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

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

Governing Board Meetings - 2023 Meeting Schedule and Locations

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

Innovations and Quality Performance - Quality Performance

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

Enroll with IEHP DualChoice

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

Provider Resources - Facility Site Review

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

Healthy Living - Coronavirus

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

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

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

Pharmacy Services - Pharmacy Quality Ratings

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

Pharmacy Services - Provider Communications

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

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

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

Special Programs - Enhanced Care Management

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

Special Programs - California Children Services

page. What is CCS? CCS is a statewide program that enables children with qualifying conditions to receive specialized services related to that condition independent from IEHP. The CCS program provides diagnostic and treatment services, and medical case management for those who have qualifying conditions. CCS also provides occupational and physical therapy services through the Medical Therapy Program (MTP). The Medical Therapy Program (MTP) is a special program that provides physical therapy (PT), occupational therapy (OT), for children who have disabling conditions, generally due to neurological or musculoskeletal disorders Who Qualifies? The CCS program services children and young adults under the age of 21 who have eligible medical conditions. Examples of CCS-eligible conditions include, but are not limited to, chronic and acute medical conditions such as cystic fibrosis, hemophilia, cerebral palsy, heart disease, cancer, traumatic injuries, and infectious diseases producing major sequelae. For a more inclusive list of diagnoses and medical criteria of qualifying conditions please reference the below links: https://www.dhcs.ca.gov/services/ccs https://www.dhcs.ca.gov/services/ccs/Documents/CCSMedicalEligibility.pdf Provider Responsibilities Primary Care Physicians (PCPs), Specialty Providers, and IPA/Medical Groups are responsible for performing appropriate baseline health assessments and diagnostic evaluations sufficient to identify children and young adults with potential CCS-qualifying conditions and refer to CCS as needed. PCPs are responsible for all well child and pediatric preventative services as these services are not a covered benefit of CCS. PCPs are also responsible in assisting CCS members with transition from CCS to IEHP authorizations at the age of 21 when members age out of the CCS program. Benefits of CCS Enrollment CCS Clients are not restricted to in area providers but have access to any CCS paneled provider within the state of California when a need for the specialty care has been determined to be CCS eligible. Once a client is determined to be eligible for CCS, the client will continue to be medically eligible for CCS until treatment is complete or age 21 when the CCS program ends. Additional Resources To assist our valued Providers, every Member active with CCS has a distinct red “CCS” widget in the Provider Portal. Opening that widget enables you to view the diagnosis being treated and any Specialists and their treatment authorization range. For any questions about your Member’s CCS care or management, please do not hesitate to contact IEHP’s CCS Team at: (800) 706-4347 or by email at CCSCareManagement@iehp.org . (By clicking on the links below, you will be leaving the IEHP site) For additional CCS resources please reference the below links: CCS Program Overview: https://www.dhcs.ca.gov/services/ccs CCS Program Application: https://www.dhcs.ca.gov/formsandpubs/forms CCS Brochure (English/Spanish): https://www.dhcs.ca.gov/services/ccs/Pages/CCSBrochure.aspx How to become a CCS Provider: https://www.dhcs.ca.gov/services/ccs/Pages/ProviderEnroll.aspx You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

Join Our Network - IPA

p 2589 E Washington Blvd., Pasadena, CA 91107 (626) 817-9217 (626) 817-9207 Dignity Health Medical Network - Inland Empire 3400 Data Drive, Rancho Cordova, CA 95670 (916) 851-2026 (916) 851-7642 LaSalle Medical Associates 1855 W. Redlands Blvd. 2nd Floor, Redlands, CA 92373 (888) 554-4562 (626) 943-6369 Optum Care Network - Inland Faculty MG 1860 Colorado Blvd. Ste 200, Los Angeles, CA 90041 (800) 371-7547 (323) 257-7329 Physicians Health Network P.O. Box 11429, San Bernardino, CA 92423 (909) 300-5030 (909) 332-5555 Horizon Valley Medical Group 18564 US Highway 18 Ste 105, Apple Valley, CA 92307 (760) 813-6950 (760) 813-6947 DualChoice CalMediConnect CPN - Horizon Valley Medical Group 18564 US Highway 18 Ste. 105, Apple Valley, CA 92307 (760) 242-7777 (760) 242-0487 Dignity Health Medical Network - Inland Empire 3400 Data Drive, Rancho Cordova, CA 95670 (916) 851-2026 (916) 851-7642 EPIC Health Plan 1615 Orange Tree Lane, Redlands, CA 92374 (909) 799-1818 (909) 786-0816 Alliance Desert Physicians, Inc.       Beaver Medical Group       Chaffey Medical Group       FENIX Medical Group       Pinnacle Medical Group       Redlands - Yucaipa Medical Group       TriValley Medical Group       Heritage Provider Network 8510 Balboa Blvd. Ste 275, Northridge, CA 91325 (818) 654-3461   Desert Oasis Healthcare 275 N El Cielo Rd., Palm Springs, CA 92262 (760) 320-8814   Heritage Victor Valley Medical Group 12370 Hesperia Rd., Victorville, CA 92395 (760) 245-4747   Regal Medical Group 621 E Carnegie Dr. Ste 140, San Bernardino, CA 92408 (818) 654-3400   PrimeCare, part of Optum Care  3990 Concourse St., Ontario, CA 91764 (909) 605-8000   PrimeCare Chino 15315 Fairfield Ranch Rd. Ste 275, Chino Hills, CA 91709 (909) 465-1397 (909) 465-6629 Optum Care Network - Citrus Valley 9130 Anaheim Place Ste 130, Rancho Cucamonga, CA 91730 (909) 466-8000 (909) 484-6825 Optum Care Network - Corona 2275 Sampson Ave. Ste 111, Corona, CA 92879 (951) 371-8440 (951) 371-3910 Optum Care Network - Hemet Valley 41391 Kalmia St. Ste 310, Murrieta, CA 92562 (951) 461-0762 (951) 698-5194 Optum Care Network -  Inland Valley 9130 Anaheim Pl. Ste 130, Rancho Cucamonga, CA 91730 (909) 466-8000 (909) 484-6825 Optum Care Network -  Moreno Valley 1467 Ford St. Ste 103, Redlands, CA 92373 (909) 798-7766 (909) 792-8627 Optum Care Network - Redlands 1520 Barton Rd., Redlands, CA 92373 (909) 798-7766 (909) 792-8627 Optum Care Network - Riverside 2275 Sampson Ave. Ste 111, Corona, CA 92879 (951) 371-8440 (951) 371-3910 Optum Care Network - San Bernardino 1467 Ford St. Ste 103, Redlands, CA 92373 (909) 798-7766 (909) 792-8627 Optum Care Network - Sun City 41391 Kalmia St. Ste 310, Murrieta, CA 92562 (951) 461-0762 (951) 698-5194 Optum Care Network - Southwestern Valleys 41391 Kalmia St. Ste 310, Murrieta, CA 92562 (951) 461-0762 (951) 698-5194 Optum Care Network - Valley Physicians  24630 Washington Ave. Ste 203, Murrieta, CA 92562 (951) 704-1900 (877) 397-7682 Riverside Medical Clinic 3660 Arlington Ave., Riverside, CA 92506    

Provider Resources - Clinical Practice Guidelines

assist primary care providers in delivering care in accordance with IEHP standards. Resources are reviewed regularly and updated to reflect changes from a regulatory and clinical standpoint. Preventive Care Guidelines American College of Obstetricians and Gynecologists (ACOG) American Academy of Pediatricians (AAP) / Bright Futures Comprehensive Perinatal Services Program (CPSP) Clinical Practice Guidelines Library The guidelines contained on this page are recommended by IEHP with the intent to enhance Member care. IEHP’s Clinical Practice Guidelines topics are organized using the following categories: United States Preventive Services Task Force (USPSTF); IEHP Internal Library; Healthcare Effectiveness Data Information Set (HEDIS); and Managed Care Accountability Set (MCAS) Links or documents embedded within the Internal Library category indicate literature that has been published by leading, formal organizations and have been endorsed/approved by IEHP’s Medical Directors and Quality Committee. IEHP produced information relevant to the topic will also be listed in this category. We have also indicated any HEDIS/ MCAS measures that are pertinent to the topic. Additionally, IEHP accepts USPSTF guidelines to help primary care clinicians identify clinical preventive services that are appropriate for their patients. IF there is a USPSTF guideline relevant to the topic, we have identified it below.  Library Catalog Click on a letter to jump to that specific section: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z A Asthma USPSTF N/A IEHP Internal Library Global Strategy for Asthma Management and Prevention (PDF) HEDIS Asthma Medication Ratio (AMR) Medication Management for People with Asthma (MMA) MCAS Asthma Medication Ratio (AMR) (Back to Library Catalog) B Breast Cancer USPSTF Breast Cancer Screening Use of Medications to Prevent Breast Cancer BRCA Testing IEHP Internal Library N/A HEDIS Breast Cancer Screening (BCS) MCAS Breast Cancer Screening (BCS) (Back to Library Catalog) C Cervical Cancer USPSTF Cervical Cancer Screening IEHP Internal Library N/A HEDIS Cervical Cancer Screening (CCS) MCAS Cervical Cancer Screening (CCS) (Back to Library Catalog) Chlamydia USPSTF Chlamydia and Gonorrhea Screening IEHP Internal Library You may also refer to Sexually Transmitted Infections in this resource guide HEDIS Chlamydia Screening in Women (CHL) MCAS Chlamydia Screening in women (CHL) (Back to Library Catalog) Cholesterol USPSTF Statin Therapy for Primary Prevention of CVD Healthful Diet and Physical Activity for CVD Prevention in Adults with CVD Risks IEHP Internal Library American Heart Association – Blood Cholesterol Management (PDF) American Heart Association – Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults (PDF) HEDIS Statin Therapy for Patients with Cardiovascular Disease-Adherence (SPC) Statin Therapy for Patients with Cardiovascular Disease – Statin Therapy (SPC) MCAS N/A (Back to Library Catalog) Chronic Obstructive Pulmonary Disorder USPSTF N/A IEHP Internal Library Global Initiative for Chronic Obstructive Lung Disease – COPD (PDF) HEDIS Pharmacology Management of COPD Exacerbation – Systemic Corticosteroids (PCE) Pharmacology Management of COPD Exacerbations – Bronchodilators (PCE) Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR) MCAS N/A (Back to Library Catalog) Colorectal Cancer USPSTF Colorectal Cancer Screening IEHP Internal Library N/A HEDIS Colorectal Cancer Screening (COL) MCAS N/A (Back to Library Catalog) D Depression USPSTF Screening for Depression in Adolescents Screening for Depression in Adults including Pregnant Women Screening for Perinatal Depression IEHP Internal Library American Academy of Pediatrics – Adolescent Depression in Primary Care (PDF) American Psychiatric Association – Major Depressive Disorder (PDF) HEDIS Antidepressant Medication Management Acute Phase (AMM) Antidepressant Medication Management Continuation Phase (AMM) MCAS Antidepressant Medication Management Acute (AMM-Acute) Antidepressant Medication Management Continuation (AMM-Cont) (Back to Library Catalog) Diabetes USPSTF Gestational Diabetes Screening Prediabetes and Type 2 Diabetes: Screening IEHP Internal Library American Diabetes Association – Diabetes Care (PDF) National Kidney Foundation – Diabetes and Chronic Kidney Disease (PDF) HEDIS Statin Therapy for Patients with Diabetes – Adherence (SPD) Statin Therapy for Patients with Diabetes – Statin Therapy (SPD) Comprehensive Diabetes Care – HbA1C Testing (CDC) Comprehensive Diabetes Care - HbA1C Control (<=9) (CDC) Comprehensive Diabetes Care (<8) (CDC) Comprehensive Diabetes Care - Eye Exam (CDC) Comprehensive Diabetes Care – Monitoring for Nephropathy (CDC) Comprehensive Diabetes Care – Blood Pressure Control (<140/90) (CDC) MCAS Comprehensive Diabetes Care HbA1C Testing (CDC HT) Comprehensive Diabetes Care HbA1C Testing >9%) (CDC H9) (Back to Library Catalog) E (Back to Library Catalog)   F (Back to Library Catalog)   G Gonorrhea USPSTF Chlamydia and Gonorrhea Screening IEHP Internal Library You may also refer to Sexually Transmitted Infections in this resource guide HEDIS N/A MCAS N/A (Back to Library Catalog) H Hepatitis C USPSTF Hepatitis C Virus Infection in Adolescents and Adults: Screening IEHP Internal Library American Association for the Study of Liver Diseases – Hepatitis C (PDF) HEDIS N/A MCAS N/A (Back to Library Catalog) Human Immunodeficiency Virus (HIV) USPSTF HIV Screening in Pregnant Persons HIV Screening in Adults and Adolescents HIV Prevention – Preexposure Prophylaxis IEHP Internal Library You may also refer to Sexually Transmitted Infections in this resource guide HEDIS N/A MCAS N/A (Back to Library Catalog) Hypertension USPSTF Screening for Hypertension in Adults IEHP Internal Library Joint National Committee – Hypertension Guidelines (PDF) HEDIS Controlling high blood pressure (CBP) MCAS Controlling high blood pressure (CBP) (Back to Library Catalog) I (Back to Library Catalog)   J (Back to Library Catalog)   K (Back to Library Catalog) L (Back to Library Catalog)   M (Back to Library Catalog)   N (Back to Library Catalog)   O Obesity USPSTF Weight Loss to Prevent Obesity Related Morbidity and Mortality in Adults - Counseling Screening for Obesity in Children and Adolescents Behavioral Health Counseling for Adults that are Overweight or Obese and Have Other CVD Risk Factors IEHP Internal Library N/A HEDIS Weight Assessment and Counseling (WCC-BMI) Adult Body Mass Index (ABA) MCAS Weight Assessment and Counseling (WCC-BMI) Adult Body Mass Index (ABA) (Back to Library Catalog) Osteoporosis USPSTF Osteoporosis to Prevent Fractures: Screening IEHP Internal Library N/A HEDIS Osteoporosis management in women who have had a fracture (OMW) MCAS N/A (Back to Library Catalog) P (Back to Library Catalog) Q (Back to Library Catalog) R (Back to Library Catalog) S Sexually Transmitted Infections USPSTF Syphilis Screening in Pregnant Women Syphilis Screening for those at Increased Risk for Infection Chlamydia and Gonorrhea Screening HIV Screening in Pregnant Persons HIV Screening in Adults and Adolescents HIV Prevention – Preexposure Prophylaxis IEHP Internal Library Centers for Disease Control Public Health Media Library – STD Treatment You may also refer to individual topics as they appear in this library: Chlamydia Gonorrhea HIV Syphilis HEDIS Chlamydia Screening in women (CHL) MCAS Chlamydia Screening in women (CHL) (Back to Library Catalog) Skin Cancer Behavioral Counseling USPSTF Skin Cancer Prevention: Counseling IEHP Internal Library N/A HEDIS N/A MCAS N/A   (Back to Library Catalog) Smoking Cessation/Tobacco Usage USPSTF Smoking Cessation Smoking Cessation – Pharmacotherapy Lung Cancer Screening Tobacco Use in Children and Adolescents – Primary Care Interventions IEHP Internal Library N/A HEDIS N/A MCAS N/A (Back to Library Catalog) Syphilis USPSTF Syphilis Screening in Pregnant Women Syphilis Screening for Those at Increased Risk for Infection IEHP Internal Library You may also refer to Sexually Transmitted Infections in this resource guide HEDIS N/A MCAS N/A (Back to Library Catalog) T Tuberculosis USPSTF Latent Tuberculosis Screening IEHP Internal Library N/A HEDIS N/A MCAS N/A (Back to Library Catalog) U (Back to Library Catalog) V (Back to Library Catalog) W (Back to Library Catalog) X (Back to Library Catalog) Y (Back to Library Catalog) Z (Back to Library Catalog) You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

Provider Resources - Utilization Management Criteria

e. IEHP has created UM Subcommittee Approved Authorization Guidelines to serve as one of the sets of criteria for medical necessity decisions. Our goal in creating this page is to provide you with easily accessible electronic versions of IEHP’s UM guidelines. IEHP utilizes a variety of sources in developing our UM guidelines which include: Medicare and Medi-Cal’s coverage policy statements Evidence in the peer-reviewed published medical literature Technology assessments and structured evidence reviews Evidence-based consensus statements Expert opinions of healthcare Providers Evidence-based guidelines from nationally recognized professional healthcare organizations and public health agencies. IEHP is also licensed to use MCG Guidelines, Apollo Medical Review Criteria, and InterQual to guide in utilization management decisions. Since medical technology is constantly evolving, our clinical guidelines are subject to change without prior notification. Additional UM Subcommittee Guidelines may be developed as needed or may be withdrawn from use. Please note that benefits may vary based on Member’s line of business; therefore, certain services discussed in the UM Subcommittee Guidelines may not be a covered benefit. Table of Contents (PDF) Providers may obtain information about criteria, either in general or relating to specific UM decisions, from IEHP upon request by contacting the IEHP UM Department. Please contact the IEHP Provider Relations Team at (909) 890-2054 to be connected to the UM Department.  Behavioral Health Behavioral Health Treatment (BHT) Criteria (PDF) Behavioral Health Home Based Services (PDF) Criteria for Multidisciplinary Diagnostic Treatment (PDF) Community Supports Services Community Transition Services Nursing Facility Transition to a Home (PDF) Nursing Facility Transition-Diversion to Assisted Living (PDF) Housing Deposits (PDF) Housing Transition Navigation Services (PDF) Housing Tenancy and Sustaining Services (PDF) Asthma Remediation (PDF) Environmental Accessibility Adaptations (Home Modifications) (PDF) Medically Tailored Meals (PDF) Sobering Centers (PDF) Recuperative Care (PDF) Short-Term Post-Hospitalization Housing (PDF) Diagnostic Testing Elastography (PDF) Inflammatory Bowel Disease Serology (PDF) Vestibular Autorotation Test (PDF) Gynecology and Obstetrics Fetal Non-Stress Testing (PDF) Neurology Bone Marrow Transplant in Treatment of Multiple Sclerosis (PDF) Pain Management Pain Management - Centers of Excellence (COE) (PDF) Referrals to Pain Management Specialist (PDF) Pharmacy Biosimilar Products (PDF) CAR-T Therapy (PDF) Surgical Procedures Adolescent Bariatric Consultation and Surgery (PDF) Bronchial Thermoplasty (PDF) Liver Biopsy in Conjunction with Bariatric Surgery (PDF) Natural Orifice Transluminal Endoscopic Surgery (PDF) Transgender Services (PDF) Other Allocation of Limited Critical Care Resources During a Public Health Emergency (PDF) Care Plan Option (PDF) Complementary and Alternative Medicine or Holistic Therapies (PDF) Congregate Living Health Facilities (PDF) Criteria for Custodial Care: Medi-Cal (PDF) Enhanced Care Management (PDF) Hair Removal Guideline (PDF) Health Homes Program (HHP) (PDF) My Path (A Palliative Care Approach) (PDF) Tertiary Care Center Referral Requests (PDF) Transitional Care Medicine (PDF) Transportation Criteria (PDF)   You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

Provider Resources - Pharmacy

gram, Prior Authorization Criteria, Clinical Practice Guidelines, Forms, IEHP Formulary, and Safety Resources with drug recall information. If you have any questions regarding services provided by the Pharmaceutical Services Department, please feel free to contact the IEHP Pharmacy Department at (909) 890-2049. Pharmaceutical Services

Provider Resources - Claims

d range of topics for all types of Providers with questions regarding billing requirements and claims processing guidelines. Resources are not limited to webinars, computer based training, and webinars. Providers also have direct access to their Regional Representative and the Small Provider Billing Unit (SPBU) through this link (By clicking on this link, you will be leaving the IEHP website) https://learn.medi-cal.ca.gov/. Medi-Cal Rates and Codes By clicking on these links, you will be leaving the IEHP website. Medi-Cal Rates The file lists the maximum reimbursement rates payable by the Medi-Cal program for covered procedures described in the HCPCS and CPT-4 coding system. Resource: website CPT Codes This website is aimed at providing information to Providers on Medicare's National CCI edits, but will not address specific CCI edits. Resource: website Alpha-Numeric HCPCS Files These files contain the Level II alpha-numeric HCPCS procedure and modifier codes, their long and short descriptions, and applicable Medicare administrative, coverage, and pricing data. Resource: website ZIP code To Carrier Locality File This file is primarily intended for use by ambulance suppliers to map ZIP Codes to CMS carriers and localities. This file will also map ZIP Codes to their State and can determine whether the ZIP Code has a rural designation as determined by CMS. Resource: website Medicare Physician Fee Schedule Information on services covered by the Medicare Physician Fee Schedule (MPFS). Resource: website IEHP Fee Schedule IEHP Fee Schedule - December 08, 2020 (PDF) Other Health Coverage (OHC) Coordination of Benefits with Other Health Coverage (OHC) (PDF) Frequently Asked Questions (FAQs) - OHC (PDF)

Care After Hours - Get Care After Hours

hen you can't reach your Doctor after-hours or your Doctor is not available, you have options to get your needed care.  Call the IEHP 24-Hour Nurse Advice Line at (888) 244-4347, TTY 711. 1. Speak to our Nurse  Our Nurse can offer you medical advice on the phone or guide you to get the care you need.  Common reasons to call our Nurse:   Cough Mild stomach ache Mild fever Sore throat Cold or flu Questions about your medicine  Ear ache  Nurse Advice Video 2. Speak to a Doctor Our Nurse may decide you need to talk with a Doctor. If so, our Nurse will connect you with a Doctor for a live phone chat or schedule a virtual visit through an app. 3. Visit an IEHP Urgent Care Clinic Our Nurse may direct you to an Urgent Care Clinic, so you can see a Doctor the same day. Many clinics are open late, weekends and holidays. Some clinics have X-rays and lab tests. We have more than 90 Urgent Care Clinics in our network. For one near you, visit the IEHP Provider Search. Common reasons to visit an Urgent Care Clinic:  Mild sore throat Mild fever Rash Nose bleed Minor trauma Animal or insect bite Asthma (non-critical) Cuts & lacerations Call 911 or go to the nearest Emergency Room (ER) for emergency medical and behavioral health conditions. Don’t wait!   Urgent Care Video

Care After Hours - Emergency Room vs. Urgent Care Clinic

iding between the ER and Urgent Care. For medical advice before visiting the ER or an Urgent Care Clinic, you can call your Doctor or IEHP 24-Hour Nurse Advice Line (888) 244-4347, TTY 711. Note that ERs are open 24 hours a day and many Urgent Care clinics close in the late evening. When Should I Go to the ER? An emergency is when a person could die or be permanently hurt. The ER provides care for critical or life-threatening conditions.   Visit your closest ER or call 911 if you experience: Changes in mental status, such as confusion Chest pain or pressure Coughing or vomiting blood Difficulty breathing or shortness of breath Severe allergic reaction Severe or persistent vomiting or diarrhea Sudden dizziness, weakness or changes in vision Sudden or severe pain Visit Provider Search for listing of emergency room locations near you. When Should I go to an Urgent Care? Go to an Urgent Care Clinic when you need care after hours for non-life-threatening conditions.  Here are some examples of conditions: A common illness like the flu Minor fever or headache Painful sore throat Earache or sinus pain Minor injuries like a sprained ankle Back pain Cuts or small wounds Small burns Rash or minor allergic reactions Nausea Diarrhea Urinary tract infections There are more than 90 clinics in our IEHP network. Many are open late and on weekends. Search Provider Search or call the IEHP 24-Hour Nurse Advice Line (888) 244-4347, TTY 711.

Medi-Cal Evidence of Coverage Updates

book for the benefit year of January 1, 2022 – December 31, 2022. How to get care Sensitive care Minor consent services You may only get the following services without your parent or guardian’s permission if you are 12 years old or older: Outpatient mental health care for (minors age 12 or older): Sexual assault (no lower age limit) Incest Physical assault Child abuse When you have thoughts of hurting yourself or others (minors age 12 or older) HIV/AIDS prevention/testing/treatment Sexually transmitted infections prevention/testing/treatment Substance use disorder treatment services (minors age 12 or older). For more information see “Substance use disorder treatment services” in this handbook. If you are under 18 years old, you can go to a doctor without permission from your parents or guardian for these types of care: Pregnancy Family planning/birth control Abortion services For pregnancy testing, family planning services, birth control, or sexually transmitted infection services, the doctor or clinic does not have to be part of the IEHP network. You can choose any Medi-Cal provider and go to them for these services without a referral or pre-approval (prior authorization). Services from an out-of-network provider not related to sensitive care may not be covered. For help finding a doctor or clinic giving these services, or for help getting to these services (including transportation), you can call IEHP Member Services at 1-800-440-IEHP (4347) (TTY 1-800-718-4347 or 711). Minors can talk to a representative in private about their health concerns by calling the 24/7 at 1-888-244-IEHP (4347) (TTY 711). Benefits and services What your health plan covers This chapter explains your covered services as a member of IEHP. Your covered services are free as long as they are medically necessary and provided by an in-network provider. You must ask us for pre-approval (prior authorization) if the care is out-of-network except for sensitive services, emergencies and some urgent care services. Your health plan may cover medically necessary services from an out-of-network provider. But you must ask IEHP for pre-approval (prior authorization) for this. Medically necessary services are reasonable and necessary to protect your life, keep you from becoming seriously ill or disabled, or reduces severe pain from a diagnosed disease, illness or injury. For Members under the age of 21, Medi-Cal services include care that is medically necessary to fix or help relieve a physical or mental illness or condition. For more details on your covered services, call IEHP Member Services at 1-800-440-IEHP (4347) (TTY 1-800-718-4347 or 711). Members under 21 years old get extra benefits and services. Read Chapter 5: Child and youth well care for more information. Some of the basic health benefits IEHP offers are listed below. Benefits with a star ( * ) may need pre-approval. Acupuncture* Acute (short-term treatment) home health therapies and services Adult immunizations (shots) Allergy testing and injections Ambulance services for an emergency Anesthesiologist services Asthma prevention Audiology* Behavioral health treatments* Cardiac rehabilitation Chiropractic services* Chemotherapy & Radiation therapy Cognitive health assessment Dialysis/hemodialysis services Durable medical equipment (DME)* Emergency room visits Enteral and parenteral nutrition* Family planning office visits and counseling (you can go to a non-participating provider) Habilitative services and devices* Hearing aids Home health care* Hospice care* Inpatient medical and surgical care* Lab and radiology* Long-term home health therapies and services* Maternity and newborn care Major organ transplant* Occupational therapy* Orthotics/prostheses* Ostomy and urological supplies Outpatient hospital services Outpatient mental health services Outpatient surgery* Palliative care* PCP visits Pediatric services Physical therapy* Podiatry services* Pulmonary rehabilitation Rapid Whole Genome Sequencing Rehabilitation services and devices* Skilled nursing services Specialist visits Speech therapy* Surgical services Telemedicine/Telehealth Transgender services* Urgent care Vision services* Women’s health services