetime history of any other psychotic disorder; Current or lifetime history of rapid cycling bipolar disorder; Current secondary diagnosis of delirium, dementia, amnesia, or other cognitive disorder; Current suicidal intent; or, Treatment with another investigational device or investigational drugs. CMS reviews studies to determine if they meet the criteria listed in Section 160.18 of the National Coverage Determination Manual. Nationally Non-Covered Indications VNS is non-covered for the treatment of TRD when furnished outside of a CMS-approved CED study. All other indications of VNS for the treatment of depression are nationally non-covered. Patients implanted with a VNS device for TRD may receive a VNS device replacement if it is required due to the end of battery life, or any other device-related malfunction. Click here for more information on Vagus Nerve Stimulation.  14. Chimeric Antigen Receptor (CAR) T-cell Therapy (Effective: August 7, 2019) (Implementation Date: September 20, 2021) CMS has updated Section 110.24 of the Medicare National Coverage Determinations Manual to include coverage of chimeric antigen receptor (CAR) T-cell therapy when specific requirements are met. What is covered: Effective for dates of service on or after August 7, 2019, CMS covers autologous treatment for cancer with T-cell expressing at least one chimeric antigen receptor (CAR) when administered at healthcare facilities enrolled in the Food and Drug Administration’s (FDA) Risk Evaluation and Mitigation Strategies (REMS) and when specific requirements are met. Who is covered: Beneficiaries receiving autologous treatment for cancer with T-cell expressing at least one least one chimeric antigen receptor CAR, when all the following requirements are met: Autologous treatment is for cancer with T-cells expressing at least one chimeric antigen receptor (CAR); and Treatment is administered at a healthcare facility enrolled in the FDA’s REMS; and The therapy is used for a medically accepted indication, which is defined as used for either and FDA approved indication according to the label of that product, or the use is supported in one or more CMS approved compendia. Non-Covered Use: The use of non-FDA-approved autologous T-cell expressing at least one CAR is non-covered or when the coverage requirements are not met. Click here for more information on chimeric antigen receptor (CAR) T-cell therapy coverage.  15. Screening for Colorectal Cancer (CRC)-Blood-Based Biomarker Tests (Effective: January 19, 2021)  (Implementation Date: October 4, 2021)  What is covered: Effective January 19, 2021, CMS has determined that blood-based biomarker tests are an appropriate colorectal cancer screening test, once every 3 years for Medicare beneficiaries when certain requirements are met.  Who is covered: Medicare beneficiaries will have their blood-based colorectal cancer screening test covered once every 3 years when ordered by a treating physician and the following conditions are met: The procedure is performed in a Clinical Laboratory Improvement Act (CLIA)-certified laboratory The Patient is:  age 50-85 years, and, asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test), and, average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer) The screen test must have all the following: Food and Drug Administration (FDA) market authorization with an indication for colorectal cancer screening; and Proven test performance characteristics for a blood-based screening test with both sensitivity greater than or equal to 74% and specificity greater than or equal to 90% in the detection of colorectal cancer compared to the recognized standard (accepted as colonoscopy at this time), based on the pivotal studies included in the FDA labeling. What is not covered: All other indications for colorectal cancer screening not otherwise specific in the regulations or the National Coverage Determination above. This includes: All screening sDNA tests, effective April 28, 2008, through October 8, 2014. Effective for dates of service on or after October 9, 2014, all other screening sDNA tests not otherwise specified above remain nationally non-covered. Screening computed tomographic colonography (CTC), effective May 12, 2009. Click here for more information on NGS coverage. 16. Ventricular Assist Devices (VADs) (Effective: December 1, 2020) (Implementation Date: July 27, 2021) What is covered: Effective for dates of service on or after December 1, 2020, CMS has updated section 20.9.1 of the National Coverage Determination Manual to cover ventricular assist devices (VADs) when received at facilities credentialed by a CMS approved organization and when specific requirements are met. Who is covered: Beneficiaries receiving treatment for implanting a ventricular assist device (VAD), when the following requirements are met and: The device is used following post-cardiotomy (period following open heart surgery) to support blood circulation. The device must be approved by the Food and Drug Administration (FDA) for this purpose; OR They receive a left ventricular device (LVADs) if the device is FDA approved for short- or long-term use for mechanical circulatory support for beneficiaries with heart failure who meet the following requirements: Have New York Heart Association (NYHA) Class IV heart failure; and Have a left ventricular ejection fraction (LVEF) ≤ 25%; and Are inotrope dependent OR have a Cardiac Index (CI) < 2.2 L/min/m2, while not on inotropes, and meet one of the following: Are on optimal medical management, based on current heart failure practice guidelines for at least 45 out of the last 60 days and are failing to respond; or Have advanced heart failure for at least 14 days and are dependent on an intra‐aortic balloon pump (IABP) or similar temporary mechanical circulatory support for at least 7 days. Beneficiaries must be managed by a team of medical professionals meeting the minimum requirements in the National Coverage Determination Manual. Facilities must be credentialed by a CMS approved organization. Non-Covered Use: All other indications for the use of VADs not otherwise listed remain non-covered, except in the context of Category B investigational device exemption clinical trials (42 CFR 405) or as a routine cost in clinical trials defined under section 310.1 of the National Coverage Determinations (NCD) Manual. Click here for more information on Ventricular Assist Devices (VADs) coverage. 17. Blood-Derived Products for Chronic, Non-Healing Wounds (Effective: April 13, 2021) (Implementation Date: February 14, 2022) What is covered: Effective for dates of service on or after April 13, 2021, CMS has updated section 270.3 of the National Coverage Determination Manual to cover Autologous (obtained from the same person) Platelet-Rich Plasma (PRP) when specific requirements are met. Who is covered: Beneficiaries receiving treatment for chronic non-healing diabetic wounds for a duration of 20 weeks, when prepared by a device cleared by the Food and Drug Administration (FDA) for the management of exuding (bleeding, oozing, seeping, etc.) wounds affecting the skin. Non-Covered Use: The following uses are considered non-covered: Use of autologous Platelet-Derived Growth Factor (PDGF) for treatment of chronic, non-healing, cutaneous (affecting the skin) wounds, and, Becaplermin, a non-autologous growth factor for chronic, non-healing, subcutaneous (beneath the skin) wounds, and, Autologous Platelet-Rich Plasma (PRP) treatment of acute surgical wounds when applied directly to the close incision, or for splitting or open wounds. Other: Coverage for the treatment beyond 20 weeks, or for all other chronic non-healing wounds will be determined by the local Medicare Administrative Contractors ( Click here for more information on Blood-Derived Products for Chronic, Non-Healing Wounds coverage. 18. Transcatheter Edge-to-Edge Repair [TEER] for Mitral Valve Regurgitation (Effective: January 19, 2021) (Implementation Date: October 8, 2021) What is covered: Effective for dates of service on or after January 19, 2021, CMS has updated section 20.33 of the National Coverage Determination Manual to cover Transcatheter Edge-to-Edge Repair (TEER) for Mitral Valve Regurgitation when specific requirements are met. Who is covered: Beneficiaries receiving treatment for Transcatheter Edge-to-Edge Repair (TEER) when either of the following are met: For the treatment of symptomatic moderate to severe mitral regurgitation (MR) when the patient still has symptoms, despite stable doses of maximally tolerated guideline directed medical therapy (GDMT) and cardiac resynchronization therapy, when appropriate and the following are met: Treatment is a Food and Drug Administration (FDA) approved indication, The procedure is used with a mitral valve TEER system that has received premarket approval from the FDA. The beneficiary is under pre- or post-operative care of a heart team meeting the following: Cardiac Surgeon meeting the requirements listed in the determination. Interventional Cardiologist meeting the requirements listed in the determination. Interventional echocardiographer meeting the requirements listed in the determination. Heart failure cardiologist with experience treating patients with advanced heart failure. Providers from other groups including patient practitioners, nurses, research personnel, and administrators. Patient must be evaluated for suitability for repair and must documented and made available to the Heart team members meeting the requirements of this determination. The procedure must be performed by an interventional cardiologist or cardiac surgeon.< An interventional echocardiographer must perform transesophageal echocardiography during the procedure. All physicians participating in the procedure must have device-specific training by the manufacturer of the device. The procedure must be performed in a hospital with infrastructure and experience meeting the requirements in this determination. The Heart team must participate in the national registry and track outcomes according to the requirements in this determination.> Mitral valve TEERs are covered for other uses not listed as an FDA-approved indication when performed in a clinical study and the following requirements are met: The procedure must be performed by an interventional cardiologist or cardiac surgeon. An interventional echocardiographer must perform transesophageal echocardiography during the procedure.> All physicians participating in the procedure must have device-specific training by the manufacturer of the device. The clinical research must evaluate the required twelve questions in this determination. The clinical research must evaluate the patient’s quality of life pre and post for a minimum of one year and answer at least one of the questions in this determination section. The clinical research study must meet the standards of scientific integrity and relevance to the Medicare population described in this determination. Submit the required study information to CMS for approval. Non-Covered Use: The following uses are considered non-covered: Treatment for patients with existing co-morbidities that would preclude the benefit from the procedure. Treatment for patients with untreated severe aortic stenosis. Other: This determination will expire ten years after the effective date if a reconsideration is not made during this time.  Upon expiration, coverage will be determined by the local Medicare Administrative Contractors (MACs). Click here for more information on Transcatheter Edge-to-Edge Repair [TEER] for Mitral Valve Regurgitation coverage . 19. Positron Emission Tomography NaF-18 (NaF-18 PET) to Identify Bone Metastasis of Cancer- Manual Update Only  (Effective: December 15, 2017) (Implementation Date: January 17, 2022)  Effective for dates of service on or after December 15, 2017, CMS has updated section 220.6.19 of the National Coverage Determination Manual clarifying there are no nationally covered indications for Positron Emission Tomography NaF-18 (NaF-18 PET). Non-Covered Use: Positron Emission Tomography NaF-18 (NaF-18 PET) services to identify bone metastases of cancer provided on or after December 15, 2017, are nationally non-covered. Other Use of other PET radiopharmaceutical tracers for cancer may be covered at the discretion of local Medicare Administrative Contractors (MACs), when used in accordance to their Food and Drug Administration (FDA) approval indications. Click here for more information on Positron Emission Tomography NaF-18 (NaF-18 PET) to Identify Bone Metastasis of Cancer coverage. Information on the page is current as of December 28, 2021 H5355_CMC_22_2746205 Accepted 20. Home Use of Oxygen  (Effective: September 27, 2021) (Implementation Date: January 3, 2023) What is covered: Effective September 27, 2021, CMS has updated section 240.2 of the National Coverage Determination Manual to cover oxygen therapy and oxygen equipment for in home use of both acute and chronic conditions, short- or long- term, when a patient exhibits hypoxemia. CMS has updated section 240.2 of the National Coverage Determination Manual to amend the period of initial coverage for patients in section D of NCD 240.2 from 120 days to 90 days, to align with the 90-day statutory time period Who is covered: Beneficiaries who exhibit hypoxemia (low oxygen in your blood) when ALL (A, B, and C) of the following are met:   A. Hypoxemia is based on results of a clinical test ordered and evaluated by a patient’s treating practitioner meeting either of the following: a. A clinical test providing a measurement of the partial pressure of oxygen (PO2) in arterial blood. i. PO2 measurements can be obtained via the ear or by pulse oximetry. ii. PO2 may be performed by the treating practitioner or by a qualified provider or supplier of laboratory services. b. A clinical test providing the measurement of arterial blood gas. i. If PO2 and arterial blood gas results are conflicting, the arterial blood gas results are preferred source to determine medical need. B. The clinical test must be performed at the time of need: a. The time of need is indicated when the presumption of oxygen therapy within the home setting will improve the patient’s condition. i. For inpatient hospital patient’s, the time of need is within 2 days of discharge. ii. For patient’s whose initial prescription for oxygen did not originate during an inpatient hospital stay, the time of need occurs when the treating practitioner identifies signs and symptoms of hypoxemia that can be relieved with at home oxygen therapy. C. Beneficiary’s diagnosis meets one of the following defined groups below: a. Group I: i. Arterial PO2 at or below 55 mm Hg or arterial oxygen saturation at or below 88% when tested at rest in breathing room air, or; ii. Arterial PO2 at or below 55 mm Hg, or arterial oxygen saturation at or below 88% when tested during sleep for patients that demonstrate an arterial PO2 at or above 56 mmHg, or iii. Arterial oxygen saturation at or above 89% when awake;or greater than normal decrease in oxygen level while sleeping represented by a decrease in arterial PO2 more than 10 mmHg or a decrease in arterial oxygen saturation more than 5%. a. Patient must also present hypoxemia signs and symptoms such as nocturnal restlessness, insomnia, or impairment of cognitive process. 2. During these events, oxygen during sleep is the only type of unit that will be covered. 3. Portable oxygen would not be covered. iv. Arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88%, tested during functional performance of the patient or a formal exercise, 1. For a patient demonstrating arterial PO2 at or above 56 mm Hg, or an arterial oxygen saturation at or above 89%, at rest and during the day. 2. During these events, supplemental oxygen is provided during exercise, if the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air. b. Group II: i. Patients demonstrating arterial PO2 between 56-59 mm Hg, or who’s arterial blood oxygen saturation is 89%, with any of the following condition: 1. Dependent edema (gravity related swelling due to excess fluid) suggesting congestive heart failure; or, 2. Pulmonary hypertension or cor pulmonale (high blood pressure in pulmonary arteries), determined by the measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVFL; or, 3. Erythrocythemia (increased red blood cells) with a hematocrit greater than 56%. c. The Medicare Administrative Contractors (MACs) will review the arterial PO2 levels above and also take into consideration various oxygen measurements that can results from factors such as patient’s age, patients skin pigmentation, altitude level and the patients decreased oxygen carrying capacity. Non-Covered Use: The following medical conditions are not covered for oxygen therapy and oxygen equipment in the home setting: Angina pectoris (chest pain) in the absence of hypoxemia; or, Breathlessness without cor pulmonale or evidence of hypoxemia; or, Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities; or, Terminal illnesses, unless it affects the patient’s ability to breathe. Other: The MAC may determine necessary coverage for in home oxygen therapy for patient’s that do not meet the criteria described above. Initial coverage for patient’s experiencing conditions not described above can be limited to a prescription shorter than 90 days, or less than the numbers of days indicated on the practitioner’s prescription. Oxygen therapy can be renewed by the MAC if deemed medically necessary. The MAC may also approve the use of portable oxygen systems to beneficiaries who are mobile in home and benefit from of this unit alone, or in conjunction to a stationary oxygen system. For more information on Home Use of Oxygen coverage click here. 21. 180.1 - Medical Nutrition Therapy (MNT) (Effective: January 1, 2022) (Implementation Date: July 5, 2022) What is covered: Effective for dates of service on or after January 1, 2022, CMS has updated section 180.1 of the National Coverage Determination Manual to cover three hours of administration during one year of Medical Nutrition Therapy (MNT) in patients with a diagnosis of renal disease or diabetes, as defined in 42 CFR 410.130. Coverage for future years is two hours for patients diagnosed with renal disease or diabetes. Medicare will cover both MNT and Diabetes Outpatient Self-Management Training (DSMT) during initial and subsequent years, if the physician determines treatment is medically necessary and as long as DSMT and MNT are not provided on the same date. Dieticians and Nutritionist will determine how many units will be administered per day and must meet the requirements of this NCD as well at 42 CFR 410.130 – 410.134. Additional hours of treatment are considered medically necessary if a physician determines there has been a shift in the patients’ medical condition, diagnosis or treatment regimen that requires an adjustment in MNT order or additional hours of care. Who is covered: Beneficiaries with either a renal disease or diabetes diagnosis as defined in 42 CFR 410.130. For more information on Medical Nutrition Therapy (MNT) coverage click here. 22.  Reconsideration – Screening for Lung Cancer with Low Dose Computed Tomography (LDCT) (Effective: February 10, 2022) (Implementation Date: October 3, 2022)  What is covered: Effective for claims with dates of service on or after February 10, 2022, CMS will cover, under Medicare Part B, a lung cancer screening counseling and shared decision-making visit. An annual screening for lung cancer with LDCT will be available if specific eligibility criteria are met.  Prior to the beneficiary’s first lung cancer LDCT screening, the beneficiary must receive a counseling and shared decision-making visit that meets specific criteria. Who is covered: Members must meet all of the following eligibility criteria:  50– 77 years old; Asymptomatic (no signs or symptoms of lung cancer); Tobacco smoking history of at least 20 pack-years (one pack-year = smoking one pack per day for one year; 1 pack =20 cigarettes); Current smoker or one who has quit smoking within the last 15 years; Receive an order for lung cancer screening with LDCT. Click here for more information on LDCT coverage.  23. (Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease (AD))  (Effective: April 7, 2022) (Implementation Date: December 12, 2022)  What is covered: Effective on April 7, 2022, CMS has updated section 200.3 of the National Coverage Determination (NCD) Manual to cover Food and Drug Administration (FDA) approved monoclonal antibodies directed against amyloid for treatment of Alzheimer’s Disease (AD) when the coverage criteria below is met.  Who is covered: Beneficiaries with Alzheimer’s Disease (AD) may be covered for treatment when the following conditions (A or B) are met:  The treatment is based upon efficacy from a change in surrogate endpoint such as amyloid reduction. The treatment is considered reasonably likely to predict a clinical benefit and is administrated in a randomized controlled trial under an investigational new drug application. The treatment is based upon efficacy from a direct measure of clinical benefit in CMS-approved prospective comparative studies. Study data for CMS-approved prospective comparative studies may be collected in a registry. For CMS-approved studies, the protocol, including the analysis plan, must meet requirements listed in this NCD. CMS-approved studies of a monoclonal antibody directed against amyloid approved by the FDA for the treatment of AD based upon evidence of efficacy from a direct measure of clinical benefit must address all of the questions included in section B.4 of this National Coverage Determination. CMS approved studies must also adhere to the standards of scientific integrity that have been identified in section 5 of this NCD by the Agency for Healthcare Research and Quality (AHRQ). Click here for more information on study design and rationale requirements. Non-Covered Use: Monoclonal antibodies directed against amyloid for the treatment of AD provided outside of an FDA-approved randomized controlled trial, CMS-approved studies, or studies supported by the NIH. Other: N/A. Click here for more information on Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimer’s Disease (AD). Information on the page is current as of December 1, 2022 H8894_DSNP_22_3617111_M Accepted

IEHP DualChoice - IEHP DualChoice

Cal Plan, allows you to get your covered Medicare and Medi-Cal benefits through our plan.  Our plan includes doctors, hospitals, pharmacies, providers of long-term services and supports, behavioral health providers, and other providers. It also has care coordinators and care teams to help you manage all your providers and services. They all work together to provide the care you need. IEHP DualChoice (HMO D-SNP) helps make your Medicare and Medi-Cal benefits work better together and work better for you. Some of the advantages include: You can work with us for all of your health care needs. You have a care team that you help put together. Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. You have access to a care coordinator. This is a person who works with you, with our plan, and with your care team to help make a care plan. Your care team and care coordinator work with you to make a care plan designed to meet your health needs. The care team helps coordinate the services you need. For example, this means that your care team makes sure: Your doctors know about all the medicines you take so they can make sure you’re taking the right medicines and can reduce any side effects you may have from the medicines. Your test results are shared with all of your doctors and other providers, as appropriate.  Who is eligible for IEHP DualChoice? IEHP DualChoice is for people with both Medicare (Part A and B) and Medi-Cal. The following information explains who qualifies for IEHP DualChoice (HMO D-SNP). You are eligible for our plan as long as you:         Live in our service area (incarcerated individuals are not considered living in the geographic service area even if they are physically located in it.), and Are age 21 and older at the time of enrollment, and Have both Medicare Part A and Medicare Part B, and Are currently eligible for Medi-Cal, and Are a full-benefit dual eligible beneficiary and enroll in IEHP DualChoice for your Medicare benefits and Inland Empire Health Plan (IEHP) for your Medi-Cal benefits. This is known as “Exclusively Aligned Enrollment”, and Are a United States citizen or are lawfully present in the United States. Service Area  Only people who live in our service area can join IEHP DualChoice. Our service area includes all of Riverside and San Bernardino counties.  How to Enroll To enroll, please call the: IEHP DualChoice Medicare Team at (800) 741-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY users should call (800) 718-4347 Visit our enrollment page to learn more.  IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. This is not a complete list.  Information on this page is current as of October 01, 2022. H8894_DSNP_23_3241532_M

Innovations and Quality Performance - Quality Performance

rting our providers. We are committed to quality, driving us to create programs and services to meet the needs of our members and providers. In fact, IEHP is one of the top-rated Medicaid plans in California. Determined by both the Healthcare Effectiveness Data and Information Set (HEDIS) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS), NCQA has awarded IEHP an Accreditation status for Medi-Cal. This status is only given to health plans that have clinical and service programs that meet or exceed NCQA standards. Learn more about how IEHP delivers quality services and care below.  Quality Report Inside the 2022 Quality Report, we take you through our quality journey by looking at our performance over the past year with critical measures. We show you how that data translates into tangible outcomes for our Members, Providers and Team Members. While there were many areas where we excelled, there were also places where we found opportunities for improvement. The goal of this Quality Report is to be transparent—with you and with ourselves. This journey is ongoing, and we hope to learn from it so we can do better and be better for those who rely on us the most. 2022 Annual Quality Report 2020 Annual Quality Report (PDF) Quality Management IEHP supports an active, ongoing, and comprehensive quality management program with the primary goal of continuously monitoring and improving the quality of care, access to care, patient safety, and quality of services delivered to IEHP Members. The Quality Management (QM) Program provides a formal process to systematically monitor and objectively evaluate, track and trend the health plan’s quality, efficiency and effectiveness. Quality Management Evaluation 2021 Quality Management Annual Evaluation (PDF) Quality Management Program Description 2022 Quality Management Program Description (PDF) HEDIS Every year, IEHP assesses the overall quality of health care experienced by IEHP members. To achieve this IEHP uses  NCQA, a private, non-profit organization dedicated to improving health care quality. NCQA accredits and certifies a wide range of health care organizations and manages the evolution of HEDIS® which provides: a set of standardized performance measures based on statistically valid samples of members the public with information to compare health plan performance HEDIS Rate: 2021 Medi-Cal HEDIS Rates (PDF) 2021 Medicare HEDIS Rates (PDF) Physician Satisfaction IEHP values a strong partnership with our providers. To support them we offer many services from online support, to a call center, to a dedicated service representative. That's why doctors think highly of IEHP. In fact, according to the 2021 Provider Satisfaction Survey conducted by SPH Analytics, 98.1% of physicians would recommend IEHP to other physicians. See the full results of the 2021 Provider Satisfaction Survey (PDF). Population Needs Assessment Every year, IEHP sends out a Population Assessment Survey to IEHP Members to learn more about their needs. View the results below.  2020 Population Needs Assessment Results  You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Download Adobe Acrobat Reader. 

Enroll with IEHP DualChoice

th Medi-Cal and Medicare, you may be eligible to enroll in the IEHP DualChoice (HMO D-SNP) plan. Our IEHP DualChoice plan helps you get the care you need to achieve your best possible health. Get covered benefits for $0 including: Doctor visits such as routine checkups and sick visits Prescriptions from the IEHP DualChoice formulary Hospital care such as emergency room and urgently needed servicesAre currently eligible for Medi-Cal, and  Specialist case PLUS extra benefits like: Vision care: $350 limit every two years for contact lenses and eyeglasses (frames and lenses) Utilities allowance of $40 for covered utilities. You must qualify for this benefit. Who is eligible for IEHP DualChoice (HMO D-SNP)? IEHP DualChoice is for people with both Medicare (Part A and B) and Medi-Cal. The following information explains who qualifies for IEHP DualChoice (HMO D-SNP). Included Population: With mandatory enrollment for Medi-Cal benefits, including Long-Term Services and Supports (LTSS) benefits and Medicare benefits. You are eligible for our Plan as long as you: Live in our service area (incarcerated individuals are not considered living in the geographic service area even if they are physically located in it.), and Are age 21 and older at the time of enrollment, and  Have both Medicare Part A and Medicare Part B, and Are currently eligible for Medi-Cal, and Are a full-benefit dual eligible beneficiary and enroll in IEHP DualChoice for your Medicare benefits and Inland Empire Health Plan (IEHP) for your Medi-Cal benefits. This is known as “Exclusively Aligned Enrollment”, and Are a United States citizen or are lawfully present in the United States For questions or to enroll over the phone, please call the IEHP DualChoice Medicare Team at 1-800-741-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347. IEHP DualChoice Enrollment Form IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contact renewal. Information on this page is current as of October 01, 2022. H8894_DSNP_23_3241532_M Pending Accepted

Innovations and Quality Performance - Our Commitment to Innovation

healthcare needs of our Members for more than two decades. With our Strategic Priorities guiding us, we will continue to seek opportunities for innovation and improvement – putting access to quality healthcare and our Members, Providers and Community above all else. Community Health Assessment The 2022 Inland Empire Community Health Assessment Stakeholder Committee, comprised of over 40 representatives across 25 community organizations, united over the past year to collect and analyze the region’s health and wellness data. The group identified those four at-risk population groups, Senior citizens, communities of color, individuals with low incomes and those living in remote and rural areas, as well as six priority areas of focus: Basic Needs for Health and Safety, Human Housing, Meaningful Work and Wealth, Cardiovascular Disease and Diabetes, Maternal and Infant Health and Mental and Behavioral Health. The committee shared the findings in a first-of-its-kind joint regional Community Health Assessment report. Community Health Needs Assessment (CHNA) The 2022 Inland Empire Community Health Needs Assessment (CHNA) identifies the top health and well-being needs of Inland Empire residents. The findings in the CHNA will be used to build community interventions that generate collective investments addressing the identified priorities. There are seven assessments within the CHNA, the first three target the entire Inland Empire region, along with Riverside and San Bernardino counties. The remaining four assessments comprise drilled-down analyses for Montclair Hospital Medical Center, Redlands Community Hospital, San Antonio Regional Hospital and San Gorgonio Memorial Hospital service areas. Click here to view the assessment. Provider Recruitment IEHP’s innovative Network Expansion Fund (NEF) was the first program of its kind in the state. Established in 2014, the NEF allocates $30 million in specially designated funds to attract board-certified PCPs, Specialists and mid-level Providers to the Inland Empire, addressing the region’s chronic Provider shortage and improving access to care for more than 1.2 million IEHP Members. To date, more than 280 Providers have been recruited as a direct result of this program. Behavioral Health Integration Complex Care Initiative The Behavioral Health Integration Complex Care Initiative (BHICCI) is a collaboration between IEHP and more than 30 clinics in the Inland Empire that provides a footprint for the California Department of Health Care Services (DHCS) Health Homes Program, going live January 1, 2019. The goal is to improve Members’ health outcomes by staffing a complex care team to provide comprehensive care management and by coordinating complex physical and behavioral health needs across multiple Providers and health care systems in Riverside and San Bernardino counties. BHICCI care teams are currently transitioning into community-based care management entities (CB-CMEs) that provide Health Homes services in preparation for Health Homes go-live. Health Homes Program The Health Homes program (HHP) is an integrated care management program for patients with complex needs that builds on IEHP’s Behavioral Health Integration Complex Care Initiative (BHICCI), as legislated by the Department of Health Care Services (DHCS). The HHP coordinates the physical, behavioral, and community-based Long-Term Services and Supports (LTSS) needs of Members with severe chronic physical and/or mental health conditions. The primary goal of HHP is to improve the overall health outcomes of members through the delivery of care coordination and complex care management. Since the launch of the program in January 2019, more than 9,000 Members have seen overwhelmingly positive clinical health outcomes related to blood pressure, diabetes and depression. Click here to learn more about the Health Homes Program.  EHR and Health Information Exchange IEHP has partnered with the San Bernardino County Medical Society and the Riverside County Medical Association to form the Inland Empire EHR Resource Center, to assist Providers and clinics in selecting and implementing electronic health record systems. Additionally, IEHP was part of the Inland Empire Health Information Exchange, which merged with the CalIndex Health Information Exchange to form Manifest Medex (MX). MX is a statewide health information exchange that has significant penetration and use in the Inland Empire, with all Inland Empire acute care hospitals and many medical groups and Physicians contributing patient clinical and administrative data. MX brings needed technology to access and securely share electronic patient health records for most of the 4.4 million people living in the Inland Empire. It allows Doctors, clinics, hospitals and other health care Providers to electronically review and access medical records, resulting in timely and improved quality of health care for patients in our community. DocOnline This innovative program provides another option for Members to receive medical advice after hours from a Physician. IEHP Members can speak to a board-certified Physician by phone or via video chat, quickly and easily. The Physician can access the IEHP formulary and the IEHP Pharmacy Network to e-prescribe medications for IEHP Members if needed. When fully implemented, this service will enhance Member access and convenience while reducing unnecessary emergency room and urgent care visits. Telehealth IEHP is supporting the expansion of telehealth services throughout the Inland Empire, to improve access to critically needed specialty care and to aid in rapid diagnosis and treatment. Telehealth eliminates one of the Inland Empire’s longstanding barriers to care – geographic distance to health care resources. With telehealth’s information and communication technologies, the treatment and prevention of disease or injury can occur long-distance, erasing geography as a critical factor impeding care. Telehealth can also be used to support Provider training and Member education. IEHP is currently supporting telehealth for certain services: behavioral health, retinal examinations, dermatology, and orthopedic consultations. Plans are underway to expand to additional services in alignment with Member needs. eConsult eConsult, a collaboration among IEHP, Arrowhead Regional Medical Center and Riverside University Health Care System, allows PCPs to connect directly with specialists electronically when a patient may need a specialist referral. Through a private, secure system, PCPs can receive timely clinical advice from specialists that may allow them to manage a majority of patients in the primary care setting (some patients may need a face-to-face visit with a specialist). IEHP is sponsoring the initiative for the first 24 months and will design, implement and evaluate eConsult at more than 70 clinic sites throughout Riverside and San Bernardino counties. Secure Online Member Portal and App IEHP Members can take an active role in managing their own health 24/7 via a secure online account that can be accessed through the IEHP website or mobile app. Members can view and print their IEHP Member Cards; view lab tests, Immunization Cards and authorizations; find or change Doctors; search the Provider Directory; enroll in health education classes; check eligibility; and more. The separate Baby-N-Me prenatal care app helps improve maternity health outcomes by making it easy for expectant moms to track pregnancy milestones, identify health issues, and stay healthy with reminders and helpful tools. Texting and Alerts IEHP uses two-way texting and Short Message Service (SMS) alerts to educate Members about their plan benefits and how to navigate the health care system. These alerts are targeted approaches that communicate seasonal health information about topics such as immunizations, preventive care, medication adherence, and new health plan features. Long-Term Services and Supports (LTSS) IEHP’s Long-Term Services and Supports (LTSS) program enables seniors and persons with disabilities to live independently in their homes as long as safely possible, and provides care in a Skilled Nursing Facility (SNF) when they cannot. LTSS includes the Multipurpose Senior Services Program (MSSP) and Community-Based Adult Services (CBAS), as well as SNF services when required. IEHP also helps coordinate any In-Home Supportive Services (IHSS) benefits. Since May 2018, IEHP has helped transition 750 Members out of long-term care facilities and back into the community. A 24-hour in-home emergency caregiver program and a case management program, developed in partnership with the Riverside County Department of Social Services, received the 2017 and 2018 Achievement Award from the National Association of Counties. IEHP has also partnered with the University of California, Los Angeles on a Geriatric Workforce Enhancement Program to provide patients, families and caregivers with the knowledge and skills they need to improve health outcomes and increase the quality of care for older adults.   

COVID-19 - Testing Locations

provider, and receive treatment for COVID-19 – all in one place at a Test to Treat site.  If you have a medical condition which makes you more likely to get very sick from COVID-19, you may be eligible to receive treatments.  Adults and Children over the age of 12 can receive treatments, but treatment must be started as soon as possible and within 5 days of symptom onset. Click here for more information on the COVID-19 Test to Treat Program.  Walgreens Test to Treat Program  Select Walgreens pharmacies are now dispensing oral antivirals for the treatment of COVID-19.  Eligible members must have a valid prescription from their healthcare provider. Walgreens offers a variety of delivery options, like same day or free 2-day delivery. Most prescriptions are eligible for Same Day Delivery.  Click here for more information. FREE at-home COVID-19 tests Every home in the U.S. is eligible to order one free COVID-19 test kit, which includes four at-home tests. The tests are completely free. Click here to order your free at-home tests from USPS.  Effective 2/1/22, Medi-Cal Members can receive at-home COVID-19 tests from a Medi-Cal enrolled pharmacy. California Department of Health Care Services (DHCS) will cover up to 8 test kits per month per member. For information on which test kits are covered or if you need assistance with a prescription, please ask your Doctor or your Pharmacist. Medi-Cal Members will be reimbursed for at-home test kits purchased between March 11, 2021, and January 31, 2022, by DHCS the cost (with a receipt) using the process outlined here. San Bernardino County-facilitated testing sites will offer free at-home COVID-19 tests kits to people who live, work, or attend school in San Bernardino County (proof of residency or employment required). Click here to find a list of county-facilitated testing sites. Testing If you believe you are at risk for COVID-19, you can get COVID-19 screening and testing at the sites below.   IEHP covers provider-ordered tests, regardless of whether it’s PCR, rapid, at-home, etc. If your doctor orders the test for you, IEHP will cover the cost of the test. Your provider is required to bill IEHP directly for these tests.  IEHP does NOT reimburse Members who choose to pay for COVID tests that are not ordered by a provider.  Riverside County COVID-19 Testing Sites Banning Banning Family Care Center 3055 W. Ramsey, Banning Schedule an Appointment Beaumont Beaumont Women's Club 306 E 6th St., Beaumont, 92223 Call (888) 634-1123 Schedule an Appointment Borrego Health Multiple Locations Available Click here for information on COVID-19 sites in your area. Cathedral City Plaza Rio Vista Kiosk 67908 Vista Chino, Cathedral City Schedule an Appointment Coachella Our Lady of Soledad 52525 Oasis Palm Ave., Coachella Schedule an Appointment Coachella TODEC Legal Center COVID Testing 1560 6th St., Coachella Schedule an Appointment Corona Corona Community Health Center 2813 S. Main St., Corona Schedule an Appointment Corona Unicare Community Health Center 107 N. MicKinley St., Corona Call (909) 457-3603 CVS MinuteClinic Multiple Locations Available* Schedule an Appointment Hours vary by location Desert Hot Springs Henry V. Lozano Community Center 12800 West Arroyo, Desert Hot Springs Schedule an Appointment Indio Indio Fleet Services 82775 Plaza Ave., Indio Schedule an Appointment Indio Old Amistad High School 44801 Golf Center Pkwy, Indio Schedule an Appointment Jurupa Avalon Park Community Center 2500 Avalon St., Jurupa Schedule an Appointment La Quinta La Quinta Wellness Center 78450 Avenida La Fonda, La Quinta Schedule an Appointment Lake Elsinore The Outlets at Lake Elsinore Testing 17600 Collier Ave., Suite J-195 Parking Lot, Lake Elsinore Schedule an Appointment Moreno Valley Moreno Valley Family Care Center 23520 Cactus Ave., Moreno Valley Schedule an Appointment Moreno Valley Cottonwood Golf Center 13671 Frederick St., Moreno Valley Schedule an Appointment Moreno Valley Moreno Valley Kiosk 14075 Frederick St., Moreno Valley M-F 10am - 6:30pm Schedule an Appointment Moreno Valley Riverside University Health System Medical Center 26520 Cactus Ave., Moreno Valley M-F 10am - 6:30pm Schedule an Appointment Murrieta California Oaks Center Trailer 40565 California Oaks Rd., Murrieta Schedule an Appointment Palm Desert UCR Palm Desert Campus 75080 Frank Sinatra Dr., Palm Desert Schedule an Appointment Palm Springs Palm Springs Convention Center 277 N. Avenida Caballeros, Palm Springs Schedule an Appointment Perris Perris' City Council Chamber 101 N D St., Perris Schedule an Appointment Perris Perris Community Health Center 308 E. San Jacinto Ave., Perris Schedule an Appointment Perris Rapid Care Enterprises 126 Avocado Ave. Ste 102, Perris Call (951) 490-4910 Mon-Fri | 9 a.m. - 9 p.m. Sat-Sun | 12 p.m. - 5 p.m. Costs may be associated with this site Rite Aid Pharmacy Multiple Locations Available* Schedule an Appointment Mon-Fri | 10 a.m. - 8 p.m. Sat-Sun | 10 a.m. - 5 p.m. Riverside Jurupa Valley Family Care Center 8876 Mission Blvd., Riverside Schedule an Appointment Riverside Riverside City Hall Kiosk (test only) 3900 Main St., Riverside Schedule an Appointment Riverside Riverside Neighborhood Health Clinic 7140 Indiana Ave., Riverside Schedule an Appointment Riverside La Sierra Park Drive Through (test only) 5272 Mitchell Ave., Riverside Schedule an Appointment Temecula Vail Ranch Center Kiosk 31699 Temecula Pkwy., Temecula Schedule an Appointment For more information on COVID-19 testing sites in Riverside County, please visit the Riverside County Public Health website. San Bernardino County COVID-19 Testing Sites Adelanto Adelanto Health Center 11336 Bartlett Ave., Ste. 11, Adelanto Call (800) 722-4777 Apple Valley James A. Woody Community Center 13467 Navajo Rd., Apple Valley Schedule an Appointment Barstow Barstow Adult School 720 E. Main St., Barstow Schedule an Appointment Big Bear Big Bear Health Center 477 Summit Blvd., Big Bear Lake Schedule an Appointment Barstow Barstow Health Center 303 E. Mountain View St., Barstow Call (800) 722-4777 Bloomington Kessler Park COVID-19 Testing Bus 18401 Jurupa Ave., Bloomington Schedule an Appointment Borrego Health Multiple Locations Available Click here for information on COVID-19 sites in your area. Chino CVUSD Chino Valley Adult School 12970 3rd St., Chino Schedule an Appointment Chino Lani City Medical 4036 Grand Ave., Suite A, Chino (909) 465-5000 Schedule an Appointment Colton Arrowhead Regional Medical Center 400 N. Pepper Ave., Colton Call (855) 422-8029 Colton Colton Urgent Care Center 1181 N. Mt. Vernon Ave., Colton Colton Urgent Care Center Online Check-In Colton Gonzales Community Center 670 Colton Ave., Colton Schedule an Appointment Colton Unicare Community Health Center 308 N. La Cadena Dr., Colton Call (909) 457-3603 CVS Multiple Locations Available Schedule an Appointment Fontana Jessie Turner Health & Fitness Community Center 15556 Summit Ave., Fontana Schedule an Appointment Fontana West Point Medical Center 7774 Cherry Ave., Fontana Call (909) 355-1296, option 1 Hesperia Hesperia Health Center 16453 Bear Valley Rd., Hesperia Call (800) 722-4777 Joshua Tree Community Center 6171 Sunburst St., Joshua Tree Schedule an Appointment Loma Linda Loma Linda Senior Center 25571 Barton Rd., Loma Linda Schedule an Appointment Montclair Montclair Kid's Station - COVID Testing Bus 4985 Richton St., Montclair Schedule an Appointment Montclair Montclair Place - Moreno St. Market Food Court 5060 N. Montclair Plaza Ln., 2nd Floor, Ste. 2138 Schedule an Appointment Ontario Drive-Through COVID Clinic 2500 E. Airport Dr., Ontario Schedule an Appointment Ontario Drive-Through COVID Clinic 1 Mills Circle, Ontario Schedule an Appointment Ontario Ontario Health Center 150 E. Holt Blvd., Ontario Call (800) 722-4777 Ontario Parktree Community Health Center 2680 E. Riverside Dr., Ontario Call (909) 630-7927 Ontario Unicare Community Health Center 437 N. Euclid Ave., Ontario Call (909) 988-2555 Rancho Cucamonga Lani City Medical 1398 Kenyon Way, Suite J, Rancho Cucamonga (909) 727-3911 Schedule an Appointment Rancho Cucamonga RC Family Resource Center 9791 Arrow Rte., Rancho Cucamonga Schedule an Appointment Rancho Cucamonga Terra Vista Town Center - Theater Parking Lot COVID Testing Bus 10701 Town Center Dr., Rancho Cucamonga Schedule an Appointment Rancho Cucamonga West Point Medical Center 8520 Archibald Ave., St B., Rancho Cucamonga Call (909) 481-3909, option 1 Redlands Redlands Urgent Care Center 301 W. Redlands Blvd., Redlands Redlands Urgent Care Center Online Check-In Rialto Carl Johnson Center 214 N. Palm Ave., Rialto Schedule an Appointment Rite-Aid Pharmacy Multiple Locations Available Schedule an Appointment San Bernardino Court Street Square 349 N East St., San Bernardino Event Dates: March 3, 17 and 31 Schedule an Appointment San Bernardino Department of Public Health COVID-19 Testing Bus 172 W. 3rd St., San Bernardino Schedule an Appointment San Bernardino Drive-Through COVID Clinic 500 Inland Center Dr, San Bernardino Schedule an Appointment San Bernardino Premier Urgent Care Centers of California 284 E. Highland Ave., San Bernardino Daily | 9 a.m. - 9 p.m. San Bernardino SAC Health System 250 S. G St., San Bernardino Call (909) 771-2911 T/W/F | 3 p.m. - 5 p.m. San Bernardino San Bernardino Health Center 606 E. Mill St., San Bernardino Call (800) 722-4777 San Bernardino West Point Medical Center 1800 Medical Center Dr., St. 99, San Bernardino Call (909) 880-6400, option 1 Twentynine Palms Twentynine Palms - Patriotic Hall 5885 Luckie Ave., Twentynine Palms Schedule an Appointment Upland Advanced Medical & Urgent Care Center 974 W. Foothill., Upland Call (909) 981-2273 Mon-Fri | 8 a.m. - 2:30 p.m. Upland Landecena Community Building 1325 San Bernardino Rd., Upland Schedule an Appointment Victorville Drive-Through COVID Clinic 14400 Bear Valley Dr., Victorville Schedule an Appointment Victorville Green Tree Golf Course Banquet Room 14144 Green Tree Blvd., Victorville Schedule an Appointment Victorville Victor Valley College 65 Mojave Fish Hatchery Rd., Victorville Portables located behind Construction Technology Building 65 Schedule an Appointment Walgreens Multiple Locations Available Schedule an Appointment Yucaipa 7th Street Pool 12385 7th St., Yucaipa Schedule an Appointment Yucca Valley Yucca Valley Community Center COVID-19 Testing Bus 57090 Twentynine Palms Highway, Yucca Valley Schedule an Appointment Yucaipa Yucaipa Urgent Care Center 33494 Oak Glen Rd., Yucaipa Yucaipa Urgent Care Center Online Check-In For more information on COVID-19 testing sites in San Bernardino County, please visit the San Bernardino County COVID Testing Sites.

Provider Resources - Facility Site Review

th us to offer our members the highest quality care and service they need. Facility Site Reviews are the required standards by the California Department of Health Care Services (DHCS)/Medi-Cal Managed Care Division (MMCD) for all primary care provider (PCP) sites. Below you will find various resources in regards to DHCS information, Physical Accessibility Reviews (PARS), Facility Site Review (FSR), and Medical Record Reviews (MRR) as well as IEHP’s addendum tools for your reference. Facility Site Review Training Index: Department of Health Care Services (DHCS) IEHP Addendum Tools PARS Facility Site Review Medical Record Review Department of Health Care Services (DHCS) 2022 Facility Site Review Standards (FSR) (PDF) 2022 Facility Site Review Tool  (FSR) (PDF) 2022 Medical Record Review Standards (MRR) (PDF) 2022 Medical Record Review Tool (MRR) (PDF) APL 22-017 - Facility Site Review and Medical Record Review (PDF) DPL 14-005 - FSR Physical-Accessibility Reviews (PDF) PL 12-006 - Revised FSR Tool (PDF) PL 14-004 - Facility Site Review and Medical Record Review (PDF) (Back to Index) IEHP Addendum Tools Att 06 - IEHP Urgent Care Evaluation Tool (PDF) IEHP Interim Review (PDF) (Back to Index) PARS APL with PARS C (PDF) APL with PARS D & CBAS (PDF) PAR-FSR-C_PARS - Survey (PDF) PAR-FSR-D_PARS - Ancillary (PDF) PAR-FSR-E_PARS - CBAS (PDF) (Back to Index) Facility Site Review Menu Click on the following links to jump to that specific section: Facility Site Review Audit Tool Sections Additional Documents Medical Record Review Audit Tool Sections Additional Documents (Back to Index) Access/Safety Facility Site Review Blank Pre-Calculated Dosage Chart (PDF) Emergency Exit Routes Factsheet (PDF) Evacuation Routes (PDF) Glucometer Log (PDF) Hemocue Log (PDF) Medical Emergency, Earthquake, Fire Protocols (PDF) Sample of Sizes of Ambu Bags (PDF) Sample Oxygen Tank Set (PDF) Workplace Violence (PDF) (Back to FSR Menu) Adult Preventive Medical Record Review ACES Screening (PDF) Adult Health History (PDF) Adult Sterilization & Special Consent P&P (PDF) Alcohol Resources (PDF) AUDIT-C (PDF) Brief Addiction Monitor (BAM) (PDF) Comprehensive Pediatric and Adult Health Assessment Forms (PDF) PHQ-2 - Sample (PDF) PHQ-9 - Sample (PDF) Required Documentation Checklist for Adult (PDF) Social Needs Screening Tool (PDF) TB Risk Assessment Adult (PDF) (Back to FSR Menu) Clinical Services Facility Site Review Checklist for Safe Vaccine Storage and Handling (PDF) Clean and Dirty Sign (PDF) Controlled Substance Distribution Log (PDF) Controlled Substance Narcotic Log (PDF) Monthly Expiration Date & Verification Log (PDF) P&P Distribution of Sample Medications (PDF) Patient Distribution Log for Samples (PDF) Plan for Vaccine Protection in Case of Power Outage (PDF) Radiology - Notice to Employees (PDF) Sample Radiology Inspection Report (PDF) Vaccine Information Sheet (VIS) Protocol (PDF) Vaccine Storage (PDF) (Back to FSR Menu) Coordination of Care Medical Record Review Adult Progress Note - Sample (PDF) Missed Appointment Log - Sample (PDF) Pediatric Progress Note - Sample (PDF) (Back to FSR Menu) Documentation Medical Record Review Adult General Consent to Treat (PDF) Advance Health Care Directive Acknowledgement Form (PDF) CAIR Sharing Request (PDF) General Consent to Treat Minor (PDF) Medical Record Release (PDF) Sample Medication List (PDF) Signature Page - IEHP (PDF) (Back to FSR Menu) Format Medical Record Review Acknowledgment of Receipt of Notice of Privacy Practice (PDF) (Back to FSR Menu) Infection Control Facility Site Review AAP Infection Prevention and Control in Pediatric Ambulatory Settings - COVID (PDF) Autoclave Log (PDF) Biohazardous Sign (PDF) Bloodborne Pathogens & Post Exposure Plan - Fillable (PDF) Cleaning Schedule (PDF) Communicable Disease (ISOLATION) Protocol (PDF) Infection Control, Biohazardous Waste and Disposition of Patients with Contagious Disease (PDF) Instrument Transportation Log (PDF) Isolation & Transmissions Based Precautions (PDF) OSHA Employee Injury Report Form (PDF) P&P Autoclave (PDF) P&P Autoclaving Instruments in Peel (PDF) P&P Chemical Disinfection (PDF) P&P Cold Sterilization (PDF) P&P Transport for Reusable Instruments (PDF) Reusable Sharps Container (PDF) Safety Needle Fact Sheet (PDF) Sharps Injury Log Sample (PDF) Transfer Stations and Treatment Facilities (PDF) (Back to FSR Menu) OB/CPSP Preventive Medical Record Review CPSP Initial and Trimester Assessment and Care Plan (PDF) CPSP Postpartum Assessment and Care Plan (PDF) Edinburgh Postnatal Depression Scale (EPDS) (PDF) Required Documentation Checklist for OB (PDF) (Back to FSR Menu) Office Management Facility Site Review Access Standards (PDF) After Hour Script (PDF) CLAS Standards (PDF) Confidentiality Form (PDF) Fax Sheet (PDF) Medical Emergency, Earthquake, Fire Protocols (PDF) Medical Record Release (PDF) Office Hours Sample Form (PDF) On-Call Provider Schedule (PDF) PCP Referral Tracking Log (PDF) Referral Process (PDF) Sample Office Hours (PDF) Wait Time Survey Tool (PDF) (Back to FSR Menu) Pediatric Preventive Medical Record Review AAP Infection Prevention and Control in Pediatric Ambulatory Settings - COVID (PDF) AAP Schedule (PDF) AAP Supplemental Information (PDF) Alcohol Resources (PDF) AUDIT-C (PDF) Brief Addiction Monitor (BAM) (PDF) CDC BMI Growth Chart - Boys (PDF) CDC BMI Growth Chart - Girls (PDF) CDC Growth Chart Head Circumference - Boys (PDF) CDC Growth Chart Head Circumference - Girls (PDF) CDC Growth Chart Weight for Age - Boys (PDF) CDC Growth Chart Weight for Age - Girls (PDF) Child Health History - English (PDF) Child Health History - Spanish (PDF) Comprehensive Pediatric and Adult Health Assessment Forms (PDF) Edinburgh Postnatal Depression Scale (EPDS) (PDF) General Consent to Treat Minor (PDF) PEARLS Assessment (PDF) PEARLS Teen Self-Assessment (PDF) PHQ-2 - Sample (PDF) PHQ-A - Sample (PDF) Required Documentation Checklist for Pediatric (PDF) Social Needs Screening Tool (PDF) TB Risk Assessment Pediatrics (PDF) What Do You Eat (8-19 years) - English (PDF) What Do You Eat (8-19 years) - Spanish (PDF) What Does Your Child Eat (Birth - 8 years) - English (PDF) What Does Your Child Eat (Birth - 8 years) - Spanish (PDF) Youth Nutrition and Activity Assessment (8 - 19 years) (PDF) (Back to FSR Menu) Personnel Facility Site Review Accessibility Obligations of Medical Practices (PDF) Bloodborne Pathogens & Post Exposure Plan - Fillable (PDF) Domestic Violence (PDF) Electronic Resources for Required Employee Training (PDF) Employee File Checklist (PDF) IEHP Cultural and Linguistics Training (PDF) IEHP Evidence of Staff Training (PDF) IEHP Grievance Resolution Process - English (PDF) IEHP Grievance Resolution Process - Spanish (PDF) IEHP P&P Child Abuse Reporting (PDF) IEHP P&P Elder or Adult Abuse Reporting (PDF) IEHP P&P Sensitive Services-Access Standards (PDF) Medical Assistant Letter of Competency - Fillable (PDF) Medical Assistant Venipuncture Form (PDF) Medication Administration Procedures (PDF) Mid-level Supervision of Medical Assistant (PDF) Notice to Consumer PA Sign - English (PDF) Notice to Consumer PA Sign - Spanish (PDF) Notice to Consumer Sign - English (PDF) Notice to Consumer Sign - Spanish (PDF) SB697 Practice Agreement (PDF) SOC 341 (PDF) Standardized Procedures for Nurse Practitioner (PDF) Suspected Child Abuse Report (PDF) (Back to FSR Menu) Preventive Services Facility Site Review Pure Tone Audiometer (PDF) Sample Eye Chart (PDF) (Back to FSR Menu) Additional Documents Facility Site Review IEHP Phone List (PDF) (Back to FSR Menu) Additional Documents Medical Record Review Electronic Resources for Medical Record Review (PDF) (Back to FSR Menu) You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

Healthy Living - Coronavirus

how eating right and being active are the secrets to a long, healthy life. These are important. But there’s more you can do to stop disease. Finding health problems early gives you more treatment choices or a cure. That’s where health screenings come in.  Health screenings are vital for all people, from newborns to seniors. These tests are designed to look for signs that you may be at risk for certain conditions. They help spot health problems at an early stage, even if you do not have symptoms.  Types of cancer screenings Breast Cancer A mammogram is a breast X-ray. It can spot breast cancer early when it’s most treatable and when your chance of a cure is much higher. Both women and men can get breast cancer and should get screened every two years, starting at age 50. Those who are at high risk or would like to start screening at an earlier age can talk to their Doctor about starting screening at age 40. Cervical Cancer (Pap Smear)  The Pap test also known as a pap smear, can detect not normal cells on your cervix early enough so they can be treated before cancer has a chance to grow. The screening is recommended for woman ages 21-65 every 3-5 years, depending on the risk and type of screening. To schedule a screening, talk to your Doctor.  Colorectal Cancer Colorectal cancer affects the colon and the rectum. Screening can find and remove growths in these areas before they turn into cancer. Everyone ages 50-75 should get screened for colorectal cancer every 1-10 years, depending on risk and type of test used. Talk with your Doctor about which test is the best for you. Lung Cancer Screening for lung cancer with imaging (CT scan) in people who smoke or who have quit within the past 15 years, can help find cancer at an early stage. Catching it early keeps you healthy. A yearly screening is recommended for anyone ages 50-80 who smokes cigarettes or has quit smoking in the last 15 years.  If you’re due for a screening, call your Doctor today to schedule your appointment. Don’t wait. Take charge of your health! For help, call IEHP Member Services at 1-800-440-4347, Monday – Friday, 7 a.m. – 7 p.m., and Saturday-Sunday, 8 a.m. – 5 p.m.

CalAIM - Pay for Performance (P4P)

th Care Services (DHCS), California Advancing and Innovating Medi‐Cal (CalAIM) is a long‐term commitment to transform and strengthen Medi‐Cal, offering Californians a more equitable, coordinated, and person‐centered approach to maximizing their health and life trajectory.1 DHCS Goals For CalAIM 2 Identify and manage comprehensive needs through whole person care approaches and social drivers of health. Improve quality outcomes, reduce health disparities, and transform the delivery system through value-based initiatives, modernization, and payment reform. Make Medi‐Cal a more consistent and seamless system for enrollees to navigate by reducing complexity and increasing flexibility. Resource Links DHCS CalAIM page DHCS CalAIM Transformation Infographic (PDF) DHCS Medi-Cal Alignment Primer (PDF) IEHP Enhanced Care Management IEHP Enhanced Care Management (Member Page) IEHP Community Support Services IEHP Community Support Services (Member Page)   1,2https://dhcs.ca.gov/calaim You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

Plan Updates - Public Health Advisory

ory Syncytial Virus (RSV) and Seasonal Influenza Activity (PDF) October 25, 2022 - Riverside University Health Systems - Outbreak of Ebola Virus Disease Due to Sudan Virus in Central Uganda (PDF) October 21, 2022 - Riverside University Health Systems - Influenza (PDF) August 18, 2022 - Updated Monkeypox Guidance (PDF) August 18, 2022 - Riverside University Health System - Monkeypox Home Isolation Instructions (PDF) August 18, 2022 - CDC - Dear Colleague: 2022 Monkeypox Outbreak (PDF) July 19, 2022 - Updated Monkeypox Guidance (PDF) March 14, 2022 - Riverside County Legionnaires' Disease Advisory (PDF) February 24, 2022 - PHA Gonococcal Infections (PDF) February 1, 2022 - CHDP Upcoming Trainings (PDF) January 31, 2022 - San Bernardino County Black Infant Health Program - Two Locations (PDF) December 01, 2021 - San Bernardino County - Safe Sleep Video (Provided by Children's Network) November 05, 2021 - CDC - Expansion of Recall of LeadCare Blood Lead Tests Due to Risk of Falsely Low Results (PDF) March 05, 2021 - Health Alert: Ebola Virus Disease Outbreak (PDF) By clicking on the links below, you will be leaving the IEHP website.

Medicare DSNP Formulary Search Tool - IEHP DualChoice (HMO D-SNP) Formulary Search Tool

h Plan by searching for the exact name of the medication or by browsing our formulary database. You can also view the IEHP Medicare Formulary (PDF)  Additional resources to help you understand drug coverage information are available via your desktop at https://www.formularylookup.com or download the free mobile app from http://ios.formularylookup.com or http://android.formularylookup.com, If the prescription is not in IEHP's Formulary, providers may print and submit a new Prescription Drug Prior Authorization (Rx PA) Request Form or submit the Prescription Drug Prior Authorization Online.

Pharmacy Services - Pharmacy Quality Ratings

ated to help IEHP Members to find high-quality local pharmacies for your pharmacy services. This searchable system will display the rating of each participating pharmacy. The ratings range from 1 to 5 stars (with 1 being the lowest and 5 being the highest). What does the rating scale mean? The rating is on a scale of 1 to 5 stars (with 1 being the lowest and 5 being the highest).    Star Ratings Performance Description 1 Star Well below average 2 Stars Below average 3 Stars Average 4 Stars Good 5 Stars Exceptional No Star No information is available for this pharmacy Please keep in mind that Pharmacy Quality Star Rating is currently under development and may not reflect the most recent ratings of your Pharmacy at this time. IEHP Pharmacy Quality Rating is visible with IEHP "Find a Doctor, Urgent Care, or Pharmacy" webpage (select “Pharmacies” and put in your zip code or city, then hit “Find”). The quality rating information is displayed on the right side of each pharmacy. Information on this page is current as of January 1, 2022      

Pharmacy Services - Provider Communications

otices from most recent P&T Formulary changes to current PER processing changes, and even CME event invitations.  The published notifications are grouped respectively for: Provider Communication - Pharmacy Provider Communication - Physician

Medicare CMC Formulary Search Tool - IEHP DualChoice (HMO D-SNP) Formulary Search Tool

e Health Plan by searching for the exact name of the medication or by browsing our formulary database. You can also view the IEHP Medicare Formulary (PDF)  Additional resources to help you understand drug coverage information are available via your desktop at https://www.formularylookup.com or download the free mobile app from http://ios.formularylookup.com or http://android.formularylookup.com, If the prescription is not in IEHP's Formulary, providers may print and submit a new Prescription Drug Prior Authorization (Rx PA) Request Form or submit the Prescription Drug Prior Authorization Online.

Special Programs - Enhanced Care Management

addresses the clinical and non-clinical needs of high-need, high-cost IEHP Members through systematic coordination of services and comprehensive care management. ECM is a collaborative and interdisciplinary approach to providing intensive and comprehensive care management services to individuals. It serves to build on the Health Homes Program (HHP) and Whole Person Care (WPC) pilots and transitions those pilots to one larger program to provide a broader platform to build on positive outcomes from each program. ECM provides these vulnerable Members an additional care team to help coordinate and manage their care. The care team consists of a Nurse Care Manager, a Behavioral Health Care Manager, a Care Coordinator, and a Community Health Worker. These specially trained professionals collaborate with IEHP Members' Primary Care Physicians, Specialists, and family support systems to create a personalized plan of care. Beginning January 1, 2022, please direct eligible IEHP Members who need the ECM services to call IEHP Member Services at (800) 440-4347, Monday - Friday, 8am - 5pm. TTY users should call (800) 718-4347. If you have programmatic questions, please submit them to ECM@iehp.org. IEHP Enhanced Care Management Member Brochure (PDF) CalAIM Enhanced Care Management Policy Guide (PDF)   You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.