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contracted provider. Prior to extending a contract, we must receive the following documents.  PLEASE NOTE, IEHP is only accepting Vision Providers who meet the following exceptions through October 31, 2022: Providers practicing in any of the CalAIM service area expansion territories effective January 1, 2022 (including formerly voluntary and excluded zip codes) Providers filling positions that have been vacated in an existing practice Providers transitioning from an existing group agreement to their own individual agreement Providers being added to existing Vision groups Please completely fill out all required documents and submit to contract@iehp.org. Any delay in receiving the below stated documents will affect the effective date of the contract that will be mailed to you.  1. Vision Provider Network Participation Form (PDF) 2. Letter of Interest that outlines the following: What Specialty/Services you are interested in contracting for Facility locations(s) National Provider Identifier (NPI) for each facility Medi-Cal Provider information number (PIN) 3. W-9 Form (PDF) A current Taxpayer Identification Number and Certification Form 4. California Participating Physician Application (PDF) 5. Liability Insurance Certificate Professional general liability in the minimum amount of One Million Dollars ($1,000,000) per occurrance; and Three Million Dollars ($3,000,000) aggregate per year for professional liability 6. Facility Business License - Faculty 7. Ownership Information (PDF) Name, Title, and Percent of Ownership Contracts Maintenance Request Form can be found here (PDF). All documents should be e-mailed to contract@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.

tions in compliance with ethical standards, contractual obligations under State and Federal programs, laws, and regulations applicable to Medi-Cal and IEHP DualChoice. This commitment extends to our business associates and delegated entities that support IEHP’s mission to improve the delivery of quality, accessible, and wellness based healthcare services for our community.  Our Compliance Program is designed to: Ensure we comply with applicable laws, rules, and regulations Reduce or eliminate Fraud, Waste, and Abuse (FWA) Prevent, detect, and correct non-compliance Reinforce our commitment to culture of compliance for which we strive Establish and implement our shared commitment to honesty, integrity, transparency, and accountability FDR Information What is an FDR? A First Tier, Downstream or Related Entity (FDR) is a delegated entity subcontracted on behalf of IEHP to provide health plan related services.  FDR Requirements FDRs are required to follow IEHP’s policies and procedures, Code of Business Conduct and Ethics, and other contractual requirements.  FDR Resources Compliance Program Requirements Manual/Vendor First Tier Downstream and Related Entities (FDRs) IEHP Compliance Program Description IEHP Code of Business Conduct and Ethics  Non Retaliation Policy Delegation Oversight Provider Manual PnP (Coming Soon) Document Retention (Coming Soon) FDR Compliance Program Attestation CMS Compliance, FWA, and HIPAA training material ICE FWA Training ICE General Compliance Training Code of Business Conduct and Ethics Inland Empire Health Plan (IEHP) expects Team Members and business entities doing business with IEHP to conduct business activities in an ethical and professional manner that promotes public trust and confidence in the integrity of IEHP. The Code provides guidance about the compliance culture at IEHP and the role that each Team Member, including Senior Management, Chief Officers, the Governing Board, and our business partners, play in building and preserving that culture. IEHP Code of Business Conduct and Ethics Compliance, Fraud, Waste, and Abuse (FWA), and Privacy Program Training The IEHP Compliance, FWA, and Privacy Training Program focuses on to the elements of an effective Compliance Program, conduct & ethics, and the Fraud, Waste and Abuse and Privacy Programs. IEHP requires delegated entities to provide Compliance Training to  their employees, Providers, downstream entities, Board of Directors, and Contractors within 90 days of hire/start date. IEHP is committed to a culture of compliance, ethics, and integrity, the goal of Compliance Training is to provide all associated parties the ability to demonstrate awareness of IEHP’s requirements, including regulations and policies & procedures associated with Compliance as it relates to daily work. If you have questions or additional suggestions, please e-mail The IEHP Compliance Department at compliance@iehp.org General Compliance Training Compliance Fraud, Waste and Abuse (FWA) HIPAA Privacy and Security (PDF) Reporting Information IEHP has the following resources available for reporting fraud, waste or abuse, Privacy issues, and other compliance issues: Compliance Hotline: (866) 355-9038 Fax: (909) 477-8536 E-mail: compliance@iehp.org Mail: IEHP Compliance Officer P.O. Box 1800 Rancho Cucamonga, CA 91729-1800 Online: Report a Compliance Issue

IEHP GOVERNING YOUR USE OF THE DEVELOPER PORTAL AND THE IEHP APIS (DEFINED BELOW). BY CLICKING “I AGREE” OR ACCESSING THE DEVELOPER PORTAL OR USING IEHPS APIS YOU ARE AGREEING TO BE BOUND BY THE TERMS OF THIS DEVELOPER AGREEMENT AND ANY OTHER APPLICABLE TERMS AND CONDITIONS POSTED ON IEHPS WEBSITE LOCATED AT WWW.IEHP.ORG/EN/ABOUT/PRIVACY-POLICY. IF YOU DO NOT AGREE TO THE TERMS OF THIS AGREEMENT, YOU MAY NOT ACCESS THE DEVELOPER PORTAL OR USE THE IEHP APIs. By entering into this Agreement, you affirm that you are at least 13 years old and of legal age to enter into this Agreement and are authorized to enter into this Agreement on behalf of your Company. No legal partnership or agency relationship is created between IEHP and you or your Company by virtue of this Agreement. We may update this Agreement by posting the updated version(s) on this Website. Updated versions of the Agreement will apply to your use of the IEHP APIs occurring on or after the date of the last update. The "Last Updated" legend above indicates when this Agreement was last changed. You should periodically review this page to determine if this Agreement has been updated. Your continued use of the IEHP APIs following any updates to this Agreement shall constitute notice and acceptance of any such updates. PERMISSIBLE USE OF IEHP APIS We provide access to Our application programming interfaces (“APIs”), including Our Patient Access API, Provider Directory API and Promoting Interoperability API, and their associated documentation and sandbox (collectively, the “IEHP APIs”) on the Developer Portal. We may update, change, discontinue or add IEHP APIs or functionality or features to the IEHP APIs in Our discretion with or without providing notice to you. Subject to the terms of this Agreement, IEHP grants you a limited, non-sublicensable, non-assignable, non- transferable, royalty-free, non-exclusive license only to use: (a) the Patient Access API to retrieve certain health plan information maintained by Inland Empire Health Plan, a local public entity of the State of California, and its subsidiary health plans with the approval and at the direction of the applicable member or their personal representative consistent with applicable law; (b) the Provider Directory API to retrieve certain provider and pharmacy directory information; and (c) the Promoting Interoperability API to retrieve certain health care information with the consent of the applicable patient or their personal representative consistent with applicable law. You may only access the Patient Access API and Promoting Interoperability API by means of an application that has been registered with IEHP to access them. You agree to comply with all applicable laws, regulations, and governmental issuances. RESTRICTIONS You may not: (a) decompile, disassemble, reverse engineer, or otherwise attempt to derive, reconstruct, identify, or discover any source code, underlying ideas, or algorithms of the IEHP APIs by any means, except to the extent that the foregoing restriction is prohibited by applicable law; (b) remove any proprietary notices, labels, or marks from the IEHP APIs; (c) interrupt or attempt to interrupt the operation of the IEHP APIs in any way, including, without limitation, by restricting, inhibiting, or interfering with the ability of any other user to use the IEHP APIs (including by means of hacking or defacing any portion of the IEHP APIs, or by engaging in spamming, flooding, or other disruptive activities); (d) disrupt, interfere with, modify, bypass, or otherwise circumvent IEHP APIs functionality or features, limitations, security measures, technical processes, availability, integrity, or performance (or attempt the same); (e) transmit or attempt to transmit data over a IEHP APIs unless such transmission is authorized and formatted in accordance with applicable specifications in the IEHP APIs implementation guide; (f) transmit or otherwise make available through or in connection with the IEHP APIs any malicious, harmful or invasive code; (g) attempt to exceed IEHP APIs rate limits; (h) conduct security research on or testing against IEHP APIs, services, applications, systems, devices, or networks without prior written approval from IEHP; or (i) use the IEHP APIs (1) for any unlawful purpose or in any manner not authorized or intended in the IEHP APIs implementation guide, (2) in any way that could pose a threat to, disrupt, interfere with, harm, or impair the IEHP APIs, IEHP or other IEHP services, applications, systems, devices, or networks, or Inland Empire Health Plan members’, patients’, customers’, or other users’ use of IEHP APIs, (3) in any manner that, in IEHP’s reasonable determination, constitutes excessive or abusive usage, (4) to gain unauthorized access to any IEHP service, application, system, device, or network, or (5) to transmit malicious code or exploit security flaws, vulnerabilities, or deficiencies. MONITORING Your use of this Website and the IEHP APIs may be monitored by IEHP to ensure compliance with this Agreement. You consent to such monitoring. REPORTING SECURITY ISSUES You agree to promptly report to IEHP any security flaws, vulnerabilities, or deficiencies identified through normal use of IEHP APIs by calling the Inland Empire Compliance Hotline at 1-866-355-9038. You may not publicly disclose security flaws, vulnerabilities, or deficiencies in the IEHP APIs or other IEHP applications, systems, devices, or networks of which you become aware. ACCOUNTS/REGISTRATION You agree to promptly report to IEHP any security flaws, vulnerabilities, or deficiencies identified through normal use of IEHP APIs by calling the Inland Empire Health Plan Compliance Hotline at 1-866-355-9038. You may not publicly disclose security flaws, vulnerabilities, or deficiencies in the IEHP APIs or other IEHP applications, systems, devices, or networks of which you become aware. PROPRIETARY RIGHTS IEHP or its licensors own the IEHP APIs and the content on this Website and all intellectual property rights therein. You may not use any Inland Empire Health Plan entity’s name, trademarks, service marks, tradenames, logos or other distinctive brand features except as necessary to comply with your obligation, above, and agree not to remove any proprietary notices, labels, or marks from the IEHP APIs, and, in any case, you may not use those notices, labels or marks to imply affiliation with or endorsement by Inland Empire Health Plan. You have only those rights to access and use the IEHP APIs as are expressly granted by IEHP under this Agreement and all other rights in the IEHP APIs are reserved to IEHP or its licensors. You acknowledge that these rights are valid and protected in all forms, media, and technologies existing now or hereinafter developed. “Inland Empire Health Plan, a local public entity of the State of California,” means the health care organization doing business as Inland Empire Health Plan including, without limitation, Inland Empire Health Plan, and the subsidiaries, partners, and successors of the foregoing. PUBLIC ENTITY STATUS; BROWN ACT/PUBLIC RECORDS ACT The parties hereby acknowledge and agree that IEHP is a local public entity of the State of California subject to the Brown Act, California Government Code Sections 54950 et seq., and the Public Records Act, California Government Code Sections 6250 et seq. PRIVACY Your submission of information through the Website is governed by our Privacy Policy. RESPONSIBILITY FOR HARDWARE, SOFTWARE, TELECOMMUNICATIONS AND OTHER SERVICES You are responsible for obtaining, maintaining, and paying for all hardware, software, and all telecommunications and other services, needed for you to use the IEHP APIs. DISCLAIMER OF WARRANTY IEHP AND ITS SERVICE PROVIDERS DISCLAIM ALL EXPRESS OR IMPLIED REPRESENTATIONS OR WARRANTIES REGARDING THE IEHP APIS, INFORMATION, CONTENT, SERVICES, FUNCTIONALITY, AND ANY OTHER RESOURCES AVAILABLE ON OR ACCESSIBLE THROUGH THIS WEBSITE, INCLUDING, WITHOUT LIMITATION, ANY IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, OR NON- INFRINGEMENT. ALL SUCH IEHP APIS, INFORMATION, CONTENT, SERVICES, FUNCTIONALITY AND RESOURCES ARE MADE AVAILABLE "AS IS" AND "AS AVAILABLE", AT YOUR SOLE RISK, WITHOUT WARRANTY OF ANY KIND. IEHP DOES NOT WARRANT THAT THE WEBSITE OR IEHP APIS WILL BE ACCURATE OR OPERATE WITHOUT INTERRUPTION OR ERROR. LIMITATION OF LIABILITY TO THE MAXIMUM EXTENT PERMITTED BY APPLICABLE LAW, IN NO EVENT SHALL IEHP, INLAND EMPRIE HEALTH PLAN OR THEIR SERVICE PROVIDERS, LICENSORS OR RESPECTIVE EMPLOYEES, OFFICERS, DIRECTORS, AGENTS, AFFILIATES, SUPPLIERS, VENDORS, LICENSORS, CO-BRANDERS OR PARTNERS (COLLECTIVELY, THE “INLAND EMPRIE HEALTH PLAN PARTIES") BE LIABLE FOR ANY DIRECT, INDIRECT, SPECIAL, PUNITIVE, INCIDENTAL, EXEMPLARY, OR CONSEQUENTIAL DAMAGES, OR ANY DAMAGES WHATSOEVER RESULTING FROM ANY LOSS OF USE, LOSS OF DATA, LOSS OF PROFITS, BUSINESS INTERRUPTION, LITIGATION, OR ANY OTHER PECUNIARY LOSS, WHETHER BASED ON BREACH OF CONTRACT, TORT (INCLUDING NEGLIGENCE), PRODUCT LIABILITY, OR OTHERWISE ARISING OUT OF OR IN ANY WAY CONNECTED WITH THE USE, OPERATION OR PERFORMANCE OF THE IEHP APIS, WITH THE DELAY OR INABILITY TO USE THE IEHP APIS, ANY DEFECTS IN THE IEHP APIS, OR WITH THE PROVISION OF, OR FAILURE TO MAKE AVAILABLE, ANY INFORMATION, SERVICES, PRODUCTS, MATERIALS, OR OTHER RESOURCES AVAILABLE ON OR ACCESSIBLE THROUGH THE IEHP APIS, EVEN IF ADVISED OF THE POSSIBILITY OF SUCH DAMAGES. You acknowledge and agree that the limitations set forth above are fundamental elements of this Agreement. INDEMNIFICATION You agree to indemnify, defend, and hold the Inland Empire Health Plan Parties harmless from any liability, loss, claim, and expense (including reasonable attorneys' fees) actually or allegedly related to or arising out of your use of the IEHP APIs or this Website, your use or disclosure of information obtained through the IEHP APIs, your violation of this Agreement, and/or your violation of the rights of any other person. TERM, TERMINATION, SUSPENSION AND REVOCATION This Agreement is effective until terminated by either party. If you no longer agree to be bound by this Agreement, you must cease your use of the IEHP APIs. If you breach any provision of this Agreement, then you may no longer use the IEHP APIs. IEHP may suspend or revoke your Credentials or access to the IEHP APIs without prior notice for your failure to comply with this Agreement or if IEHP determines that your access to the IEHP APIs would present an unacceptable level of risk to the security of IEHP’s systems. IEHP may terminate this Agreement if you fail to comply with its terms and, to the extent permitted by law, for any or no reason. If this Agreement is terminated for any reason, then: (a) this Agreement will continue to apply and be binding upon you in respect of your prior use of the IEHP APIs (and any unauthorized further use of the IEHP APIs); and (b) any rights granted to us under this Agreement will survive such termination. GENERAL LEGAL TERMS This Agreement constitutes the entire agreement between you and IEHP with respect to its subject matter IEHP’s failure to exercise or enforce any right or provision of this Agreement shall not constitute a waiver of such right or provision. If a court of competent jurisdiction rules that any provision of the Agreement is invalid, then that provision will be removed from the Agreement without affecting the rest of the Agreement and the remaining provisions will continue to be valid and enforceable. There are no third- party beneficiaries to this Agreement. The rights granted in this Agreement may not be assigned or transferred by You without the prior written approval of IEHP. You may not delegate your responsibilities or obligations under this Agreement without the prior written approval of IEHP. This Agreement shall be governed by the laws of the State of California without regard to its conflict of laws provisions. You agree to submit to the exclusive jurisdiction of the courts located within the county of San Bernardino, California to resolve any legal matter arising from this Agreement. IEHP may, notwithstanding this, seek injunctive remedies in any jurisdiction.

h plan operations in compliance with ethical standards, contractual obligations under State and Federal programs, laws, and regulations applicable to Medi-Cal and IEHP DualChoice. This commitment extends to our business associates and delegated entities that support IEHP’s mission to organize and improve the delivery of quality, accessible, and wellness based healthcare services for our community.   Our Compliance Program is designed to: Ensure we comply with applicable laws, rules, and regulations Reduce or eliminate Fraud, Waste, and Abuse (FWA) Prevent, detect, and correct non-compliance Reinforce our commitment to culture of compliance for which we strive Establish and implement our shared commitment to honesty, integrity, transparency, and accountability Code of Business Conduct and Ethics Inland Empire Health Plan (IEHP) expects Team Members and business entities doing business with IEHP to conduct business activities in an ethical and professional manner that promotes public trust and confidence in the integrity of IEHP. The Code is meant to provide guidance about the compliance culture at IEHP and the role that each Team Member, including management, Chief Officers and the Governing Board, plays in building and preserving that culture. IEHP Code of Business Conduct and Ethics (PDF) Compliance, Fraud, Waste, and Abuse (FWA), and Privacy Program Training The IEHP Compliance, FWA, and Privacy Training Program focuses on the elements of an effective Compliance Program, conduct & ethics, and the Fraud, Waste and Abuse and Privacy Programs. IEHP requires delegated entities to provide Compliance Training to their employees, Providers, downstream entities, Board of Directors, and Contractors within 90 days of hire/start, and annually thereafter. IEHP is committed to a culture of compliance, ethics, and integrity. The goal of Compliance Training is to provide all associated parties the ability to demonstrate awareness of IEHP’s requirements, including regulations and policies & procedures associated with Compliance as it relates to daily work. If you have questions or additional suggestions, please e-mail the IEHP Compliance Department at compliance@iehp.org. Compliance Training FWA HIPAA Privacy and Security (PDF) Eligibility to Participate in Federal and State Health Care Programs Inland Empire Health Plan (IEHP) is prohibited from issuing payment for services provided, ordered, or prescribed by an individual or entity that is excluded, ineligible, or terminated from participation in State and Federal health care programs in accordance with regulatory and contractual requirements. IEHP conducts regular reviews of Federal and State exclusionary databases and lists, including but not limited to: Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE list) GSA Excluded Parties List System (EPLS) DHCS Medi-Cal Suspended and Ineligible Provider List CMS Preclusion List Restricted Provider Database (RPD) Exclusion Screening IEHP has implemented a screening process to identify individuals and entities that appear on the DHHS OIG LEIE, the GSA EPLS, the CMS Preclusion List and the DHCS Medi-Cal Suspended and Ineligible Provider List prior to appointment, contracting, and/or employment and monthly thereafter to ensure that none of these individuals or entities are excluded, ineligible or terminated from participation in State and Federal health care programs. Delegated entities must implement a screening program for employees, Board Members, contractors, and business partners to avoid relationships with individuals and/or entities that tend toward inappropriate conduct. This program includes but is not limited to: Prior to contract and monthly thereafter, review of the GSA System for Award Management (SAM), the Department of Health Care Services Medi-Cal Suspended and Ineligible list, and the Office of Inspector General’s (OIG) List of Excluded Individuals and Entities (LEIE) that are excluded from participation in government health care programs (42 CFR §10011901). A monthly review of the Department of Health Care Services Medi-Cal Suspended and Ineligible list. Criminal record checks when appropriate or as required by law. Review of the National Practitioner Databank (NPDB). Review of professional license status for sanctions and/or adverse actions. Reporting results to Compliance Committee, Governing Body, and IEHP as necessary. Fraud, Waste, and Abuse (FWA) IEHP has established a Fraud, Waste, and Abuse Program to detect, correct, and prevent fraud, waste, and abuse on part of Team Members, IEHP Members, Providers, Vendors, delegated entities and any other entity doing business with IEHP. Fraud Prevention Fraud Prevention, it’s a Team Effort In an effort to prevent fraud and abuse, IEHP encourages Providers and their staff to report any suspicious circumstances when they arise. You may want to ask for another form of identification in addition to the IEHP Member identification card. Identification with both a picture and a signature, such as a valid driver’s license or State identification card, are suggested. We are informing Members of this concern and are requesting that they have additional identification available when they come to you. To obtain more compliance guidelines, the Department of Health and Human Services (HHS) offers assistance (by clicking on this link you will be leaving the IEHP website). Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program, or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program. Examples include: Knowingly billing for services or prescriptions not furnished or supplies not provided Knowingly altering claim forms for a higher payment Selling medicine, medical equipment, or other things received through IEHP Waste includes overuse of services, or other practices that, directly or indirectly, result in unnecessary costs. Waste is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources. Examples include: Conducting excessive office visits Writing excessive prescriptions or ordering excessive tests Prescribing more medications than necessary for the treatment of a specific condition Abuse includes actions that may, directly or indirectly, result in unnecessary costs and improper payment or services. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Examples include: Billing for unnecessary medical services or medical equipment Billing for brand name drugs when generics are dispensed Misusing codes on a claim, such as upcoding and unbundling codes. Report potential FWA Click Here (By clicking on this link, you will be leaving the IEHP website). Privacy Incident/Breach IEHP has established a HIPAA Privacy Program to ensure that Member’s health information is properly protected while allowing the flow of health information needed to provide and promote high-quality health care. A privacy breach is defined as unauthorized acquisition, access, use, or disclosure of protected health information (PHI) which compromises the security or privacy of such information. PHI is health information that relates to a Member’s past, present or future physical or mental health or condition, including the provision of his/her health care, or payment for that care and contains personally identifiable information (PII) such as name, SSN, DOB, Member ID, address, or any other unique identifier related to the Member. This generally means that a breach occurs when PHI is accessed, used, or disclosed to an individual or entity that does not have a business reason to know that information. The law does allow information to be accessed, used, or disclosed when it is related to treatment, payment, or healthcare operations directly associated with the work that we do at IEHP on behalf of our Members. Report a Privacy Incident/Breach Click Here (By clicking on this link, you will be leaving the IEHP website). Reporting Information IEHP has the following resources available for reporting fraud, waste or abuse, privacy issues, and other compliance issues: Compliance Hotline: (866) 355-9038 Fax: (909) 477-8536 E-mail: compliance@iehp.org. Mail: IEHP Compliance Officer P.O. Box 1800 Rancho Cucamonga, CA 91729-1800 Online: (By clicking on this link, you will be leaving the IEHP website) Report a Compliance Issue: Click Here Report a Privacy Incident/Breach: Click Here Report potential FWA: Click Here Frequently Asked Questions (FAQs) What are some common examples of fraud? Providers Billing for services not rendered Paying a "kickback" in exchange for a referral for medical services or goods Unbundling Overcharging for services or goods  Using false credentials Members Allowing unauthorized individuals to use ID card to obtain benefits Altering prescriptions Falsifying residence information to obtain benefits Drug seeking or doctor shopping to obtain narcotics What do I do if I suspect an IEHP Member is engaging in possible fraud, waste, or abuse? First, document your suspicions. Then, contact IEHP’s Compliance Department at (866) 355-9038 and make a report with one of our Representatives. At times, IEHP may request additional information that is necessary to investigate. IEHP also has the following resources available for reporting fraud, waste or abuse, privacy issues, and other compliance issues: Compliance Hotline: (866) 355-9038 Fax: (909) 477-8536 E-mail: compliance@iehp.org Mail: IEHP Compliance Officer P.O. Box 1800 Rancho Cucamonga, CA 91729-1800 Online: (By clicking on the following links, you will be leaving the IEHP website) Report a Compliance Issue Click Here Report a Privacy Incident/Breach Click Here Report potential FWA Click Here What do I do if my facility has made some billing errors? If you suspect that errors in billing may have occurred, contact your IEHP Provider Services Representative at (909) 890-2054. What are some other things I can do as a Provider? Periodically perform internal audits of billing practices and compare billing records with payments received. Do not leave prescription pads, which include a Provider's identification and license number, out in the open. For example, do not store prescription pads in exam room cabinets or leave on office counters. IEHP DualChoice (HMO D-SNP) Model of Care Training The Centers for Medicare & Medicaid Services (CMS), the Department of Health Care Services (DHCS) and the National Committee for Quality Assurance (NCQA) require that IEHP staff and contracted consultants/vendors, our Medicare IPAs, Hospitals/SNFs, and Providers, receive training on the Plan’s Model of Care for our D-SNP Members: Interdisciplinary Care Team (ICT) Fact Sheet (PDF) IEHP DualChoice (HMO D-SNP) Model of Care Training (PDF) IEHP DualChoice (HMO D-SNP) Model of Care Training (HTML)   *We recommend opening file in: Mozilla Firefox, MS Edge or MS Internet Explorer Contact the OIG The Office of the Inspector General (OIG) is there to assist you and maintains a hotline, which offers a confidential means for reporting vital information. For information on confidentiality, please contact the hotline and ask about their confidential source program. Each caller is encouraged to assist the OIG by providing information on how they can be contacted for additional information but the caller may remain anonymous. Contacting the Office of the Inspector General Phone: (800) HHS-TIPS (447-8477) E-mail: Htips@oc.dhhs.gov Additional Hotlines DHCS Medi-Cal Fraud Hotline Phone: (800) 822-6222 E-mail: fraud@dhcs.ca.gov Web: https://apps.dhcs.ca.gov/stopfraud/Default.aspx  The recorded message may be heard in English and 10 other languages: Spanish, Vietnamese, Cantonese, Armenian, Hmong, Cambodian, Laotian, Farsi, Korean and Russian. The call is free and the caller may remain anonymous.    You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

BM) handles all Medicare pharmacy and provider prior authorization and pharmacy benefit related questions. Providers and pharmacies can call MedImpact Customer Contact Center at (800) 788-2949. Health care providers can submit prior authorizations via fax (858) 790-7100, or download forms at the MedImpact Website. Request for Redetermination of Medicare Prescription Drug Denial - English (PDF) Request for Redetermination of Medicare Prescription Drug Denial - Spanish (PDF) Coverage Determination Form - Retroactive prior authorization requests (PA requests dated before 1/1/2023) should be faxed to (909) 890-5766.   Drug Request Supplemental PER Form for Compounded Prescription (PDF) Medicare Hospice Form for Medicare Part D Plans (PDF) Medicare Prescription Drug Coverage and Your Rights - English (PDF) Medicare Prescription Drug Coverage and Your Rights - Spanish (PDF) Mail Order Mail-Order Service Fax Form (PDF) Other Pharmacy Provider Forms Appointment of Representative - English (PDF) Appointment of Representative - Spanish (PDF) Nutritional Evaluation Form - Adult (PDF) Nutritional Evaluation Form - Infant (PDF)  Opioid Edit Error Report Form (PDF) WIC Program Forms (California Department of Public Health) Pediatric Referral Form (PDF) WIC Referral For Pregnant Women (PDF) WIC Referral For Postpartum/Breastfeeding Women (PDF)   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.   Information on this page is current as of January 05, 2023.

utive Officer, CEO). En este cargo, trabaja en colaboración con la Junta Directiva de IEHP con el propósito de establecer una visión estratégica y proporcionar un liderazgo ejecutivo para uno de los 10 planes de salud más grandes de Medicaid y el mayor plan sin fines de lucro de Medicare-Medicaid en los EE. UU. EL Sr. McNaughton fomenta la sólida asociación de IEHP con los proveedores, hospitales y cientos de socios de servicios para la comunidad a fin de brindar una atención integral de calidad a más de 1.5 millones de Miembros. Asegura la administración y la estabilidad financiera del presupuesto operativo de IEHP de más de $5.4 mil millones. El Sr. McNaughton, un líder visionario en el área de la atención médica, se unió a IEHP en 2018 como Director Ejecutivo de Operaciones. En este cargo, fue responsable de los departamentos de Operaciones, Quejas, Contratos con Proveedores, Inscripciones y Elegibilidad, así como de Servicios para Miembros; además apoyó el área directiva de la organización de IEHP, fomentó la transformación LEAN de IEHP y reafirmó la misión de IEHP de brindar un servicio de calidad a nuestros Miembros y proveedores de forma efectiva y eficaz. Antes de IEHP, el Sr. McNaughton se desempeñó en diversos cargos incrementando sus responsabilidades, en hospitales y grandes sistemas hospitalarios. Durante casi 20 años, ha dirigido la innovación y las estrategias operativas en fases múltiples que han generado máximos resultados de forma consistente. El Sr. McNaughton, goza de una excelente reputación al crear equipos dinámicos, impulsar el desarrollo de líderes y fomentar relaciones clave en la comunidad. Su capacidad para eliminar obstáculos y fortalecer a cada individuo, desde los Miembros del equipo en primera línea hasta los Doctores, ayudará a apoyar la fuerte posición de IEHP en el entorno de la atención médica, el cual es siempre cambiante. Los cargos del Sr. McNaughton como presidente de Kettering Medical Center y Vicepresidente Ejecutivo de Kettering Health Network, demostraron su ingenio para las estrategias de negocio, así como su empatía y liderazgo visionario. Desarrolló una estrategia coordinada y detallada para toda la red, además de que dirigió diversos cambios progresistas en los servicios y la prestación de atención para los pacientes en dichos establecimientos. Kettering Health Network en el suroeste de Ohio incluye ocho hospitales, nueve departamentos de emergencias, numerosas clínicas para pacientes ambulatorios y más de 11,000 empleados. Antes de desempeñar este cargo en Kettering Medical Center, el Sr. McNaughton fue vicepresidente en el San Joaquin Community Hospital. Entre todos los logros que ahí alcanzó, desarrolló e implementó una nueva misión y un departamento de servicio, lo cual ayudó a incrementar las calificaciones del nivel de satisfacción de los pacientes del 40 al 85 por ciento en menos de un año. El fuerte compromiso del Sr. McNaughton con la comunidad se ajusta adecuadamente a la misión de IEHP y a la cultura de la empresa. Es Profesor Clínico Asistente en Loma Linda University y miembro de la junta de diversas agencias educativas y sin fines de lucro. Como voluntario de Global Medical Missions, una organización de ayuda internacional, dirigió equipos de misión a corto plazo para Kenia, Malaui, Nigeria, India, Nepal, Honduras y México. En su tiempo libre le gusta cantar, disfrutar del teatro musical y de volar aviones monomotores. El Sr. McNaughton asistió a Pacific Union College, donde obtuvo su título de licenciatura. Obtuvo su título de maestría en Business Administration de University of La Verne. Además, forma parte de American College of Healthcare Executives.  

l Health Forms Behavioral Health  As a local Health Plan, Inland Empire Health Plan (IEHP) is committed to improving behavioral health services for our Members by developing direct relationships with select clinicians.     IEHP now has over 1,000,000 Members. Behavioral Health Clinicians are viewed as "Specialists" that are partners in improving the health status of our Members. IEHP Behavioral Health is an integrated essential partner with primary medical care. IEHP’s Direct Behavioral Health Program will offer our Behavioral Health Specialists: Streamlined Authorization & Claims Submission - via our fast and secure website. Competitive Reimbursement Rates - based on current Medicare rates. Speedy Payments - our track record is payment in less than 3 weeks (in most cases). Personal, Friendly Service - to ensure a successful and long-lasting working relationship. IEHP is committed to develop direct partnerships with Psychiatrists, Psychologists, LCSW's, LMFT's, Psychiatric Nurse Practitioners, Physician Assistants, and most recently, Licensed Professional Clinical Counselors (LPCC) who have met the couples and family qualifications. LPCCs without this qualification will not be considered eligible to join IEHP's Behavioral Health Network. For any questions or concerns, please email Contract@iehp.org. Requirements for this certification can be found here: https://www.bbs.ca.gov/pdf/publications/lpcc_couple-fam_courses.pdf In compliance with APL 17-019 (a DHCS regulation), IEHP now requires Behavioral Health Providers to begin the process of enrolling with Medi-Cal prior to contracting with IEHP. To ensure timely processing of your application, IEHP will accept your application to contract upon receipt of verification of Medi-Cal enrollment submission. Prospective Providers: QASP PLEASE NOTE, IEHP is now accepting new QASP Providers in all services areas.  Behavioral Health Behavioral Health Provider Letter and Application (PDF) Why You Should Contract with IEHP Directly for Behavioral Health (PDF) How IEHP Keeps You Informed and Drive Business to Your Practice (PDF) Medi-Cal Number (Physicians should be enrolled in the State's Medi-Cal Program) Existing Providers: Contracts Maintenance Request Form (PDF) W-9 Form (PDF) (Remittance advice address change) Medi-Cal Number (Physicians should be enrolled in the State's Medi-Cal Program) Frequently Asked Questions (FAQs) What is IEHP? How do I contract with IEHP? What are IEHP's compensation rates? What are IEHP’s minimum requirements to be considered for your BH Network? What if I have additional information about my practice, specialties or experience that is not covered on the survey; where can I send this information? When will I hear back from IEHP after I send my contract in? What services does IEHP offer online? What are the benefits and limitations for Medicare DualChoice Members? I am a Behavioral Health Treatment Provider for one or more of the following services, how do I contract with IEHP? (Services for Individuals (0-21) with Autism, Developmental Disabilities, or Specialized Behavioral needs; utilizing Applied Behavior Analysis and Behavior Modification treatment modalities) What is IEHP? IEHP stands for Inland Empire Health Plan. IEHP is a not-for-profit health plan that serves over 1,000,000 Members in public-sponsored health coverage programs including Medi-Cal and Medicare Special Needs Plan.  How do I contract with IEHP? The first step is to fill out the Behavioral Health Provider Letter and Application (PDF) and email Contract@iehp.org. We will contact you directly once we have evaluated our Member’s needs and are ready to proceed with contracting. What are IEHP compensation Rates? Reimbursement rates for Behavioral Health Services are based on Medicare rates. What are IEHP’s minimum requirements to be considered for your BH Network? A valid California License (LCSW, LMFT, LPCC, Psychologist, Psychiatrist, Nurse Practitioner) $1 million to $3 million Malpractice Insurance Must be enrolled with Medi-Cal Satisfy all IEHP’s standard credentialing requirements What if I have additional information about my practice, specialties or experience that is not covered on the survey; where can I send this information? You can send your information to: Inland Empire Health Plan Attention: Provider Relations P.O. Box 1800 Rancho Cucamonga CA 91729-1800 When will I hear back from IEHP after I send my contract in? Over the next two to three months we will be gathering information and determining our needs and as soon as we have determined what Providers we will need we will send out draft contracts with rate sheets for review. What services does IEHP offer online? Member Eligibility Verification Claims Submission Services Claims Status Authorization Status Medication Search Pharmaceutical Services Information Resources Provider Manuals; Benefit Manuals; EDI manuals  What are the benefits and limitations for Medicare DualChoice Members? Click here.  I am a Behavioral Health Treatment Provider for one or more of the following services, how do I contract with IEHP? (Services for Individuals (0-21) with Autism, Developmental Disabilities, or Specialized Behavioral needs; utilizing Applied Behavior Analysis and Behavior Modification treatment modalities) The first step is to fill out the Behavioral Health Provider Letter and Application (PDF) and email Contract@iehp.org. We will contact you directly once we have evaluated our Member’s needs and are ready to proceed with contracting. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

ols Menu Click on the following links to jump to that specific section: After Hours Care After Hours Phone Numbers IEHP Access Standards IEHP Direct Adult Hospitalists LabCorp Locations Urgent Care Clinics After Hours Care IEHP Providers can direct Members to access care after hours. After hour care includes the 24-Hour Nurse Advice Line, DocOnline and Urgent Care Clinics. Fever? Pain? Cold? Call our 24-Hour Nurse Advice Line --> Your Members can call the IEHP 24-Hour Nurse Advice Line for medical advice anytime, day or night: 1-888-244-IEHP (4347) DocOnline, an extension to the Nurse Advice Line, allows Members to speak with a board-certified Physician for advice after hours using telephonic and/or video devices. DocOnline Physicians will triage, assess, and provide diagnoses for minor acute conditions. Physicians may also give treatment advice, refill select prescriptions and refer Members for in-person care. DocOnline FAQs (PDF) Prescription Medication Refill List (PDF) (Back to Additional Resources Menu) After Hours Phone Numbers for Coverage Determination and Expedited Appeals IEHP DualChoice (HMO D-SNP) Members The following numbers are to be used for after hour requests: Coverage Determinations: Phone: (888) 860-1297 Expedited Appeals: Phone: (866) 223-4347  Fax: (909) 890-5748 (Back to Additional Resources Menu) IEHP Access Standards On an annual basis, IEHP conducts the Appointment Availability Access Study. All Members must receive access to all covered services without regard to sex, race, color, religion, ancestry, national origin, creed, ethnic group identification, age, mental disability, physical disability, medical condition, genetic information, marital status, gender, gender identity, sexual orientation, or identification with any other persons or groups defined in Penal Code Section 422.56, except as needed to provide equal access to Limited English Proficiency (LEP) Members or Members with disabilities, or as medically indicated. Appointment Standards for All Provider Types (PDF)| Last Revised: 12/12/2022 Appointment Standards for Behavioral Health (PDF)| Last Revised: 01/11/2023 (Back to Additional Resources Menu) IEHP Direct Adult Hospitalists Direct Adult Hospitalist (PDF) | Last Revised: 02/27/2023 (Back to Additional Resources Menu) LabCorp Locations A listing of LabCorp Patient Service Centers around the Inland Empire can be found below: LabCorp Patient Service Centers (PDF) LabCorp Patient Service Centers at Walgreens (PDF) (Back to Additional Resources Menu)   Urgent Care Clinics --> Any of your IEHP Members needing medical attention may visit an Urgent Care Clinic after regular business office hours and on weekends. A listing of all Urgent Care Clinics is found on the IEHP Doctor Search. (Back to Additional Resources 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.

premio HERO Business of the Year de 2022 de Riverside Medical Clinic Charitable Foundation (RMCCF) en su evento anual de recaudación de fondos del 18 de agosto. RMCCF también reconoció con el premio HERO a la Gerente de Socios de la Comunidad de IEHP, LuAnna Jáuregui, por su excepcional cooperación y por encarnar lo que significa ser un verdadero héroe.  Los premios anuales del Programa HERO reconocen a las organizaciones y las personas que demuestran liderazgo y esfuerzos excepcionales por apoyar y promover la amabilidad, la empatía y la inclusión en la comunidad. Durante los últimos cuatro años, IEHP se ha asociado con RMCCF y los programas de su Anti-Bullying Institute para ayudar a los niños, los padres, las escuelas y las organizaciones para jóvenes a lidiar con el bullying. “IEHP ha sido socio de la fundación en la comunidad durante muchos años. Recibieron nuestro premio HERO Business of the Year de 2022 por su generoso apoyo a nuestros programas en crecimiento”, dijo Lynda Bailey, Directora Ejecutiva de RMCCF. “Continúan comunicándose con nosotros abiertamente para ayudarnos a cubrir las necesidades de nuestra comunidad. Ellos hacen que nuestra organización, que es pequeña, pero poderosa, se sienta escuchada y apoyada”. Durante más de 25 años, IEHP ha trabajado incansablemente para hacer “lo correcto” por las comunidades de Inland Empire a las que sirve, promoviendo colaboraciones que hagan énfasis en la buena voluntad y la inclusividad.  “IEHP está comprometido con ayudar a promover una cultura donde la amabilidad, la empatía y la inclusión sean la norma, no la excepción”, dijo Jarrod McNaughton, Director Ejecutivo de IEHP. “Nos sentimos honrados de haber recibido este premio, y también felicitamos con orgullo a LuAnna Jáuregui, miembro del equipo, por su bien merecido reconocimiento por sus incansables esfuerzos para hacer una diferencia en nuestras comunidades”. LuAnna Jáuregui tiende puentes y ayuda a facilitar la colaboración en nombre de IEHP. También ha participado ampliamente en los esfuerzos de RMCCF de prevención del bullying, ya que tiene un lugar especial en su corazón.  “Apoyar la amabilidad y la inclusión en Inland Empire significa que más de mis vecinos y amigos, y las familias y sus hijos tienen la oportunidad de vivir alegremente”, dijo Jáuregui. “Recibir este reconocimiento de RMCCF es verdaderamente un honor y espero seguir trabajando juntos, trayendo aún más compasión a nuestra región”.    

AN AND IEHP HEALTH ACCESS. Date of Meeting: December 13, 2021 Time of Meeting: 9:00 AM Location of Meeting:  Inland Empire Health Plan Headquarters 10801 Sixth Street, Suite 120 Rancho Cucamonga, California 91730 This Notice shall confirm the REGULAR MEETING of the Joint Powers Agencies - INLAND EMPIRE HEALTH PLAN AND IEHP HEALTH ACCESS. If disability-related accommodations are needed to participate in this meeting, please contact Annette Taylor, Secretary to the IEHP Governing Board at (909) 296-3584 during regular business hours of IEHP (M-F 8:00 a.m. – 5:00 p.m.) Agenda Copies of the Packet may be obtained here.

AN AND IEHP HEALTH ACCESS. Date of Meeting: December 13, 2021 Time of Meeting: 9:00 AM Location of Meeting:  Inland Empire Health Plan Headquarters 10801 Sixth Street, Suite 120 Rancho Cucamonga, California 91730 This Notice shall confirm the REGULAR MEETING of the Joint Powers Agencies - INLAND EMPIRE HEALTH PLAN AND IEHP HEALTH ACCESS. If disability-related accommodations are needed to participate in this meeting, please contact Annette Taylor, Secretary to the IEHP Governing Board at (909) 296-3584 during regular business hours of IEHP (M-F 8:00 a.m. – 5:00 p.m.) Agenda (coming soon) Copies of the Packet may be obtained here.

AN AND IEHP HEALTH ACCESS. Date of Meeting: November 8, 2021 Time of Meeting: 9:00 AM Location of Meeting:  Inland Empire Health Plan Headquarters 10801 Sixth Street, Suite 120 Rancho Cucamonga, California 91730 This Notice shall confirm the REGULAR MEETING of the Joint Powers Agencies - INLAND EMPIRE HEALTH PLAN AND IEHP HEALTH ACCESS. If disability-related accommodations are needed to participate in this meeting, please contact Annette Taylor, Secretary to the IEHP Governing Board at (909) 296-3584 during regular business hours of IEHP (M-F 8:00 a.m. – 5:00 p.m.) Agenda Copies of the Packet may be obtained here.

AN AND IEHP HEALTH ACCESS. Date of Meeting: March 14, 2022 Time of Meeting: 9:00 AM Location of Meeting:  Inland Empire Health Plan Headquarters 10801 Sixth Street, Suite 120 Rancho Cucamonga, California 91730 This Notice shall confirm the REGULAR MEETING of the Joint Powers Agencies - INLAND EMPIRE HEALTH PLAN AND IEHP HEALTH ACCESS. If disability-related accommodations are needed to participate in this meeting, please contact Annette Taylor, Secretary to the IEHP Governing Board at (909) 296-3584 during regular business hours of IEHP (M-F 8:00 a.m. – 5:00 p.m.) Agenda Copies of the Packet may be obtained here.

AN AND IEHP HEALTH ACCESS. Date of Meeting: April 11, 2022 Time of Meeting: 9:00 AM Location of Meeting:  Inland Empire Health Plan Headquarters 10801 Sixth Street, Suite 120 Rancho Cucamonga, California 91730 This Notice shall confirm the REGULAR MEETING of the Joint Powers Agencies - INLAND EMPIRE HEALTH PLAN AND IEHP HEALTH ACCESS. If disability-related accommodations are needed to participate in this meeting, please contact Annette Taylor, Secretary to the IEHP Governing Board at (909) 296-3584 during regular business hours of IEHP (M-F 8:00 a.m. – 5:00 p.m.) Agenda Copies of the Packet may be obtained here.

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) 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.

Control and Prevention (CDC) is responding to an outbreak of respiratory disease caused by a novel (new) coronavirus that was first detected in China and which has now been detected in almost 70 locations internationally, including in the United States. The virus has been named "SARS-CoV-2" and the disease it causes has been named "coronavirus disease 2019" (abbreviated "COVID-19"). IEHP will continually update you on the latest recommendations, news, and resources on COVID-19 as it becomes available. COVID-19 Symptoms and Members Care For a complete list of COVID-19 symptoms and step-by-step Member direction, visit our COVID-19 Member page. COVID-19 Therapeutics Available for Members In an effort to provide the most up-to-date treatments against COVID-19, IEHP continues to maintain a list of providers, including but not limited to infusion clinics, ancillary, hospital and non-hospital based infusion centers offering COVID-19 infusion therapy treatment. Under all Member coverage, outpatient COVID therapeutics will be offered immediately after a Member is determined to be clinically eligible under and Emergency Use Authorization (EUA). For more information, Providers can utilize the COVID-19 Therapeutics Clinical Consult Line to connect with other clinicians for a free and confidential consultation on COVID-19 testing and treatment: 1-866-268-4322 (1-866-COVID-CA). List of Infusion Sites COVID-19 Infusion Treatments by Organization (PDF) Test-To-Treat COVID-19 Vaccine Reimbursement for Medi-Cal Providers DHCS has carved out the COVID-19 vaccine from Medi-Cal managed care health plans and will reimburse providers under the Fee-for-Service (FFS) delivery system for both medical and pharmacy claims. Medi-Cal will reimburse the associated COVID-19 vaccine administration fee at the allowable Medicare rate for all claims (medical, outpatient, and pharmacy), based on the number of required doses for all Medi-Cal beneficiaries. For further information: June 13, 2022 - DHCS COVID-19 Vaccine Administration Provider FAQs   How Vaccines Build Immunity While the COVID-19 vaccines are relatively new - the technology and science behind the vaccines have been in development for decades. In the video below, we demonstrate how years of vaccine research and advanced technology allowed researchers and scientists worldwide to be prepared to develop an mRNA vaccine that could help fight the spread of a global infectious disease. FIND A TESTING AND VACCINATION SITE NEAR YOU TODAY! RIVERSIDE Riverside County Public Health COVID Testing Site Vaccine Information Vaccine Locations & Registration Registrations encouraged but not required for: The CDC recommends everyone ages 6 months and older get vaccinated against COVID-19 as well as a booster for everyone 5 years and older, if eligible. For more information, visit the Riverside Country Vaccine webpage. Teenagers 5 to 17 years old must register for a vaccination clinic that offers the Pfizer vaccine and be accompanied by a parent/legal guardian or present a signed written consent from a parent/legal guardian and be accompanied by an adult. Pfizer Minor Consent Form (PDF) | Spanish  The Moderna and Johnson & Johnson vaccines can only be given to individuals age 18 years and older. Johnson & Johnson Fact Sheet (PDF) | Spanish - Published April 26, 2021  SAN BERNARDINO San Bernardino County Public Health COVID Testing Site Vaccine Locations & Registration Additional Dose and Boosters Information COVID-19 Vaccine Consent Form (PDF) | Spanish   The CDC recommends everyone ages 6 months and older get vaccinated against COVID-19 as well as a booster for everyone 5 years and older, if eligible. For more information, visit the San Bernardino County Pediatric COVID-19 Vaccination web page Walk-ins are now available at County-operated vaccination sites. Walk-in individuals will not need to bring any additional information to the site, however be prepared to register on site, which will include answering health screening questions. Walk-ins may experience longer wait times and availability may vary based on site demand.  Centers for Disease Control and Prevention (CDC) Clinical Care Guidance Vaccines Vaccination Plans January 10, 2022 - Continued Coverage of COVID-19 Diagnostic Testing (PDF) CalVax CalVax is a state-wide centralized system for health care Providers enrolled or interested in participating in the California COVID-19 Vaccination Program, developed by the California Department of Public Health (CDPH). The new CalVax platform will provide a system to manage vaccine enrollment, ordering, inventory, administration, reporting and data analytics. Training materials such as job aids, videos, and recorded demos will be available to support all system users as they navigate through the new CalVax platform (mycavax.cdph.ca.gov).  CA Notify • CA Notify Flyer in English (PDF) and Spanish(PDF) • CA Notify Shareable Tools for web and social media • CA Notify Website  Financial Assistance Resources Riverside County Medical Association - COVID-19 Financial Toolkit for Medical Practice U.S. Department of Health & Human Services (HHS) CARES Provider Relief Fund Learn more about the Provider Relief Fund (PRF) Provider Relief Fund (PRF) Portal U.S. Small Business Administration. Borrowers may be eligible for Paycheck Protection Program (PPP) loan forgiveness. See if you're eligible here. Guidance Regarding Monoclonal Antibody Treatment for COVID-19 Even with decreasing cases and hospitalizations, those with high-risk conditions who have tested positive for COVID-19 are encouraged to get monoclonal antibody treatment at Riverside University Health System (RUHS) – Medical Center. In January, the U.S. Food and Drug Administration (FDA) limited the use of certain monoclonal antibody therapies that were ineffective against the omicron variant. In response, RUHS – Medical Center is administering sotrovimab, an IV infusion shown to be effective against omicron and other variants. January 14, 2022 - RUHS-Medical Center Offers Monoclonal Antibodies Treatment Quest Diagnostic For more information, please visit Quest Diagnostics FAQs COVID-19 Specimen Collection Instructions (Watch Video Here)                        Fact Sheet for Healthcare Providers for COVID-19 Testing (View PDF Here)   LabCorp For more information, please visit LabCorp's COVID-19 page. Which COVID-19 Test is Right For You? COVID-19 FAQs If you do not have the ability to collect specimens for COVID-19, please refer to your County Public Health resources for guidance on directing Members for testing.   Telehealth IEHP is strongly encouraging the utilization of telehealth for visits that can be conducted over the phone or via other audiovisual telecommunications.  IEHP has published a telehealth FAQ which is available here: Telehealth Services Due to Limiting Exposure to COVID-19 (PDF)- October 17, 2022 Remember: IEHP Provider Telehealth Information (PDF) IEHP expects that Providers will offer telehealth services and support to their Members during their published business hours.  Existing authorizations are valid and do not need to be changed even if services are being provided via telehealth You can request a POS 02 or POS 10 on your authorization however if you do not, you can still utilize the authorization for telehealth services even if a different POS was approved. When billing the claim for the service, you will utilize a POS 02 or POS 10. ONLY Services that are deemed clinically appropriate to provide via telehealth should be provided via telehealth. If there are treatments, exams, procedures or other services that cannot be provided via telehealth, those are not eligible to be provided via telehealth.  Provider Resources for Combatting COVID-19 Fatigue ACEs Aware - Support for those on the front lines as California addresses stress and anxiety related to COVID-19   Department of Health Care Services (DHCS) and California Department of Public Health (CDPH) COVID 19 Response Department of Health Care Services (DHCS) California Department of Public Health (CDPH)   The California Department of HealthCare Services (DHCS) has published a COVID-19 response page with guidance for Providers and Partners, Home and Community Based Services and Behavioral Health. Found Here: DHCS COVID‑19 Response | DHCS COVID-19 Medi-Cal FAQs The California Department of Public Health (CDPH) also has a page with new guidance documents and additional resources and news releases. Found Here: CDHP COVID-19 Updates Centers for Medicare & Medicaid Services (CMS) CMS Health Care Provider Toolkit - Help link to COVID-19 related questions   San Bernardino Medical Society The San Bernardino County Medical Society promotes the science and art of medicine, the care and well-being of patients, the protection of the public health and to promote the betterment of the medical profession. The latest news, research and developments on the COVID-19 outbreak for physicians can be found here: SBCMS COVID-19. January 07, 2021 - COVID-19 Vaccines For All Practicing Physicians and Staff – San Bernardino County (PDF) 2-1-1 San Bernardino County Resource & Information Guide   2-1-1 San Bernardino County has curated a COVID-19 Resource & Information Guide and will update this page regularly as the situation changes. For more information, please click here.   Correspondences May 2, 2022 - Webinar - IWIN COVID and the Community April 13, 2022 - COVID-19 “Test to Treat” Initiative April 8, 2022 - 2nd Round of Free At-Home COVID-19 Test Kits Available February 23, 2022 - COVID-19 Oral Antiviral Drugs – Coverage and Dispensing Pharmacies  January 28, 2022 - Free OTC COVID-19 Antigen Kits Available January 26, 2022 - Free At-Home COVID-19 Tests Available by Request January 5, 2022 - Extending SNF COVID-19 Per Diem Rate December 22, 2021 - COVID-19 Vaccine Billing for Medicare Advantage Enrollees Effective DOS January 1, 2022 December 16, 2021- COVID-19 Vaccine Incentive Program – Program Guide December 16, 2021 - REMINDER: COVID Vaccine Enrollment Survey - Your Response is Requested December 10, 2021 - REMINDER: COVID Vaccine Enrollment Survey - Your Response is Requested December 10, 2021 - COVID-19 Vaccine Billing for Medicare Advantage Enrollees December 3, 2021- COVID-19 Vaccine Enrollment Survey December 1, 2021- CDC Encourages COVID Booster Due to Omicron Variant November 17, 2021- UPDATE! COVID-19 Vaccine FQHC, RHC and IHF Incentive Program November 9, 2021- Three Upcoming Webinars on Building COVID-19 Vaccine Trust October 22, 2021- 2021 COVID-19 Vaccination Member Incentive October 22, 2021- NEW!!! COVID-19 Vaccine FQHC and RHC Incentive Program October 19, 2021- COVID-19 Treatment – RUHS Monoclonal Antibody Treatment Center October 12, 2021- Reminder - NEW COVID-19 Vaccine PCP Incentive Program - Kickoff Meeting October 6, 2021- NEW COVID-19 Vaccine PCP Incentive Program- Kickoff Meetings October 4, 2021- New COVID-19 Vaccine PCP Incentive Program September 8, 2021- CDPH Webinar: How to Have Crucial Conversations About COVID-19 Vaccines – Thursday, September 9th August 18, 2021 - Riverside County Public Townhall on COVID-19 Vaccines For additional resources regarding COVID-19, please visit: Centers for Disease Control and Prevention (CDC) Riverside County Public Health San Bernardino Public Health You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

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 procurement@iehp.org. Code of Ethics Policy Click to Download Our Code of Ethics Policy

ness. Any pricing disputes, whether it be brand or generic, are to be handled by MedImpact. MedImpact also addresses pharmacy provider appeals on drug pricing. Please direct related inquiries and pricing appeals to MedImpact Pharmacy Provider line at 1-888-495-3147, with a 24/7/365 availability. Information on this page is current as of January 01, 2023

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. Provider Identified Overpayment Form (PDF) Provider Identified Overpayment Form (Multiple) (PDF) Provider Dispute Resolution (PDR) (PDF) Claims Project Spreadsheet (Excel) Clean Claim Tool Guide - UB04 Inpatient Form (PDF) Clean Claim Tool Guide - UB04 Outpatient Form (PDF) Waiver of Liability Statement - IEHP Dual Choice (HMO D-SNP) - effective January 2023 (PDF) Revised CMS 1500 Health Insurance Claim Form (PDF) CMS 1500 Reference Instruction Manual (PDF) (Back to top) Compliance Member Incentive Forms Focus Group Incentive (FGI) - Request for Approval Form (PDF) Focus Group Incentive (FGI) - Evaluation Form (PDF) Member Incentive (MI) Program - Request for Approval (PDF) Member Incentive (MI) Program - Annual Update/End of Program Evaluation (PDF) Survey Incentive (SI) - Request for Approval Form (PDF) Survey Incentive (SI) - Evaluation Form (PDF) Nondiscrimination Language Nondiscrimination Language Access Notice: Medi-Cal (PDF) Medicare (PDF) (Back to top) 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 (Back to top) 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) (Back to top) 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) (Back to top) Health and Wellness DPP Rx Pad (PDF) (Back to top)   Historical Data Form Historical Data Form (PDF) (Back to top) 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 (Back to top) 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, 2022 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, 2022 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, 2022 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, 2022 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, 2022 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, 2022 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, 2022 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, 2022 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, 2022 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, 2022 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 01, 2022 (Back to top) 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 (Back to top) 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 February 21, 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 February 21, 2023 Continuity of Care - Notice of Authorization 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 February 21, 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 February 21, 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 February 21, 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 February 21, 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 February 21, 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 February 21, 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 February 21, 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 February 21, 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 February 21, 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 February 21, 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 February 21, 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 February 21, 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 February 21, 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 February 21, 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 February 21, 2023   (Back to top) 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) (Back to top) 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. (Back to top) 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) (Back to top) Pharmacy Click here for Pharmacy forms. (Back to top) 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 (Back to top) UM/CM Acute Hospital Discharge Needs Request Form (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) Care Management Referral Form (PDF) Consent for HIV Test - English (PDF) Consent for HIV Test - Spanish (PDF) 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 Long Term Care (LTC) Data Sheet (PDF) Non-Emergency Medical Transportation (NEMT) Physician Certification Statement (PCS) (PDF) Referral Form (PDF) Service Request for Skilled Nursing Facilities (PDF) SNF Initial Review (PDF) SNF Follow-up Review (PDF) 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) Transportation Requests Form (SNF & LTC) (PDF) Transportation Requests Form (Hospital) (PDF) Wound Assessment - Admission (PDF) Wound Assessment - Follow - Up (PDF) Wound Assessment - Addendum (PDF) (Back to top) 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) (Back to top) Other Authorization of Release - Use & Disclosure of PHI - English (PDF) Authorization of Release - Use & Disclosure of PHI - Spanish (PDF) CMS 1696 Appointment of Representative - English (PDF) CMS 1696 Appointment of Representative - Spanish (PDF) Contracts Maintenance Request Form (PDF) Provider Services Materials Request Form (PDF) 2017 Model Output Report (MOR) Data File Layout (PDF) (Back to top) You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

s for Contracted and Non-Contracted Providers Emergency and Post-Stabilization Care for IEHP Members IEHP DualChoice (HMO D-SNP) Model of Care Training for Non-Contracted Providers Provider Referral Outside of the IEHP Network Provider Dispute Resolution Process for Contracted and Non-Contracted Providers   Definition of a Provider Dispute A provider dispute is a written notice from the provider to Inland Empire Health Plan (IEHP) that: Challenges, appeals, or appeals, or requests reconsideration of a claim (including a bundled group of similar claims) that has been denied, adjusted, or contested Challenges a request for reimbursement for an overpayment of a claim Seeks resolution of a billing determination or other contractual dispute   What is not Considered to be a Provider Dispute Claims denied for missing or additional documentation requirements such as consent forms, invoices, Explanation of Benefits from primary carrier, or itemized bills are not considered Provider Disputes Corrected Claims Pre-Service Authorization Denials   Provider Dispute Time Frame IEHP accepts disputes from providers if they are submitted within 365 days of receipt of IEHPs decision (for example, IEHPs Remittance Advice (RA) indicating a claim was denied or adjusted).   Submission of Provider Disputes When submitting a provider dispute, a provider should use a Provider Dispute Resolution Request form. If the dispute is for multiple, substantially similar claims, complete the spreadsheet on page 2 of the Provider Dispute Resolution Request Form All Provider Disputes and supporting information must be submitted to: IEHP Claims Appeal Resolution Unit PO BOX 4319 Rancho Cucamonga, CA 91729-4349   Acknowledgement of Provider Dispute IEHP acknowledges receipt of each provider dispute, regardless of whether the dispute is complete, within 15 business days of receipt.   Resolution Timeframe IEHP resolves each provider dispute within 45 business days following receipt of the dispute, and provides the provider with a written determination stating the reasons for determination.   PDR Determination Resulting in Additional Payment If IEHP determines to pay additional monies based on information originally provided and/or available at the time the claim was first presented to IEHP for adjudication, or a result of a processing error IEHP will automatically include the appropriate interest amount if payment is not issued within required regulatory timeframes.   Non-Contracted Provider Disputes Resolution Process for IEHP DualChoice (HMO D-SNP) A non-contracted provider, on his or her own behalf, is permitted to file a standard appeal for a denied claim only if the non-contracted provider completes a waiver of liability statement, which provides that the non-contracted provider will not bill IEHP DualChoice (HMO D-SNP) Plan Members.   Who to Call with Questions on IEHPs PDR Process Contracted providers may visit our online secure provider portal at www.iehp.org for more information. Providers may also call the IEHP Provider Call Center at (909) 890-2054 or (866) 223-4347 Monday-Friday, 8:00 am to 5pm PST.   (Back to Non-Contracted Providers Menu) Emergency and Post-Stabilization Care for IEHP Members   Triage and Advice Systems IEHP provides Members triage, screening, and advice services by telephone 24 hours a day, 7 days a week through its Nurse Advice Line (NAL). By calling the NAL, Members receive assistance with access to urgent or emergency services from an on-call physician, or licensed triage personnel. IEHP Members can reach this 24/7 Nurse Advice Line at (888)-244-IEHP (4347) or 711 (TTY).   Post-Stabilization Care IEHP requires contracted and non-contracted hospitals to obtain prior authorization for post-stabilization care for Members (patients). IEHP requests the patient’s diagnosis as indicated by the treating physician or surgeon and any other information reasonably necessary for the Plan to decide on whether to authorize post-stabilization care or to assume management of the patient’s care by prompt transfer to another facility. The hospital should request prior authorization from IEHP’s Utilization Management (UM) Department by: Phone at (866) 649-6327; or Fax at (909) 477-8553 to send clinical notes for medical necessity review.   IEHP makes every effort to respond to requests for necessary post-stabilization care within thirty (30) minutes of receipt. The services are considered approved if IEHP does not respond within this timeframe. All subsequent hospital day are subject to review for medical necessity. IEHP will inform the provider of the Plan’s decision and will coordinate the transfer of the Member if IEHP denies the request for authorization of post-stabilization care and elects to transfer the Member to another health care provider.   Non-Emergency Services If a Member presents at the emergency department for non-emergency services, please refer the Member to their IEHP Member Handbook, section 3 (How to Get Care), which outlines the process for obtaining a referral.   Claims Reimbursement Complete facility claims for authorized health care services must be sent to: Inland Empire Health Plan Attn: Claims Department – IEHP Direct PO BOX 4349 Rancho Cucamonga, CA 91729-4349 Complete professional claims for authorized health care services must be sent to: For IEHP-Direct Members, please send to address above. For IEHP Members assigned to an IPA, please click for here for more information on how to send to the appropriate IPA.   Billing IEHP Members Providers under the Medi-Cal program must not submit claims to, demand or otherwise collect reimbursement from a Medi-Cal beneficiary, or from other persons on behalf of the beneficiary, for any service included in the Medi-Cal program’s scope of benefits in addition to a claim submitted to the Medi-Cal program for that service.   IEHP DualChoice (HMO D-SNP) Model of Care Training for Non-Contracted Providers   The Centers for Medicare & Medicaid Services (CMS), the Department of Health Care Services (DHCS), and National Committee for Quality Assurance (NCQA) requirement that out-of-network providers routinely seen by IEHP DualChoice (HMO D-SNP) Members, receive training on IEHPs Model of Care for our D-SNP Members:   IEHP DualChoice (HMO D-SNP) Model of Care Training (PDF) IEHP DualChoice (HMO D-SNP) Model of Care Training (HTML)   *We recommend opening file in: Mozilla Firefox, MS Edge, Chrome or MS Internet Explorer 2023 IEHP DualChoice (HMO D-SNP) Model of Care eAOR 2023 IEHP DualChoice (HMO D-SNP) Model of Care Non-Contracted Provider AOR (PDF) Report an Issue To report any issues with this system or process or for any questions, please send an email to DGHospitalRelationsServiceTeam@iehp.org   (Back to Non-Contracted Providers Menu)   Provider Referral Outside of the IEHP Network   In cases where an out-of-network provider that has been approved to provide service(s) to an IEHP Member and needs to refer said IEHP Member to another out-of-network provider, the approved out-of-network provider must first contact the Member’s IPA to request the referral. The Member’s IPA will review the request for referral and provide a decision within regulatory timeframes. The Member’s IPA will approve the request if it is deemed medically necessary and if IEHP or the IPA does not have an appropriate alternative provider available within its network. If you have any questions or if you would like to request a referral, please reach out to the Member’s IPA.   (Back to Non-Contracted Providers 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.