How to Access Care

When you enroll in an IEHP Covered plan, you must select a network Primary Care Provider (“PCP”). Your PCP will manage your medical care and will give or receive authorization for a covered medical service, except for:

• Emergency services
• Out-of-network urgent care while out of the service area
• Preventive health services (including immunizations) in-network
• Obstetrician and gynecological services in-network
• Sexual and reproductive health care services in-network
• Certain behavioral health and substance use disorder services in-network

Call your PCP directly to set up a visit. To search for PCPs in the IEHP service area, head to our Find a Doctor page. You can also call IEHP Member Services at 1-855-433-IEHP (4347), 8 a.m.–6 p.m., Monday–Friday. TTY users should call 711.

Benefits for physician and hospital services are only available when you live or work in the IEHP service area and use a network provider. You must also get covered services and supplies from network ancillary, pharmacy, and behavioral health providers. The benefits for this plan are only available for covered services received from a network doctor, except for:

a. Urgent care
b. All emergency care
c. Covered services provided by a non-contracted provider when authorized by IEHP

Note: Not all doctors and hospitals that contract with IEHP are network providers for this plan. Only doctors and hospitals listed in the Covered California network may provide services under this plan. The continued participation of any one doctor, hospital or other provider can’t be guaranteed. Please call IEHP Member Services for help finding providers in the Covered California network.

If you have a doctor you want to keep or want to find a new PCP, use our Find a Doctor tool. You can also call IEHP Member Services at 1-855-433-IEHP (4347).

Each member of your household that is enrolled with IEHP may choose a different PCP. To choose a PCP, contact IEHP Member Services or log in to the IEHP Secure Member Portal. If you and your enrolled dependent(s) didn’t choose a PCP after enrolling, IEHP will assign a PCP based on:

• The language you speak
• The distance to the PCP’s office from your house. We will try to assign you a PCP within 10 miles
• The member’s age. For children, a pediatrician may be assigned as the PCP. Until you choose your PCP, IEHP will assign one for you

If you would like to change a PCP for you or your dependent, please call IEHP Member Services at 1-855-433-IEHP (4347). TTY users should call 711.

You may also change your PCP by logging into the IEHP Secure Member Portal. The requested changes will take place the next day. Please make sure that you don’t have any pending referrals before changing your PCP.

While getting Covered Services at a Network health facility, if you receive Covered Services from a non-contracted provider, you will pay the Network cost sharing amount for these services. Non-contracted Providers at Network facilities cannot bill you for their services when the services are approved by IEHP.

You have a right to receive timely and geographically accessible Mental Health and Substance Use Disorder services when you need them.

IEHP can help you identify a Network Mental Health Professional or a Network physician close to where you live or work, with whom you can set up a visit. If IEHP’s in-network Providers are not available within a reasonable time or distance, IEHP will arrange and cover MH/SUD services from an out-of-network provider. You will not have to pay more than your usual in-network costs for this care. If you need help finding a Network Mental Health Professional, call IEHP Member Services at 1-855-433-IEHP (4347) (TTY 711).

IEHP has a Maternal Mental Health Program which includes treatment for pre- and post-partum maternal mental health conditions. Your PCP or you can call IEHP Member Services at 1-855-433-IEHP (4347) (TTY 711) to set up a visit.

Mental Health and Substance Use Disorder (MH/SUD) benefits are covered under your IEHP Covered plan. IEHP provides coverage for medically necessary MH/SUD services, including therapy, inpatient care, outpatient care, emergency care, residential treatment, and medications. Certain services and supplies for MH/SUD may require prior authorization by IEHP to be covered. Please refer to "Mental Health and Substance Use Disorders" in the "Plan Benefits" section of the Evidence of Coverage (EOC) for a complete description of Mental Health and Substance Use Disorder services and supplies.

If you have questions about MH/SUD services or accessing MH/SUD services under IEHP Covered, your PCP or you can call IEHP Member Services at 1-855-433-IEHP (4347) (TTY 711)

Sometimes you may need care that the PCP cannot provide. At such times, your PCP will submit a referral for you to see to a Specialist or other health care provider for that care. Your PCP or another Specialist will provide you a referral to visit a Specialist within the time frame listed in the “Access to Care Guidelines” section of this EOC. A Specialist is a doctor who has extra education in one area of medicine. Your PCP will work with you to choose a Network Specialist.

Other services that might need a referral include in-office procedures:

• X-rays
• Lab work
• Physical therapy
• EKG
• EEG
• Medical social services
• Home health care

Your PCP may give you a form to take to the Specialist. The Specialist will fill out the form and send it back to your PCP. The Specialist will treat you for as long as they think you need treatment. If you have a health problem that needs special medical care for a long time, you may need a standing referral. Refer to the “Standing Referral to Specialty Care for Medical and Surgical Services” section of the EOC for more information.

You are completely financially responsible for medical care that the PCP does not provide or IEHP does not authorize except for medically necessary care provided in a legitimate emergency.

Timeframes by type of referral request:

• Routine or regular referral – 5 business days
• Urgent referral – 24 to 48 hours

Please call IEHP if You do not get a response within the above time frames.

Some health care services require review and approval/denial by IEHP according to medical necessity. This is called Prior Authorization.

IEHP will work with your provider to receive and review all necessary information in order to analyze the request for authorization. If the request is denied, you will be informed and told how to appeal the denial. IEHP uses specific guidelines and recognized nonprofit professional association clinical criteria to decide whether a health care service is covered. You have the right to request the criteria used in a decision about your care, at no cost. If you would like a copy of the IEHP Utilization Management processes, or would like a specific treatment guideline or criteria, please call IEHP Member Services at 1-855-433-IEHP (4347)(TTY 711).

IEHP will communicate clearly and promptly about your care and any decisions (approvals/denials, delays, or modifications) affecting it. If you disagree with a decision, you have the right to appeal it and IEHP will provide you with how to file an appeal. For information on how to file an appeal, please visit the IEHP Covered “Grievances and Appeals Process” page or refer to the “Grievance, Appeals, Independent Medical Review and Arbitration,” section of the EOC for more information.

For information on Prior Authorizations, please refer to the “Prior Authorization” section of the EOC.