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Provider Resources - Forms

liance Delegation Oversight Audit (DOA) Grievance Growth Chart Health and Wellness  Historical Data Form Inland Regional Center Medi-Cal Letter Templates Medicare-Medicaid Plan Letter Templates D-SNP Letter Templates Medicare Non-Contracted Providers Perinatal Pharmacy Provider Preventable Conditions (PPC) Staying Healthy Assessment UM/CM Vision Other Behavioral Health ABA 6 Month and Exit Progress Report Template (Word) ABA Exit Letter Template (Word) ABA Service Hour Log (Word) ABA School BHT Services Request Form (Word) Authorization Release of Information Form - English (PDF) Authorization Release of Information Form - Spanish (PDF) Behavioral Health Authorization Request Form (PDF) BHT Social Skills Template (Word) Coordination of Care Treatment Plan Form (PDF) No Further Treatment Request Form (PDF) Psych Testing Battery Plan (for Psychologist use only) (PDF)  Claims For Integrated Denial Notices please click here. Please select on the links below to obtain the revised CMS 1500 form (version 02/12) and the CMS 1500 Reference Instruction Manual. Provider Identified Overpayment Form (PDF) Provider Identified Overpayment Form (Multiple) (PDF) Provider Dispute Resolution (PDR) (PDF) Claims Project Spreadsheet (Excel) Clean Claim Tool Guide - UB04 Inpatient Form (PDF) Clean Claim Tool Guide - UB04 Outpatient Form (PDF) Waiver of Liability Statement - IEHP Dual Choice (HMO D-SNP) - effective January 2023 (PDF) Revised CMS 1500 Health Insurance Claim Form (PDF) CMS 1500 Reference Instruction Manual (PDF) (Back to top) Compliance Member Incentive Forms Focus Group Incentive (FGI) - Request for Approval Form (PDF) Focus Group Incentive (FGI) - Evaluation Form (PDF) Member Incentive (MI) Program - Request for Approval (PDF) Member Incentive (MI) Program - Annual Update/End of Program Evaluation (PDF) Survey Incentive (SI) - Request for Approval Form (PDF) Survey Incentive (SI) - Evaluation Form (PDF) Nondiscrimination Language Nondiscrimination Language Access Notice: Medi-Cal (PDF) Medicare (PDF) (Back to top) Delegation Oversight Audit (DOA) Biographical Information Sheet Credentialing DOA Audit Tool HIPAA Security - Medi-Cal DOA HIPAA Security - Medicare Medi-Cal DOA Tool UM/CM/QI Medicare DOA Tool UM/CM/QI Medi-Cal UM Referral Template Sub-Contracted Facility/Agency Services and Delegated Functions (Back to top) Grievance The Grievance Forms below are for your Member's use when filing a complaint, or has an appeal regarding any aspect of care or service provided by you. Please select the Appeal and Grievance form appropriate for their use: Medi-Cal Form      English (PDF)      Spanish (PDF)      Chinese (PDF)      Vietnamese (PDF) Medicare Form      English (PDF)      Spanish (PDF)      Chinese (PDF)      Vietnamese (PDF) The following IEHP DualChoice (HMO D-SNP) Letters will be effective January 1, 2023:      English (PDF)      Spanish (PDF)      Chinese (PDF)      Vietnamese (PDF) (Back to top) Growth Chart Inland Empire Health Plan (IEHP) offers you easy access to useful reference materials and forms you may need. It's just one click away. Select the growth chart form that you need by clicking on the link below: (0-36 months): Head Circumference-For-Age And Weight- For-Length Percentiles           Boys (PDF)          Girls (PDF) (0-36 months): Length and Weight-For-Age Percentiles           Boys (PDF)          Girls (PDF) (2-20 years): Stature and Weight-For-Age-Percentiles           Boys (PDF)         Girls (PDF) (2-20 years): Body Mass Index For-Age Percentiles           Boys (PDF)          Girls (PDF) (Back to top) Health and Wellness DPP Rx Pad (PDF) (Back to top)   Historical Data Form Historical Data Form (PDF) (Back to top) Inland Regional Center Early Start (0-36 months) Referral (PDF) Early Start Online Application Eligibility and Intake IRC Referrals (3-99+ years): San Bernardino County: For Providers - (909) 890-4711 // Intake - (909) 890-3148 Riverside County: For Providers - (909) 890-4763 // Intake - (951) 826-2648 (Back to top) Medi-Cal Letter Templates A complete template includes all documents listed under each template in the order specified listed. Changes can only be made to highlighted areas, any changes made outside of the highlighted areas are strictly prohibited by DHCS. Click on the title to expand the menu and download desired document. Member Authorization Letter English Last Updated: 09/20/2022 Spanish Last Updated: 09/20/2022   Chinese Last Updated: 09/20/2022   Vietnamese Last Updated: 09/20/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 Continuity of Care Authorization Letter English Last Updated: 09/20/2022   Spanish Last Updated: 09/20/2022   Chinese Last Updated: 09/20/2022   Vietnamese Last Updated: 09/20/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 Notice of Action – Carve Out English Last Updated: 12/29/2022   Spanish Last Updated: 12/29/2022   Chinese Last Updated: 12/29/2022   Vietnamese Last Updated: 12/29/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 Notice of Action - Delay English Last Updated: 12/27/2022   Spanish Last Updated: 12/27/2022   Chinese Last Updated: 12/27/2022   Vietnamese Last Updated: 12/27/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 Notice of Action - Deny English Last Updated: 12/27/2022   Spanish Last Updated: 12/27/2022   Chinese Last Updated: 12/27/2022   Vietnamese Last Updated: 12/27/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 Notice of Action - Modify English Last Updated: 12/28/2022   Spanish Last Updated: 12/28/2022   Chinese Last Updated: 12/28/2022   Vietnamese Last Updated: 12/28/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 Notice of Action - Terminate English Last Updated: 01/06/2023   Spanish Last Updated: 01/06/2023   Chinese Last Updated: 01/06/2023   Vietnamese Last Updated: 01/06/2023   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 Other Health Care Coverage Requesting Provider Letter English Last Updated: 03/17/2021   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 Continuity of Care Terminate Letter English Last Updated: 09/20/2022   Spanish Last Updated: 09/20/2022   Chinese Last Updated: 09/20/2022   Vietnamese Last Updated: 09/20/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 Specialist Termination Letter English Last Updated: 09/20/2022   Spanish Last Updated:09/20/2022   Chinese Last Updated:09/20/2022   Vietnamese Last Updated:09/20/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 Prior Authorization Not Required English Last Updated: 09/20/2022   Spanish Last Updated:09/20/2022   Chinese Last Updated:09/20/2022   Vietnamese Last Updated:09/20/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 (Back to top) Medicare-Medicaid Plan Letter Templates A complete template includes all documents listed under each template in the order specified listed. Changes can only be made to highlighted areas, any changes made outside of the highlighted areas are strictly prohibited by CMS. Click on the title to expand the menu and download desired document. Carve-Out Information Letter English Last Updated: 11/12/2017   Spanish Last Updated: 10/31/2017   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Denial Reason Matrix English Last Updated: 07/03/2018   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Detailed Explanation of Non-Coverage English Last Updated: 12/17/2021   Spanish Last Updated: 12/17/2021   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Detailed Notice of Discharge English Last Updated: 12/17/2021   Spanish Last Updated: 12/17/2021   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Expedited Criteria Not Met English Last Updated: 10/31/2017   Spanish Last Updated: 10/31/2017   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Extension Needed for Additional Information English Last Updated: 10/31/2017   Spanish Last Updated: 10/31/2017   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Integrated Denial Notice - Part B Drugs - 7 day appeal - IPA English Last Updated: 02/14/2022   Spanish Last Updated: 02/14/2022   Chinese Last Updated: 02/14/2022   Vietnamese Last Updated: 02/14/2022   Independent Medical Review - [English] [Spanish] [Chinese] [Vietnamese] Updated October 7, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Integrated Denial Notice - Part C - 30 day appeal - IPA English Last Updated: 03/08/2022   Spanish Last Updated: 02/14/2022   Chinese Last Updated: 02/14/2022   Vietnamese Last Updated: 02/14/2022   Independent Medical Review - [English] [Spanish] [Chinese] [Vietnamese] Updated October 7, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Integrated Denial of Payment Notice - 7 day appeal - IPA English Last Updated: 03/17/2021   Spanish Last Updated: 10/18/2021   Independent Medical Review - [English] [Spanish] [Chinese] [Vietnamese] Updated October 7, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Integrated Denial of Payment Notice - 30 day appeal - IPA English Last Updated: 03/17/2021   Spanish Last Updated: 04/12/2017   Independent Medical Review - [English] [Spanish] [Chinese] [Vietnamese] Updated October 7, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Notice of Authorization of Services English Last Updated: 10/31/2017   Spanish Last Updated: 10/31/17   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Notice of Dismissal of Coverage English Last Updated:03/10/2022   Spanish Last Updated:03/10/2022   Chinese Last Updated:03/10/2022   Vietnamese Last Updated:03/10/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Notice of Medicare Non-Coverage English Last Updated: 10/31/2017   Spanish Last Updated: 10/31/2017   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Notice of Reinstatement of Coverage English Last Updated: 10/31/2017   Spanish Last Updated: 10/31/2017   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 (Back to top) NEW D-SNP Letter Templates These templates should not be used until the effective date of January 2, 2023. Please continue using the current Medicare DualChoice letter templates currently seen on this webpage for the remainder of 2022. A complete template includes all documents listed under each template in the order specified listed. Changes can only be made to highlighted areas, any changes made outside of the highlighted areas are strictly prohibited by CMS. Click on the title to expand the menu and download desired document. AOR Dismissal Letter English Last Updated: 09/26/2022   Spanish Last Updated:09/26/2022   Chinese Last Updated:09/26/2022   Vietnamese Last Updated:09/26/2022   Multi-Language Insert - [All Languages] Updated July 26, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated September 07, 2022 AOR Request Letter English Last Updated: 09/26/2022   Spanish Last Updated:09/26/2022   Chinese Last Updated:09/26/2022   Vietnamese Last Updated:09/26/2022   Multi-Language Insert - [All Languages] Updated July 26, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated September 07, 2022 Continuity of Care - Notice of Authorization English Last Updated: 09/26/2022   Spanish Last Updated:09/26/2022   Chinese Last Updated:09/26/2022   Vietnamese Last Updated:09/26/2022   Multi-Language Insert - [All Languages] Updated July 26, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated September 07, 2022 Continuity of Care – Notice of Termination English Last Updated: 09/26/2022   Spanish Last Updated:09/26/2022   Chinese Last Updated:09/26/2022   Vietnamese Last Updated:09/26/2022   Multi-Language Insert - [All Languages] Updated July 26, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated September 07, 2022 Detailed Explanation of Non-Coverage English Last Updated: 09/26/2022   Spanish Last Updated:09/26/2022   Chinese Last Updated:09/26/2022   Vietnamese Last Updated:09/26/2022   Multi-Language Insert - [All Languages] Updated July 26, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated September 07, 2022 Detailed Notice of Discharge English Last Updated: 12/20/2022   Spanish Last Updated:12/20/2022   Chinese Last Updated:12/20/2022   Vietnamese Last Updated:12/20/2022   Multi-Language Insert - [All Languages] Updated July 26, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated September 07, 2022 Expedited Criteria Not Met English Last Updated: 09/26/2022   Spanish Last Updated: 09/26/2022   Chinese Last Updated: 09/26/2022   Vietnamese Last Updated: 09/26/2022   Multi-Language Insert - [All Languages] Updated July 26, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated September 07, 2022 Extension Needed for Additional Information English Last Updated: 09/26/2022   Spanish Last Updated: 09/26/2022   Chinese Last Updated: 09/26/2022   Vietnamese Last Updated: 09/26/2022   Multi-Language Insert - [All Languages] Updated July 26, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated September 07, 2022 Informational Letter to Beneficiary and PCP English Last Updated: 09/26/2022   Spanish Last Updated: 09/26/2022   Chinese Last Updated: 09/26/2022   Vietnamese Last Updated: 09/26/2022   Multi-Language Insert - [All Languages] Updated July 26, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated September 07, 2022 Notice of Authorization of Services English Last Updated: 09/27/2022   Spanish Last Updated: 09/27/2022   Chinese Last Updated: 09/27/2022   Vietnamese Last Updated: 09/27/2022   Multi-Language Insert - [All Languages] Updated July 26, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated September 07, 2022 Notice of Dismissal of Coverage Request English Last Updated: 09/26/2022   Spanish Last Updated: 09/26/2022   Chinese Last Updated: 09/26/2022   Vietnamese Last Updated: 09/26/2022   Multi-Language Insert - [All Languages] Updated July 26, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated September 07, 2022 Notice of Medicare Non-Coverage English Last Updated:09/27/2022   Spanish Last Updated:09/27/2022   Chinese Last Updated:09/27/2022   Vietnamese Last Updated:09/27/2022   Multi-Language Insert - [All Languages] Updated July 26, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated September 07, 2022 Cancelled Relocation Letter English Last Updated: 09/22/2022   Spanish Last Updated:09/22/2022   Chinese Last Updated:09/22/2022   Vietnamese Last Updated:09/22/2022   Multi-Language Insert - [All Languages] Updated July 26, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated September 07, 2022 Long-Term Care IPA and PCP Change Letter English Last Updated: 09/26/2022   Spanish Last Updated:09/26/2022   Chinese Last Updated:09/26/2022   Vietnamese Last Updated:09/26/2022   Multi-Language Insert - [All Languages] Updated July 26, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated September 07, 2022 Coverage Decision Letter Part B - 7 Day Appeal English Last Updated: 10/03/2022   Spanish Last Updated:10/03/2022   Chinese Last Updated:10/03/2022   Vietnamese Last Updated:10/03/2022   *Additional Information for IPAs: Please include the integrated Coverage Decision Letter, the most recent IMR form, application instructions, DMHC’s toll-free telephone number, and an envelope addressed to DMHC. Multi-Language Insert - [All Languages] Updated July 26, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated September 07, 2022 Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated January 01, 2023 State Fair Hearing Form - [English] [Spanish] [Chinese] [Vietnamese] Updated September 01, 2021 Coverage Decision Letter Medical – 30 Day Appeal English Last Updated: 10/03/2022   Spanish Last Updated:10/03/2022   Chinese Last Updated:10/03/2022   Vietnamese Last Updated:10/03/2022   *Additional Information for IPAs: Please include the integrated Coverage Decision Letter, the most recent IMR form, application instructions, DMHC’s toll-free telephone number, and an envelope addressed to DMHC. Multi-Language Insert - [All Languages] Updated July 26, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated September 07, 2022 Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated January 01, 2023 State Fair Hearing Form - [English] [Spanish] [Chinese] [Vietnamese] Updated September 01, 2021 Coverage Decision Letter - Claims English Last Updated: 11/22/2022   Spanish Last Updated:11/22/2022   Chinese Last Updated:11/22/2022   Vietnamese Last Updated:11/22/2022   Multi-Language Insert - [All Languages] Updated July 26, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated September 07, 2022   (Back to top) Medicare Certificates of Medical Necessity (CMN) & DME Information Forms (DIF) Positive Airway Pressure Devices for Obstructive Sleep Apnea (PDF) Enteral and Parenteral Nutrition (PDF) External Infusion Pump (PDF) Osteogenesis Stimulators (PDF) Oxygen (PDF) Seat Lift Mechanisms (PDF) Continuation Form (PDF) Transcutaneous Electrical Nerve Stimulator (TENS) (PDF) Pneumatic Compression Device (PDF) (Back to top) Non-Contracted Providers To submit a referral to IEHP, please fill out the referral form below, include all clinical notes and fax it to IEHP. If you are referring back to yourself, please indicate such. If you need IEHP to direct the referral, please indicate that on the form. Referral Authorization Request Form - Non-Contracted Providers (PDF) If you are interested in becoming a network Provider, please click here. (Back to top) Perinatal IEHP provides standard risk assessment forms that can be used by all Providers of obstetrical (OB) services. Please refer to IEHP Provider Policy 10D1, "Obstetrical Services, Guidelines for Obstetrical Services" for further detail. To obtain copies, simply click on the links below. Edinburgh Postnatal Depression Screening Tool - English (PDF) Edinburgh Postnatal Depression Screening Tool - Spanish (PDF) ACOG Antepartum Record (PDF) (Back to top) Pharmacy Click here for Pharmacy forms. (Back to top) Provider Preventable Conditions (PPC) By clicking on these links, you will be leaving the IEHP website. On May 23,2017, the Department of Healthcare Services (DHCS) released All Plan Letter (APL) 17-009, reporting requirements related to Provider Preventable Conditions. In conjunction, DHCS released Dual Plan Letter (DPL) 17-002. As part of these instructions, the Health Plan, Network Providers, Delegates, Contracted Hospitals, and ambulatory surgical centers must report using PPC Form on DHCS secure online portal for both Medicare and Medi-Cal lines of business. Further information is available on the following pages: Instructions for Completing Online Reporting of PPCs Medi-Cal Guidance on Reporting Provider-Preventable Conditions Frequently Asked Questions All Plan Letter (APL) 17-009 Duals Plan Letter (DPL) 17-002 PPC Form Medicare and Medi-Cal lines of business must follow the instructions below: Providers are REQUIRED to send a copy of the completed PPC submission from the DHCS secure online portal to IEHP by fax at (909) 890-5545 within five (5) business days of reporting to DHCS; IEHP does not pay Provider claims nor reimburse a Provider for a PPC, in accordance with 42 CFR Section 438.3(g) and IEHP's three-way Cal MediConnect contract. Per IEHP policy and the Coordinated Care Initiative 3-Way Contract, IEHP reserves the right to recover or recoup any claim related to a PPC; As outlined in both the APL/DPL - Reporting Requirements related to Provider Preventable Conditions, the following classify as PPCs and must be reported: Category 1 - HCACs (For Any Inpatient Hospital Setting in Medicaid) Any unintended foreign object retained after surgery A clinically significant air embolism An incidence of blood incompatibility A stage III or stage IV pressure ulcer that developed during the patient's stay in the hospital A significant fall or trauma that resulted in fracture, dislocation, intracranial injury, crushing injury, burn, or electric shock A catheter-associated urinary tract infection Vascular catheter-associated infection Any of the following manifestations of poor glycemic control: diabetic ketoacidosis; nonketotic hyperosmolar coma; hypoglycemic coma; secondary diabetes with ketoacidosis; or secondary diabetes with hyperosmolarity A surgical site infection following: Coronary artery bypass graft (CABG) - mediastinitis Bariatric surgery; including laparoscopic gastric bypass, gastroenterostomy, laparoscopic gastric restrictive surgery Orthopedic procedures; including spine, neck, shoulder, elbow Cardiac implantable electronic device procedures Deep vein thrombosis/pulmonary embolism following total knee replacement or hip replacement with pediatric and obstetric exceptions Latrogenic pneumothorax with venous catheterization A vascular catheter-associated infection Category 2 - Other Provider Preventable Conditions (For Any Health Care Setting) Wrong surgical or other invasive procedure performed on a patient Surgical or other invasive procedure performed on the wrong body part Surgical or other invasive procedure performed on the wrong patient (Back to top) Staying Healthy Assessment PCPs are responsible for assuring the Staying Healthy Assessment (SHA) Questionnaire is administered during the Initial Health Assessment to each IEHP Member within 120 days of the Member's enrollment. The SHA Questionnaire is available in over nine different languages and in nine separate age categories.  Printed English and Spanish versions are available through your IPA or you can get the forms you need by using the menu below. Please see the PDFs below in the language of your choice. 7098 A    0-6 Months  Select Language: English, Spanish, Arabic, Armenian, Chinese, Hmong, Korean, Russian, Tagalog, Vietnamese 7098 B    7-12 Months  Select Language: English, Spanish, Arabic, Armenian, Chinese,  Hmong, Korean, Russian, Tagalog, Vietnamese 7098 C    1-2 Years Select Language: English, Spanish, Arabic, Armenian, Chinese,  Hmong, Korean, Russian, Tagalog, Vietnamese 7098 D    3-4 Years Select Language: English, Spanish, Arabic, Armenian, Chinese,  Hmong, Korean, Russian, Tagalog, Vietnamese 7098 E    5-8 Years Select Language: English, Spanish, Arabic, Armenian, Chinese,  Hmong, Korean, Russian, Tagalog, Vietnamese 7098 F    9-11 Years Select Language: English, Spanish, Arabic, Armenian, Chinese,  Hmong, Korean, Russian, Tagalog, Vietnamese 7098 G    12-17 Years Select Language: English, Spanish, Arabic, Armenian, Chinese,  Hmong, Korean, Russian, Tagalog, Vietnamese 7098 H    Adult Select Language: English, Spanish, Arabic, Armenian, Chinese,  Hmong, Korean, Russian, Tagalog, Vietnamese 7098 I    Senior  Select Language: English, Spanish, Arabic, Armenian, Chinese,  Hmong, Korean, Russian, Tagalog, Vietnamese (Back to top) UM/CM Acute Hospital Discharge Needs Request Form (PDF) Authorization for Use and/or Disclosure of Patient Health Information - English (PDF) Authorization for Use and/or Disclosure of Patient Health Information - Spanish (PDF) Care Management Referral Form (PDF) Consent for HIV Test - English (PDF) Consent for HIV Test - Spanish (PDF) Health Risk Assessment (HRA) - IEHP DualChoice (CMC) - English (PDF) Health Risk Assessment (HRA) - IEHP DualChoice  (CMC)- Spanish (PDF) Health Risk Assessment (HRA) - IEHP DualChoice (HMO D-SNP) - English (PDF) - effective 1/1/2023 Health Risk Assessment (HRA) - IEHP DualChoice (HMO D-SNP) - Spanish (PDF) - effective 1/1/2023 Health Risk Assessment (HRA) - IEHP DualChoice (HMO D-SNP) - Chinese (PDF) - effective 1/1/2023 Health Risk Assessment (HRA) - IEHP DualChoice (HMO D-SNP) - Vietnamese (PDF) - effective 1/1/2023 HIV Testing Sites - Riverside and San Bernardino (PDF) Home Health Check Off List (PDF) Home Modification Consent Form (PDF) Long Term Care (LTC) Data Sheet (PDF) Non-Emergency Medical Transportation (NEMT) Physician Certification Statement (PCS) (PDF) Referral Form (PDF) Service Request for Skilled Nursing Facilities (PDF) SNF Initial Review (PDF) SNF Follow-up Review (PDF) Standing Referral and Extended Access Referral to Specialty Care (PDF) Sterilization Consent Form PM-330 PM-330 Form - Tips and Example (PDF) PM-330 Form - English (PDF) PM-330 Form - Spanish (PDF) Transportation Requests Form (SNF & LTC) (PDF) Transportation Requests Form (Hospital) (PDF) Wound Assessment - Admission (PDF) Wound Assessment - Follow - Up (PDF) Wound Assessment - Addendum (PDF) (Back to top) Vision Ophthalmologist Referral Form (PDF) Vision Exception Request (VER) Form (PDF) PCP Vision Report Form (PDF) IEHP Lab Form (PDF) Medi-Cal Non-Covered Services/Materials Waiver Form-English (PDF) Medi-Cal Non-Covered Services/Materials Waiver Form-Spanish (PDF) Medi-Cal Non-Covered Services/Materials Waiver Form-Chinese (PDF) Medi-Cal Non-Covered Services/Materials Waiver Form-Vietnamese (PDF) The following IEHP DualChoice (HMO D-SNP) Letters will be effective January 1, 2023: IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-English (PDF) IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-Spanish (PDF) IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-Chinese (PDF) IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-Vietnamese (PDF) (Back to top) Other Authorization of Release - Use & Disclosure of PHI - English (PDF) Authorization of Release - Use & Disclosure of PHI - Spanish (PDF) CMS 1696 Appointment of Representative - English (PDF) CMS 1696 Appointment of Representative - Spanish (PDF) Contracts Maintenance Request Form (PDF) Provider Services Materials Request Form (PDF) 2017 Model Output Report (MOR) Data File Layout (PDF) (Back to top) You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

Provider Manuals - 2023 Manuals

Provider Manual - Medi-Cal Provider Manual - IEHP DualChoice (HMO D-SNP) Summary of Effected Changes - Medi-Cal Summary of Effected Changes - IEHP DualChoice (HMO D-SNP) Benefit Manuals EDI Manual Regulatory Trainings 2023 Acknowledgement of Receipt Provider Manuals The Inland Empire Health Plan (IEHP) Provider Policy and Procedure is designed to help IEHP's Contracted Entities (Providers) understand how IEHP works and understand the rules and regulations IEHP must comply with, as governed by the California Department of Health Care Services (DHCS), California Department of Managed Health Care (DMHC), California Managed Risk Medical Insurance Board (MRMIB) and the Centers for Medicare and Medicaid Services (CMS). The provisions of these Provider Manuals must be adhered by all of IEHP's Providers. Provider Manual - Medi-Cal 00 - Table of Contents and Introduction (PDF) 01 - Organizational Structure (PDF) 02 - Committee Overview (PDF) 03 - Enrollment and Assignment (PDF)  04 - Eligibility and Verification (PDF) 05 - Credentialing and Recredentialing (PDF)  06 - Facility Site Review (PDF) 07 - Medical Records Requirements (PDF) 08 - Infection Control (PDF) 09 - Access Standards (PDF)  10 - Medical Care Standards (PDF) 11 - Pharmacy (PDF)  12 - Coordination of Care (PDF) 13 - Quality Management (PDF) 14 - Utilization Management (PDF)  15 - Health Education (PDF) 16 - Grievance and Appeals Resolution System (PDF) 17 - Member Transfers and Disenrollment (PDF) 18 - Provider Network (PDF)  19 - Finance and Reimbursement (PDF) 20 - Claims Processing (PDF) 21 - Encounter Data Reporting (PDF)  22 - Rights and Responsibilities (PDF) 23 - Compliance (PDF) 24 - Program Descriptions (PDF)  25 - Delegation and Oversight (PDF)  26 - Quick Reference (PDF)  Summary of Effected Changes (PDF) - Published: September 30, 2022 (Back to top) Provider Manual - IEHP DualChoice (HMO D-SNP) 00 - Table of Contents and Introduction (PDF)  01 - Organizational Structure (PDF) 02 - Committee Overview (PDF)  03 - Enrollment and Assignment (PDF)  04 - Eligibility and Verification (PDF) 05 - Credentialing and Recredentialing (PDF) 06 - Facility Site Review (PDF) 07 - Medical Records Requirements (PDF) 08 - Infection Control (PDF) 09 - Access Standards (PDF)  10 - Medical Care Standards (PDF) 11 - Pharmacy (PDF) 12 - Coordination of Care (PDF)  13 - Quality Management (PDF)  14 - Utilization Management (PDF)  15 - Health Education (PDF) 16 - Grievance and Appeals Resolution System (PDF) 17 - Member Transfers and Disenrollment (PDF) 18 - Provider Network (PDF)  19 - Finance and Reimbursement (PDF) 20 - Claims Processing (PDF) 21 - Encounter Data Reporting (PDF)  22 - Rights and Responsibilities (PDF) 23 - Compliance (PDF) 24 - Program Descriptions (PDF)  25 - Delegation and Oversight (PDF)  26 - Quick Reference (PDF)  Summary of Effected Changes (PDF) - Published: September 30, 2022 (Back to top) Benefits These Benefit Manuals are offered as guidelines to determine benefit eligibility and are not intended to be construed as or to serve as a standard of medical care, or as a contractual agreement for payment. Standards of medical care are determined on the basis of all facts and circumstances for each individual case. Benefit Manual Information The subheadings “Examples of Covered Benefits” and “Examples of Non-Covered Benefits” are meant to give specific examples but are not intended to be an all-inclusive list of examples, unless specified in the text of the benefit. 2023 Medi-Cal 2023 IEHP DualChoice (HMO D-SNP) and Plan Benefits and Cost Sharing  If a benefit question is not addressed in the Benefit Manual, please contact IEHP at (909) 890-2000 for further information. (Back to top) Electronic Data Interchange (EDI) The manual documents the procedures, protocols and formats for electronic data exchange between IEHP and its contracted Providers related to Member eligibility, encounter data, bed-day reporting, capitation reports and electronic claims submissions. The following sections document the processing schedules, file formats, procedures and narrative information that is necessary for Providers to understand and conduct electronic data exchange that is HIPAA compliant which is required under the IEHP Agreement. EDI Manual 00 - Table of Contents (PDF) 01 - General Information (PDF) 02 - Getting Started (PDF) 03 - Eligibility Processing Procedures (PDF) 04 - Encounter Data Processing Procedures (PDF) 05 - Capitation Processing Procedures (PDF) 06 - Claims EDI Processing Procedures (PDF) 07 - Timeframe and Schedules (PDF)  08 - IEHP 5010 837I Institutional IEHP DualChoice Encounter Companion Guide (PDF)  09 - IEHP 5010 837I Institutional Medi-Cal Encounter Companion Guide (PDF) 10 - IEHP 5010 837P Professional IEHP DualChoice Encounter Companion Guide (PDF)  11 - IEHP 5010 837P Professional Medi-Cal Encounter Companion Guide (PDF) 12 - IEHP 5010 837I Institutional Claims Companion Guide (PDF) 13 - IEHP 5010 837P Professional Claims Companion Guide (PDF) 14 - Authorization Data Exchange (PDF) 15 - IEHP 5010 834 Standard Companion Guide (PDF)  16 - IEHP 835 Standard Companion Guide (PDF) 17 - IEHP Misdirected Outbound Professional Claims Companion Guide (PDF) 18 - IEHP Misdirected Outbound Institutional Claims Companion Guide (PDF)  For comments, questions about this manual or technical support, contact the IEHP IT Help Desk at (909) 890-2025 or by email at: HELPDESK@iehp.org. (Back to top) Regulatory Trainings Code of Business Conduct and Ethics (PDF) Compliance Training (FWA, HIPAA Privacy and Security) (PDF) Cultural and Linguistics (C & L) Training (PDF) IEHP DualChoice (HMO D-SNP) Model of Care Training (PDF) IEHP DualChoice (HMO D-SNP) Model of Care Training (HTML) (Back to top) 2023 Acknowledgement of Receipt Provider eAOR Providers are encouraged to attest electronically using the following recommended browsers: Google Chrome, Microsoft Edge, Mozilla Firefox How-To Guide for Provider eAOR (PDF) FAQs for Provider eAOR (PDF) Provider AOR (PDF) Hospital AOR (PDF) Delegate AOR (PDF) (Back to top)   You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

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Dual Choice Cal MediConnect Plan (Medicare-Medicaid Plan).

- Urgent Care

HP Dual Choice Cal MediConnect Plan (Medicare-Medicaid Plan).

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