Search Results For : " MAKE FREEDHARDEMAN UNIVERSITY "

aprender sobre los medicamentos para el asma y maneras de mantenerse activo y sano. Haga clic aquí para inscribirse en esta clase en persona Dirección Centro de Recursos para la Comunidad IEHP (San Bernardino) 805 W 2nd St San Bernardino, CA 92410  

des. Tema: Reacciones saludables: Aprenderá a transformar la frustración en motivación. Haga clic aquí para inscribirse en esta clase en persona Dirección Centro de Recursos para la Comunidad IEHP (San Bernardino) 805 W 2nd St San Bernardino, CA 92410

rata temas que ayudarán a proteger la salud de su bebé y mantenerlo seguro, como seguridad en el auto, chequeos, evaluaciones y sueño sin riesgos.  Haga clic aquí para inscribirse en esta clase de WebEx   Número de sesión: 26341775891 Descargar Webex para usuarios de Apple  Descargar Webex para usuarios de Android  Descargar Webex para usuarios de PC 

. Tema: Cómo establecer objetivos para mejorar su vida: Aprenderá a establecer objetivos para conseguir la vida que quiera tener. También aprenderá a establecer objetivos razonables. Haga clic aquí para inscribirse en esta clase en persona Dirección Centro de Recursos para la Comunidad IEHP (Riverside) 3590 Tyler St Riverside, CA 92503

s en dos partes. En la parte 1, le mostraremos qué comidas tienen un mayor (y un menor) impacto en los niveles de azúcar en la sangre y qué comidas (y grasas) son mejores opciones para controlarlos. Además, recibirá consejos para reducir la grasa y el colesterol.   Haga clic aquí para inscribirse en esta clase en persona Dirección Centro de Recursos para la Comunidad IEHP (Victorville) 12353 Mariposa Rd Suites C-2 & C-3 Victorville, CA 92395  

vertido para toda la familia!  No es necesario tener una costosa membresía para un gimnasio. Acompáñenos para una divertida clase en la que podrá disfrutar la actividad física por medio de SPARK (deportes, juegos y recreación activa para niños). Se aceptan personas de todas las edades y capacidades. Haga clic aquí para inscribirse en esta clase en persona Dirección Centro de Recursos para la Familia de Mead Valley 21091 Rider Street. Perris, CA 92570

erá sobre el colesterol y cómo afecta a su salud, y hábitos para toda la vida para tener un peso saludable. Haga clic aquí para inscribirse en esta clase en persona Dirección Centro de Recursos para la Familia de Mead Valley 21091 Rider Street. Perris, CA 92570  

ades. Tema: Cómo conseguir apoyo para alcanzar sus objetivos: Aprenderá a encontrar a las personas indicadas que lo ayudarán cuando enfrente problemas para alcanzar su objetivo. Haga clic aquí para inscribirse en esta clase en persona Dirección Centro de Recursos para la Comunidad IEHP (Riverside) 3590 Tyler St Riverside, CA 92503

rata temas que ayudarán a proteger la salud de su bebé y mantenerlo seguro, como seguridad en el auto, chequeos, evaluaciones y sueño sin riesgos.  Haga clic aquí para inscribirse en esta clase en persona Dirección Centro de Recursos para la Familia de Mead Valley 21091 Rider Street. Perris, CA 92570  

erá los distintos tipos de actividad física para mejorar la salud del corazón y aprenderá a controlar su presión arterial.  Haga clic aquí para inscribirse en esta clase en persona Dirección Centro de Recursos para la Familia de Mead Valley 21091 Rider Street. Perris, CA 92570

ara perder y controlar el peso. Haga clic aquí para inscribirse en esta clase en persona Dirección Centro de Recursos para la Comunidad IEHP (Victorville) 12353 Mariposa Rd Suites C-2 & C-3 Victorville, CA 92395

tación consciente. Haga clic aquí para inscribirse en esta clase en persona Dirección Centro de Recursos para la Comunidad IEHP (Victorville) 12353 Mariposa Rd Suites C-2 & C-3 Victorville, CA 92395

ción consciente. Haga clic aquí para inscribirse en esta clase en persona Dirección Centro de Recursos para la Familia de Mead Valley 21091 Rider Street. Perris, CA 92570

ia médica. ¿Quién decidirá sobre su atención médica cuando usted no pueda hacerlo? ¿Saben sus seres queridos cómo decidir por usted? Esta clase lo ayudará a responder estas dos preguntas. También le mostraremos dónde puede obtener un formulario llamado “Instrucciones por Adelantado”, cómo completarlo y por qué debería tener uno. Planeamos fiestas de cumpleaños y bodas, ¿por qué no planear nuestra futura atención médica?  Haga clic aquí para inscribirse en esta clase de WebEx   Número de sesión: 26325687202 Descargar Webex para usuarios de Apple  Descargar Webex para usuarios de Android  Descargar Webex para usuarios de PC   

d is to support the hiring of PCPs, Specialists, and Advanced Practice Providers that will serve the Medi-Cal population in the Inland Empire. Entities that hire qualified candidates are eligible to receive a subsidy up to $75,000 for Advanced Practice Providers, $100,000 for PCPs, and $150,000 for Specialists. All candidates must be a new access point in IEHP's network and not have prior history in the Inland Empire. Please take note of the following: The NEF Program will be targeting specific Provider types. The Provider types and corresponding regions displayed below comprise the list of positions that are currently eligible to receive a subsidy through the NEF Program.   The funding disbursement schedule is as follows:  50% when the qualified candidate completes credentialing 25% when the candidate completes six (6) months of service 25% when the candidate completes one (1) year of service Entities that are interested in receiving support through the NEF Program must submit a complete application to be considered for the funding opportunity. Completed applications and questions should be e-mailed to NEFProgram@iehp.org NEF Program Description (PDF) NEF Application (PDF) You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here. Click on the following links to jump to that specific section: Corona/Temecula/Hemet High Desert Low Desert Mohave Valley Palo Verde Valley Riverside San Bernardino Proper West San Bernardino Corona/Temecula/Hemet Family Practice Internal Medicine Pediatrics Cardiac/Thoracic Surgery General Surgery Genetics OB/GYN Pulmonary Medicine Plastic Surgery Psychiatry Urology   High Desert Family Practice Internal Medicine Pediatrics Allergy and Immunology Cardiac/Thoracic Surgery Cardiology Dermatology General Surgery Genetics Neurology Neurosurgery OB/GYN Oncology/Hematology Orthopedic Surgery Otolaryngology Pain Management Pediatric Subspecialties Physical Therapy Podiatry Psychiatry Psychology Pulmonary Medicine Rheumatology Speech Therapy Urology   Low Desert Family Practice Internal Medicine Pediatrics Allergy and Immunology Cardiology General Surgery OB/GYN Pain Management Pediatric Surgery Physical Therapy Psychiatry Pulmonary Medicine Rheumatology Urology   Mohave Valley Family Practice Internal Medicine Pediatrics Allergy and Immunology Cardiology Dermatology Gastroenterology General Surgery Nephrology Neurology OB/GYN Oncology/Hematology Ophthalmology Otolaryngology Pain Management Psychiatry Pulmonary Medicine Rheumatology   Palo Verde Valley Family Practice Internal Medicine Pediatrics Allergy and Immunology Cardiology Dermatology Endocrinology Gastroenterology General Surgery Neurology OB/GYN Ophthalmology Otolaryngology Pain Management Physical Therapy Podiatry Psychiatry Pulmonary Medicine Speech Therapy Urology   Riverside Family Practice Internal Medicine Pediatrics Cardiology Dermatology General Surgery Genetics OB/GYN Occupational Therapy Ophthalmology Pain Management Podiatry Psychiatry Speech Therapy Urology   San Bernardino Proper Family Practice Internal Medicine Pediatrics Allergy and Immunology Dermatology OB/GYN Pain Management Pediatric Surgery Psychiatry Pulmonary Medicine   West San Bernardino Family Practice Internal Medicine Pediatrics Genetics OB/GYN Pediatric Surgery Plastic Surgery Psychiatry   Updated May 5, 2023    

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 (PDF) 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.

(IEHP) Pay for Performance program, also known as P4P. IEHP’s P4P was designed to increase the provision of preventive health services to IEHP Members as well as improve HEDIS® results to ensure that all IEHP Direct DualChoice Members receive timely annual assessment visits with an emphasis on review and management of chronic illnesses. IEHP Direct PCPs will be reimbursed directly by IEHP through the DualChoice Annual Visit program. PCPs participating in IEHP's network through an IPA only are not eligible for this program: Overview (PDF) DualChoice Annual Visit (PDF) To learn more about P4P IEHP DualChoice Annual Visit, contact a Provider Services Representative at (909) 890-2054. Click on the following links to jump to that specific section: Provider Quality Incentives Brochure Medicare P4P IEHP Direct IEHP Direct Stars Incentive Program D-SNP Model of Care Incentive Program Global Quality P4P Program OB/GYN P4P Program Hospital P4P Program Provider Quality Incentives Brochure Inland Empire Health Plan (IEHP) is pleased to announce the 2022 Provider Quality Incentive Brochure. 2022 Provider Quality Incentive Brochure (PDF) | June 22, 2022 (Back to P4P Menu) Medicare P4P IEHP Direct Program Inland Empire Health Plan (IEHP) is pleased to announce the Medicare P4P IEHP Direct Program.  The goal of the program is designed to reward IEHP Direct Primary Care Providers (PCPs) for providing quality care to IEHP DualChoice Members. Medicare P4P IEHP Direct Program Guide (PDF) Published: February 16, 2023 (Back to P4P Menu) IEHP Direct Stars Incentive Program Inland Empire Health Plan (IEHP) is pleased to announce the IEHP Direct Stars Incentive Program for Primary Care Physicians (PCPs). The goal of the program is to reward PCPs who provide high-quality care to IEHP DualChoice (HMO D-SNP) members. IEHP Direct Stars Incentive Program Guide (PDF) Updated: April 12, 2023 (Back to P4P Menu) D-SNP Model of Care Incentive Program Inland Empire Health Plan (IEHP) is pleased to announce the D-SNP Model of Care Incentive Program for Independent Physicians Associations (IPAs). The goal of the program is to reward IPAs who provide high-quality care to IEHP DualChoice (HMO D-SNP) members. D-SNP Model of Care Incentive Program (PDF) Published: March 24, 2023 Chronic Care Improvement Program Planning and Reporting Document The Chronic Care Improvement Program (CCIP) Planning and Reporting document can be used for the following D-SNP Model of Care Incentive Program activity: Chronic Care Improvement Program (CCIP) Activity. CCIP Planning and Reporting Document (Word Document) CCIP Planning and Reporting Document - Reference Guide (PDF) (Back to P4P Menu) Global Quality P4P Program If you would like more information about IEHP’s GQ P4P Program or best practices to help improve quality scores and outcomes, visit our Secure Provider Portal, email the Quality Team at QualityPrograms@iehp.org or call the IEHP Provider Relations Team at (909) 890-2054. 2023 IEHP Global Quality P4P Program Guide IPA (PDF) Published: April 21, 2023 2023 IEHP Global Quality P4P Program Guide PCP (PDF) Published: April 20, 2023 2023 IEHP Global Quality P4P Program Guide IPA (PDF) Published: March 14, 2023 2022 IEHP Global Quality P4P Program Guide PCP (PDF) Published: April 20, 2023 2022 IEHP Global Quality P4P Program Guide IPA (PDF) Published: December 16, 2022 2022 Provider Quality Resource Guide (PDF) Published: July 14, 2022 (Back to P4P Menu) Quality Improvement Activity Strategy Forms The Quality Improvement Activity (QIA) Strategy Forms can be used for the following 2023 and 2022 Global Quality P4P QIA Activities: Reducing Health Disparities and Potentially Avoidable Emergency Department Visits or Potentially Preventable Admissions. 2023 Equity Quality Improvement Activity #1 - Strategy Form (PDF) 2023 Quality Improvement Activity #2 - Strategy Form (PDF) 2022 Equity Quality Improvement Activity #1 - Strategy Form (PDF) 2022 Quality Improvement Activity #2 - Strategy Form (PDF) (Back to P4P Menu) Potentially Avoidable Emergency Department (ED) Visits: Potentially Preventable Diagnosis Codes The Potentially Preventable Diagnosis Code List includes diagnosis codes for visits to an ED in which the condition could be treated by a Physician or other health care Provider in a non-emergency setting or conditions that are potentially preventable or are ambulatory care sensitive. Potentially Preventable Diagnosis List (PDF) Published: February 04, 2022 Patient Experience This toolkit is full of proven tips and successful strategies based on the kinds of questions your IEHP Members could be asked to answer regarding their Provider's service. Your Provider Relations Team has targeted nine specific topics in this toolkit to help Providers and their staff continue to achieve the highest marks in Patient experience from their IEHP Members. Serve Well Customer Service Toolkit (PDF) Well Child 2021 Recommendations for Preventive Pediatric Health Care from the American Academy of Pediatrics (PDF) Immunizations IEHP provides vaccine coverage based on the latest ACIP recommendation and guidelines. Please refer to the Immunization Update and "Summary of Recommendations" for both Child and Adolescents AND Adult Vaccines as follows: 2023 Immunization Timing Chart - English (PDF) 2023 Immunization Timing Chart - Spanish (PDF) 2023 Immunization Timing Chart - Chinese (PDF) 2023 Immunization Timing Chart - Vietnamese (PDF) Immunization Updates (PDF) 2023 Recommended Child and Adolescent Immunization Schedule (0-18 years) (PDF) 2023 Recommended Adult Immunization Schedule (19+ years) (PDF) Adult Vaccines are a covered benefit and do not require prior authorization (must adhere to CDC/ACIP Immunization Recommendation and/or FDA approved indication). Grow Well Childhood Immunization Toolkit for Providers (PDF) This toolkit contains commonly used immunization codes, best practices for reporting immunizations including information on registering with CAIR, tips on talking with parents and information on understanding vaccination hesitancy. CAIR2 Resource Guide (PDF) This guide contains helpful links and contact information for locations to register for CAIR2 or current users. Reimbursement process: Complete a CMS1500 form by including the appropriate CPT codes, quantity dispensed and billed amount. Mail:  IEHP Claims Department P.O. Box 4349  Rancho Cucamonga, CA 91729-4349. For the latest updates and news regarding the vaccines, please visit CDC's ACIP website at https://www.cdc.gov/vaccines/hcp/acip-recs/index.html. By clicking on this link, you will be leaving the IEHP website. (Back to P4P Menu) Quality Bonus Services Dispute Form Please e-mail completed forms to QualityPrograms@iehp.org Quality Bonus Service Dispute Request Form (PDF) (Back to P4P Menu) OB/GYN P4P Program Inland Empire Health Plan (IEHP) has released the OB/GYN P4P Program Guide which details the program requirements, performance measures, updated code sets, and payment timelines. OB/GYN P4P Program Guide (PDF) Published: January 01, 2023 OB P4P Frequently Asked Questions FAQs (PDF) Published: February 13, 2023 Postpartum Depression Screening (PDF) (Back to P4P Menu) Hospital P4P Program Inland Empire Health Plan (IEHP) is pleased to announce the Hospital Pay For Performance Program (Hospital P4P) for IEHP Medi-Cal contracted Hospitals servicing Riverside and San Bernardino Counties. The goal of the Hospital P4P Program is to provide substantial financial rewards to Hospitals that meet quality performance targets and demonstrate high-quality care to IEHP Members. 2023 Hospital P4P Program Guide (PDF) Published: May 9, 2023 2023 Hospital P4P Program Guide (PDF) Published: March 23, 2023 P4P 2023 MX Data Contributions (PDF) Published: February 02, 2023 IEHP P4P 2023 Data Guidelines (PDF) Published: February 02, 2023 2022 Hospital P4P Program Guide (PDF) Published: March 20, 2023 P4P 2022 MX Data Contribution (PDF) Published: April 18, 2022 P4P 2022 MX Data Guidelines (PDF) Published: April 18, 2022 (Back to P4P Menu) Potentially Avoidable Emergency Department (ED) Visits: Potentially Preventable Diagnosis Codes The Potentially Preventable Diagnosis Code List includes diagnosis codes for visits to an ED in which the condition could be treated by a Physician or other health care Provider in a non-emergency setting or conditions that are potentially preventable or are ambulatory care sensitive. Potentially Preventable Diagnosis List (PDF) Published: February 04, 2022 (Back to P4P Menu) Substance Use Disorders and Mental Health Diagnosis Lists The Substance Use Disorders and Mental Health Diagnosis Lists includes diagnosis codes to identify substance use disorders, drug overdose, mental health or intentional self-harm diagnoses. Mental Health Diagnosis List (PDF) Published: February 02, 2022 Substance Use Disorders Diagnosis List (PDF) Published: February 02, 2022 (Back to P4P Menu)   You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here

th us to offer our members the highest quality care and service they need. Facility Site Reviews are the required standards by the California Department of Health Care Services (DHCS)/Medi-Cal Managed Care Division (MMCD) for all primary care provider (PCP) sites. Below you will find various resources in regards to DHCS information, Physical Accessibility Reviews (PARS), Facility Site Review (FSR), and Medical Record Reviews (MRR) as well as IEHP’s addendum tools for your reference. Facility Site Review Training Index: Department of Health Care Services (DHCS) IEHP Addendum Tools PARS Facility Site Review Medical Record Review Department of Health Care Services (DHCS) 2022 Facility Site Review Standards (FSR) (PDF) 2022 Facility Site Review Tool  (FSR) (PDF) 2022 Medical Record Review Standards (MRR) (PDF) 2022 Medical Record Review Tool (MRR) (PDF) APL 22-017 - Facility Site Review and Medical Record Review (PDF) DPL 14-005 - FSR Physical-Accessibility Reviews (PDF) PL 12-006 - Revised FSR Tool (PDF) (Back to Index) IEHP Addendum Tools Att 06 - IEHP Urgent Care Evaluation Tool (PDF) IEHP Interim Review (PDF) (Back to Index) PARS APL with PARS C (PDF) APL with PARS D & CBAS (PDF) PAR-FSR-C_PARS - Survey (PDF) PAR-FSR-D_PARS - Ancillary (PDF) PAR-FSR-E_PARS - CBAS (PDF) (Back to Index) Facility Site Review Menu Click on the following links to jump to that specific section: Facility Site Review Audit Tool Sections Additional Documents Medical Record Review Audit Tool Sections Additional Documents (Back to Index) Access/Safety Facility Site Review Emergency Exit Routes Factsheet (PDF) Evacuation Routes (PDF) Glucometer Log (PDF) Hemocue Log (PDF) Medical Emergency, Earthquake, Fire Protocols (PDF) Emergency Exit Routes Factsheet (PDF) Pre-filled Emergency Medications Dosage Chart (PDF) Sample Oxygen Tank Set (PDF) Workplace Violence (PDF) (Back to FSR Menu) Adult Preventive Medical Record Review ACES Screening (PDF) Adult Health History (PDF) Adult Sterilization & Special Consent P&P (PDF) Alcohol Resources (PDF) AUDIT-C (PDF) Brief Addiction Monitor (BAM) (PDF) Comprehensive Pediatric and Adult Health Assessment Forms (PDF) CRAFFT-2.0 Clinician Interview (PDF) Hepatitis Risk Assessment Tool (PDF) Intimate Partner Violence (IPV) Screening Tools (PDF) Intimate Partner Violence (IPV) and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings (PDF) PHQ-2 - Sample (PDF) PHQ-9 - Sample (PDF) Social Needs Screening Tool (PDF) TB Risk Assessment Adult (PDF) (Back to FSR Menu) Clinical Services Facility Site Review Checklist for Safe Vaccine Storage and Handling (PDF) Clean and Dirty Sign (PDF) Controlled Substance Distribution Log (PDF) Controlled Substance Narcotic Log (PDF) Monthly Expiration Date & Verification Log (PDF) P&P Distribution of Sample Medications (PDF) Patient Distribution Log for Samples (PDF) Plan for Vaccine Protection in Case of Power Outage (PDF) Radiology - Notice to Employees (PDF) Sample Radiology Inspection Report (PDF) Vaccine Information Sheet (VIS) Protocol (PDF) Vaccine Storage (PDF) (Back to FSR Menu) Coordination of Care Medical Record Review Adult Progress Note - Sample (PDF) Missed Appointment Log - Sample (PDF) Pediatric Progress Note - Sample (PDF) (Back to FSR Menu) Documentation Medical Record Review Adult General Consent to Treat (PDF) Advance Health Care Directive Acknowledgement Form (PDF) CAIR Sharing Request (PDF) General Consent to Treat Minor (PDF) Medical Record Release (PDF) Sample Medication List (PDF) Signature Page - IEHP (PDF) (Back to FSR Menu) Format Medical Record Review Acknowledgment of Receipt of Notice of Privacy Practice (PDF) (Back to FSR Menu) Infection Control Facility Site Review AAP Infection Prevention and Control in Pediatric Ambulatory Settings - COVID (PDF) Autoclave Log (PDF) Biohazardous Sign (PDF) Bloodborne Pathogens & Post Exposure Plan - Fillable (PDF) Cleaning Schedule (PDF) Communicable Disease (ISOLATION) Protocol (PDF) Infection Control, Biohazardous Waste and Disposition of Patients with Contagious Disease (PDF) Instrument Transportation Log (PDF) Isolation & Transmissions Based Precautions (PDF) OSHA Employee Injury Report Form (PDF) P&P Autoclave (PDF) P&P Autoclaving Instruments in Peel (PDF) P&P Chemical Disinfection (PDF) P&P Cold Sterilization (PDF) P&P Transport for Reusable Instruments (PDF) Reusable Sharps Container (PDF) Safety Needle Fact Sheet (PDF) Sharps Injury Log Sample (PDF) Transfer Stations and Treatment Facilities (PDF) (Back to FSR Menu) OB/CPSP Preventive Medical Record Review CPSP Initial and Trimester Assessment and Care Plan (PDF) CPSP Postpartum Assessment and Care Plan (PDF) Edinburgh Postnatal Depression Scale (EPDS) (PDF) Required Documentation Checklist for OB (PDF) (Back to FSR Menu) Office Management Facility Site Review Access Standards (PDF) After Hour Script (PDF) CLAS Standards (PDF) Confidentiality Form (PDF) Fax Sheet (PDF) Medical Emergency, Earthquake, Fire Protocols (PDF) Medical Record Release (PDF) Office Hours Sample Form (PDF) On-Call Provider Schedule (PDF) PCP Referral Tracking Log (PDF) Referral Process (PDF) Sample Office Hours (PDF) Wait Time Survey Tool (PDF) (Back to FSR Menu) Pediatric Preventive Medical Record Review AAP Infection Prevention and Control in Pediatric Ambulatory Settings - COVID (PDF) AAP Schedule (PDF) AAP Supplemental Information (PDF) Alcohol Resources (PDF) AUDIT-C (PDF) Brief Addiction Monitor (BAM) (PDF) CDC BMI Growth Chart - Boys (PDF) CDC BMI Growth Chart - Girls (PDF) CDC Growth Chart Head Circumference - Boys (PDF) CDC Growth Chart Head Circumference - Girls (PDF) CDC Growth Chart Weight for Age - Boys (PDF) CDC Growth Chart Weight for Age - Girls (PDF) Child Health History - English (PDF) Child Health History - Spanish (PDF) Comprehensive Pediatric and Adult Health Assessment Forms (PDF) CRAFFT-2.0 Clinician Interview (PDF) Edinburgh Postnatal Depression Scale (EPDS) (PDF) General Consent to Treat Minor (PDF) Hepatitis Risk Assessment Tool (PDF) Intimate Partner Violence (IPV) Screening Tools (PDF) Intimate Partner Violence (IPV) and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings (PDF) Oral Health Risk Assessment Tool (PDF) PEARLS Assessment (PDF) PEARLS Teen Self-Assessment (PDF) PHQ-2 - Sample (PDF) PHQ-A - Sample (PDF) Social Needs Screening Tool (PDF) TB Risk Assessment Pediatrics (PDF) What Do You Eat (8-19 years) - English (PDF) What Do You Eat (8-19 years) - Spanish (PDF) What Does Your Child Eat (Birth - 8 years) - English (PDF) What Does Your Child Eat (Birth - 8 years) - Spanish (PDF) Youth Nutrition and Activity Assessment (8 - 19 years) (PDF) (Back to FSR Menu) Personnel Facility Site Review Accessibility Obligations of Medical Practices (PDF) Bloodborne Pathogens & Post Exposure Plan - Fillable (PDF) Domestic Violence (PDF) Electronic Resources for Required Employee Training (PDF) Employee File Checklist (PDF) IEHP Cultural and Linguistics Training (PDF) IEHP Evidence of Staff Training (PDF) IEHP Grievance Resolution Process - English (PDF) IEHP Grievance Resolution Process - Spanish (PDF) IEHP P&P Child Abuse Reporting (PDF) IEHP P&P Elder or Adult Abuse Reporting (PDF) IEHP P&P Sensitive Services-Access Standards (PDF) Medical Assistant Letter of Competency - Fillable (PDF) Medical Assistant Venipuncture Form (PDF) Medication Administration Procedures (PDF) Mid-level Supervision of Medical Assistant (PDF) Notice to Consumer PA Sign - English (PDF) Notice to Consumer PA Sign - Spanish (PDF) Notice to Consumer Sign - English (PDF) Notice to Consumer Sign - Spanish (PDF) SB697 Practice Agreement (PDF) SOC 341 (PDF) Standardized Procedures for Nurse Practitioner (PDF) Suspected Child Abuse Report (PDF) (Back to FSR Menu) Preventive Services Facility Site Review Pure Tone Audiometer (PDF) Sample Eye Chart (PDF) (Back to FSR Menu) Additional Documents Facility Site Review IEHP Phone List (PDF) (Back to FSR Menu) Additional Documents Medical Record Review Online Resources for Medical Record Review (PDF) (Back to FSR Menu) You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

rtura de atención médica, cuidado dental y de la vista* a residentes de bajos ingresos de California que reúnen los requisitos. ¿Quién puede solicitar Medi-Cal y afiliarse a IEHP?   Las personas que viven en nuestra área de servicio (la mayor parte de los condados de Riverside y San Bernardino) Las personas adultas con o sin hijos, niños, adultos mayores y personas con discapacidad Las personas que cumplen las pautas de ingresos y otros requisitos del programa  Adultos indocumentados mayores de 50 años ¿Cuánto pagaré? Los adultos no pagan ninguna prima mensual por la cobertura de Medi-Cal. Los niños con cobertura de Medi-Cal bajo el Programa de Seguro Médico para Niños (Children's Health Insurance Program, CHIP) tendrán una prima mensual baja. ¿Qué atención recibiré con Medi-Cal a través de IEHP? La cobertura de su plan incluye: Servicios para pacientes ambulatorios (de consulta externa)* Servicios de emergencia Servicios de Transgénero* Atención paliativa y para enfermos terminales* Hospitalización* Atención de maternidad y para el recién nacido Servicios de salud mental Medicamentos con recetados Servicios y dispositivos de rehabilitación y habilitación* Servicios de laboratorio y radiología, como radiografías* Servicios de prevención y bienestar, y manejo de enfermedades crónicas Servicios sensibles Servicios de tratamiento para trastornos por uso de sustancias Servicios pediátricos Servicios de la vista* Transporte médico que no sea de emergencia (non-emergency medical transportation, NEMT) Transporte no médico (non-medical transportation, NMT) Servicios y Apoyo a Largo Plazo (Long-Term Services and Supports, LTSS) Servicios de telesalud   Algunos de los servicios indicados están cubiertos solo si IEHP o su Asociación de Médicos Independientes (Independent Physician Association, IPA) los aprueban primero. Los servicios cubiertos que pueden necesitar ser aprobados primero por IEHP o su IPA o grupo médico están marcados con un asterisco (*). ¿Cómo solicito Medi-Cal? Llame a los Asesores de Inscripción de IEHP al (866) 294-4347, lunes – viernes, 8am – 5pm. Los usuarios de TTY deben llamar al (800) 720-4347. También puede llamar a Opciones de Atención Médica al 1-800-430-4263 o visitar www.healthcareoptions.dhcs.ca.gov. Los usuarios de TTY deben llamar al 1-800-430-7077. Lectura importante para los Miembros de IEHP Medi-Cal El Manual para Miembros de Medi-Cal Este manual explica cómo obtener atención con IEHP y los beneficios cubiertos del plan. Guía de Beneficios de Medi-Cal Use esta guía para buscar información importante sobre los beneficios y servicios en su Manual para Miembros de IEHP. Directorio de Proveedores de Medi-Cal Enumera nuestra creciente red y las opciones para recibir la atención que necesita de forma rápida, de día y de noche.    Para ver los archivos PDF, debe tener el programa Adobe Acrobat Reader 6.0 o superior. Descargue una copia gratuita. Haga clic en Adobe Acrobat Reader.

n pocas excepciones, mientras sea Miembro de nuestro plan debe ver a proveedores de la red para obtener atención médica y servicios. Las únicas excepciones son las emergencias, la atención de urgencia cuando la red no esté disponible (normalmente, cuando usted está fuera del área), servicios de diálisis fuera del área y casos en los que IEHP DualChoice (HMO D-SNP) autorice el uso de proveedores fuera de la red. ¿Qué son los proveedores de la red? Los proveedores de la red son los Doctoress y otros profesionales médicos, grupos médicos, hospitales y otros centros de atención médica que tienen un acuerdo con nosotros para aceptar nuestro pago  como el pago total. Hemos hecho acuerdos para que estos proveedores presten servicios cubiertos a los Miembros de nuestro plan. Todos los proveedores que participan en nuestro plan también tienen un contrato con nosotros para dar los beneficios cubiertos de Medi-Cal. Cómo encontrar un Doctor Use el Directorio de Proveedores y Farmacias de IEHP DualChoice abajo para encontrar un proveedor de la red: Directorio de Proveedores y Farmacias de IEHP DualChoice de 2023 (PDF)  ¿Qué es un Proveedor de Atención Primaria (PCP) y cuál es su rol en el Plan? Un PCP es su Proveedor de Atención Primaria. Normalmente verá primero a su PCP para la mayoría de sus necesidades de atención médica de rutina. Su PCP también lo ayudará a organizar o coordinar el resto de los servicios cubiertos que reciba como Miembro de nuestro Plan. “Coordinar” sus servicios incluye controlar o consultar con otros proveedores del Plan sobre su atención y cómo está yendo, incluyendo: sus radiografías análisis de laboratorio, terapias atención de doctores que son especialistas hospitalizaciones y tratamiento continuo Los proveedores de atención primaria (PCP) suelen tener vínculos con determinados hospitales. Cuando elija a su PCP, recuerde lo siguiente: Debe elegir a su PCP de su Directorio de Proveedores y Farmacias. Llame a Servicios para Miembros de IEHP DualChoice si necesita ayuda para elegir PCP o cambiarlo. Elija un PCP que esté en un radio de 10 millas o 15 minutos de su casa. El PCP que elija solo puede ingresarlo a determinados hospitales. Intente elegir un PCP que pueda ingresarlo al hospital que quiera en un radio de 30 millas o 45 minutos de su domicilio. Algunos hospitales tienen “hospitalistas” que se especializan en la atención de personas durante su hospitalización. Si lo ingresan en uno de estos hospitales, es posible que un “hospitalista” actúe como su cuidador mientras permanezca en el hospital. Cuando le den el alta del hospital, regresará con su PCP para sus necesidades de atención médica. Si necesita cambiar de PCP por cualquier motivo, es posible que también tenga que cambiar de hospital y especialista. Su PCP debería hablar su idioma. Sin embargo, su PCP puede usar siempre los servicios de Language Line para obtener ayuda de un intérprete, si es necesario. Si no elige un PCP cuando se una a IEHP DualChoice, elegiremos uno por usted. Le enviaremos su tarjeta de identificación con la información de su PCP. Recuerde que puede pedir un cambio de PCP en cualquier momento. Puede cambiar de  Doctor (y hospital) por cualquier motivo (una vez al mes). Si IEHP recibe su solicitud de cambio  antes del día 25 del mes, el cambio entrará en vigor el primer día del siguiente mes; si IEHP recibe su solicitud de cambio  después del día 25 del mes, el cambio entrará en vigor el primer día del mes siguiente (para algunos proveedores, es posible que necesite una referencia de su PCP).  Cómo obtener atención médica de un especialista Normalmente verá primero a su Proveedor de Atención Primaria (PCP) para la mayoría de sus necesidades de atención médica de rutina, como chequeos físicos, inmunizaciones, etc. Cuando su PCP considere que usted necesita suministros o tratamientos especializados, su PCP tendrá que obtener autorización previa (es decir, aprobación con antelación) de su Plan o grupo médico. Esto se llama referencia. Su PCP enviará una referencia a su plan o grupo médico.  Es muy importante que obtenga una referencia (aprobación con antelación) de su PCP antes de ver a un especialista del u otros proveedores determinados del Plan. Si no obtiene una referencia (aprobación con antelación) antes de recibir los servicios de un especialista, es posible que tenga que pagar usted mismo estos servicios. ¿Qué sucede si está fuera del área de servicio del plan cuando tiene una necesidad urgente de atención? Imagínese que está temporalmente fuera del área de servicio de nuestro plan, pero sigue estando en los EE. UU.. Si tiene una necesidad urgente de recibir atención médica, es probable que no pueda encontrar o ir a ver a uno de los proveedores de la red de nuestro plan. En esta situación (cuando esté fuera del área de servicio y no pueda recibir atención médica de un proveedor de la red), nuestro plan cubrirá la atención médica que necesite con urgencia y que reciba de cualquier proveedor. Nuestro plan no cubre la atención médica que necesite con urgencia ni cualquier otra atención médica si la recibe fuera de los EE. UU.. Cómo cambiar de Proveedor de Atención Primaria (PCP) Puede cambiar de PCP por cualquier motivo, en cualquier momento. Además, es posible que su PCP se vaya de la red de proveedores de nuestro plan, y usted tenga que buscar un nuevo PCP. Si esto sucede, tendrá que cambiar a otro proveedor que sea parte de nuestro Plan. Si su PCP se va de nuestro Plan, se lo avisaremos y lo ayudaremos a elegir otro PCP para que pueda seguir recibiendo servicios cubiertos. Los Servicios para Miembros de IEHP DualChoice pueden ayudarlo a encontrar y elegir otro proveedor. Puede cambiar de Doctor llamando a Servicios para Miembros de IEHP DualChoice. Llame a Servicios para Miembros de IEHP DualChoice al (877) 273-IEHP (4347), 8am – 8pm (Hora del Pacífico), los 7 días de la semana, incluyendo feriados. Los usuarios de TTY deben llamar al (800) 718-4347. Para obtener más información sobre los proveedores de la red, consulte el Capítulo 1 del Manual para Miembros de IEHP DualChoice. IEHP DualChoice (HMO D-SNP) es un Plan HMO con un contrato con Medicare. La inscripción en IEHP DualChoice (HMO D-SNP) depende de la renovación del contrato. Esta no es una lista completa.  Necesitará Adobe Acrobat Reader 6.0 o una versión superior para ver los archivos en formato PDF. Para descargar una copia gratuita, haga clic en Adobe Acrobat Reader La información de esta página está vigente desde el 01 de octubre de 2022 H8894_DSNP_23_3241532_M