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Rx Prior Authorization Drug Treatment Criteria - Prior Authorization Drug Treatment
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking Adobe Acrobat Reader. By clicking on this link, you will be leaving the IEHP website. Medicare: For IEHP DualChoice (HMO D-SNP) - Medicare-Medicaid Plan - Formulary and Criteria information, please click here IEHP DualChoice (HMO D-SNP). Medicaid: On January 7, 2019, Governor Gavin Newsom issued Executive Order N-01-19 (EO-N-01-19) for achieving cost-savings for drug purchases made by the state. A key component of EO N-01-19 requires the Department of Health Care Services (DHCS) transition all Medi-Cal pharmacy services from managed care (MC) to fee for service (FFS). Click here to go to the “DHCS Medi-Cal Rx” page on IEHP website Click here to go to “Medi-Cal Rx: Transition” page on DHCS website Updated April 7, 2021, this document describes DHCS’ multi-faceted pharmacy transition policy, inclusive of “grandfathering” previously approved PAs from managed care and fee-for-service, as well as a 180-day period with no PA requirements for existing prescriptions, to help support the Medi-Cal Rx transition. During this transition period, Magellan will provide system messaging, reporting and outreach to provide for a smooth transition to Medi-Cal Rx. Click here to view “Medi-Cal Rx Pharmacy Transition Policy” from DHCS website To view Drug Criteria Referenced in Summary Table - Click Links Below: Clinical Practice Guidelines - CPGs Drug Prior Authorization Criteria HP Acthar (repository corticotropin injection) (PDF) Nucala (PDF) Spinraza (nusinersen) (PDF) Synagis (PDF) Xolair (omalizumab) (PDF) Drug Class Prior Authorization Criteria Growth Hormones (PDF) Immuno Globulins (PDF) Therapeutic Agents in Rheumatic And Inflammatory Diseases (PDF) Zynteglo (PDF) Pharmacy Policies Discharge Policy (PDF) Drug Trial and Failure (PDF) High Daily Morphine Milligram Equivalent (PDF) IEHP Drug Prior Authorization Policy (PDF) Intradialytic Parenteral Nutrition (IDPN) Policy (PDF) Non-Formulary Drug (PDF) Non-Sterile Compounded Medication (PDF) Off-Label Indication Policy (PDF) Pharmacy Drug Management Program for Pain (PDF) Quantity Limit Policy (PDF) Information on this page is current as of June 02, 2023.
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 Bone Disease-Arthritis-Rheumatoid Arthritis Chronic Heart Failure (CHF) Diabetes Dyslipidemia End-Stage Renal Disease (ESRD) 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 Beta Blockers Biophosphonates Bronchodilators Calcium Channel Blockers Disease-Modifying Anti-Rheumatic Drugs (DMARDs) Diuretics Insulins Oral Hypoglycemics Selective Serotonin Reuptake Inhibitors (SSRIs) Tumor Necrosis Factors (TNFs) Inhaled Corticosteroids Calcimimetic Cardiac Glycoside Colony Stimulating Factors Glucagon-Like Peptide-1 Glucocorticosteroids Neprilysin Inhibitor NSAIDs Phosphate Binders Vitamin D Analogs 3. Drug costs of $1,233.75 (one-fourth of $4,935) 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, 2022. DSNP_23_3241532_M
Upcoming Events - Eat Healthy, Be Active Workshop (Online)
Upcoming Events - Understanding Diabetes (Online)
ze symptoms of low and high blood sugar levels, how to treat them, and how to prevent them. Also, learn to manage blood sugar levels when you get sick. Click here to register for this Webex class Session Number: 26344912265 Download Webex for Apple users Download Webex for Android users Download Webex for PC users
Upcoming Events - Understanding Diabetes (Online)
symptoms of low and high blood sugar levels, how to treat them, and how to prevent them. Also, learn to manage blood sugar levels when you get sick. Click here to register for this Webex class Session Number: 26337069256 Download Webex for Apple users Download Webex for Android users Download Webex for PC users
Upcoming Events - Eat Healthy, Be Active Workshop (Online)
Latest News - Trona Strong: Small town, big heart
ing earthquakes rocked the rural desert community nearly four years ago, many of the residents couldn’t recover, shuttered their homes and simply walked away. Others who stayed just haven’t been able to replace the broken glass. But make no mistake – the Trona citizens who remain love their town. They’re Trona Strong. Despite the damaged windows, the door to welcome partners like Inland Empire Health Plan (IEHP) – and the help and resources it can offer – is wide open. ‘BRING NEW HOPE’ “We’re isolated out here in a lot of different ways and it’s a struggle to get many services,” said Trona resident Julia Pitman, who recently attended a special in-person meeting with IEHP CEO Jarrod McNaughton at the Trona Community Senior Center. “I was pleased to hear that we had a visit from your team (to) bring new hope to the community.” IEHP was eager to show up for Trona. “The questions that came up, the suggestions that came up today – none of that, I don’t believe, we would have received if we had done some kind of a virtual call or something,” said McNaughton later that day. “I think you have to come in person to really feel what folks are going through, to feel their passion for their community as well.” Even before the 6.4, then 7.1 temblors that hit the town just one day apart, July 4 and 5, 2019, Trona struggled with the changing landscape of its dwindling population (now less than 2,000) and employment opportunities. Searles Valley Minerals is still the largest employer in Trona. Trona was “born” a company town – literally. In 1914, the American Trona Company established its namesake for the mineral found in the Searles dry lakebed. The community and its residents flourished for the next 60 years, until a series of unfortunate events including factory buy-outs, production cuts and massive layoffs. Thousands of people left Trona. Then, in 2019, the double-whammy of the double quakes, followed by the COVID-19 pandemic less than a year later. Then more residents moved away. BRIGHT SPOTS Along Trona’s timeline, there are bright spots. Football is still a big draw, including games at Trona High School’s all-dirt gridiron – known as the “Pit” –home to the Tornadoes’ eight-man football team. The unique surface mix of sand, grit and rocks is famous: It’s been featured in national media outlets. Future athletes are only a short pass away at the neighboring elementary school whose mascot is the Twisters and where students and teachers alike occasionally dress up as their favorite character for Disney Days. The nearby Trona Pinnacles and surrounding areas – with their otherworldly look and feel – appear as unusual scenic landscapes in various TV shows and Hollywood films, mostly of the sci-fi variety. And sometimes, news crews and photographers pass through town to document Trona’s struggles and steadfast devotion. Much to diners’ delight, Trona’s only eatery – Esparza’s Family Restaurant – recently reopened in a new location, but still serving everyone’s favorite Mexican fare. Its previous spot remains red-tagged from the earthquakes. LOOKING AHEAD Nowadays, Trona residents say it’s time to look forward and find solutions for current gaps like health care access and potential career development for its young people. On Dec. 14, IEHP hosted Winter Wonderland, a large resource fair with dental services, vaccines and other health information. The well-attended event also featured a regular bi-weekly fresh produce distribution, established after ongoing feedback sessions with residents. This collaboration started in 2021, before IEHP officially expanded its health plan coverage area to rural areas, including outlying areas along the borders of San Bernardino County, in January 2022. At the community meeting with IEHP’s CEO McNaughton – which included a lunch catered by Esparza’s – Trona residents were asked to share their town’s top needs. “The biggest thing is how can we get health services in Trona,” said Priscilla Benadom, a longtime Trona resident and recent retiree as the senior center’s program coordinator. Following the meeting, McNaughton wanted to see the area and some of its logistical challenges firsthand, so he took a tour of the city. McNaughton also stopped for a brief visit with those Twisters at the elementary school, distributing IEHP swag bags and chocolate chip cookies. And because it was Disney Day, he even broke out into a booming rendition of the theme song, “Let It Go” from the mega hit movie “Frozen” for one of several Elsas in the classroom. “It’s an honor for IEHP to be connected now – finally – into this community where we can do some pretty cool things together with them,” McNaughton said.
CalAIM - Pay for Performance (P4P)
th Care Services (DHCS), California Advancing and Innovating Medi‐Cal (CalAIM) is a long‐term commitment to transform and strengthen Medi‐Cal, offering Californians a more equitable, coordinated, and person‐centered approach to maximizing their health and life trajectory.1 DHCS Goals For CalAIM 2 Identify and manage comprehensive needs through whole person care approaches and social drivers of health. Improve quality outcomes, reduce health disparities, and transform the delivery system through value-based initiatives, modernization, and payment reform. Make Medi‐Cal a more consistent and seamless system for enrollees to navigate by reducing complexity and increasing flexibility. Resource Links DHCS CalAIM page DHCS CalAIM Transformation Infographic (PDF) DHCS Medi-Cal Alignment Primer (PDF) IEHP Enhanced Care Management IEHP Enhanced Care Management (Member Page) IEHP Community Support Services IEHP Community Support Services (Member Page) 1,2https://dhcs.ca.gov/calaim You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.
IEHP DualChoice - Important Resources
rm (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, 2022. H8894_DSNP_23_3241532_M
Renew your Medi-Cal coverage - Medi-Cal FAQs
to act now! During the COVID-19 Public Health Emergency (PHE), your Medi-Cal was renewed automatically – even if you had changes in your household. But now Medi-Cal members like you must again renew coverage each year to keep your health care benefits. Your county will mail you a letter or yellow envelope about your Medi-Cal eligibility. The letter will tell you if your Medi-Cal coverage was renewed automatically. If the county could not auto-renew, then you’ll need to complete the packet and return it right away by mail or in-person to your Medi-Cal office. Or fill it out online at www.BenefitsCal.com. Always make sure your contact information is updated with your local county office. What if I’m not sure of my Medi-Cal renewal date? You can contact your local Medi-Cal county office, call IEHP’s Eligibility team at 1-888-860-1296 or visit www.BenefitsCal.com. (You can set up an online account if you don’t have one yet.) How do I update my contact information? Call IEHP’s Eligibility team at 1-888-860-1296, Monday-Friday, 8am-5pm, or Create and update your online account at www.BenefitsCal.com, or Call or visit your county office: Riverside County: 1-877-410-8827, Monday - Friday, 8am-5pm San Bernardino County: 1-877-410-8829, Monday - Friday, 8am-5pm How do I report a change if I have SSI? If you get SSI, Social Security will process your Medi-Cal renewal. If you have questions: Call 1-800-772-1213 (TTY: 1-800-325-0778, Monday through Friday, 8am – 7pm, or Contact your local Social Security office via their online locator. What if I am no longer eligible for Medi-Cal? You may be able to get health coverage through Covered California. The county office will send you information about how to sign up. Who do I contact if I have additional questions? If you need more help, call IEHP’s Eligibility team at 1-888-860-1296, Monday-Friday, 8am-5pm. Or contact your county Medi-Cal office: Riverside County: 1-877-410-8827, Monday-Friday, 8am-5pm San Bernardino County: 1-877-410-8829, Monday-Friday, 7am-5pm
Provider Resources - Educational Opportunities
isciplinary Care Team (ICT) Dual Choice Medicare CM IPA Training Alzheimer's and Dementia Care Specialty Mental Health Care Coordination National LGBT Health Education Webinars Online Cultural Competency Training Interdisciplinary Care Team (ICT) Fact Sheet (PDF) Healthcare Provider Toolkit: Assisting Patients with Requests for Workplace Accommodations or Leaves of Absence (PDF) Dual Choice Medicare CM IPA Training 2021 Care Management Delegation Oversight Medi-Cal IPA Training (MP4 Video) - December 08, 2021 Discussion Topics: Health Risk Assessments (HRA) Individual Care Plans (ICP) Interdisciplinary Care Team (ICT) Coordination of Care Delegated IPA Reporting Requirements 2021 Care Management Delegation Oversight Medi-Cal IPA Training (MP4 Video) - February 16, 2021 Alzheimer's and Dementia Care Project ECHO Opportunities From The Alzheimer's Association For Inland Empire Primary Care Clinics Alzheimer’s Association / UCSF Memory and Aging Center Alzheimer’s and Dementia Care ECHO Faculty partners: UCSF Memory and Aging Center faculty When: Thursdays beginning February 16, 2023 until July 20, 2023 from 12:00 pm - 1:00 pm PT via Zoom Who can be involved: All California based Primary care practice teams (including MD/DO, NP, PA, social work, MA) UCSF/Inland Empire ECHO 2023 Flyer (PDF) To register, please contact Kelsey Burnham at email@example.com UCLA ADC ECHO Faculty partners: UCLA Alzheimer’s and Dementia Care (ADC) program faculty When: Wednesdays beginning March 29, 2023 until September 6, 2023 from 11:00 am - 12:00 pm PT via Zoom Who can be involved: Nationwide teams interested in adding to their own knowledge and skills and those interested in learning about or implementing the highly effective UCLA ADC program ADC ECHO 2023 Flyer (PDF) To register, please contact Rachel Goldberger at firstname.lastname@example.org Specialty Mental Health Care Coordination The Centers for Medicare and Medicaid Services (CMS) is requiring IEHP and its IPAs to document and report the efforts made to coordinate the care of IEHP DualChoice (HMO D-SNP) Members receiving specialty mental health services through the County Mental Health Plans. As of June 1, 2018, IEHP has put policies and procedures in place to comply with these process and reporting requirements: On the first (1st) of each month, IEHP will provide IPAs and County MH Clinics a list of IEHP DualChoice (HMO D-SNP) Members known to be receiving specialty mental health services through the County MH Plans. IPAs are expected to outreach to these Members and their County MH Clinic Provider, as well as, document their outreach attempts and outcomes as outlined in Policy 25C2, “Care Management Requirements – Delegated IPA Responsibilities.” IPAs are required to provide data elements specific to this measure, as outlined in Policy 25F1, “Encounter Data Reporting - Medicare MMP Reporting Requirements – IEHP DualChoice (HMO D-SNP)" and Attachment, “Medicare Provider Reporting Requirements Schedule” in Section 25. IEHP, through its Delegation Oversight process, will monitor the IPAs’ compliance with documentation and reporting requirements, as outlined in Policy 25A2, “Delegation Oversight Audit.” To access the On-Site training material presented to IPAs and County Mental Health Clinics, click here (PDF). National LGBT Health Education Webinars IEHP has put together a list of webinars, provided by a third party, to provide educational programs, resources, and consultation to health care organizations with the goal of optimizing quality, cost-effective health care for lesbian, gay, bisexual, transgender, and all sexual and gender minority (LGBT) people. The National LGBT Health Education Center is part of the Division of Education and Training at The Fenway Institute, Fenway Health. The Fenway Institute (TFI) is an interdisciplinary center for research, training, education, and policy development that works to ensure access to quality, culturally affirming medical and mental health care for traditionally underserved communities, including LGBTQIA+ people and those affected by HIV/AIDS. The mission of Fenway Health is to enhance the wellbeing of the LGBTQIA+ community as well as people in our neighborhoods and beyond through access to the highest quality health care, education, research, and advocacy. Fenway Health is one of the largest providers of LGBTQIA+ health care and HIV primary care in the country; as such, it is a leader in the field of LGBTQIA+ health and informs much of the promising practices and innovative models that the Education Center disseminates to health centers nationwide. By clicking on these links, you will be leaving the IEHP website. The National LGBT Health Education Center Webinars Courses Include: HIV Prevention/PrEP at Health Centers: An Overview and Current Best Practices What’s new in PrEP and STIs? Cases From a Sexual Health Clinic Insurance Considerations for Navigating Gender-affirming Care Building Your Family: LGBTQ Reproductive Options Behavioral Health Assessments and Referral for Gender-Affirming Surgery Navigating Gender Affirming Care Collecting Sexual Orientation and Gender Identity (SO/GI) Data In Electronic Health Records Providing Mental Health Assessments for Gender Affirming Surgery Referral Letters Online Cultural Competency Training AHRQ Health Literacy Modules Available for Continuing Education (CE) and Maintenance of Certification (MOC) Credit Physicians and nurses can earn CE credits while learning about the challenges in caring for patients with low health literacy as well as strategies to improve overall patient communication and care. OptumHealth Education is issuing continuing education credit for taking the AHRQ-developed Health Literacy Knowledge Self-Assessment. No fees are charged for the two CE activities: By clicking on these links, you will be leaving the IEHP website. 1. An Updated Overview of Health Literacy Link (optumhealtheducation.com) 2. Improving Health Literacy by Improving Communication Skills Link (optumhealtheducation.com) Pediatricians and family physicians can earn credit for re-certification (MOC Part 2) as well as CE by taking the Health Literacy Knowledge Self-Assessment through the American Board of Pediatrics and the American Academy of Family Physicians, respectively. To learn about AHRQ’s tools to address health literacy, visit Health Literacy Topics at: https://www.ahrq.gov/health-literacy/index.html To find out about other free AHRQ continuing education opportunities, go to: https://www.ahrq.gov/patient-safety/education/continuing-ed/index.html To contact AHRQ, visit https://www.ahrq.gov/contact/index.html Office of Minority Health - https://cccm.thinkculturalhealth.hhs.gov/ CDC - www.cdc.gov U.S. Department of Health and Human Service, Health Resources and Services Administration - www.hrsa.gov You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.
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
RFPs and Bids - Procurement
Procurement department is continuously looking for suppliers of the varied goods and services it procures. IEHP procures goods and services through the solicitation process, and in the case of repetitively purchased items, establishes long-term contracts. With the exception of Public Works (construction type bids) and a few specialty bids, most bids for goods and services procured are completed using a third-party solicitation website called Bonfire. Vendors have the option to view IEHP’s open solicitations on the Bonfire website. IEHP invites all vendors to register with Bonfire and participate in IEHP’s fair and open solicitation process for goods and services. Mission Statement The Procurement department is committed to supporting the mission of IEHP, which is “to organize and improve the delivery of quality, accessible and wellness based healthcare services for our community”. As a community-developed health plan, we are accountable to the public. IEHP’s Procurement professionals possess the necessary skill set, knowledge base, and negotiating skills to assist IEHP with the acquisition of materials, equipment and contractual services. Utilizing this expertise, our best procurement practices, and the highest standards of professional ethics and integrity, we ensure that procurement decisions made are in the best interest of IEHP and in compliance with all applicable laws, regulations and policies. Compliance with Economic Sanctions Imposed in Response to Russia’s Actions in Ukraine On March 4, 2022, Governor Gavin Newsom issued Executive Order N-6-22 (EO) regarding sanctions in response to Russian aggression in Ukraine. The EO is located at https://www.gov.ca.gov/wp-content/uploads/2022/03/3.4.22-Russia-Ukraine-Executive-Order.pdf. This serves as a notice under the EO that as a vendor, contractor or grantee, compliance with the economic sanctions imposed in response to Russia’s actions in Ukraine is required, including with respect to, but not limited to, the federal executive orders identified in the EO and the sanctions identified on the U.S. Department of the Treasury website (https://home.treasury.gov/policy-issues/financial-sanctions/sanctions-programs-and-country-information/ukraine-russia-related-sanctions). Failure to comply may result in the termination of contracts or grants, as applicable. For general inquiries, please email email@example.com. Code of Ethics Policy Click to Download Our Code of Ethics Policy
Renew your Medi-Cal coverage - Medi-Cal Renewal
The Clock Is Ticking on Your Medi-Cal Benefits... Over the past three years of the COVID public health emergency - known as PHE - you were able to keep your Medi-Cal without renewing it. As we move out of the PHE, you need to take action now to keep getting the same health care coverage. Complete the renewal packet inside and return it right away to your county Medi-Cal office. You can renew your Medi-Cal online, by mail, in person or by phone. Need help filling out the forms? Call IEHP’s Eligibility team at: 1-888-860-1296, Monday-Friday 8am-5pm. Your Medi-Cal needs to be renewed each year to keep your benefits update Once a year, you will get a letter in the mail from the county that tells you if your Medi-Cal was automatically renewed by the county or if your county needs more information. warning It’s important to read this letter and follow the instructions. What Information Will the County Ask for? Completed Renewal Forms Income Verification Contact Info Updates If your county asks for more information, you must give it to them by the due date. If you do not respond by the due date, your Medi-Cal benefits may end. Notice: State Leaders Issue Warning of Medi-Cal ScamScammers and con artists are contacting Medi-Cal members asking for a fee to apply for or renew their coverage. IMPORTANT: Medi-Cal will NOT ask you for payment in an application or renewal process. If someone contacts you posing as a county, state or community partner and asks for money, do NOT send it to them. Questions? Call IEHP’s Eligibility team at 1-888-860-1296, Monday-Friday, 8am-5pm. How Can You Turn in This Information? You may submit the information online, by mail, in person, or phone. 1. Go Online Create your online account today at BenefitsCal.com, and select the “Create an Account” link. Watch the video above. If you already have a BenefitsCal.com account, you can submit by following the steps in the video above. 2. Mail packet to county San Bernardino County:Click to look for a mailing location near youRiverside County:Click to look for a mailing location near you*Note: The packet comes with an envelope for you to return the paperwork. 3. Visit your county office San Bernardino County:Click to look for a county office near youRiverside County:Click to look for a county office near you 4. Call your county office San Bernardino County:1-877-410-8829Monday-Friday, 7am-5pmRiverside County:1-877-410-8827Monday-Friday, 7am-5pm FAQs: Questions & Answers About Renewing Your Medi-Cal access_time What if I miss the due date? Contact the county to find out if you can still turn in your paperwork. send What happens after I submit the form? You will receive a letter from the county once your documents have been reviewed. forum Who do I talk to if I have more questions If you need more help, call IEHP at 1-888-860-1296, Monday-Friday, 8am-5pm or your county Medi-Cal office: Riverside County: 1-877-410-8827, Monday-Friday, 8am-5pm San Bernardino County: 1-877-410-8829, Monday-Friday, 7am-5pm home What should I do if I moved? Contact the county office to make sure they have current information for you and your family: Current Name Address Phone Number Email Address The county needs this to contact you with important information about your Medi-Cal. View More Frequently Asked Questions 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 45-75 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.
ndation is focused on connecting the diverse communities of the Inland Empire with access to a better, more joyful life through programs and initiatives aimed at resolving the root causes of illness, health equity and core needs, including food, shelter and safety. The Foundation was established in July 2022 by Inland Empire Health Plan (IEHP) to ensure all communities throughout the region have access to Vibrant Health, which entails going beyond traditional healthcare services and reaching the region’s most vulnerable populations. Efforts include supporting pilot programs, identifying innovative solutions that improve health outcomes, acting as a convener, collaborator and partner with community and faith-based organizations and much more. IEHP Foundation Board of Directors The Foundation is guided by an esteemed, experienced and passionate group of individuals who comprise the Board of Directors: Chair Stephen Bennett, Caravanserai Project Board Chair and Co-Founder Vice Chair Karen Scott, First 5 San Bernardino Executive Director Secretary Regina Weatherspoon-Bell, Founder DVL Project/A Better Way/Victor Valley Domestic, Inc. Treasurer Conrado Bárzaga, MD, Desert Healthcare District & Foundation Chief Executive Officer Josh Candelaria, Viewpoint Advocacy Principal Edward Juhn, MD, MBA, MPH, IEHP Chief Quality Officer Geoffrey Leung, MD, County of Riverside Public Health Officer Jarrod McNaughton, MBA, FACHE, IEHP Chief Executive Officer Combined with their sincere and heartfelt desire to make a difference for all the communities in the region, the board is committed to long-term sustainable change for overall community health improvement. Follow Along on Our Journey Join us as we meet with local communities and organizations to listen to their needs and gain an in-depth understanding of the Inland Empire non-profit landscape. Follow us on Instagram @IEHPFoundation and connect with us on LinkedIn We aspire to significantly transform this region but to make a definitive and long-lasting impact, we are committed to in-depth and ongoing collaborative discussions about the needs and desires of the communities we hope to serve. If you would like to connect, please email us at Foundation@iehp.org Press Releases IEHP Announces Angelica Baltazar as New Foundation President IEHP Foundation Launches to Serve Most Vulnerable Communities IEHP Foundation is a 501(c)(3) nonprofit
Join Our Network - Community Supports
offer in place of services or settings covered under the Medicaid State Plan. These services should be medically appropriate and cost-effective alternatives. Beginning January 1, 2022, Inland Empire Health Plan (IEHP) is offering 11 of the 14 DHCS Preapproved Community Supports services: Asthma Remediation Community Transition Services/Nursing Facility Transition to a Home Home Modifications Housing Deposits Housing Tenancy and Sustaining Services Housing Transition Navigation Services Medically Supportive Food/Meals/Medically Tailored Meals Nursing Facility Transition/Diversion to Assisted Living Facilities, such as Residential Care Recuperative Care (Medical Respite) Short-Term Post-Hospitalization Housing Sobering Centers (Riverside County) Upcoming Services Beginning July 1, 2023, three new Community Supports services will be offered: Day Habilitation Personal Care and Homemaker Services Respite Services Community Supports FAQs (PDF) Please return the completed Community Supports Service Provider Assessment (PDF) via email to DGCommunitySupportTeam@iehp.org 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 - Provider Network Expansion Fund
d is to support the hiring of PCPs, Specialists, and Advanced Practice Providers that will serve the Medi-Cal population in the Inland Empire. Entities that hire qualified candidates are eligible to receive a subsidy up to $75,000 for Advanced Practice Providers, $100,000 for PCPs, and $150,000 for Specialists. All candidates must be a new access point in IEHP's network and not have prior history in the Inland Empire. Please take note of the following: The NEF Program will be targeting specific Provider types. The Provider types and corresponding regions displayed below comprise the list of positions that are currently eligible to receive a subsidy through the NEF Program. The funding disbursement schedule is as follows: 50% when the qualified candidate completes credentialing 25% when the candidate completes six (6) months of service 25% when the candidate completes one (1) year of service Entities that are interested in receiving support through the NEF Program must submit a complete application to be considered for the funding opportunity. Completed applications and questions should be e-mailed to NEFProgram@iehp.org NEF Program Description (PDF) NEF Application (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. Click on the following links to jump to that specific section: Corona/Temecula/Hemet High Desert Low Desert Mohave Valley Palo Verde Valley Riverside San Bernardino Proper West San Bernardino Corona/Temecula/Hemet Family Practice Internal Medicine Pediatrics Cardiac/Thoracic Surgery General Surgery Genetics OB/GYN Pulmonary Medicine Plastic Surgery Psychiatry Urology High Desert Family Practice Internal Medicine Pediatrics Allergy and Immunology Cardiac/Thoracic Surgery Cardiology Dermatology General Surgery Genetics Neurology Neurosurgery OB/GYN Oncology/Hematology Orthopedic Surgery Otolaryngology Pain Management Pediatric Subspecialties Physical Therapy Podiatry Psychiatry Psychology Pulmonary Medicine Rheumatology Speech Therapy Urology Low Desert Family Practice Internal Medicine Pediatrics Allergy and Immunology Cardiology General Surgery OB/GYN Pain Management Pediatric Surgery Physical Therapy Psychiatry Pulmonary Medicine Rheumatology Urology Mohave Valley Family Practice Internal Medicine Pediatrics Allergy and Immunology Cardiology Dermatology Gastroenterology General Surgery Nephrology Neurology OB/GYN Oncology/Hematology Ophthalmology Otolaryngology Pain Management Psychiatry Pulmonary Medicine Rheumatology Palo Verde Valley Family Practice Internal Medicine Pediatrics Allergy and Immunology Cardiology Dermatology Endocrinology Gastroenterology General Surgery Neurology OB/GYN Ophthalmology Otolaryngology Pain Management Physical Therapy Podiatry Psychiatry Pulmonary Medicine Speech Therapy Urology Riverside Family Practice Internal Medicine Pediatrics Cardiology Dermatology General Surgery Genetics OB/GYN Occupational Therapy Ophthalmology Pain Management Podiatry Psychiatry Speech Therapy Urology San Bernardino Proper Family Practice Internal Medicine Pediatrics Allergy and Immunology Dermatology OB/GYN Pain Management Pediatric Surgery Psychiatry Pulmonary Medicine West San Bernardino Family Practice Internal Medicine Pediatrics Genetics OB/GYN Pediatric Surgery Plastic Surgery Psychiatry Updated May 5, 2023
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 2022 Provider Quality Incentive Brochure. 2022 Provider Quality Incentive Brochure (PDF) | June 22, 2022 (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: April 12, 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: March 24, 2023 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) (Back to P4P Menu) 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 IPA (PDF) Published: April 21, 2023 2023 IEHP Global Quality P4P Program Guide PCP (PDF) Published: April 20, 2023 2023 IEHP Global Quality P4P Program Guide IPA (PDF) Published: March 14, 2023 2022 IEHP Global Quality P4P Program Guide PCP (PDF) Published: April 20, 2023 2022 IEHP Global Quality P4P Program Guide IPA (PDF) Published: December 16, 2022 2022 Provider Quality Resource Guide (PDF) Published: July 14, 2022 (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 Codes 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) Immunization Updates (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. By clicking on this link, you will be leaving the IEHP website. (Back to P4P Menu) Quality Bonus Services Dispute Form Please e-mail completed forms to QualityPrograms@iehp.org Quality Bonus Service Dispute Request Form (PDF) (Back to P4P Menu) 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) 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: May 9, 2023 2023 Hospital P4P Program Guide (PDF) Published: March 23, 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 Codes 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 (Back to P4P Menu) 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: February 02, 2022 Substance Use Disorders Diagnosis List (PDF) Published: February 02, 2022 (Back to P4P 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