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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
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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
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IEHP Direct Stars Incentive Program
Inland Empire Health Plan (IEHP) is pleased to announce the IEHP Direct Stars Incentive Program for Primary
Care
Physicians (PCPs). The goal of the program is to reward PCPs who provide high-quality care to IEHP
DualChoice
(HMO D-SNP) members.
IEHP Direct Stars Incentive Program Guide
(PDF) Updated: June 29, 2023
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D-SNP Model of Care Incentive Program
Inland Empire Health Plan (IEHP) is pleased to announce the D-SNP Model of Care Incentive Program for
Independent
Physicians Associations (IPAs). The goal of the program is to reward IPAs who provide high-quality care to
IEHP
DualChoice (HMO D-SNP) members.
D-SNP Model of Care Incentive Program
(PDF) Published: July 24, 2023
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Chronic Care Improvement Program Planning and Reporting Document
The Chronic Care Improvement Program (CCIP) Planning and Reporting document can be used for the following
D-SNP
Model of Care Incentive Program activity: Chronic Care Improvement Program (CCIP) Activity.
CCIP Planning and Reporting Document
(Word
Document)
CCIP Planning and Reporting
Document - Reference Guide (PDF)
Global Quality P4P Program
If you would like more information about IEHP’s GQ P4P Program or best practices to help improve quality
scores and outcomes, visit our Secure
Provider
Portal, email the Quality Team at QualityPrograms@iehp.org or call the IEHP Provider Relations Team at (909) 890-2054.
2023 IEHP Global Quality
P4P
Program Guide PCP (PDF) Published: July 25, 2023
2023 IEHP Global Quality
P4P
Program Guide IPA (PDF) Published: July 25, 2023
2022 IEHP Global Quality P4P Program Guide PCP (PDF) Published: August 28, 2023
2022 IEHP Global Quality
P4P
Program Guide IPA (PDF) Published: July 25, 2023
2023 Provider Quality Resource Guide (PDF) Published: June 21, 2023
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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)
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Potentially Avoidable Emergency Department (ED) Visits: Potentially Preventable Diagnosis Code
The Potentially Preventable Diagnosis Code List includes diagnosis codes for visits to an ED in which the
condition
could be treated by a Physician or other health care Provider in a non-emergency setting or conditions that are
potentially preventable or are ambulatory care sensitive.
Potentially Preventable Diagnosis List
(PDF) Published: February 04, 2022
Patient Experience
This toolkit is full of proven tips and successful strategies based on the kinds of questions your IEHP Members
could
be asked to answer regarding their Provider's service. Your Provider Relations Team has targeted nine specific
topics in this toolkit to help Providers and their staff continue to achieve the highest marks in Patient
experience
from their IEHP Members.
Serve Well Customer Service Toolkit (PDF)
Well Child
2021
Recommendations for Preventive Pediatric Health Care from the American Academy of Pediatrics (PDF)
Immunizations
IEHP provides vaccine coverage based on the latest ACIP recommendation and guidelines. Please refer to the
Immunization
Update and "Summary of Recommendations" for both Child and Adolescents AND Adult Vaccines as follows:
2023 Immunization Timing Chart - English
(PDF)
2023 Immunization Timing Chart - Spanish
(PDF)
2023 Immunization Timing Chart - Chinese
(PDF)
2023 Immunization Timing Chart - Vietnamese
(PDF)
2023 Recommended
Child and Adolescent Immunization Schedule (0-18 years) (PDF)
2023 Recommended Adult
Immunization
Schedule (19+ years) (PDF)
Adult Vaccines are a covered benefit and do not require prior authorization (must adhere to CDC/ACIP Immunization
Recommendation and/or FDA approved indication).
Grow Well Childhood Immunization
Toolkit for Providers (PDF)
This toolkit contains commonly used immunization codes, best practices for reporting immunizations including
information
on registering with CAIR, tips on talking with parents and information on understanding vaccination hesitancy.
CAIR2 Resource
Guide
(PDF)
This guide contains helpful links and contact information for locations to register for CAIR2 or current users.
Reimbursement process:
Complete a CMS1500 form by including the appropriate CPT codes, quantity dispensed and billed amount.
Mail:
IEHP Claims Department
P.O. Box 4349
Rancho Cucamonga, CA 91729-4349
For the latest updates and news regarding the vaccines, please visit CDC's ACIP website at:
https://www.cdc.gov/vaccines/hcp/acip-recs/index.html
Quality Bonus Services Dispute Form
Please e-mail completed forms to QualityPrograms@iehp.org
Quality Bonus Service Dispute Request Form
(PDF)
OB/GYN P4P Program
Inland Empire Health Plan (IEHP) has released the OB/GYN P4P Program Guide which details the program requirements,
performance measures, updated code sets, and payment timelines.
OB/GYN P4P
Program Guide (PDF) Published: January 01, 2023
OB
P4P Frequently Asked Questions FAQs (PDF) Published: February 13, 2023
Postpartum
Depression Screening (PDF)
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Urgent Care + Wellness Quality Incentive Program
Inland Empire Health Plan (IEHP) is pleased to announce the Urgent Care + Wellness Quality Incentive Program. The goal of the program is to reward urgent care providers for providing wellness services to IEHP Medi-Cal Members.
Urgent Care + Wellness Quality Incentive Program Guide (PDF) Published: September 08, 2023
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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: July 24, 2023
P4P 2023 MX Data Contributions (PDF) Published:
February 02, 2023
IEHP P4P
2023 Data Guidelines (PDF) Published: February 02, 2023
2022
Hospital P4P Program Guide (PDF) Published: March 20, 2023
P4P 2022
MX
Data Contribution (PDF) Published: April 18, 2022
P4P 2022
MX
Data Guidelines (PDF) Published: April 18, 2022
(Back to P4P Menu)
Potentially Avoidable Emergency Department (ED) Visits: Potentially Preventable Diagnosis Code
The Potentially Preventable Diagnosis Code List includes diagnosis codes for visits to an ED in which the
condition
could be treated by a Physician or other health care Provider in a non-emergency setting or conditions that are
potentially preventable or are ambulatory care sensitive.
Potentially Preventable Diagnosis List
(PDF) Published: February 04, 2022
Substance Use Disorders and Mental Health Diagnosis Lists
The Substance Use Disorders and Mental Health Diagnosis Lists includes diagnosis codes to identify substance use
disorders, drug overdose, mental health or intentional self-harm diagnoses.
Mental
Health
Diagnosis List (PDF) Published: June 23, 2023
Substance Use Disorders Diagnosis List (PDF)
Published: June 23, 2023
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by
clicking here
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)
Synagis (PDF)
Xolair (omalizumab) (PDF)
Zynteglo (PDF)
Drug Class Prior Authorization Criteria
Erythropoiesis Stimulating Agents (PDF)
Growth Hormones (PDF)
Immuno Globulins (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 September 08, 2023.
Pharmacy Services - Formulary
most appropriate, high quality and cost-effective drug therapies.
The Inland Empire Health Plan Pharmacy and Therapeutics (P & T) Subcommittee develops and monitors the Formulary. The P & T is composed of the IEHP Chief Medical Officer, Medical Directors, Director of Pharmaceutical Services, physicians from various medical specialties, local communities, and clinical pharmacists. This panel reviews the medications in all therapeutic categories based on safety, clinical efficacy, and cost-effectiveness and selects the most appropriate drugs in each class.
Formulary development and maintenance is a dynamic process. The IEHP P & T Subcommittee is responsible for developing, managing, updating and administering the Formulary. The Subcommittee also ensures that the IEHP Formulary remains responsive to the needs of our members and providers.
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy by clicking Adobe Acrobat Reader. By clicking on this link, you will be leaving the IEHP website.
IEHP Medi-Cal Formulary Items:
DHCS Noncapitated Physician Administered Drugs (PADs)
Medi-Cal Medical Benefit PA (PDF)
Medi-Cal Medical Benefit Formulary (PDF)
Referral Form for Medi-Cal Benefit (PDF)
Exceptions to criteria or requests for coverage of drugs not on the Medi-Cal Drug Benefit Formulary may be submitted by prescribers on the Referral Form for Medi-Cal Benefit.
Starting January 1, 2022, all IEHP Medi-Cal pharmacy services will be transitioned from managed care (MC) to fee for service (FFS). The Medi-Cal pharmacy benefits and services administered by the Department of Health Care Services (DHCS) will be identified collectively as "Medi-Cal Rx."
Magellan Medicaid Administration, Inc. (MMA) will assume operations for Medi-Cal Rx on behalf of DHCS.
For further information on Medi-Cal Rx, please visit: https://www.iehp.org/en/providers/pharmacy-services?target=medi-cal-rx
For more information on the Medi-Cal Rx Covered Drug List (CDL), please visit: https://medi-calrx.dhcs.ca.gov/home/cdl
IEHP DualChoice (HMO D-SNP) - Medicare-Medicaid Plan Items:
IEHP DualChoice (HMO D-SNP) Formulary Book (PDF)
Grievance Coverage Determination and Appeals Process
IEHP DualChoice (HMO D-SNP) Formulary Search Tool
E-prescribing Tips (PDF)
Information on this page is current as of September 8, 2023
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: August 23, 2023
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.
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)
Provider Dispute Resolution Process
For more information about the Provider dispute resolution process for contracted and non-contracted Providers, click here
Other Health Coverage (OHC)
Coordination of Benefits with Other Health Coverage (OHC) (PDF)
Frequently Asked Questions (FAQs) - OHC (PDF)
Helpful Information and Resources - Member Newsletters
n programs, and important reminders to help you live a better life.
The Pulse: this newsletter is for adults and families with children and who have Medi-Cal with IEHP.
Health Spotlight: this newsletter is for IEHP Members with both Medi-Cal and Medicare (CMC).
AccessAbility: this newsletter is for seniors and people with disabilities who have Medi-Cal with IEHP.
Provider Resources - Forms
liance
Delegation Oversight Audit (DOA)
Grievance
Growth Chart
Health and Wellness
Historical Data Form
Inland Regional Center
Medi-Cal Letter Templates
Medicare-Medicaid Plan Letter Templates
D-SNP Letter Templates
Medicare
Non-Contracted Providers
Perinatal
Pharmacy
Provider Preventable Conditions (PPC)
UM/CM
Vision
Other
Behavioral Health
ABA 6 Month and Exit Progress Report Template (Word)
ABA Exit Letter Template (Word)
ABA Service Hour Log (Word)
ABA School BHT Services Request Form (Word)
Authorization Release of Information Form - English (PDF)
Authorization Release of Information Form - Spanish (PDF)
Behavioral Health Authorization Request Form (PDF)
BHT Social Skills Template (Word)
Coordination of Care Treatment Plan Form (PDF)
No Further Treatment Request Form (PDF)
Psych Testing Battery Plan (for Psychologist use only) (PDF)
(For BH Providers Only) Transition of Care Tool (PDF)
Claims
For Integrated Denial Notices please click here.
Please select on the links below to obtain the revised CMS 1500 form (version 02/12) and the CMS 1500 Reference Instruction Manual.
Acknowledgement Letter (Word)
Capitation Data File Format (Word)
Capitation Payment Deduction (Word)
Cease and Desist Letter (Word)
Claims Project Spreadsheet (Excel)
Clean Claim Tool Guide - UB04 Inpatient Form (PDF)
Clean Claim Tool Guide - UB04 Outpatient Form (PDF)
CMS 1500 Reference Instruction Manual (PDF)
Demand For Payment Letter (Word)
Determination Letter (Word)
Encounter Data CAP Request Letter (Word)
Encounter Data Penalty Letter (Word)
Hospital Directed Payment Dispute Form (Word)
ICE - Claim Denial Reason Guide - IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid) (Word)
Irrevocable Letter of Credit (Word)
Manifest Report (Word)
Medi-Cal Universe Layout Instructions (Word)
Notice of CAP Deductions (Word)
Notice of Denial of Payment - English (Word)
Notice of Denial of Payment - Spanish (Word)
Notice of Dismissal of Appeal Request (PDF)
Part C Organization Determinations, Appeals, and Grievances (ODAG) (PDF)
Payment Attestation (Word)
Provider Identified Overpayment Form (PDF)
Provider Identified Overpayment Form (Multiple) (PDF)
Provider Dispute Resolution (PDR) (PDF)
Remittance Advice - Medicare DualChoice Annual Visit (PDF)
Revised CMS 1500 Health Insurance Claim Form (PDF)
Sample Capitation Report (PDF)
Waiver of Liability Statement - IEHP Dual Choice (HMO D-SNP) - effective January 2023 (PDF)
Table 3 Payment Organization Determinations and Reconsiderations (PYMT_C) (PDF)
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Compliance
DHCS Privacy Incident Report (PDF)
Notice of Privacy Practices (Word)
IEHP Code of Business Conduct and Ethics (PDF)
Member Incentive Forms
Focus Group Incentive (FGI) - Request for Approval Form (Word)
Focus Group Incentive (FGI) - Evaluation Form (Word)
Member Incentive (MI) Program - Request for Approval (Word)
Member Incentive (MI) Program - Annual Update/End of Program Evaluation (Word)
Survey Incentive (SI) - Request for Approval Form (Word)
Survey Incentive (SI) - Evaluation Form (Word)
Nondiscrimination Language
Nondiscrimination Language Access Notice:
Medi-Cal (PDF)
Medicare (PDF)
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Delegation Oversight Audit (DOA)
Biographical Information Sheet
Credentialing DOA Audit Tool
HIPAA Security - Medi-Cal DOA
HIPAA Security - Medicare
Medi-Cal DOA Tool UM/CM/QI
Medicare DOA Tool UM/CM/QI
Medi-Cal UM Referral Template
Sub-Contracted Facility/Agency Services and Delegated Functions
Approved Referral Audit Tool (Excel)
California Specific - Reporting Requirements (PDF)
Care Coordinator to Member Ratio Template 5.1 (Excel)
Care Coordinator Training for Supporting Self-Direction (Excel)
Care Management California Children's Services Review Tool (PDF)
Care Transition Cases Log (Excel)
Credentialing and Recredentialing Report for Delegated Networks (Excel)
Credentialing and Recredentialing Report (Excel)
Delegation Oversight Audit Preparation Instructions - IEHP DualChoice (Word)
Delegation Oversight Audit Preparation Instructions - Medi-Cal (NCQA) (Word)
Delegation Oversight Audit Preparation Instructions - Medi-Cal (Word)
Denial Log Review Tool - IEHP DualChoice (Excel)
Denial Log Review Tool - IEHP Medi-Cal (Excel)
DOA CAP Response Form (Excel)
Enrollee Protections Reporting Template, CA2.1 (Excel)
IEHP ASM File Template (Excel)
IEHP Universe Expedited Auth MESAR Data Dictionary (PDF)
IEHP Universe Expedited Auth MESAR Template (Excel)
IEHP Universe M_Claims Data Dictionary (PDF)
IEHP Universe M_Claims Template (Excel)
IEHP Universe M_SAR Table 1 Standard and Expedited Service Authorization Requests (Excel)
IEHP Universe PYMT_C Table 3 Payment Organization Determinations and Reconsiderations (Excel)
IEHP Universe Standard Auth MSSAR Data Dictionary (PDF)
IEHP Universe Standard Auth MSSAR Template (Excel)
IPA Care Management Review Tool - IEHP DualChoice (PDF)
IPA Delegation Agreement - IEHP DualChoice (Word)
IPA Delegation Agreement - Medi-Cal (Word)
IPA Performance Evaluation Tool (Excel)
Medi-Cal Care Coordination Review Tool (PDF)
Medi-Cal Monthly Care Management Log (PDF)
Medi-Cal SPD Review Tool Data Dictionary (PDF)
MM Capitated Financial Alignment Model Reporting Requirements (PDF)
Monthly CCS Referral Log 2.0 (PDF)
Monthly Medicare Care Management Log 2.3 (PDF)
Monthly Medicare Plan Outreach Log 1.1 (PDF)
Practitioner Profile Template (Excel)
Precontractual Audit Preparation Instructions - IEHP DualChoice (Word)
Precontractual Audit Preparation Instruction - Medi-Cal (Word)
Program Description - Denial letter Sanction - IEHP DualChoice (PDF)
Referral Universe (Excel)
Request for UM Criteria Log (Word)
Response to Request for UM Criteria Letter (Word)
Second Opinion Tracking Log (Word)
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Grievance
The Grievance Forms below are for your Member's use when filing a complaint, or has an appeal regarding any aspect of care or service provided by you. Please select the Appeal and Grievance form appropriate for their use:
Medi-Cal Form
English (PDF)
Spanish (PDF)
Chinese (PDF)
Vietnamese (PDF)
Medicare Form
English (PDF)
Spanish (PDF)
Chinese (PDF)
Vietnamese (PDF)
The following IEHP DualChoice (HMO D-SNP) Letters will be effective January 1, 2023:
English (PDF)
Spanish (PDF)
Chinese (PDF)
Vietnamese (PDF)
Appeal Resolution Process - Medi-Cal - [English] (Word)
Appeal Resolution Process - Medi-Cal - [Spanish] (Word)
Grievance Resolution Process - Medi-Cal - [English] (Word)
Grievance Resolution Process - Medi-Cal - [Spanish] (Word)
Provider Fair Hearing Process (Word)
Provider Grievance Acknowledgement Letter (Word)
Provider Grievance Resolution Letter (Word)
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Growth Chart
Inland Empire Health Plan (IEHP) offers you easy access to useful reference materials and forms you may need. It's just one click away. Select the growth chart form that you need by clicking on the link below:
(0-36 months): Head Circumference-For-Age And Weight- For-Length Percentiles
Boys (PDF) Girls (PDF)
(0-36 months): Length and Weight-For-Age Percentiles
Boys (PDF) Girls (PDF)
(2-20 years): Stature and Weight-For-Age-Percentiles
Boys (PDF) Girls (PDF)
(2-20 years): Body Mass Index For-Age Percentiles
Boys (PDF) Girls (PDF)
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Health and Wellness
DPP Rx Pad (PDF)
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Historical Data Form
Historical Data Form (PDF)
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Inland Regional Center
Early Start (0-36 months) Referral (PDF)
Early Start Online Application
Eligibility and Intake
IRC Referrals (3-99+ years):
San Bernardino County: For Providers - (909) 890-4711 // Intake - (909) 890-3148
Riverside County: For Providers - (909) 890-4763 // Intake - (951) 826-2648
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Medi-Cal Letter Templates
A complete template includes all documents listed under each template in the order specified listed. Changes can only be made to highlighted areas, any changes made outside of the highlighted areas are strictly prohibited by DHCS.
Click on the title to expand the menu and download desired document.
Member Authorization Letter
English
Last Updated: 09/20/2022
Spanish
Last Updated: 09/20/2022
Chinese
Last Updated: 09/20/2022
Vietnamese
Last Updated: 09/20/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Continuity of Care Authorization Letter
English
Last Updated: 09/20/2022
Spanish
Last Updated: 09/20/2022
Chinese
Last Updated: 09/20/2022
Vietnamese
Last Updated: 09/20/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Notice of Action – Carve Out
English
Last Updated: 12/29/2022
Spanish
Last Updated: 12/29/2022
Chinese
Last Updated: 12/29/2022
Vietnamese
Last Updated: 12/29/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated May 22, 2023
Notice of Action - Delay
English
Last Updated: 12/27/2022
Spanish
Last Updated: 12/27/2022
Chinese
Last Updated: 12/27/2022
Vietnamese
Last Updated: 12/27/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated May 22, 2023
Notice of Action - Deny
English
Last Updated: 12/27/2022
Spanish
Last Updated: 12/27/2022
Chinese
Last Updated: 12/27/2022
Vietnamese
Last Updated: 12/27/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated May 22, 2023
Notice of Action - Modify
English
Last Updated: 12/28/2022
Spanish
Last Updated: 12/28/2022
Chinese
Last Updated: 12/28/2022
Vietnamese
Last Updated: 12/28/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated May 22, 2023
Notice of Action - Terminate
English
Last Updated: 01/06/2023
Spanish
Last Updated: 01/06/2023
Chinese
Last Updated: 01/06/2023
Vietnamese
Last Updated: 01/06/2023
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated May 22, 2023
Other Health Care Coverage Requesting Provider Letter
English
Last Updated: 03/17/2021
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Continuity of Care Terminate Letter
English
Last Updated: 09/20/2022
Spanish
Last Updated: 09/20/2022
Chinese
Last Updated: 09/20/2022
Vietnamese
Last Updated: 09/20/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Specialist Termination Letter
English
Last Updated: 09/20/2022
Spanish
Last Updated:09/20/2022
Chinese
Last Updated:09/20/2022
Vietnamese
Last Updated:09/20/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Prior Authorization Not Required
English
Last Updated: 09/20/2022
Spanish
Last Updated:09/20/2022
Chinese
Last Updated:09/20/2022
Vietnamese
Last Updated:09/20/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 14, 2023
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Medicare-Medicaid Plan Letter Templates
A complete template includes all documents listed under each template in the order specified listed. Changes can only be made to highlighted areas, any changes made outside of the highlighted areas are strictly prohibited by CMS.
Click on the title to expand the menu and download desired document.
Carve-Out Information Letter
English
Last Updated: 11/12/2017
Spanish
Last Updated: 10/31/2017
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Denial Reason Matrix
English
Last Updated: 07/03/2018
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Detailed Explanation of Non-Coverage
English
Last Updated: 12/17/2021
Spanish
Last Updated: 12/17/2021
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Detailed Notice of Discharge
English
Last Updated: 12/17/2021
Spanish
Last Updated: 12/17/2021
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Expedited Criteria Not Met
English
Last Updated: 10/31/2017
Spanish
Last Updated: 10/31/2017
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Extension Needed for Additional Information
English
Last Updated: 10/31/2017
Spanish
Last Updated: 10/31/2017
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Integrated Denial Notice - Part B Drugs - 7 day appeal - IPA
English
Last Updated: 02/14/2022
Spanish
Last Updated: 02/14/2022
Chinese
Last Updated: 02/14/2022
Vietnamese
Last Updated: 02/14/2022
Independent Medical Review - [English] [Spanish] [Chinese] [Vietnamese] Updated October 7, 2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Integrated Denial Notice - Part C - 30 day appeal - IPA
English
Last Updated: 03/08/2022
Spanish
Last Updated: 02/14/2022
Chinese
Last Updated: 02/14/2022
Vietnamese
Last Updated: 02/14/2022
Independent Medical Review - [English] [Spanish] [Chinese] [Vietnamese] Updated October 7, 2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Integrated Denial of Payment Notice - 7 day appeal - IPA
English
Last Updated: 03/17/2021
Spanish
Last Updated: 10/18/2021
Independent Medical Review - [English] [Spanish] [Chinese] [Vietnamese] Updated October 7, 2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Integrated Denial of Payment Notice - 30 day appeal - IPA
English
Last Updated: 03/17/2021
Spanish
Last Updated: 04/12/2017
Independent Medical Review - [English] [Spanish] [Chinese] [Vietnamese] Updated October 7, 2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Notice of Authorization of Services
English
Last Updated: 10/31/2017
Spanish
Last Updated: 10/31/17
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Notice of Dismissal of Coverage
English
Last Updated:03/10/2022
Spanish
Last Updated:03/10/2022
Chinese
Last Updated:03/10/2022
Vietnamese
Last Updated:03/10/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Notice of Medicare Non-Coverage
English
Last Updated: 10/31/2017
Spanish
Last Updated: 10/31/2017
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Notice of Reinstatement of Coverage
English
Last Updated: 10/31/2017
Spanish
Last Updated: 10/31/2017
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
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NEW D-SNP Letter Templates
These templates should not be used until the effective date of January 2, 2023. Please continue using the current Medicare DualChoice letter templates currently seen on this webpage for the remainder of 2022.
A complete template includes all documents listed under each template in the order specified listed. Changes can only be made to highlighted areas, any changes made outside of the highlighted areas are strictly prohibited by CMS.
Click on the title to expand the menu and download desired document.
AOR Dismissal Letter
English
Last Updated: 09/26/2022
Spanish
Last Updated:09/26/2022
Chinese
Last Updated:09/26/2022
Vietnamese
Last Updated:09/26/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
AOR Request Letter
English
Last Updated: 09/26/2022
Spanish
Last Updated:09/26/2022
Chinese
Last Updated:09/26/2022
Vietnamese
Last Updated:09/26/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Continuity of Care - Notice of Authorization
English
Last Updated:08/24/2023
Spanish
Last Updated:08/24/2023
Chinese
Last Updated:08/24/2023
Vietnamese
Last Updated:08/24/2023
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Continuity of Care – Notice of Termination
English
Last Updated: 09/26/2022
Spanish
Last Updated:09/26/2022
Chinese
Last Updated:09/26/2022
Vietnamese
Last Updated:09/26/2022
Nondiscrimination Notice, Tagline, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Detailed Explanation of Non-Coverage
English
Last Updated: 09/26/2022
Spanish
Last Updated:09/26/2022
Chinese
Last Updated:09/26/2022
Vietnamese
Last Updated:09/26/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Detailed Notice of Discharge
English
Last Updated: 12/20/2022
Spanish
Last Updated:12/20/2022
Chinese
Last Updated:12/20/2022
Vietnamese
Last Updated:12/20/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Expedited Criteria Not Met
English
Last Updated: 09/26/2022
Spanish
Last Updated: 09/26/2022
Chinese
Last Updated: 09/26/2022
Vietnamese
Last Updated: 09/26/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Extension Needed for Additional Information
English
Last Updated: 09/26/2022
Spanish
Last Updated: 09/26/2022
Chinese
Last Updated: 09/26/2022
Vietnamese
Last Updated: 09/26/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Informational Letter to Beneficiary and PCP
English
Last Updated: 09/26/2022
Spanish
Last Updated: 09/26/2022
Chinese
Last Updated: 09/26/2022
Vietnamese
Last Updated: 09/26/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Notice of Authorization of Services
English
Last Updated: 09/27/2022
Spanish
Last Updated: 09/27/2022
Chinese
Last Updated: 09/27/2022
Vietnamese
Last Updated: 09/27/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Notice of Dismissal of Coverage Request
English
Last Updated: 09/26/2022
Spanish
Last Updated: 09/26/2022
Chinese
Last Updated: 09/26/2022
Vietnamese
Last Updated: 09/26/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Notice of Medicare Non-Coverage
English
Last Updated:09/27/2022
Spanish
Last Updated:09/27/2022
Chinese
Last Updated:09/27/2022
Vietnamese
Last Updated:09/27/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Cancelled Relocation Letter
English
Last Updated: 09/22/2022
Spanish
Last Updated:09/22/2022
Chinese
Last Updated:09/22/2022
Vietnamese
Last Updated:09/22/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Long-Term Care IPA and PCP Change Letter
English
Last Updated: 09/26/2022
Spanish
Last Updated:09/26/2022
Chinese
Last Updated:09/26/2022
Vietnamese
Last Updated:09/26/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Coverage Decision Letter Part B - 7 Day Appeal
English
Last Updated: 10/03/2022
Spanish
Last Updated:10/03/2022
Chinese
Last Updated:10/03/2022
Vietnamese
Last Updated:10/03/2022
*Additional Information for IPAs: Please include the integrated Coverage Decision Letter, the most recent IMR form, application instructions, DMHC’s toll-free telephone number, and an envelope addressed to DMHC.
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated January 01, 2023
State Fair Hearing Form - [English] [Spanish] [Chinese] [Vietnamese] Updated September 01, 2021
Coverage Decision Letter Medical – 30 Day Appeal
English
Last Updated: 10/03/2022
Spanish
Last Updated:10/03/2022
Chinese
Last Updated:10/03/2022
Vietnamese
Last Updated:10/03/2022
*Additional Information for IPAs: Please include the integrated Coverage Decision Letter, the most recent IMR form, application instructions, DMHC’s toll-free telephone number, and an envelope addressed to DMHC.
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated January 01, 2023
State Fair Hearing Form - [English] [Spanish] [Chinese] [Vietnamese] Updated September 01, 2021
Coverage Decision Letter - Claims
English
Last Updated: 11/22/2022
Spanish
Last Updated:11/22/2022
Chinese
Last Updated:11/22/2022
Vietnamese
Last Updated:11/22/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
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Medicare
Certificates of Medical Necessity (CMN) & DME Information Forms (DIF)
Positive Airway Pressure Devices for Obstructive Sleep Apnea (PDF)
Enteral and Parenteral Nutrition (PDF)
External Infusion Pump (PDF)
Osteogenesis Stimulators (PDF)
Oxygen (PDF)
Seat Lift Mechanisms (PDF)
Continuation Form (PDF)
Transcutaneous Electrical Nerve Stimulator (TENS) (PDF)
Pneumatic Compression Device (PDF)
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Non-Contracted Providers
To submit a referral to IEHP, please fill out the referral form below, include all clinical notes and fax it to IEHP. If you are referring back to yourself, please indicate such. If you need IEHP to direct the referral, please indicate that on the form.
Referral Authorization Request Form - Non-Contracted Providers (PDF)
If you are interested in becoming a network Provider, please click here.
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Perinatal
IEHP provides standard risk assessment forms that can be used by all Providers of obstetrical (OB) services. Please refer to IEHP Provider Policy 10D1, "Obstetrical Services, Guidelines for Obstetrical Services" for further detail. To obtain copies, simply click on the links below.
Edinburgh Postnatal Depression Screening Tool - English (PDF)
Edinburgh Postnatal Depression Screening Tool - Spanish (PDF)
ACOG Antepartum Record (PDF)
California Prenatal Screening Program (PDF)
Contraceptive Informed Choice Form - English (Word)
Contraceptive Informed Choice Form - Spanish (Word)
Initial Perinatal Risk Assessment Form - English (Word)
Initial Perinatal Risk Assessment Form - Spanish (Word)
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Pharmacy
Click here for Pharmacy forms.
Part D Excluded Provider Letter - English (Word)
Part D Excluded Provider Letter - Spanish (Word)
Prescription Transition Notice - English (PDF)
Prescription Transition Notice - Spanish (PDF)
Request for Addition or Deletion of a Drug to the Formulary (PDF)
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Provider Preventable Conditions (PPC)
By clicking on these links, you will be leaving the IEHP website.
On May 23,2017, the Department of Healthcare Services (DHCS) released All Plan Letter (APL) 17-009, reporting requirements related to Provider Preventable Conditions. In conjunction, DHCS released Dual Plan Letter (DPL) 17-002. As part of these instructions, the Health Plan, Network Providers, Delegates, Contracted Hospitals, and ambulatory surgical centers must report using PPC Form on DHCS secure online portal for both Medicare and Medi-Cal lines of business.
Further information is available on the following pages:
Instructions for Completing Online Reporting of PPCs
Medi-Cal Guidance on Reporting Provider-Preventable Conditions
Frequently Asked Questions
All Plan Letter (APL) 17-009
Duals Plan Letter (DPL) 17-002
PPC Form
Medicare and Medi-Cal lines of business must follow the instructions below:
Providers are REQUIRED to send a copy of the completed PPC submission from the DHCS secure online portal to IEHP by fax at (909) 890-5545 within five (5) business days of reporting to DHCS;
IEHP does not pay Provider claims nor reimburse a Provider for a PPC, in accordance with 42 CFR Section 438.3(g) and IEHP's three-way Cal MediConnect contract. Per IEHP policy and the Coordinated Care Initiative 3-Way Contract, IEHP reserves the right to recover or recoup any claim related to a PPC;
As outlined in both the APL/DPL - Reporting Requirements related to Provider Preventable Conditions, the following classify as PPCs and must be reported:
Category 1 - HCACs (For Any Inpatient Hospital Setting in Medicaid)
Any unintended foreign object retained after surgery
A clinically significant air embolism
An incidence of blood incompatibility
A stage III or stage IV pressure ulcer that developed during the patient's stay in the hospital
A significant fall or trauma that resulted in fracture, dislocation, intracranial injury, crushing injury, burn, or electric shock
A catheter-associated urinary tract infection
Vascular catheter-associated infection
Any of the following manifestations of poor glycemic control: diabetic ketoacidosis; nonketotic hyperosmolar coma; hypoglycemic coma; secondary diabetes with ketoacidosis; or secondary diabetes with hyperosmolarity
A surgical site infection following:
Coronary artery bypass graft (CABG) - mediastinitis
Bariatric surgery; including laparoscopic gastric bypass, gastroenterostomy, laparoscopic gastric restrictive surgery
Orthopedic procedures; including spine, neck, shoulder, elbow
Cardiac implantable electronic device procedures
Deep vein thrombosis/pulmonary embolism following total knee replacement or hip replacement with pediatric and obstetric exceptions
Latrogenic pneumothorax with venous catheterization
A vascular catheter-associated infection
Category 2 - Other Provider Preventable Conditions (For Any Health Care Setting)
Wrong surgical or other invasive procedure performed on a patient
Surgical or other invasive procedure performed on the wrong body part
Surgical or other invasive procedure performed on the wrong patient
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UM/CM
Acute Hospital Discharge Needs Request Form (PDF)
Acute Inpatient Data Sheet (Word)
Advance Health Care Directive - [English] (PDF)
Advance Health Care Directive - [Spanish] (PDF)
Advance Health Care Directive FAQs - [English] (Word)
Advance Health Care Directive FAQs - [Spanish] (Word)
Authorization or Refusal to Release Medical Record - Out of Network Family Planning - [English] (PDF)
Authorization or Refusal to Release Medical Record - Out of Network Family Planning - [Spanish] (PDF)
Authorization for Use and/or Disclosure of Patient Health Information - English (PDF)
Authorization for Use and/or Disclosure of Patient Health Information - Spanish (PDF)
Behavioral Health Hospital Survey - Corrective Action Plan Tool (PDF)
Behavioral Health Hospital Survey Tool (PDF)
California Minor Consent and Confidentiality Laws (PDF)
Care Management Referral Form (PDF)
CCS-GHPP Client Service Auth Request - Established Case (PDF)
CCS-GHPP Client Service Auth Request - New Case (PDF)
Consent for HIV Test - English (PDF)
Consent for HIV Test - Spanish (PDF)
Consent for Special Procedure - English (Word)
Consent for Special Procedure - Spanish (PDF)
Corrective Action Plan Notification Tool (PDF)
Desert AIDS Project Enrollment Form (PDF)
DMHC Provider Appointment Availability Survey Methodology (PDF)
DMHC Provider Appointment Availability Survey Tools (PDF)
GHPP Application to Determine Eligibility (PDF)
Health Plan Referral Form for Out-of-Network and Special Services (Word)
Health Risk Assessment (HRA) - IEHP DualChoice (HMO D-SNP) - English (PDF) - effective 1/1/2023
Health Risk Assessment (HRA) - IEHP DualChoice (HMO D-SNP) - Spanish (PDF) - effective 1/1/2023
Health Risk Assessment (HRA) - IEHP DualChoice (HMO D-SNP) - Chinese (PDF) - effective 1/1/2023
Health Risk Assessment (HRA) - IEHP DualChoice (HMO D-SNP) - Vietnamese (PDF) - effective 1/1/2023
HIV Testing Sites - Riverside and San Bernardino (PDF)
Home Health Check Off List (PDF)
Home Modification Consent Form - English (PDF) - effective 04/01/2023
Home Modification Consent Form - Spanish (PDF) - effective 04/01/2023
Home Modification Consent Form - Chinese (PDF) - effective 04/01/2023
Home Modification Consent Form - Vietnamese (PDF) - effective 04/01/2023
IEHP Medical Record Review Survey Addendum (PDF)
Interim Facility Site Review (Assessment) Tool (PDF)
Interim Facility Site Review (On-Site) Tool (PDF)
Long Term Care Initial Review Form (Word)
Long Term Care (LTC) Follow-Up Review Form (Word)
Long Term Care (LTC) Data Sheet (PDF)
MC 171 Form and Instruction 05-07 (PDF)
Medi-Cal FFS-Approved Transplant Centers of Excellence (PDF)
Medicare Non-Covered Benefits (Word)
My Path Palliative Care Program CAP Form (PDF)
Non-Emergency Medical Transportation (NEMT) Physician Certification Statement (PCS) (PDF)
PCP Referral Tracking Log (Word)
Periodicity Schedule - Dental (PDF)
Provider Appointment Availability Survey Manual (PDF)
Referral Audit CAP Notification Letter (Word)
Referral Audit Corrective Action Plan Tool (Word)
Referral Form (PDF)
Reportable Diseases and Conditions - Riverside (PDF)
Reportable Diseases and Conditions - San Bernardino (PDF)
Service Request Form for Skilled Nursing Facilities (PDF)
Service Request for Skilled Nursing Facilities (PDF)
SNF Initial Review (PDF)
SNF Follow-up Review (PDF)
Specialty Office Service Authorization Sets Grid (Word)
Standing Referral and Extended Access Referral to Specialty Care (PDF)
Sterilization Consent Form PM-330
PM-330 Form - Tips and Example (PDF)
PM-330 Form - English (PDF)
PM-330 Form - Spanish (PDF)
Transplant Team Referral Form (Word)
Transportation Requests Form (SNF & LTC) (PDF)
Transportation Requests Form (Hospital) (PDF)
UM Timeliness Standards - IEHP DualChoice (Word)
UM Timeliness Standards - Medi-Cal (Word)
Urgent Care CAP Complete Tool and Notification Letter (PDF)
Wound Assessment - Admission (PDF)
Wound Assessment - Follow - Up (PDF)
Wound Assessment - Addendum (PDF)
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Vision
Ophthalmologist Referral Form (PDF)
Vision Exception Request (VER) Form (PDF)
PCP Vision Report Form (PDF)
IEHP Lab Form (PDF)
Medi-Cal Non-Covered Services/Materials Waiver Form-English (PDF)
Medi-Cal Non-Covered Services/Materials Waiver Form-Spanish (PDF)
Medi-Cal Non-Covered Services/Materials Waiver Form-Chinese (PDF)
Medi-Cal Non-Covered Services/Materials Waiver Form-Vietnamese (PDF)
The following IEHP DualChoice (HMO D-SNP) Letters will be effective January 1, 2023:
IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-English (PDF)
IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-Spanish (PDF)
IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-Chinese (PDF)
IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-Vietnamese (PDF)
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Other
AEVS Alpha Codes (PDF)
Attachment I - Statement of Agreement by Supervising Provider (PDF)
Authorization of Release - Use & Disclosure of PHI - English (PDF)
Authorization of Release - Use & Disclosure of PHI - Spanish (PDF)
Bariatric Surgeon Case Volume Attestation (PDF)
BIC Card (Word)
Change in Hospital Affiliation Letter (Word)
Change in IPA Affiliation Letter (Word)
Chronic Care Improvement Program (CCIP) Planning & Reporting Document (Word)
Corrective Action Plan Notification Tool (Word)
CMS 1696 Appointment of Representative - English (PDF)
CMS 1696 Appointment of Representative - Spanish (PDF)
Compliant Termination Letter (Word)
Contract Maintenance Request Form (PDF)
Coverage Determination Form - Provider and Member - [Chinese] (Word)
Coverage Determination Form - Provider and Member - [Spanish] (Word)
Credentialing Subcommittee Termination Letter (PDF)
Death Master File Identity Attestation (PDF)
Delegation of Services Agreement and Supervising Physician Form (PDF)
DHCS MMCD Facility Site Review (FSR) Standards (PDF)
DHCS MMCD Facility Site Review (FSR) Tool (PDF)
DHCS MMCD FSR Attachment 0C - Physical Accessibility Review Survey (Word)
DHCS MMCD FSR Attachment 0D - Ancillary Physical Accessibility Review Survey (PDF)
DHCS MMCD FSR Attachment 0E - CBAS Physical Accessibility Review Survey (PDF)
DHCS MMCD Medical Record Review (MRR) Standards (PDF)
DHCS MMCD Medical Record Review (MRR) Tool (PDF)
Frozen Enrollment Change Status (Word)
Hospital Admitting Arrangement Attestation - Admitter (PDF)
Hospital Admitting Arrangement Attestation - Admitting Physician (PDF)
Hospital Admitting Arrangement Attestation - Hospitalist (PDF)
Hospital Admitting Privileges Reference by Specialty (PDF)
Hospital Geographic Service Areas (Word)
IEHP Addendum E (PDF)
IEHP ID Card - Medi-Cal (Word)
IEHP ID Card - DualChoice (PDF)
IEHP Interim Facility Site Review Tool (Word)
IEHP Medical Record Review Survey Addendum (PDF)
IEHP Urgent Care Center Evaluation Tool (PDF)
IEHP PCP Leave of Absence Coverage Form (Word)
IEHP Peer Review Level I and Credentialing Appeal (PDF)
IEHP Peer Review Process and Level II Appeal (PDF)
IPA Hospital Link Responsibility Grid - IEHP DualChoice (Excel)
IPA Hospital Link Responsibility Grid - Medi-Cal (PDF)
Licensed Midwife Attestation (PDF)
Limited Enrollment Change Status (Word)
Member PCP Termination Notification Letter - [English] (Word)
Member PCP Termination Notification Letter - [Spanish] (Word)
Non-Compliant Termination Letter (Word)
Over Enrollment Change Status (Word)
Patient Transfer Agreement (PDF)
Peer Review Termination Letter (PDF)
Persons with Disabilities Workgroup Application (Word)
Plan Choice Form - Riverside - English - Medi-Cal (PDF)
Plan Choice Form - Riverside - Spanish - Medi-Cal (PDF)
Plan Choice Form - SB - English - Medi-Cal (PDF)
Plan Choice Form - SB - Spanish - Medi-Cal (PDF)
Prescribing Arrangements for DEA and CDS Eligible Practitioners (PDF)
Provider Preventable Conditions (Word)
Provider Privilege Adjustment Request Form (PDF)
Specialty Network Review (PDF)
The Code of Conduct of the Persons with Disabilities Workgroup (Word)
Transgender Questionnaire (PDF)
Urgent Care CAP Complete Tool and Notification Letter (Word)
Verification of Qualifications for HIV/AIDS Physician Specialists (PDF)
Work History Form Past Five (5) Years' Request (PDF)
2017 Model Output Report (MOR) Data File Layout (PDF)
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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 - Problems with Part D
have problems getting a Part D drug or you want us to pay you back for a Part D drug.
Your benefits as a member of our plan include coverage for many prescription drugs. Most of these drugs are “Part D drugs.” There are a few drugs that Medicare Part D does not cover but that Medi-Cal may cover.
Can I ask for a coverage determination or make an appeal about Part D prescription drugs?
Yes. Here are examples of coverage determination you can ask us to make about your Part D drugs.
You ask us to make an exception such as:
Asking us to cover a Part D drug that is not on the plan’s List of Covered Drugs (Formulary)
Asking us to waive a restriction on the plan’s coverage for a drug (such as limits on the amount of the drug you can get)
You ask us if a drug is covered for you (for example, when your drug is on the plan’s Formulary but we require you to get approval from us before we will cover it for you).
Please note: If your pharmacy tells you that your prescription cannot be filled, you will get a notice explaining how to contact us to ask for a coverage determination.
You ask us to pay for a prescription drug you already bought. This is asking for a coverage determination about payment.
If you disagree with a coverage decision we have made, you can appeal our decision.
What is an exception?
An exception is permission to get coverage for a drug that is not normally on our List of Covered Drugs, or to use the drug without certain rules and limitations. If a drug is not on our List of Covered Drugs, or is not covered in the way you would like, you can ask us to make an “exception.”
When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons why you need the exception.
Here are examples of exceptions that you or your doctor or another prescriber can ask us to make:
Covering a Part D drug that is not on our List of Covered Drugs (Formulary).
If we agree to make an exception and cover a drug that is not on the Formulary, you will need to pay the cost-sharing amount that applies to drug.
You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug.
Removing a restriction on our coverage. There are extra rules or restrictions that apply to certain drugs on our Formulary.
The extra rules and restrictions on coverage for certain drugs include:
Being required to use the generic version of a drug instead of the brand name drug.
Getting plan approval before we will agree to cover the drug for you. (This is sometimes called “prior authorization.”)
Being required to try a different drug first before we will agree to cover the drug you are asking for. (This is sometimes called “step therapy.”)
Quantity limits. For some drugs, the plan limits the amount of the drug you can have.
If we agree to make an exception and waive a restriction for you, you can still ask for an exception to the co-pay amount we require you to pay for the drug.
Important things to know about asking for exceptions
Your doctor or other prescriber must give us a statement explaining the medical reasons for requesting an exception. Our decision about the exception will be faster if you include this information from your doctor or other prescriber when you ask for the exception.
Typically, our Formulary includes more than one drug for treating a particular condition. These different possibilities are called “alternative” drugs. If an alternative drug would be just as effective as the drug you are asking for, and would not cause more side effects or other health problems, we will generally not approve your request for an exception.
We will say Yes or No to your request for an exception.
If we say Yes to your request for an exception, the exception usually lasts until the end of the calendar year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.
If we say No to your request for an exception, you can ask for a review of our decision by making an appeal.
Coverage Decision
What to do
Ask for the type of coverage decision you want. Call, write, or fax us to make your request. You, your representative, or your doctor (or other prescriber) can do this.
You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347.
You can fax us at: (909) 890-5877
You can to write us at:
IEHP DualChoice
P.O. Box 1800
Rancho Cucamonga, CA 91729-1800
You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage decision. You can also have a lawyer act on your behalf.
You do not need to give your doctor or other prescriber written permission to ask us for a coverage determination on your behalf.
If you are requesting an exception, provide the “supporting statement.” Your doctor or other prescriber must give us the medical reasons for the drug exception. We call this the “supporting statement.”
Your doctor or other prescriber can fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone, and then fax or mail a statement.
Request for Medicare Prescription Drug Coverage Determination (PDF)
These forms are also available on the CMS website:
Medicare Prescription Drug Determination Request Form (for use by enrollees and providers)
By clicking on this link, you will be leaving the IEHP DualChoice website.
Deadlines for a “standard coverage decision” about a drug you have not yet received
If we are using the standard deadlines, we must give you our answer within 72 hours after we get your request or, if you are asking for an exception, after we get your doctor’s or prescriber’s supporting statement. We will give you our answer sooner if your health requires it.
If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. At Level 2, an Independent Review Entity will review the decision.
If our answer is Yes to part or all of what you asked for, we must approve or give the coverage within 72 hours after we get your request or, if you are asking for an exception, your doctor’s or prescriber’s supporting statement.
If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No. The letter will also explain how you can appeal our decision.
Deadlines for a “standard coverage decision” about payment for a drug you have already bought
We must give you our answer within 14 calendar days after we get your request.
If we do not meet this deadline, we will send your request to Level 2 of the appeals process. At level 2, an Independent Review Entity will review the decision.
If our answer is Yes to part or all of what you asked for, we will make payment to you within 14 calendar days.
If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No. This statement will also explain how you can appeal our decision.
If your health requires it, ask us to give you a “fast coverage decision”
We will use the “standard deadlines” unless we have agreed to use the “fast deadlines.”
A standard coverage decision means we will give you an answer within 72 hours after we get your doctor’s statement.
A fast coverage decision means we will give you an answer within 24 hours after we get your doctor’s statement.
You can get a fast coverage decision only if you are asking for a drug you have not yet received. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.)
You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function.
If your doctor or other prescriber tells us that your health requires a “fast coverage decision,” we will automatically agree to give you a fast coverage decision, and the letter will tell you that.
If you ask for a fast coverage decision on your own (without your doctor’s or other prescriber’s support), we will decide whether you get a fast coverage decision.
If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will use the standard deadlines instead.
We will send you a letter telling you that. The letter will tell you how to make a complaint about our decision to give you a standard decision.
You can file a “fast complaint” and get a response to your complaint within 24 hours.
Deadlines for a “fast coverage decision”
If we are using the fast deadlines, we must give you our answer within 24 hours. This means within 24 hours after we get your request. Or, if you are asking for an exception, 24 hours after we get your doctor’s or prescriber’s statement supporting your request. We will give you our answer sooner if your health requires us to.
If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. At Level 2, an outside independent organization will review your request and our decision.
If our answer is Yes to part or all of what you asked for, we must give you the coverage within 24 hours after we get your request or your doctor’s or prescriber’s statement supporting your request.
If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No. The letter will also explain how you can appeal our decision.
Level 1 Appeal for Part D drugs
To start your appeal, you, your doctor or other prescriber, or your representative must contact us.
If you are asking for a standard appeal, you can make your appeal by sending a request in writing. You may also ask for an appeal by calling IEHP DualChoice Member Services at 1-877-273-IEHP (4347), 8am – 8pm (PST), 7 days a week, including holidays. TTY/TDD users should call 1-800-718-4347.
If you want a fast appeal, you may make your appeal in writing or you may call us.
Make your appeal request within 60 calendar days from the date on the notice we sent to tell you our decision. If you miss this deadline and have a good reason for missing it, we may give you more time to make you appeal. For example, good reasons for missing the deadline would be if you have a serious illness that kept you from contacting us or if we gave you incorrect or incomplete information about the deadline for requesting an appeal.
You can ask for a copy of the information in your appeal and add more information.
You have the right to ask us for a copy of the information about your appeal.
If you wish, you and your doctor or other prescriber may give us additional information to support your appeal.
You may use the following form to submit an appeal:
Coverage Determination Form (PDF)
Can someone else make the appeal for me?
Yes. Your doctor or other provider can make the appeal for you. Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative Form. The form gives the other person permission to act for you.
If the appeal comes from someone besides you or your doctor or other provider, we must receive the completed Appointment of Representative form before we can review the appeal.
Deadlines for a “standard appeal”
If we are using the standard deadlines, we must give you our answer within 7 calendar days after we get your appeal, or sooner if your health requires it. If you think your health requires it, you should ask for a “fast appeal.” If you are asking us to pay you back for a drug you already bought, we must give you our answer within 14 calendar days after we get your appeal.
If we do not give you a decision within 7 calendar days, or 14 days if you asked us to pay you back for a drug you already bought, we will send your request to Level 2 of the appeals process. At Level 2, an Independent Review Entity will review our decision.
If your health requires it, ask for a “fast appeal”
If you are appealing a decision our plan made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a “fast appeal.”
The requirements for getting a “fast appeal” are the same as those for getting a “fast coverage decision.”
Our plan will review your appeal and give you our decision
We take another careful look at all of the information about your coverage request. We check to see if we were following all the rules when we said No to your request. We may contact you or your doctor or other prescriber to get more information.
Deadlines for a “fast appeal”
If we are using the fast deadlines, we will give you our answer within 72 hours after we get your appeal, or sooner if your health requires it.
If we do not give you an answer within 72 hours, we will send your request to Level 2
of the appeals process. At Level 2, an Independent Review Entity will review your appeal.
If our answer is Yes to part or all of what you asked for, we must give the coverage within 72 hours after we get your appeal.
If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No.
Level 2 Appeal for Part D drugs
If we say No to your appeal, you then choose whether to accept this decision or continue by making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Entity (IRE) will review our decision.
If you want the Independent Review Organization to review your case, your appeal request must be in writing.
Ask within 60 days of the decision you are appealing. If you miss the deadline for a good reason, you may still appeal.
You, your doctor or other prescriber, or your representative can request the Level 2 Appeal.
When you make an appeal to the Independent Review Entity, we will send them your case file. You have the right to ask us for a copy of your case file. You have a right to give the Independent Review Entity other information to support your appeal. The Independent Review Entity is an independent organization that is hired by Medicare. It is not connected with this plan and it is not a government agency. Reviewers at the Independent Review Entity will take a careful look at all of the information related to your appeal. The organization will send you a letter explaining its decision.
If we uphold the denial after Redetermination, you have the right to request a Reconsideration. See form below:
Reconsideration Form (PDF)
Deadlines for a “fast appeal” at Level 2
If your health requires it, ask the Independent Review Entity for a “fast appeal.”
If the review organization agrees to give you a “fast appeal,” it must give you an answer to your Level 2 Appeal within 72 hours after getting your appeal request.
If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize or give you the drug coverage within 24 hours after we get the decision.
Deadlines for “standard appeal” at Level 2
If you have a standard appeal at Level 2, the Independent Review Entity must give you an answer to your Level 2 Appeal within 7 calendar days after it gets your appeal.
If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize or give you the drug coverage within 72 hours after we get the decision.
If the Independent Review Entity approves a request to pay you back for a drug you already bought, we will send payment to you within 30 calendar days after we get the decision.
What if the Independent Review Entity says No to your Level 2 Appeal?
No means the Independent Review Entity agrees with our decision not to approve your request. This is called “upholding the decision.” It is also called “turning down your appeal.”
If the dollar value of the drug coverage you want meets a certain minimum amount, you can make another appeal at Level 3. The letter you get from the Independent Review Entity will tell you the dollar amount needed to continue with the appeals process. The Level 3 Appeal is handled by an administrative law judge.
For more information see Chapter 9 of your IEHP DualChoice Member Handbook.
IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal.
Information on this page is current as of October 01, 2022.
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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)
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)
Day Habilitation Programs (PDF)
Respite Services (PDF)
Personal Care and Homemaker Services (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
Referrals to Pain Management Specialist (PDF)
Pharmacy
Biosimilar Products (PDF)
CAR-T Therapy (PDF)
Surgical Procedures
Adolescent Bariatric Consultation and Surgery (PDF)
Natural Orifice Transluminal Endoscopic Surgery (PDF)
Other
Allocation of Limited Critical Care Resources During a Public Health Emergency (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)
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.
Upcoming Events - Healthy Heart (Online): Keep Your Cholesterol in Check + Embrace Your Health: Aim for a Healthy Weight (Online)
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Upcoming Events - Understanding Diabetes (Online)
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Upcoming Events - Breathe Well, Live Well (Victorville)
Upcoming Events - Healthy Heart : Knowledge is Power + React in Time to Heart Attack Signs (Victorville)
will understand how the heart works and lifestyle changes for a healthy heart. We will also be discussing early signs of a heart attack and how to prevent a heart attack.
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IEHP Community Resource Center (Victorville)
12353 Mariposa Rd Suites C-2 & C-3
Victorville, CA 92395
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Topic: Building Support to Reach Your Goals: You will learn how to find the right people to help you when you run into a problem reaching your goal.
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Location
IEHP Community Resource Center (Victorville)
12353 Mariposa Rd Suites C-2 & C-3
Victorville, CA 92395
Upcoming Events - Understanding Diabetes (Victorville)
Upcoming Events - Understanding Diabetes: Healthy Eating Pt. 1 (Victorville)
to two parts. In Part 1, we will show you which foods affect blood sugar levels the most (and the least) and which foods (and fats) are better options for blood sugar control. Plus, get tips to cut fat and cholesterol.
Click here to register for this in-person class
Location
IEHP Community Resource Center (Victorville)
12353 Mariposa Rd Suites C-2 & C-3
Victorville, CA 92395
Upcoming Events - Healthy Heart (Online): Knowledge is Power + React in Time to Heart Attack Signs (Online)
l understand how the heart works and lifestyle changes for a healthy heart. We will also be discussing early signs of a heart attack and how to prevent a heart attack.
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Session Number: 26310238435
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