Search Results For : " KAA77788SEADJOA0 "
Upcoming Events - With Every Heartbeat is Life: Get Energized! Say Yes to Physical Activity (San Bernardino)
ll learn:
Why physical activity is good for their hart and overall health
About different types of physical activity
How much physical activity adults and children need
Ways to fit physical activity into their schedule
Click here to register for this in-person class
Location
San Bernardino Community Seventh-day Adventist Church
1696 N. G St.
San Bernardino, CA 92405
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) - [APPROVED] [REDLINE]
01 - Organizational Structure (PDF) - [APPROVED] [REDLINE]
02 - Committee Overview (PDF) - [APPROVED] [REDLINE]
03 - Enrollment and Assignment (PDF) - [APPROVED] [REDLINE]
04 - Eligibility and Verification (PDF) - [APPROVED] [REDLINE]
05 - Credentialing and Recredentialing (PDF) - [APPROVED] [REDLINE]
06 - Facility Site Review (PDF) - [APPROVED] [REDLINE]
07 - Medical Records Requirements (PDF) - [APPROVED] [REDLINE]
08 - Infection Control (PDF) - [APPROVED] [REDLINE]
09 - Access Standards (PDF) - [APPROVED] [REDLINE]
10 - Medical Care Standards (PDF) - [APPROVED] [REDLINE]
11 - Pharmacy (PDF) - [APPROVED] [REDLINE]
12 - Coordination of Care (PDF) - [APPROVED] [REDLINE]
13 - Quality Management (PDF) - [APPROVED] [REDLINE]
14 - Utilization Management (PDF) - [APPROVED] [REDLINE]
15 - Health Education (PDF) - [APPROVED] [REDLINE]
16 - Grievance and Appeals Resolution System (PDF) - [APPROVED] [REDLINE]
17 - Member Transfers and Disenrollment (PDF) - [APPROVED] [REDLINE]
18 - Provider Network (PDF) - [APPROVED] [REDLINE]
19 - Finance and Reimbursement (PDF) - [APPROVED] [REDLINE]
20 - Claims Processing (PDF) - [APPROVED] [REDLINE]
21 - Encounter Data Reporting (PDF) - [APPROVED] [REDLINE]
22 - Rights and Responsibilities (PDF) - [APPROVED] [REDLINE]
23 - Compliance (PDF) - [APPROVED] [REDLINE]
24 - Program Descriptions (PDF) - [APPROVED] [REDLINE]
25 - Delegation and Oversight (PDF) - [APPROVED] [REDLINE]
26 - Quick Reference (PDF) - [APPROVED] [REDLINE]
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) - [APPROVED] [REDLINE]
01 - Organizational Structure (PDF) - [APPROVED] [REDLINE]
02 - Committee Overview (PDF) - [APPROVED] [REDLINE]
03 - Enrollment and Assignment (PDF) - [APPROVED] [REDLINE]
04 - Eligibility and Verification (PDF) - [APPROVED] [REDLINE]
05 - Credentialing and Recredentialing (PDF) - [APPROVED] [REDLINE]
06 - Facility Site Review (PDF) - [APPROVED] [REDLINE]
07 - Medical Records Requirements (PDF) - [APPROVED] [REDLINE]
08 - Infection Control (PDF) - [APPROVED] [REDLINE]
09 - Access Standards (PDF) - [APPROVED] [REDLINE]
10 - Medical Care Standards (PDF) - [APPROVED] [REDLINE]
11 - Pharmacy (PDF) - [APPROVED] [REDLINE]
12 - Coordination of Care (PDF) - [APPROVED] [REDLINE]
13 - Quality Management (PDF) - [APPROVED] [REDLINE]
14 - Utilization Management (PDF) - [APPROVED] [REDLINE]
15 - Health Education (PDF) - [APPROVED] [REDLINE]
16 - Grievance and Appeals Resolution System (PDF) - [APPROVED] [REDLINE]
17 - Member Transfers and Disenrollment (PDF) - [APPROVED] [REDLINE]
18 - Provider Network (PDF) - [APPROVED] [REDLINE]
19 - Finance and Reimbursement (PDF) - [APPROVED] [REDLINE]
20 - Claims Processing (PDF) - [APPROVED] [REDLINE]
21 - Encounter Data Reporting (PDF) - [APPROVED] [REDLINE]
22 - Rights and Responsibilities (PDF) - [APPROVED] [REDLINE]
23 - Compliance (PDF) - [APPROVED] [REDLINE]
24 - Program Descriptions (PDF) - [APPROVED] [REDLINE]
25 - Delegation and Oversight (PDF) - [APPROVED] [REDLINE]
26 - Quick Reference (PDF) - [APPROVED] [REDLINE]
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) - [APPROVED] [REDLINE]
01 - General Information (PDF) - [APPROVED] [REDLINE]
02 - Getting Started (PDF) - [APPROVED] [REDLINE]
03 - Eligibility Processing Procedures (PDF) - [APPROVED] [REDLINE]
04 - Encounter Data Processing Procedures (PDF) - [APPROVED] [REDLINE]
05 - Capitation Processing Procedures (PDF) - [APPROVED] [REDLINE]
06 - Claims EDI Processing Procedures (PDF) - [APPROVED] [REDLINE]
07 - Timeframe and Schedules (PDF) - [APPROVED] [REDLINE]
08 - IEHP 5010 837I Institutional IEHP DualChoice Encounter Companion Guide (PDF) - [APPROVED] [REDLINE]
09 - IEHP 5010 837I Institutional Medi-Cal Encounter Companion Guide (PDF) - [APPROVED] [REDLINE]
10 - IEHP 5010 837P Professional IEHP DualChoice Encounter Companion Guide (PDF) - [APPROVED] [REDLINE]
11 - IEHP 5010 837P Professional Medi-Cal Encounter Companion Guide (PDF) - [APPROVED] [REDLINE]
12 - IEHP 5010 837I Institutional Claims Companion Guide (PDF) - [APPROVED] [REDLINE]
13 - IEHP 5010 837P Professional Claims Companion Guide (PDF) - [APPROVED] [REDLINE]
14 - Authorization Data Exchange (PDF) - [APPROVED] [REDLINE]
15 - IEHP 5010 834 Standard Companion Guide (PDF) - [APPROVED] [REDLINE]
16 - IEHP 835 Standard Companion Guide (PDF) - [APPROVED] [REDLINE]
17 - IEHP Misdirected Outbound Professional Claims Companion Guide (PDF) - [APPROVED] [REDLINE]
18 - IEHP Misdirected Outbound Institutional Claims Companion Guide (PDF) -[APPROVED] [REDLINE]
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.
P4P - Proposition 56 - GEMT - Pay for Performance (P4P)
(IEHP) Pay for Performance
program, also known as P4P. IEHP’s P4P was designed to increase the provision of preventive health
services to
IEHP Members as well as improve HEDIS® results to ensure that all IEHP Direct DualChoice
Members
receive timely annual assessment visits with an emphasis on review and management of chronic illnesses.
IEHP Direct PCPs will be reimbursed directly by IEHP through the
DualChoice Annual Visit program. PCPs participating in IEHP's network through an IPA only are not eligible for
this
program:
Overview
(PDF)
DualChoice Annual Visit (PDF)
To learn more about P4P IEHP DualChoice Annual Visit, contact a Provider Services
Representative at (909) 890-2054.
Click on the following links to jump to that specific section:
Provider Quality Incentives Brochure
Medicare P4P IEHP Direct
IEHP Direct Stars Incentive Program
D-SNP Model of Care Incentive Program
Global Quality P4P Program
OB/GYN
P4P
Program
Hospital P4P Program
Provider Quality Incentives Brochure
Inland Empire Health Plan (IEHP) is pleased to announce the 2023 Provider Quality Incentive Brochure.
2023 Provider Quality Incentive Brochure (PDF) | September 27, 2023
(Back to P4P Menu)
Medicare P4P IEHP Direct Program
Inland Empire Health Plan (IEHP) is pleased to announce the Medicare P4P IEHP Direct Program. The goal
of
the program is designed to reward IEHP Direct Primary Care Providers (PCPs) for providing quality care to
IEHP
DualChoice Members.
Medicare P4P IEHP Direct Program Guide
(PDF)
Published: February 16, 2023
(Back to P4P Menu)
IEHP Direct Stars Incentive Program
Inland Empire Health Plan (IEHP) is pleased to announce the IEHP Direct Stars Incentive Program for Primary
Care
Physicians (PCPs). The goal of the program is to reward PCPs who provide high-quality care to IEHP
DualChoice
(HMO D-SNP) members.
IEHP Direct Stars Incentive Program Guide
(PDF) Updated: June 29, 2023
(Back to P4P Menu)
D-SNP Model of Care Incentive Program
Inland Empire Health Plan (IEHP) is pleased to announce the D-SNP Model of Care Incentive Program for
Independent
Physicians Associations (IPAs). The goal of the program is to reward IPAs who provide high-quality care to
IEHP
DualChoice (HMO D-SNP) members.
D-SNP Model of Care Incentive Program
(PDF) Published: July 24, 2023
(Back to P4P Menu)
Chronic Care Improvement Program Planning and Reporting Document
The Chronic Care Improvement Program (CCIP) Planning and Reporting document can be used for the following
D-SNP
Model of Care Incentive Program activity: Chronic Care Improvement Program (CCIP) Activity.
CCIP Planning and Reporting Document
(Word
Document)
CCIP Planning and Reporting
Document - Reference Guide (PDF)
Global Quality P4P Program
If you would like more information about IEHP’s GQ P4P Program or best practices to help improve quality
scores and outcomes, visit our Secure
Provider
Portal, email the Quality Team at QualityPrograms@iehp.org or call the IEHP Provider Relations Team at (909) 890-2054.
2023 IEHP Global Quality
P4P
Program Guide PCP (PDF) Published: July 25, 2023
2023 IEHP Global Quality
P4P
Program Guide IPA (PDF) Published: July 25, 2023
2022 IEHP Global Quality P4P Program Guide PCP (PDF) Published: August 28, 2023
2022 IEHP Global Quality
P4P
Program Guide IPA (PDF) Published: July 25, 2023
2023 Provider Quality Resource Guide (PDF) Published: June 21, 2023
(Back to P4P Menu)
Quality Improvement Activity Strategy Forms
The Quality Improvement Activity (QIA) Strategy Forms can be used for the following 2023 and 2022 Global Quality P4P
QIA
Activities: Reducing Health Disparities and Potentially Avoidable Emergency Department Visits or Potentially
Preventable
Admissions.
2023 Equity Quality
Improvement
Activity #1 - Strategy Form (PDF)
2023 Quality Improvement Activity #2
-
Strategy Form (PDF)
2022 Equity Quality
Improvement
Activity #1 - Strategy Form (PDF)
2022 Quality Improvement Activity #2 -
Strategy Form (PDF)
(Back to P4P Menu)
Potentially Avoidable Emergency Department (ED) Visits: Potentially Preventable Diagnosis Code
The Potentially Preventable Diagnosis Code List includes diagnosis codes for visits to an ED in which the
condition
could be treated by a Physician or other health care Provider in a non-emergency setting or conditions that are
potentially preventable or are ambulatory care sensitive.
Potentially Preventable Diagnosis List
(PDF) Published: February 04, 2022
Patient Experience
This toolkit is full of proven tips and successful strategies based on the kinds of questions your IEHP Members
could
be asked to answer regarding their Provider's service. Your Provider Relations Team has targeted nine specific
topics in this toolkit to help Providers and their staff continue to achieve the highest marks in Patient
experience
from their IEHP Members.
Serve Well Customer Service Toolkit (PDF)
Well Child
2021
Recommendations for Preventive Pediatric Health Care from the American Academy of Pediatrics (PDF)
Immunizations
IEHP provides vaccine coverage based on the latest ACIP recommendation and guidelines. Please refer to the
Immunization
Update and "Summary of Recommendations" for both Child and Adolescents AND Adult Vaccines as follows:
2023 Immunization Timing Chart - English
(PDF)
2023 Immunization Timing Chart - Spanish
(PDF)
2023 Immunization Timing Chart - Chinese
(PDF)
2023 Immunization Timing Chart - Vietnamese
(PDF)
2023 Recommended
Child and Adolescent Immunization Schedule (0-18 years) (PDF)
2023 Recommended Adult
Immunization
Schedule (19+ years) (PDF)
Adult Vaccines are a covered benefit and do not require prior authorization (must adhere to CDC/ACIP Immunization
Recommendation and/or FDA approved indication).
Grow Well Childhood Immunization
Toolkit for Providers (PDF)
This toolkit contains commonly used immunization codes, best practices for reporting immunizations including
information
on registering with CAIR, tips on talking with parents and information on understanding vaccination hesitancy.
CAIR2 Resource
Guide
(PDF)
This guide contains helpful links and contact information for locations to register for CAIR2 or current users.
Reimbursement process:
Complete a CMS1500 form by including the appropriate CPT codes, quantity dispensed and billed amount.
Mail:
IEHP Claims Department
P.O. Box 4349
Rancho Cucamonga, CA 91729-4349
For the latest updates and news regarding the vaccines, please visit CDC's ACIP website at:
https://www.cdc.gov/vaccines/hcp/acip-recs/index.html
Quality Bonus Services Dispute Form
Please e-mail completed forms to QualityPrograms@iehp.org
Quality Bonus Service Dispute Request Form
(PDF)
OB/GYN P4P Program
Inland Empire Health Plan (IEHP) has released the OB/GYN P4P Program Guide which details the program requirements,
performance measures, updated code sets, and payment timelines.
OB/GYN P4P
Program Guide (PDF) Published: January 01, 2023
OB
P4P Frequently Asked Questions FAQs (PDF) Published: February 13, 2023
Postpartum
Depression Screening (PDF)
(Back to P4P Menu)
Urgent Care + Wellness Quality Incentive Program
Inland Empire Health Plan (IEHP) is pleased to announce the Urgent Care + Wellness Quality Incentive Program. The goal of the program is to reward urgent care providers for providing wellness services to IEHP Medi-Cal Members.
Urgent Care + Wellness Quality Incentive Program Guide (PDF) Published: September 08, 2023
(Back to P4P Menu)
Hospital P4P Program
Inland Empire Health Plan (IEHP) is pleased to announce the Hospital Pay For Performance Program (Hospital P4P) for
IEHP
Medi-Cal contracted Hospitals servicing Riverside and San Bernardino Counties. The goal of the Hospital P4P Program
is
to provide substantial financial rewards to Hospitals that meet quality performance targets and demonstrate
high-quality
care to IEHP Members.
2023 Hospital P4P Program Guide (PDF) Published: September 21, 2023
P4P 2023 MX Data Contributions (PDF) Published:
February 02, 2023
IEHP P4P
2023 Data Guidelines (PDF) Published: February 02, 2023
2022
Hospital P4P Program Guide (PDF) Published: March 20, 2023
P4P 2022
MX
Data Contribution (PDF) Published: April 18, 2022
P4P 2022
MX
Data Guidelines (PDF) Published: April 18, 2022
(Back to P4P Menu)
Potentially Avoidable Emergency Department (ED) Visits: Potentially Preventable Diagnosis Code
The Potentially Preventable Diagnosis Code List includes diagnosis codes for visits to an ED in which the
condition
could be treated by a Physician or other health care Provider in a non-emergency setting or conditions that are
potentially preventable or are ambulatory care sensitive.
Potentially Preventable Diagnosis List
(PDF) Published: February 04, 2022
Substance Use Disorders and Mental Health Diagnosis Lists
The Substance Use Disorders and Mental Health Diagnosis Lists includes diagnosis codes to identify substance use
disorders, drug overdose, mental health or intentional self-harm diagnoses.
Mental
Health
Diagnosis List (PDF) Published: June 23, 2023
Substance Use Disorders Diagnosis List (PDF)
Published: June 23, 2023
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by
clicking here
MediCal Open Access Program - Open Access Program
a better life, and a better future. Many children enter foster care with a list of physical or behavioral health concerns. Due to changing placements, these concerns often go untreated. By speeding up the process to see a Doctor, the Open Access Program makes it simple for your child to get ongoing medical care. No matter where you live in the Inland Empire, your child can see any Doctor in the network. Plus, our program gives your child many services you won’t find with the Regular Medi-Cal system.
How Open Access makes it simpler for your child to get healthcare:
Your child can see any PCP in our large network.
You can switch Doctors any time, for any reason. IEHP will help you find one. Call 1-800-440-IEHP (4347) / TTY (800) 718-4347.
The Program gives your Doctor a record of your child’s health history (shots, medicines, checkups) so there’s no guesswork.
If you misplaced your IEHP Member ID Card or Beneficiary Identification Card (BIC), an Open Access Doctor can go online and quickly confirm your child’s eligibility.
You and your child get extra services at no cost:
Keep your child feeling well with no-cost Wellness Programs like asthma or diabetes.
Keep your child safe and healthy and get extras a parent enjoy like an infant car seat, children’s vitamins, and a bicycle helmet.
A team helps you care for your child with a chronic illness. Working with your child’s Doctor, we call you, making sure your child gets the right care. We even lend a hand if things like Doctor visits, lab tests or medicine pile up.
Important Resources
Open Access Provider Directory Riverside County (PDF)
Open Access Provider Directory San Bernardino County (PDF)
To get more information about the Open Access Program call an IEHP Foster Care Specialist at (800) 706-4347, Monday–Friday, 8am-5pm.
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Download a free copy. Click Adobe Acrobat Reader.
Medi-Cal California Medical Insurance Requirements
vision* coverage to qualified low-income California residents.
Who Can Apply for Medi-Cal and Join IEHP?
People who live in our service area (Riverside and San Bernardino counties)
Adults with or without children, children, seniors, and people with a disability
People who meet income guidelines and other program requirements
Undocumented adults ages 50+
How Much Will I Pay?
Adults pay no monthly premium for Medi-Cal coverage. Children with Medi-Cal coverage under the Children’s Health Insurance Program (CHIP) will have a low monthly premium.
What Care Will I Get with Medi-Cal Through IEHP?
Your plan coverage includes:
Outpatient (ambulatory) services*
Emergency services
Transgender services*
Hospice and palliative care*
Hospitalization*
Maternity and newborn care
Mental health services
Prescription drugs
Rehabilitative and habilitative services and devices*
Laboratory and radiology services, such as X-rays*
Preventive and wellness services and chronic disease management
Sensitive services
Substance use disorder treatment services
Pediatric services
Vision services*
Non-emergency medical transportation (NEMT)
Non-medical transportation (NMT)
Long-term services and supports (LTSS)
Telehealth services
Some of the services listed are covered only if IEHP or your IPA approves first. Covered services that may need an approval from IEHP or your IPA or medical group first are marked by an asterisk (*).
How do I apply for Medi-Cal:
Call the IEHP Enrollment Advisors at (866) 294-4347, Monday – Friday, 8am – 5pm. TTY users should call (800) 720-4347.
You may also call Health Care Options at 1-800-430-4263 or visit www.healthcareoptions.dhcs.ca.gov. TTY users should call 1-800-430-7077.
Important Reading for IEHP Medi-Cal Members
Medi-Cal Member Handbook (PDF): explains how to get care with IEHP and plan covered benefits.
IEHP Member Handbook Guide to Medi-Cal Benefits (PDF): This guide helps you find important information about benefits and services in your IEHP Member Handbook.
Medi-Cal Provider Directory Riverside County (PDF): lists our growing network and options to get needed care quickly – day and night.
Medi-Cal Provider Directory San Bernardino County (PDF): lists our growing network and options to get needed care quickly – day and night.
Resources for the uninsured
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Download a free copy by clicking Adobe Acrobat Reader.
IEHP DualChoice - How to Access Care
ited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which IEHP DualChoice (HMO D-SNP) authorizes use of out-of-network providers.
What are Network providers?
Network providers are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with us to accept our payment as payment in full. We have arranged for these providers to deliver covered services to members in our plan.
All of our plan participating providers also contract us to provide covered Medi-Cal benefits.
Find a Doctor
Use the IEHP DualChoice Provider and Pharmacy Directory below to find a network provider:
2023 IEHP DualChoice Provider and Pharmacy Directory (PDF)
2024 IEHP DualChoice Provider and Pharmacy Directory (PDF) (Coming soon)
What is a Primary Care Provider (PCP) and their role in your Plan?
A PCP is your Primary Care Provider. You will usually see your PCP first for most of your routine health care needs. Your PCP will also help you arrange or coordinate the rest of the covered services you get as a member of our Plan. "Coordinating" your services includes checking or consulting with other Plan providers about your care and how it is going. This includes:
your X-rays
laboratory tests, therapies
care from doctors who are specialists
hospital admissions, and follow-up care
Primary Care Providers (PCPs) are usually linked to certain hospitals. When you choose your PCP, remember the following:
You must choose your PCP from your Provider and Pharmacy Directory. Call IEHP DualChoice Member Services if you need help in choosing a PCP or changing your PCP.
Choose a PCP that is within 10 miles or 15 minutes of your home.
The PCP you choose can only admit you to certain hospitals. Try to choose a PCP that can admit you to the hospital you want within 30 miles or 45 minutes of your home.
Some hospitals have “hospitalists” who specialize in care for people during their hospital stay. If you are admitted to one of these hospitals, a “hospitalist” may serve as your caregiver as long as you remain in the hospital. When you are discharged from the hospital, you will return to your PCP for your health care needs.
If you need to change your PCP for any reason, your hospital and specialist may also change. Your PCP should speak your language. However, your PCP can always use Language Line Services to get help from an interpreter, if needed.
If you do not choose a PCP when you join IEHP DualChoice, we will choose one for you. We will send you your ID Card with your PCP’s information. Remember, you can request to change your PCP at any time.
You can switch your Doctor (and hospital) for any reason (once per month). If your change request is received by IEHP by the 25th of the month, the change will be effective the first of the following month; if your change request is received by IEHP after the 25th of the month, the change will be effective the first day of the subsequent month (for some providers, you may need a referral from your PCP).
How to Get Care from a Specialist
You will usually see your Primary Care Provider (PCP) first for most of your routine healthcare needs such as physical check-ups, immunization, etc. When your PCP thinks that you need specialized treatment or supplies, your PCP will need to get prior authorization (i.e., prior approval) from your Plan and/or medical group. This is called a referral. Your PCP will send a referral to your plan or medical group. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. If you don't have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself.
What if you are outside the plan’s service area when you have an urgent need for care?
Suppose that you are temporarily outside our plan’s service area, but still in the United States. If you have an urgent need for care, you probably will not be able to find or get to one of the providers in our plan’s network. In this situation (when you are outside the service area and cannot get care from a network provider), our plan will cover urgently needed care that you get from any provider.
Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States.
Changing your Primary Care Provider (PCP)
You may change your PCP for any reason, at any time. Also, it’s possible that your PCP might leave our plan’s network of providers and you would have to find a new PCP. If this happens, you will have to switch to another provider who is part of our Plan. If your PCP leaves our Plan, we will let you know and help you choose another PCP so that you can keep getting covered services. IEHP DualChoice Member Services can assist you in finding and selecting another provider. You can change your Doctor by calling IEHP DualChoice Member Services. Please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call (800) 718-4347.
For more information on network providers refer to Chapter 1 of the IEHP DualChoice Member Handbook.
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.
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy by clicking Adobe Acrobat Reader
Information on this page is current as of October 01, 2023
H8894_DSNP_24_4164896_M Pending 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, 2023.
H8894_DSNP_24_4164896_M Pending Accepted
Provider Manuals - General Information
EHP's contracted Providers understand how IEHP functions 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), the Centers for Medicare and Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA).
The Delegate or Provider has the responsibility to ensure review, understanding, and attestation of the information contained in the Manual.
Acknowledgement of Receipt (AOR)
2024
Providers:
2024 Provider eAOR
Providers are encouraged to attest electronically using the following recommended browsers: Google Chrome, Microsoft Edge, Mozilla Firefox
2024 Hospital & IPA AORs
For more information regarding 2024 Manuals, click here.
2023
Providers:
2023 Provider eAOR
Providers are encouraged to attest electronically using the following recommended browsers: Google Chrome, Microsoft Edge, Mozilla Firefox
2023 Hospital & IPA AORs
For more information regarding 2023 Manuals, click here.
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 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 for Part C services?
It can take 5 business days from the time we receive the necessary information to make a determination and no later
than 14 calendar days. If we don’t give you our decision within 14 calendar days, you can appeal.
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 within 72 hours.
Asking for a fast coverage decision:
If you request a fast 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:
You must meet the following two requirements to get a fast coverage decision:
You can get a fast coverage decision only if you are asking for coverage for care or an item you have not yet
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 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.
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.
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 https://www.dmhc.ca.gov/FileaComplaint/IndependentMedicalReviewComplaintForms.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 by
https://www.dmhc.ca.gov/FileaComplaint/SubmitanIndependentMedicalReviewComplaintForm.aspx.
You complete Part A and the person you want to give permission to assist you with the Interdependent Medical
Review will complete Part B.
If you cannot complete the Authorized Assistant form, the person with legal authority to act for you will only
need to complete Part B and
attach a copy of the power of attorney for health care decisions or other documents that say that this person
can make decision for you.
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 5 business days from the time we receive the necessary information
to make a determination and no later than 14 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 30 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, 2023.
H8894_DSNP_24_4164896 M Pending Accepted
IEHP DualChoice - Problems with Part D
have problems getting a Part D drug or you want us
to pay you back for a Part D drug.
Your benefits as a member of our plan include coverage for many prescription drugs. Most of these drugs are
“Part D drugs.” There are a few drugs that Medicare Part D does not cover but that Medi-Cal may
cover.
Can I ask for a coverage determination or make an appeal about Part D prescription
drugs?
Yes. Here are examples of coverage determination you can ask us to make about your Part D
drugs.
You ask us to make an exception such as:
Asking us to cover a Part D drug that is not on the plan’s List of Covered Drugs (Formulary)
Asking us to waive a restriction on the plan’s coverage for a drug (such as limits on the amount
of the drug you can get)
You ask us if a drug is covered for you (for example, when your drug is on the plan’s Formulary but we
require you to get approval from us before we will cover it for you).
Please note: If your pharmacy tells you that your prescription cannot be filled, you will get a notice
explaining how to contact us to ask for a coverage determination.
You ask us to pay for a prescription drug you already bought. This is asking for a coverage determination
about payment.
If you disagree with a coverage decision we have made, you can appeal our decision.
What is an exception?
An exception is permission to get coverage for a drug that is not normally on our List of Covered Drugs, or to use
the drug without certain rules and limitations. If a drug is not on our List of Covered Drugs, or is not covered in
the way you would like, you can ask us to make an “exception.”
When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need
the exception.
Here are examples of exceptions that you or your doctor or another prescriber can ask us to make:
Covering a Part D drug that is not on our List of Covered Drugs (Formulary).
If we agree to make an exception and cover a drug that is not on the Formulary, you will need to pay
the cost-sharing amount that applies to drug.
You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the
drug.
Removing a restriction on our coverage. There are extra rules or restrictions that apply to certain drugs
on our Formulary.
The extra rules and restrictions on coverage for certain drugs include:
Being required to use the generic version of a drug instead of the brand name drug.
Getting plan approval before we will agree to cover the drug for you. (This is sometimes
called “prior authorization.”)
Being required to try a different drug first before we will agree to cover the drug you are
asking for. (This is sometimes called “step therapy.”)
Quantity limits. For some drugs, the plan limits the amount of the drug you can have.
If we agree to make an exception and waive a restriction for you, you can still ask for an exception
to the co-pay amount we require you to pay for the drug.
Important things to know about asking for exceptions
Your doctor or other prescriber must give us a statement explaining the medical reasons for requesting an exception.
Our decision about the exception will be faster if you include this information from your doctor or other prescriber
when you ask for the exception.
Typically, our Formulary includes more than one drug for treating a particular condition. These different
possibilities are called “alternative” drugs. If an alternative drug would be just as effective
as the drug you are asking for, and would not cause more side effects or other health problems, we will
generally not approve your request for an exception.
We will say Yes or No to your request for an exception.
If we say Yes to your request for an exception, the exception usually lasts until the end of the
calendar year. This is true as long as your doctor continues to prescribe the drug for you and that drug
continues to be safe and effective for treating your condition.
If we say No to your request for an exception, you can ask for a review of our decision by making an
appeal.
Coverage Decision
What to do
Ask for the type of coverage decision you want. Call, write, or fax us to make your request. You, your
representative, or your doctor (or other prescriber) can do this.
You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY
users should call 1-800-718-4347.
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
You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage
decision. You can also have a lawyer act on your behalf.
You do not need to give your doctor or other prescriber written permission to ask us for a coverage
determination on your behalf.
If you are requesting an exception, provide the “supporting statement.” Your doctor or other
prescriber must give us the medical reasons for the drug exception. We call this the “supporting
statement.”
Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other prescriber can
tell us on the phone, and then fax or mail a statement.
Request for MediImpact Medicare Part D
Coverage Determination Request Form (PDF)
These forms are also available on the CMS website:
Medicare
Prescription Drug Determination Request Form (for use by enrollees and providers)
By clicking on this link, you will be leaving the IEHP DualChoice website.
Deadlines for a “standard coverage decision” about a drug you have not yet received
If we are using the standard deadlines, we must give you our answer within 72 hours after we get your
request or, if you are asking for an exception, after we get your doctor’s or prescriber’s
supporting statement. We will give you our answer sooner if your health requires it.
If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. At
Level 2, an Independent Review Entity will review the decision.
If our answer is Yes to part or all of what you asked for, we must approve or give
the coverage within 72 hours after we get your request or, if you are asking for an exception, your
doctor’s or prescriber’s supporting statement.
If our answer is No to part or all of what you asked for, we will send you a letter that explains
why we said No. The letter will also explain how you can appeal our decision.
Deadlines for a “standard coverage decision” about payment for a drug you have already
bought
We must give you our answer within 14 calendar days after we get your request.
If we do not meet this deadline, we will send your request to Level 2 of the appeals process. At level
2, an Independent Review Entity will review the decision.
If our answer is Yes to part or all of what you asked for, we will make payment to
you within 14 calendar days.
If our answer is No to part or all of what you asked for, we will send you a letter that explains
why we said No. This statement will also explain how you can appeal our decision.
If your health requires it, ask us to give you a “fast coverage decision”
We will use the “standard deadlines” unless we have agreed to use the “fast
deadlines.”
A standard coverage decision means we will give you an answer within 72 hours after we get your
doctor’s statement.
A fast coverage decision means we will give you an answer within 24 hours after we get your
doctor’s statement.
You can get a fast coverage decision only if you are asking for a drug you have not yet received. (You
cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already
bought.)
You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your
health or hurt your ability to function.
If your doctor or other prescriber tells us that your health requires a “fast coverage
decision,” we will automatically agree to give you a fast coverage decision, and the letter will
tell you that.
If you ask for a fast coverage decision on your own (without your doctor’s or other
prescriber’s support), we will decide whether you get a fast coverage decision.
If we decide that your medical condition does not meet the requirements for a fast coverage decision,
we will use the standard deadlines instead.
We will send you a letter telling you that. The letter will tell you how to make a complaint
about our decision to give you a standard decision.
You can file a “fast complaint” and get a response to your complaint within 24
hours.
Deadlines for a “fast coverage decision”
If we are using the fast deadlines, we must give you our answer within 24 hours. This means within 24
hours after we get your request. Or, if you are asking for an exception, 24 hours after we get your
doctor’s or prescriber’s statement supporting your request. We will give you our answer
sooner if your health requires us to.
If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. At
Level 2, an outside independent organization will review your request and our decision.
If our answer is Yes to part or all of what you asked for, we must give you the
coverage within 24 hours after we get your request or your doctor’s or prescriber’s statement
supporting your request.
If our answer is No to part or all of what you asked for, we will send you a letter that explains
why we said No. The letter will also explain how you can appeal our decision.
Level 1 Appeal for Part D drugs
To start your appeal, you, your doctor or other prescriber, or your representative must contact us.
If you are asking for a standard appeal, you can make your appeal by sending a request in writing. You
may also ask for an appeal by calling IEHP DualChoice Member Services at 1-877-273-IEHP (4347), 8am
– 8pm (PST), 7 days a week, including holidays. TTY/TDD users should call 1-800-718-4347.
If you want a fast appeal, you may make your appeal in writing or you may call us.
Make your appeal request within 60 calendar days from the date on the notice 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 you appeal. For example, good reasons for missing the deadline would be if you have a serious
illness that kept you from contacting us or if we gave you incorrect or incomplete information about the
deadline for requesting an appeal.
You can ask for a copy of the information in your appeal and add more information.
You have the right to ask us for a copy of the information about your appeal.
If you wish, you and your doctor or other prescriber may give us additional information to support
your appeal.
You may use the following form to submit an appeal:
Request for Redetermination of Medicare Prescription Drug Denial (PDF)
Can someone else make the appeal for
me?
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.
Deadlines for a “standard appeal”
If we are using the standard deadlines, we must give you our answer within 7 calendar days after we
get your appeal, or sooner if your health requires it. If you think your health requires it, you should
ask for a “fast appeal.” If you are asking us to pay you back for a drug you already bought,
we must give you our answer within 14 calendar days after we get your appeal.
If we do not give you a decision within 7 calendar days, or 14 days if you asked us to pay you back
for a drug you already bought, we will send your request to Level 2 of the appeals process. At Level 2,
an Independent Review Entity will review our decision.
If your health requires it, ask for a “fast
appeal”
If you are appealing a decision our plan made about a drug you have not yet received, you and your
doctor or other prescriber will need to decide if you need a “fast appeal.”
The requirements for getting a “fast appeal” are the same as those for getting a
“fast coverage decision.”
Our plan will review your appeal and give you our decision
We take another careful look at all of the information about your coverage request. We check to see if
we were following all the rules when we said No to your request. We may contact you or your doctor or
other prescriber to get more information.
Deadlines for a “fast appeal”
If we are using the fast deadlines, we will give you our answer within 72 hours after we get your
appeal, or sooner if your health requires it.
If we do not give you an answer within 72 hours, we will send your request to Level 2
of the appeals process. At Level 2, an Independent Review Entity will
review your appeal.
If our answer is Yes to part or all of what you asked for, we must give 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 that explains
why we said No.
Level 2 Appeal for Part D drugs
If we say No to your appeal, you then choose whether to
accept this decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, the
Independent Review Entity (IRE) will review our decision.
If you want the Independent Review Organization to review your case, your
appeal request must be in writing.
Ask within 60 days of the decision you are appealing. If you miss the deadline for a good reason, you
may still appeal.
You, your doctor or other prescriber, or your representative can request the Level 2 Appeal.
When you make an appeal to the Independent Review Entity, we will send them your case file. You have the
right to ask us for a copy of your case file. You have a right to give the Independent Review Entity other
information to support your appeal. The Independent Review Entity is an independent organization that is
hired by Medicare. It is not connected with this plan and it is not a government agency. Reviewers at the
Independent Review Entity will take a careful look at all of the information related to your appeal. The
organization will send you a letter explaining its decision.
If we uphold the denial after Redetermination, you have the right to request a Reconsideration. Fill out
the Independent Medical Review/Complain Form available at:
https://www.dmhc.ca.gov/FileaComplaint/IndependentMedicalReviewComplaintForms.aspx
Deadlines for a “fast appeal” at Level 2
If your health requires it, ask the Independent Review Entity for a “fast appeal.”
If the review organization agrees to give you a “fast appeal,” it must give you an answer
to your Level 2 Appeal within 72 hours after getting your appeal request.
If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize or
give you the drug coverage within 24 hours after we get the decision.
Deadlines for “standard appeal” at Level 2
If you have a standard appeal at Level 2, the Independent Review Entity must give you an answer to your
Level 2 Appeal within 7 calendar days after it gets your appeal.
If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize or
give you the drug coverage within 72 hours after we get the decision.
If the Independent Review Entity approves a request to pay you back for a drug you already bought, we
will send payment to you within 30 calendar days after we get the decision.
What if the Independent Review Entity says No to your Level 2 Appeal?
No means the Independent Review Entity agrees with our decision not to approve your request. This is called
“upholding the decision.” It is also called “turning down your appeal.”
If the dollar value of the drug coverage you want meets a certain minimum amount, you can make another
appeal at Level 3. The letter you get from the Independent Review Entity will tell you the dollar amount
needed to continue with the appeals process. The Level 3 Appeal is handled by an administrative law judge.
For more information see Chapter 9 of your IEHP DualChoice Member
Handbook.
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, 2023.
H8894_DSNP_24_4164896_M Pending Accepted
Medication Therapy Management
MTM is a term used to describe a broad range of services offered by Pharmacists on our health care team.
The IEHP Clinical Pharmacy Team reviews your medicines, making sure you’re taking the right ones for your health conditions. If you are a Member who qualifies for the MTM Program, you will receive a letter from us. You will be enrolled—unless you opt-out. The program costs $0 for those who qualify.
Who might be eligible?
Some Members who have been identified for this program may have only Medi-Cal coverage with IEHP.
Or they may be enrolled in the IEHP DualChoice (HMO D-SNP). They must meet the criteria and will receive the services for the Medicare MTM Program. (See description below.)
What are MTM services?
IEHP’s MTM services include these core elements:
Medicine therapy reviews
Medicine education - includes a medication action plan
Disease management
Our IEHP Clinical Pharmacy Team reviews the Member’s medicines, family history, disease states, and goals for medicine therapy. Based on a full review, this team then offers recommendations to the Member and Providers.
A Team of registered Pharmacists and technicians work with your Doctor (or other Provider) and Pharmacies to offer full care. We also work with our Care Management teams to offer “whole health” care to our Members.
Medicare MTM Program
IEHP Clinical Pharmacy offers the MTM services at no extra cost for IEHP DualChoice Members who:
have a number of health issues, and
are taking many prescription drugs, and
have high medicine costs
Once enrolled in the program, you will get a packet by mail with details. You’ll also get information on how to disenroll, should you choose not to be in the program. If you decide not to take part in the program, your enrollment and eligibility with IEHP DualChoice will not change. We hope that if you qualify that you will take part in in this program that is offered free of charge—to help you better manage your medicines.
The MTM program includes a yearly comprehensive medication review (CMR) and targeted medication review (TMR). Here are some details on MTM services:
Comprehensive Medication Review (CMR)
An IEHP Clinical Pharmacist will give you a full yearly review of your meds by phone. The Pharmacist goes over your medicines to make sure you have the right ones for your condition and that you avoid drug interactions, and more.
Once your CMR is done, you will get your Medication Action Plan (MAP) and Personal Medication List (PML) by mail. MTM services documents, with a copy of a Personal Medication List, can be accessed by calling Member Services and asking to speak to the Clinical Pharmacy Team.
Targeted Medication Review (TMR)
The IEHP Clinical Pharmacy Team will also offer TMRs through the year by reviewing issues with the participating IEHP DualChoice Member’s medicines. The team will perform TMRs for all enrolled beneficiaries every three months. The beneficiary may get TMR recommendations by mail and their Primary Care Provider may receive recommendations by fax—if the IEHP Clinical Pharmacy Team deems it necessary.
For more information, IEHP DualChoice Members eligible for CMR or TMR services can call 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347. Click here for a blank personal medication list.
Eligibility Criteria
These MTM Program services may have limited eligibility criteria and are not considered a benefit. They are available for these conditions:
1. The Member has a minimum of three (3) disease states:
Bone Disease-Arthritis-Osteoporosis
Chronic Heart Failure (CHF)
Diabetes
Dyslipidemia
End-Stage Renal Disease (ESRD)
HIV/AIDS
Hypertension
Mental Health Chronic/ Disabling Mental Health Conditions
Respiratory Disease – Asthma
Respiratory Disease – Chronic Obstructive Pulmonary Disease (COPD)
2. The Member is prescribed a minimum of five (5) different medications to treat those disease states:
ACE-Inhibitors
Angiotensin II Receptor Blockers (ARBs)
Antidepressants
Antihyperlipidemic
Antihypertensives
Antipsychotics
Antiretroviral Therapy
Beta Blockers
Biophosphonates
Bronchodilators
Calcium Channel Blockers
Diuretics
Insulins
Oral Hypoglycemics
Selective Serotonin Reuptake Inhibitors (SSRIs)
Inhaled Corticosteroids
Calcimimetic
Cardiac Glycoside
Colony Stimulating Factors
Glucagon-Like Peptide-1
Glucocorticosteroids
Neprilysin Inhibitor
Phosphate Binders
Vitamin D Analogs
3. Drug costs of $1,332.50 (one-fourth of $5,330) for the previous three months are likely to be incurred.
To learn more about MTM, call IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347.
Information on this page is current as of October 01, 2023.
H8894_DSNP_24_4164896_M Pending Accepted
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, 2023.
H8894_DSNP_243_4164896_M Pending Accepted
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, 2023.
H8894_DSNP_24_4164896_M Pending Accepted
IEHP DualChoice - 2024 Plan Benefits
ou will pay:
Benefits
Doctor Visit: $0
Vision Care: a combined limit of $350 each year for contact lenses and/or eyeglasses (frames).
Inpatient Hospital Care: $0
Home Health Agency Care: $0
Ambulance Services: $0
Transportation: $0. Including bus pass. Call the Car (CTC) at 1-855-673-3195, 24 hours a day, 7 days a week. For TTY users, call your relay service or California Relay Service at 711. For reservations call Monday-Friday, 7am-6pm (PST). Call at least 5 days before your appointment.
Diagnostic Tests, X-Rays & Lab Services: $0
Durable Medical Equipment: $0
Home and Community Based Services (HCBS): $0
Community Based Adult Services (CBAS): $0
Long Term Care that includes custodial care and facility: $0
Utilities allowance of $65 for covered utilities. You must qualify for this benefit.
Over the Counter (OTC) items allowance of $40 per quarter (every 3 months) towards the purchase of certain Over the Counter (OTC) items.
You pay nothing for a one-month or long term-supply of drugs
With IEHP DualChoice, you pay nothing for covered drugs as long as you follow the plan’s rules.
Tier 1 drugs are: generic, brand and biosimilar drugs. They have a copay of $0.
After your coverage begins with IEHP DualChoice, you must receive medical services and prescription drug services in the IEHP DualChoice network.
To learn more about the plan’s benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook.
2024 Summary of Benefits (PDF)(Coming soon)
2024 Annual Notice of Changes (PDF)
2024 IEHP DualChoice Member Handbook (PDF) (Coming soon)
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here. By clicking on this link, you will be leaving the IEHP DualChoice website.
Plan Premium
There is a monthly premium of $0-$41.00 for IEHP DualChoice. You may qualify for “Extra Help” which can help reduce your monthly premium.
Plan Deductible
There is no deductible for IEHP DualChoice.
Because you are eligible for Medi-Cal, you qualify for and are getting “Extra Help” from Medicare to pay for your prescription drug plan costs. You do not need to do anything further to get this Extra Help.
You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, you can contact:
1-800-MEDICARE (1-800-633-4227). , TTY users should call (877) 486-2048, 24 hours a day/7days a week
The Social Security Office at (800) 772-1213 between 7 a.m. and 7 p.m., Monday through Friday, TTY users should call (800) 325-0778; or
Your State Medicaid Office
How to get care coordination
Do you need help getting the care you need? A care team can help you. A care team may include your doctor, a care coordinator, or other health person that you choose. A care coordinator is a person who is trained to help you manage the care you need. You will get a care coordinator when you enroll in IEHP DualChoice. This person will also refer you to community resources, if IEHP DualChoice does not provide the services that you need.
To speak with a care coordinator, please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347.
Prior Authorization and Out of Network Coverage
What kinds of medical care and other services can you get without getting approval in advance from your Primary Care Provider (PCP) in IEHP DualChoice (HMO D-SNP)? You can get services such as those listed below without getting approval in advance from your Primary Care Provider (PCP).
Routine women’s health care, which includes breast exams, screening mammograms (X-rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider.
Flu shots as long as you get them from a network provider.
Emergency services from network providers or from out-of-network providers.
Urgently needed care from in-network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible, e.g., when you are temporarily outside of the plan’s service area.
Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area. (If possible, please call IEHP DualChoice Member Services before you leave the service area so we can help arrange for you to have maintenance dialysis while you are away.)
How to get care from specialists and other network providers
A specialist is a doctor who provides health care services for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples:
Oncologists care for patients with cancer.
Cardiologists care for patients with heart conditions.
Orthopedists care for patients with certain bone, joint, or muscle conditions.
You will usually see your PCP first for most of your routine healthcare needs such as physical checkups, immunization, etc. When your PCP thinks that you need specialized treatment or supplies, your PCP will need to get prior authorization (i.e., prior approval) from your Plan and/or medical group. This is called a referral. Your PCP will send a referral to your plan or medical group. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. If you don’t have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself. PCPs are usually linked to certain hospitals and specialists. When you choose a PCP, it also determines what hospital and specialist you can use.
What if a specialist or another network provider leaves our plan?
Sometimes a specialist, clinic, hospital or other network provider you are using might leave the plan. When a provider leaves a network, we will mail you a letter informing you about your new provider. If you prefer a different one, please call IEHP DualChoice Member Services and we can assist you in finding and selecting another provider.
How to get care from out-of-network providers
When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. In order to receive out-of-network services, your Primary Care Provider (PCP) or Specialist must submit a referral request to your plan or medical group. All requests for out-of-network services must be approved by your medical group prior to receiving services.
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, 2023.
H8894_DSNP_24_4164896_M Pending Accepted
IEHP DualChoice - 2023 Plan Benefits
ou will pay:
Benefits
Doctor Visit: $0
Vision Care: $350 limit every year for contact lenses and eyeglasses (frames and lenses) -->
Vision care: Up to $350 limit every twelve months for eyeglasses (frames). Lenses are separately reimbursable based on prior approval and medical necessity.
Contact Lenses are covered up to $350 every twelve months in lieu of eyeglasses (Lenses and Frames).
Inpatient Hospital Care: $0
Home Health Agency Care: $0
Ambulance Services: $0
Transportation: $0. Including bus pass. Call our transportation vendor Call the Car (CTC) at (866) 880-3654, for TTY users, call your relay service or California Relay Service at 711. For reservations call Monday-Friday, 7am-6pm (PST). Call at least 5 days before your appointment.
Diagnostic Tests, X-Rays & Lab Services: $0
Durable Medical Equipment: $0
Home and Community Based Services (HCBS): $0
Community Based Adult Services (CBAS): $0
Long Term Care that includes custodial care and facility: $0
Utilities allowance of $40 for covered utilities. You must qualify for this benefit.
You pay nothing for a one-month or long term-supply of drugs
With IEHP DualChoice, you pay nothing for covered drugs as long as you follow the plan’s rules.
Tier 1 drugs are: generic, brand and biosimilar drugs. They have a copay of $0.
After your coverage begins with IEHP DualChoice, you must receive medical services and prescription drug services in the IEHP DualChoice network.
To learn more about the plan’s benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook.
2023 Summary of Benefits (PDF)
2023 Annual Notice of Changes (PDF)
2023 IEHP DualChoice Member Handbook (PDF)
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy of Adobe Acrobat Reader.By clicking on this link, you will be leaving the IEHP DualChoice website.
Plan Premium
With "Extra Help," there is no plan premium for IEHP DualChoice.
Plan Deductible
There is no deductible for IEHP DualChoice.
Because you are eligible for Medi-Cal, you qualify for and are getting “Extra Help” from Medicare to pay for your prescription drug plan costs. You do not need to do anything further to get this Extra Help.
You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, you can contact:
1-800-MEDICARE (1-800-633-4227). , TTY users should call (877) 486-2048, 24 hours a day/7days a week
The Social Security Office at (800) 772-1213 between 7 a.m. and 7 p.m., Monday through Friday, TTY users should call (800) 325-0778; or
Your State Medicaid Office
How to get care coordination
Do you need help getting the care you need? A care team can help you. A care team may include your doctor, a care coordinator, or other health person that you choose. A care coordinator is a person who is trained to help you manage the care you need. You will get a care coordinator when you enroll in IEHP DualChoice. This person will also refer you to community resources, if IEHP DualChoice does not provide the services that you need.
To speak with a care coordinator, please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347.
Prior Authorization and Out of Network Coverage
What kinds of medical care and other services can you get without getting approval in advance from your Primary Care Provider (PCP) in IEHP DualChoice (HMO D-SNP)? You can get services such as those listed below without getting approval in advance from your Primary Care Provider (PCP).
Routine women’s health care, which includes breast exams, screening mammograms (X-rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider.
Flu shots as long as you get them from a network provider.
Emergency services from network providers or from out-of-network providers.
Urgently needed care from in-network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible, e.g., when you are temporarily outside of the plan’s service area.
Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area. (If possible, please call IEHP DualChoice Member Services before you leave the service area so we can help arrange for you to have maintenance dialysis while you are away.)
How to get care from specialists and other network providers
A specialist is a doctor who provides health care services for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples:
Oncologists care for patients with cancer.
Cardiologists care for patients with heart conditions.
Orthopedists care for patients with certain bone, joint, or muscle conditions.
You will usually see your PCP first for most of your routine healthcare needs such as physical checkups, immunization, etc. When your PCP thinks that you need specialized treatment or supplies, your PCP will need to get prior authorization (i.e., prior approval) from your Plan and/or medical group. This is called a referral. Your PCP will send a referral to your plan or medical group. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. If you don’t have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself. PCPs are usually linked to certain hospitals and specialists. When you choose a PCP, it also determines what hospital and specialist you can use.
What if a specialist or another network provider leaves our plan?
Sometimes a specialist, clinic, hospital or other network provider you are using might leave the plan. When a provider leaves a network, we will mail you a letter informing you about your new provider. If you prefer a different one, please call IEHP DualChoice Member Services and we can assist you in finding and selecting another provider.
How to get care from out-of-network providers
When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. In order to receive out-of-network services, your Primary Care Provider (PCP) or Specialist must submit a referral request to your plan or medical group. All requests for out-of-network services must be approved by your medical group prior to receiving services.
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 1, 2022.
H8894_DSNP_23_3241532_M
IEHP DualChoice - Making Complaints
he kinds of problems related to:
Quality of your medical care
Respecting your privacy
Disrespect, poor customer service, or other negative behaviors
Physical accessibility
Waiting times
Cleanliness
Information you get from our plan
Language access
Communication from us
Timeliness of our actions related to coverage decisions or appeals
How to file a Grievance with IEHP DualChoice (HMO D-SNP)
1. Contact us promptly – call IEHP DualChoice at (877) 273-IEHP (4347), 8am - 8pm, 7 days a week, including holidays.TTY users should call 1-800-718-4347. You can make the complaint at any time unless it is about a Part D drug. If the complaint is about a Part D drug, you must file it within 60 calendar days after you had the problem you want to complain about.
If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you put your complaint in writing, we will respond to your complaint in writing.
You can use our "Member Appeal and Grievance Form." All of our Doctor’s offices and service providers have the form or we can mail one to you. You can file a grievance online. You can give a completed form to our Plan provider or send it to us at the address listed below or fax the completed form to the fax number listed below. This form is for IEHP DualChoice as well as other IEHP programs.
IEHP DualChoice
P.O. Box 1800
Rancho Cucamonga, CA 91729-1800
Fax: (909) 890-5877
Whether you call or write, you should contact IEHP DualChoice Member Services right away.
2. We will look into your complaint and give you our answer
If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer on the same phone call. If your health condition requires us to answer quickly, we will do that.
Most complaints are answered in 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more days (44 days total) to answer your complaint.
If we do not agree with some or all of your complaint or don’t take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer. We must respond whether we agree with the complaint or not.
Fast Grievances
If you are making a complaint because we denied your request for a “fast coverage determination” or fast appeal, we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.
Who may file a grievance?
You or someone you name may file a grievance. The person you name would be your “representative.” You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. To learn how to name your representative, you may call IEHP DualChoice Member Services.
External Complaints
You can tell Medicare about your complaint
You can send your complaint to Medicare. The Medicare Complaint Form is available at: https://www.medicare.gov/MedicareComplaintForm/home.aspx.
Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program.
If you have any other feedback or concerns, or if you feel the plan is not addressing your problem, please call (800) MEDICARE (800) 633-4227). TTY/TDD (877) 486-2048. The call is free.
You can tell Medi-Cal about your complaint
The Office of the Ombudsman also helps solve problems from a neutral standpoint to make sure that our members get all the covered services that we must provide. The Office of the Ombudsman is not connected with us or with any insurance company or health plan.
The phone number for the Office of the Ombudsman is 1-888-452-8609. The services are free.
You can tell the California Department of Managed Health Care about your complaint
The California Department of Managed Health Care (DMHC) is responsible for regulating health plans. You can call the DMHC Help Center for help with complaints about Medi-Cal services. You may contact the DMHC if you need help with a complaint involving an urgent issue or one that involves an immediate and serious threat to your health, you disagree with our plan’s decision about your complaint, or our plan has not resolved your complaint after 30 calendar days.
Here are two ways to get help from the Help Center:
Call (888) 466-2219, TTY (877) 688-9891. The call is free.
Visit the Department of Managed Health Care's website: http://www.dmhc.ca.gov/
You can file a complaint with the Office for Civil Rights
You can make a complaint to the Department of Health and Human Services’ Office for Civil Rights if you think you have not been treated fairly. For example, you can make a complaint about disability access or language assistance. The phone number for the Office for Civil Rights is (800) 368-1019. TTY users should call (800) 537-7697. You can also visit https://www.hhs.gov/ocr/index.html for more information.
You may also contact the local Office for Civil Rights office at:
U.S. Department of Health and Human Services
90 7th Street, Suite 4-100
San Francisco, CA 94103
Telephone: (800) 368-1019
TDD: (800) 537-7697
Fax: (415) 437-8329
You may also have rights under the Americans with Disability Act. You can contact the Office of the Ombudsman for assistance. The phone number is (888) 452-8609.
When your complaint is about quality of care
You have two extra options:
You can make your complaint to the Quality Improvement Organization. If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to our plan). To find the name, address, and phone number of the Quality Improvement Organization in your state, look in Chapter 2 of your IEHP DualChoice Member Handbook. If you make a complaint to this organization, we will work with them to resolve your complaint.
Or you can make your complaint to both at the same time. If you wish, you can make your complaint about quality of care to our plan and also to the Quality Improvement Organization.
For more information on Grievances see Chapter 9 of your IEHP DualChoice Member Handbook.
Handling problems about your Medi-Cal benefits
If you have Medi-Cal with IEHP and would like information on how to pursue appeals and grievances related to Medi-Cal covered services, please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), TTY (800) 718-4347, 8am - 8pm (PST), 7 days a week, including holidays.
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, 2023.
H8894_DSNP_24_4164896_M Pending Accepted
IEHP DualChoice - Important Resources
PDF) (Coming soon)
Appointment of Representatives Form (PDF)
Medicare Complaint Form (by clicking this link, you will be leaving the IEHP DualChoice website)
The IEHP DualChoice Privacy Notice describes how medical information about you may be used and disclosed, and how you can get access to this information.
IEHP DualChoice Privacy Notice (PDF)
Centers for Medicare and Medicaid Services
The following link will take you to the Centers for Medicaid and Medicare Services website, where you can look through the CMS Best Available Evidence Policy using the following link: CMS Best Available Evidence Policy. By clicking on this link, you will be leaving the IEHP DualChoice website.
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here. By clicking on this link, you will be leaving the IEHP DualChoice website.
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, 2023.
H8894_DSNP_24_4164896_M Pending Accepted
IEHP DualChoice - Rights and Responsibilities
, you have the right to:
Receive information about your rights and responsibilities as an IEHP DualChoice Member.
Be treated with respect and courtesy. IEHP DualChoice recognizes your dignity and right to
privacy.
Receive services without regard to race, ethnicity, national origin, religion, sex, age, mental or
physical disability or medical condition, sexual orientation, claims experience, medical history, evidence of
insurability (including conditions arising out of acts of domestic violence), disability, genetic information,
or source of payment.
Receive information about IEHP DualChoice, its programs and services, its Doctors, Providers, health care
facilities, and your drug coverage and costs, which you can understand.
Have a Primary Care Provider who is responsible for coordination of your care.
If your Primary Care Provider changes, your IEHP DualChoice benefits and required co-payments will stay
the same.
Your IEHP DualChoice Doctor cannot charge you for covered health care services, except for required
co-payments.
Request a second opinion about a medical condition.
Receive emergency care whenever and wherever you need it.
See plan Providers, get covered services, and get your prescription filled timely.
Receive information about clinical programs, including staff qualifications, request a change of treatment
choices, participate in decisions about your health care, and be informed of health care issues that require
self-management.
If you have been receiving care from a health care provider, you may have a right to keep your provider
for a designated time period.
If you are under a Doctor’s care for an acute condition, serious chronic condition, pregnancy,
terminal illness, newborn care, or a scheduled surgery, you may ask to continue seeing your current Doctor. To
make this request, or if you have any concerns about your continuity of care, please call IEHP DualChoice Member
Services at 1-877-273-IEHP (4347).
Receive Member informing materials in alternative formats, including Braille, large print, and audio.
Information on procedures for obtaining prior authorization of services, Quality Assurance, disenrollment,
and other procedures affecting IEHP DualChoice Members.
IEHP DualChoice will honor authorizations for services already approved for you. If you have any
authorizations pending approval, if you are in them idle of treatment, or if specialty care has been scheduled
for you by your current Doctor, contact IEHP to help you coordinate your care during this transition time. Call
IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should
call 1-800-718-4347.
Review, request changes to, and receive a copy of your medical records in a timely fashion.
Receive interpreter services at no cost.
Notify IEHP if your language needs are not met.
Make recommendations about IEHP DualChoice Members’ rights and responsibilities policies.
Be informed regarding Advance Directives, Living Wills, and Power of Attorney, and to receive information
regarding changes related to existing laws.
Decide in advance how you want to be cared for in case you have a life-threatening illness or injury.
Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or
retaliation
Complain about IEHP DualChoice, its Providers, or your care. IEHP DualChoice will help you with the
process. You have the right to choose someone to represent you during your appeal or grievance process and for
your grievances and appeals to be reviewed as quickly as possible and be told how long it will take.
Have grievances heard and resolved in accordance with Medicare guidelines;
Request quality of care grievances data from IEHP DualChoice.
Appeal any decision IEHP DualChoice makes regarding, but not limited to, a denial, termination, payment,
or reduction of services. This includes denial of payment for a service after the service has been rendered
(post-service) or denial of service prior to the service being rendered (pre-service).
Request fast reconsideration;
Request and receive appeal data from IEHP DualChoice;
Receive notice when an appeal is forwarded to the Independent Review Entity (IRE);
Automatic reconsideration by the IRE when IEHP DualChoice upholds its original adverse determination in
whole or in part;
Administrative Law Judge (ALJ) hearing if the independent review entity upholds the original adverse
determination in whole or in part and the remaining amount in controversy is $100 or more;
Request Departmental Appeals Board (DAB) review if the ALJ hearing is unfavorable to the Member in whole
or in part;
Judicial review of the hearing decision if the ALJ hearing and/or DAB review is unfavorable to the
Member in whole or in part and the amount remaining in controversy is $1,000 or more;
Make a quality of care complaint under the QIO process;
Request QIO review of a determination of noncoverage of inpatient hospital care;
Request QIO review of a determination of noncoverage in skilled nursing facilities, home health agencies
and comprehensive outpatient rehabilitation facilities;
Request a timely copy of your case file, subject to federal and state law regarding confidentiality of
patient information;
Challenge local and national Medicare coverage determination.
As an IEHP DualChoice Member, you have the responsibility to:
Review your Member Handbook, and call IEHP DualChoice Member Services if you do not understand something
about your coverage and benefits
Inform your Doctor about your medical condition, and concerns.
Follow the plan of treatment your Doctor feels is necessary
Make necessary appointments for routine and sick care, and inform your Doctor when you are unable to make
a scheduled appointment.
Learn about your health needs and leading a healthy lifestyle.
Make every effort to participate in the health care programs IEHP
DualChoice offers you.
For more information on Member Rights and Responsibilities refer to Chapter 8 of your
IEHP DualChoice Member Handbook.
Rights and Responsibilities Upon Disenrollment
Ending your membership in IEHP DualChoice (HMO D-SNP) may be voluntary (your own
choice) or involuntary (not your own choice)
You might leave our plan because you have decided that you want to leave.
There are also limited situations where you do not choose to leave, but we are
required to end your membership.Chapter 10 of your IEHP DualChoice Member Handbook tells you
about situations when we must end your membership.
When can you end your membership in our plan?
Because you get assistance from Medi-Cal, you can end your membership in IEHP DualChoice at any time.
Your membership will usually end on the first day of the month after we receive your request to change
plans. Your enrollment in your new plan will also begin on this day.
How to voluntarily end your membership in our plan?
If you would like to switch from our plan to another Medicare Advantage plan simply enroll in the new
Medicare Advantage plan. You will be automatically disenrolled from IEHP DualChoice, when your new
plan’s coverage begins.
If you would like to switch from our plan to Original Medicare but you have not selected a separate
Medicare prescription drug plan, you must ask to be disenrolled from IEHP DualChoice. There are three ways you can
asked to be disenrolled:
You can make a request in writing to us. Contact IEHP DualChoice Member Services if you need more information on how to do this.
Call Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users (people who have difficulty with
hearing or speaking) should call 1-877-486-2048. When you call 1-800-MEDICARE, you can also enroll in another Medicare health or drug plan.
Call Health Care Options at 1-844-580-7272, Monday through Friday from 8:00 a.m. to 6:00 p.m. TTY users should call 1-800-430-7077.
For additional information, please see Chapter 10 of the IEHP DualChoice Member Handbook.
Until your membership ends, you are still a member of our plan.
If you leave IEHP DualChoice, it may take time before your membership ends and
your new Medicare coverage goes into effect. (See Chapter 10 of the IEHP DualChoice Member Handbook for information on when your new coverage
begins.) During this time, you must continue to get your medical care and prescription drugs through
our plan.
You should continue to use our network pharmacies to get your prescriptions filled until your membership
in our plan ends. Usually, your prescription drugs are only covered if they are filled at a network pharmacy
including through our mail-order pharmacy services.
If you are hospitalized on the day that your membership ends, you will usually be covered by our plan
until you are discharged (even if you are discharged after your new health coverage begins).
If you no longer qualify for Medi-Cal or your circumstances have changed that make you no longer eligible
for Dual Special Needs Plan, you may continue to get your benefits from IEHP DualChoice for an additional
two-month period. This additional time will allow you to correct your eligibility information if you believe
that you are still eligible. You will get a letter from us about the change in your eligibility with
instructions to correct your eligibility information.
To stay a member of IEHP DualChoice, you must qualify again by the last day of the two-month
period.
If you do not qualify by the end of the two-month period, you’ll de disenrolled by IEHP
DualChoice.
Involuntarily ending your membership
IEHP DualChoice must end your membership in the plan if any of the following happen:
If you do not stay continuously enrolled in Medicare Part A and Part B.
If you move out of our service area for more than six months.
If you become incarcerated.
If you lie about or withhold information about other insurance you have that provides prescription drug
coverage.
If you intentionally give us incorrect information when you are enrolling in our plan and that information
affects your eligibility for our plan.
If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical
care for you and other members of our plan.
If you let someone else use your membership card to get medical care.
Our plan is only for people who qualify for both Medicare and Medi-Cal. If you lose your Medi-Cal
eligibility and you are within our plan’s 3-month period of deemed continued eligibility, we will continue to
provide all Medicare Advantage plan-covered Medicare benefits. However, during this period, we will not continue
to cover Medicaid benefits that are included under the applicable Medicaid State Plan. Medicare cost-sharing
amounts for Medicare basic and supplemental benefits do not change during this period.
The State or Medicare may disenroll you if you are determined no longer eligible to the program.
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, 2023.
H8894_DSNP_24_4164896_M Pending Accepted
Pharmacy Communications - Pharmacy Communications
to view the PDF files. You can download a free copy by clicking here. By clicking on this link, you will be leaving the IEHP website.
TITLE
DATE
RECIPIENTS
September 2023
New DHCS Drug Use Review (DUR) Board Educational Articles
09/29
All IEHP PCPs, All IEHP Pharmacy Providers
August 2023 Pharmacy and Therapeutics Update
09/06
All IEHP PCPs, All IEHP Pharmacy Providers
URGENT: Recalls, Market Withdrawals & Safety Alerts, August 2023
09/01
All IEHP PCPs, All IEHP Pharmacy Providers
August 2023
New DHCS Drug Use Review (DUR) Board Educational Articles
08/29
All PCPs, OBs & BH Providers
Claims Processing during State of Emergency
08/20
All IEHP Pharmacy Providers
URGENT: Recalls, Market Withdrawals & Safety Alerts, July 2023
08/01
All IEHP PCPs, All IEHP Pharmacy Providers
July 2023
New DHCS Drug Use Review (DUR) Board Educational Articles
07/27
All Medi-Cal PCPs & Specialists
RESOLVED - Dual Choice Member Billing Issue
07/07
All IEHP Pharmacy Providers
DualChoice (HMO D-SNP): Known Billing Issue
07/06
All IEHP Pharmacy Providers
June 2023
URGENT: Recalls, Market Withdrawals & Safety Alerts, June 2023
06/30
All IEHP PCPs, All IEHP Pharmacy Providers
URGENT! Recalls, Market Withdrawals & Safety Alerts, May 2023
06/09
All IEHP PCPs, All IEHP Pharmacy Providers
May 2023 Pharmacy & Therapeutics Update
06/09
IEHP Provider Network
New DHCS Drug Use Review (DUR) Board Educational Articles
06/02
All Medi-Cal PCPs & Specialists
May 2023
Pharmacy Recalls, Market Withdrawals Safety Alerts - April 2023
05/10
All IEHP PCP's, All IEHP Pharmacy Providers
April 2023
Pharmacy Recalls Withdrawals Safety Alerts - January to March 2023
04/10
All IEHP PCP's & Pharmacy Providers
March 2023
IEHP DualChoice (HMO D-SNP): Known Billing Issue
03/31
All IEHP Pharmacy Providers
Pharmacy Recalls - Withdrawals - Safety Alerts - March 1-15, 2023
03/31
All IEHP PCPs & Pharmacy Providers
Pharmacy Recalls - Withdrawals - Safety Alerts - Dec 2022 to Feb 2023
03/31
All IEHP PCPs & Pharmacy Providers
DualChoice Medicare Billing for Non-FDA Approved Medications
03/21
All IEHP Pharmacy Providers
Claim Processing during State of Emergency due to Snowstorm
03/03
All IEHP Pharmacy Providers
February 2023
Transition to 30-day Coverage Determination Backdating
02/02
All LTC & SNF Providers
January 2023
IEHP DualChoice (HMO D-SNP): Over-the-Counter Drugs
01/09-01/30
All IEHP Pharmacy Providers
IEHP DualChoice (HMO D-SNP): Medicare Part B Coinsurance Billing
01/05-01/13
All IEHP Pharmacy Providers
IEHP DualChoice (HMO D-SNP): PBM Update and Medicare Part B Coinsurance
01/02-01/20
All IEHP Pharmacy Providers
IEHP DualChoice (HMO D-SNP) Members - Medication Overrides
01/02
All IEHP Pharmacy Providers
December 2022
Cal MediConnect (CMC) to Medi-Cal Rx/HMO D-SNP Transition
12/22
All IEHP Pharmacy Providers
Claims Rejected in Error
12/19
All IEHP Pharmacy Providers
PBM Change & Prior Authorization Submission Method - for DualChoice (HMO D-SNP) Members (Effective January 1, 2023)
12/13-12/29
All IEHP Pharmacy Providers
Pharmacy Recalls, Withdrawals & Safety Alerts - November 2022
12/07
All IEHP Pharmacy Providers
CoverMyMeds - Prior Authorization Submission Method for DualChoice Members (Effective January 1, 2023)
12/01-12/12
All IEHP Pharmacy Providers
November 2022
Recalls, Withdrawals & Safety Alerts - October 2022
11/14
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts - September 2022
11/02
All IEHP Pharmacy Providers
COVID-19: Test to Treat Monoclonal Antibodies
11/01
All IEHP Pharmacy Providers
October 2022
Cal MediConnect to Medi-Cal Rx Transition (D-SNP)
10/28
All IEHP Pharmacy Providers
September 2022
Recalls, Withdrawals & Safety Alerts
09/08
All IEHP Pharmacy Providers
August 2022
2022-2023 Flu Vaccination for IEHP Members
08/31
All IEHP Pharmacy Providers
Reminder: Medi-Cal Rx Gradual Reinstatement of PAs - Phase 1
08/31
All IEHP Pharmacy Providers
30-Day Countdown: Reinstatement of PA Requirements for 11 Drug Classes
08/18
All IEHP Pharmacy Providers
30-Day Countdown: Reinstatement of PA Requirements for 11 Drug Classes
08/17
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts
08/10
All IEHP Pharmacy Providers
July 2022
Academic Detailing Services Now Offered
07/15
All IEHP Pharmacy Providers
DHCS Medi-Cal Rx Update: Postponement of Implementation of NCPDP Reject Code 80
07/13
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts
07/07
All IEHP Pharmacy Providers
June 2022
New DHCS DUR Board Educational Article
06/22
All IEHP Pharmacy Providers
MTM Medicare Pharmacy Mailing Campaign
06/08
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts
06/05
All IEHP Pharmacy Providers
Academic Detailing Services Now Offered
06/04
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: Blood Pressure Monitors and Cuffs
06/03
All IEHP Pharmacy Providers
Important Notice: COVID-19 Oral Antivirals Billing
06/01
All IEHP Pharmacy Providers
May 2022
Recalls, Withdrawals & Safety Alerts
05/05
All IEHP Pharmacy Providers
April 2022
Rejected Claims Due To Prescriber Error Codes
04/06
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts
04/05
All IEHP Pharmacy Providers
MTM COVID-19: Test to Treat
04/04
All IEHP Pharmacy Providers
March 2022
MTM Medicare Pharmacy Mailing Campaign
03/29
All IEHP Pharmacy Providers
New DHCS DUR Board Educational Article
03/16
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: How To Assist IEHP Members
03/28-03/31
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: How To Assist IEHP Members
03/21-03/25
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: How To Assist IEHP Members
03/14-03/18
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: How To Assist IEHP Members
03/07-03/11
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts
03/07
All IEHP Pharmacy Providers
IEHP Contracted DME Pharmacies: CGM, BP Monitor, Nebulizer
03/02
All IEHP Pharmacy Providers
February 2022
Medi-Cal Rx Transition: How To Assist IEHP Members
02/28-03/04
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: How To Assist IEHP Members
02/22-02/25
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: How To Assist IEHP Members
02/14-02/18
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: How To Assist IEHP Members
02/10-02/11
All IEHP Pharmacy Providers
Pharmacy Empowerment Program
02/08
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts
02/07
All IEHP Pharmacy Providers
New DHCS DUR Board Educational Article
02/02
All IEHP Pharmacy Providers
January 2022
Free OTC COVID-19 Antigen Test Kits Available
01/31
All IEHP Pharmacy Providers
Medi-Cal Rx Transition Implementation
01/17-01/21
All IEHP Pharmacy Providers
Medi-Cal Rx Transition Implementation
01/10-01/14
All IEHP Pharmacy Providers
Medi-Cal Rx Transition Implementation
01/07
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts
01/05
All IEHP Pharmacy Providers
IEHP DualChoice - Plan Overview
our Medicare and
Medi-Cal benefits work better together, they work better for you.
Your care team and care coordinator work with you to make a care plan that meets your specific needs.
Plan Benefits
No Cost
DualChoice is a no-cost health coverage program. It provides coverage to qualified low-income California
residents.
Personal care teams
Doctors, Hospitals, pharmacies, specialists, behavioral-health providers and even coordinators are all on
the same page. They have access to the same information and can coordinate your care.
Shared medical information
Your medications and test results are shared with your entire team. No need for you to remind, remember or
get caught up in any red tape.
Full Coverage
Our plan includes doctors, hospitals, pharmacies, providers of long-term services and supports, behavioral
health and other providers.
Ready to sign up?
Who is eligible?
Adults 21 and older
Have both Medicare Part A and Medicare Part B
Are currently eligible for Medi-Cal
Adults who live in our service area
Are a full-benefit dual eligible beneficiary
People who are currently eligible for Medi-Cal
Enrolled in IEHP DualChoice for your Medicare benefits and Inland Empire Health Plan (IEHP) for your Medi-Cal benefits.
How do I enroll?
To enroll, please call: IEHP DualChoice at 877-273-IEHP (4347), 8 a.m. – 8 p.m. (PST), 7 days a week, including holidays.
TTY users should call 800-718-4347.
Click to enroll.
More About DualChice Plans
IEHP DualChoice.
2023 Plan Benefits.
2024 Plan Benefits.
New to IEHP DualChoice.
NCD.
How to Access Care.
IEHP DualChoice Enrollment.
Grievances, Coverage Determination and Appeals Process.
Problems with Part C.
Problems with Part D.
Making Complaints.
Rights and Responsibilities.
Important Resources.
Prescription Drugs.
IEHP DualChoice (HMP 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, 2023.
H8894_DSNP_24_4164896_M Pending Accepted