Claims
Medi-Cal Learning Portal
The Medi-Cal Learning Portal provides extensive resources and a broad range of topics for all types of Providers with questions regarding billing requirements and claims processing guidelines. Resources are not limited to webinars, computer based training, and webinars. Providers also have direct access to their Regional Representative and the Small Provider Billing Unit (SPBU) through this link (By clicking on this link, you will be leaving the IEHP website) https://learn.medi-cal.ca.gov/.
Medi-Cal Rates and Codes
By clicking on these links, you will be leaving the IEHP website.
Medi-Cal Rates
The file lists the maximum reimbursement rates payable by the Medi-Cal program for covered procedures described in the HCPCS and CPT-4 coding system.
Resource: website
CPT Codes
This website is aimed at providing information to Providers on Medicare's National CCI edits, but will not address specific CCI edits.
Resource: website
Alpha-Numeric HCPCS Files
These files contain the Level II alpha-numeric HCPCS procedure and modifier codes, their long and short descriptions, and applicable Medicare administrative, coverage, and pricing data.
Resource: website
ZIP code To Carrier Locality File
This file is primarily intended for use by ambulance suppliers to map ZIP Codes to CMS carriers and localities. This file will also map ZIP Codes to their State and can determine whether the ZIP Code has a rural designation as determined by CMS.
Resource: website
Medicare Physician Fee Schedule
Information on services covered by the Medicare Physician Fee Schedule (MPFS).
Resource: website
IEHP Fee Schedule
Provider Dispute Resolution Process
For more information about the Provider dispute resolution process for contracted and non-contracted Providers, click here
Other Health Coverage (OHC)
Compliance
Compliance Program
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.
IEHP DualChoice (HMO D-SNP) – Model of Care
The IEHP DualChoice population is composed of individuals who are dual eligible for both Medicare and Medi-Cal in Riverside and San Bernardino counties, including the most vulnerable population. This also includes members transitioning from IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan).
- IEHP has identified the most vulnerable as the following:
- Age 21-70
- Identified as High and Rising Risk
- Diagnosed with Cardiovascular Disease AND/OR Diabetes
- RUB Score of 4 & 5. *RUB is Resource Utilization Band which is a predictor of using acute or costly services.
- IEHP will identify the most vulnerable members assigned to IPAs
- IEHP and its IPAs must design care management specific interventions to demonstrate how they support these member's health and wellness goals.
- Remote Patient Monitoring
- Medically Tailored Meals and Other Community Supports
- Nutrition Education
- Pharmacy Services (medication reconciliation and other programs)
- Long-Term Services and Supports (LTSS)
- Telehealth Behavioral Health Services
- Transportation
- More frequent care management contact
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, Chrome or MS Internet Explorer
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.
Educational Opportunities
Click on the following links to jump to that specific section:
Interdisciplinary Care Team (ICT) Fact Sheet (PDF)
Healthcare Provider Toolkit: Assisting Patients with Requests for Workplace Accommodations or Leaves of Absence (PDF)
Dual Choice Medicare CM IPA Training
2021 Care Management Delegation Oversight Medi-Cal IPA Training (MP4 Video) - December 08, 2021
Discussion Topics:
- Health Risk Assessments (HRA)
- Individual Care Plans (ICP)
- Interdisciplinary Care Team (ICT)
- Coordination of Care
- Delegated IPA Reporting Requirements
2021 Care Management Delegation Oversight Medi-Cal IPA Training (MP4 Video) - February 16, 2021
Alzheimer's and Dementia Care
Project ECHO Opportunities From The Alzheimer's Association For Inland Empire Primary Care Clinics
Alzheimer’s Association / UCSF Memory and Aging Center Alzheimer’s and Dementia Care ECHO
Faculty partners: UCSF Memory and Aging Center faculty
When: Thursdays beginning February 16, 2023 until July 20, 2023 from 12:00 pm - 1:00 pm PT via Zoom
Who can be involved: All California based Primary care practice teams (including MD/DO, NP, PA, social work, MA)
- UCSF/Inland Empire ECHO 2023 Flyer (PDF)
- To register, please contact Kelsey Burnham at kburnham@alz.org
UCLA ADC ECHO
Faculty partners: UCLA Alzheimer’s and Dementia Care (ADC) program faculty
When: Wednesdays beginning March 29, 2023 until September 6, 2023 from 11:00 am - 12:00 pm PT via Zoom
Who can be involved: Nationwide teams interested in adding to their own knowledge and skills and those interested in learning about or implementing the highly effective UCLA ADC program
- ADC ECHO 2023 Flyer (PDF) To register, please contact Rachel Goldberger at rbgoldberger@alz.org
Specialty Mental Health Care Coordination
The Centers for Medicare and Medicaid Services (CMS) is requiring IEHP and its IPAs to document and report the efforts made to coordinate the care of IEHP DualChoice (HMO D-SNP) Members receiving specialty mental health services through the County Mental Health Plans. As of June 1, 2018, IEHP has put policies and procedures in place to comply with these process and reporting requirements:
- On the first (1st) of each month, IEHP will provide IPAs and County MH Clinics a list of IEHP DualChoice (HMO D-SNP) Members known to be receiving specialty mental health services through the County MH Plans.
- IPAs are expected to outreach to these Members and their County MH Clinic Provider, as well as, document their outreach attempts and outcomes as outlined in Policy 25C2, “Care Management Requirements – Delegated IPA Responsibilities.”
- IPAs are required to provide data elements specific to this measure, as outlined in Policy 25F1, “Encounter Data Reporting - Medicare MMP Reporting Requirements – IEHP DualChoice (HMO D-SNP)" and Attachment, “Medicare Provider Reporting Requirements Schedule” in Section 25.
- IEHP, through its Delegation Oversight process, will monitor the IPAs’ compliance with documentation and reporting requirements, as outlined in Policy 25A2, “Delegation Oversight Audit.”
To access the On-Site training material presented to IPAs and County Mental Health Clinics, click here (PDF).
National LGBT Health Education Webinars
IEHP has put together a list of webinars, provided by a third party, to provide educational programs, resources, and consultation to health care organizations with the goal of optimizing quality, cost-effective health care for lesbian, gay, bisexual, transgender, and all sexual and gender minority (LGBT) people.
The National LGBT Health Education Center is part of the Division of Education and Training at The Fenway Institute, Fenway Health. The Fenway Institute (TFI) is an interdisciplinary center for research, training, education, and policy development that works to ensure access to quality, culturally affirming medical and mental health care for traditionally underserved communities, including LGBTQIA+ people and those affected by HIV/AIDS.
The mission of Fenway Health is to enhance the wellbeing of the LGBTQIA+ community as well as people in our neighborhoods and beyond through access to the highest quality health care, education, research, and advocacy. Fenway Health is one of the largest providers of LGBTQIA+ health care and HIV primary care in the country; as such, it is a leader in the field of LGBTQIA+ health and informs much of the promising practices and innovative models that the Education Center disseminates to health centers nationwide.
By clicking on these links, you will be leaving the IEHP website.
The National LGBT Health Education Center WebinarsCourses Include:
- HIV Prevention/PrEP at Health Centers: An Overview and Current Best Practices
- What’s new in PrEP and STIs? Cases From a Sexual Health Clinic
- Insurance Considerations for Navigating Gender-affirming Care
- Building Your Family: LGBTQ Reproductive Options
- Behavioral Health Assessments and Referral for Gender-Affirming Surgery
- Navigating Gender Affirming Care
- Collecting Sexual Orientation and Gender Identity (SO/GI) Data In Electronic Health Records
- Providing Mental Health Assessments for Gender Affirming Surgery Referral Letters
Online Cultural Competency Training
AHRQ Health Literacy Modules Available for Continuing Education (CE) and Maintenance of Certification (MOC) Credit
Physicians and nurses can earn CE credits while learning about the challenges in caring for patients with low health literacy as well as strategies to improve overall patient communication and care. OptumHealth Education is issuing continuing education credit for taking the AHRQ-developed Health Literacy Knowledge Self-Assessment. No fees are charged for the two CE activities:
By clicking on these links, you will be leaving the IEHP website.
1. An Updated Overview of Health Literacy
Link (optumhealtheducation.com)
2. Improving Health Literacy by Improving Communication Skills
Link (optumhealtheducation.com)
Pediatricians and family physicians can earn credit for re-certification (MOC Part 2) as well as CE by taking the Health Literacy Knowledge Self-Assessment through the American Board of Pediatrics and the American Academy of Family Physicians, respectively.
To learn about AHRQ’s tools to address health literacy, visit Health Literacy Topics at:
https://www.ahrq.gov/health-literacy/index.html
To find out about other free AHRQ continuing education opportunities, go to:
https://www.ahrq.gov/patient-safety/education/continuing-ed/index.html
To contact AHRQ, visit https://www.ahrq.gov/contact/index.html
Office of Minority Health - https://cccm.thinkculturalhealth.hhs.gov/
CDC - www.cdc.gov
U.S. Department of Health and Human Service, Health Resources and Services Administration - www.hrsa.gov
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.
Forms
Click on the following links to jump to that specific section:
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)
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:
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
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)
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)
Health and Wellness
Historical Data Form
Inland Regional Center
- 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
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
- Continuity of Care Authorization Letter
- Notice of Action – Carve Out
- Notice of Action - Delay
- Notice of Action - Deny
- Notice of Action - Modify
- Notice of Action - Terminate
- Other Health Care Coverage Requesting Provider Letter
- Continuity of Care Terminate Letter
- Specialist Termination Letter
- Prior Authorization Not Required
Last Updated: 12/29/2022
Last Updated: 12/27/2022
Last Updated: 12/27/2022
Last Updated: 12/27/2022
Last Updated: 12/27/2022
Last Updated: 12/28/2022
Last Updated: 01/06/2023
Last Updated: 01/06/2023
Last Updated: 09/20/2022
Last Updated: 09/20/2022
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
- Denial Reason Matrix
- Detailed Explanation of Non-Coverage
- Detailed Notice of Discharge
- Expedited Criteria Not Met
- Extension Needed for Additional Information
- Integrated Denial Notice - Part B Drugs - 7 day appeal - IPA
- Integrated Denial Notice - Part C - 30 day appeal - IPA
- Integrated Denial of Payment Notice - 7 day appeal - IPA
- Integrated Denial of Payment Notice - 30 day appeal - IPA
- Notice of Authorization of Services
- Notice of Dismissal of Coverage
- Notice of Medicare Non-Coverage
- Notice of Reinstatement of Coverage
Last Updated: 11/12/2017
NEW D-SNP 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.
- AOR Dismissal Letter
- AOR Request Letter
- Continuity of Care - Notice of Authorization
- Continuity of Care – Notice of Termination
- Detailed Explanation of Non-Coverage
- Detailed Notice of Discharge
- Expedited Criteria Not Met
- Extension Needed for Additional Information
- Informational Letter to Beneficiary and PCP
- Notice of Authorization of Services
- Notice of Dismissal of Coverage Request
- Notice of Medicare Non-Coverage
- Cancelled Relocation Letter
- Long-Term Care IPA and PCP Change Letter
- Coverage Decision Letter Part B - 7 Day Appeal
- Coverage Decision Letter Medical – 30 Day Appeal
- Coverage Decision Letter - Claims
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)
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.
If you are interested in becoming a network Provider, please click here.
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)
Pharmacy
- Click here for Pharmacy forms.
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
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)
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)
- 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)
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)
Facility Site Review Training
Thank you for your participation in the IEHP Network and partnering with 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)
IEHP Addendum Tools
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)
Facility Site Review Menu
Click on the following links to jump to that specific section:
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)
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)
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)
Coordination of Care
Medical Record Review
- Adult Progress Note - Sample (PDF)
- Missed Appointment Log - Sample (PDF)
- Pediatric Progress Note - Sample (PDF)
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)
Format
Medical Record Review
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)
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)
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)
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)
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)
Preventive Services
Facility Site Review
Additional Documents
Facility Site Review
Additional Documents
Medical Record Review
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.Health & Wellness
IEHP partners with Providers to help educate Members about their health conditions and achieve health goals. IEHP’s Health & Wellness Programs help Members learn how to manage their health and make healthy lifestyle changes. You can refer your IEHP Members to these programs anytime by logging into the Secure Provider Website and completing the Health Education Program Request Form.
- Health Resources
- Kids and Teens
- Managing Your Illness
- Pregnancy and Postpartum
- Senior Health
- Weight Management
Health & Wellness Brochures and Handouts
Inland Empire Health Plan (IEHP) offers many Wellness Programs that focus on the health and well-being of our Members. All of our programs are free, join us at our next session and learn ways to stay healthy. Get information on important health topics through our health education brochures and handouts:- Controlling Asthma (PDF)
- Diabetes. What's next? (PDF)
- Eat Healthy, Feel Better (PDF)
- Fever in Children (PDF)
- Flu Decision Guide (PDF)
- Flu Shot (PDF)
- High Blood Pressure (PDF)
- Immunizations - English (PDF)
- PAP and HPV Tests: What to Expect (PDF)
Diabetes Prevention Program (DPP) - Live the Life You Love
Format: Online (small group)
Duration: One year
Ages: 18 years and over
This online year-long lifestyle change program helps you make real changes that last.
During the first 6 months, you will meet weekly with a small online group to learn how to make healthy choices into your life. In the second 6 months, you will meet monthly to practice what you have learned.
No person is alike, so the program will be tailored to meet your needs and honor your customs and values. You will also be paired with a health coach for one year to help you set your goals, such as how to:
- Eat healthier
- Add physical activity into your daily life
- Reduce stress
- Improve problem-solving and coping skills
Studies have shown that those who finish the program can lose weight and prevent Type 2 Diabetes.
Small changes can have big results! Let's start living the best version of you and living the life you love.
Find out if you qualify!
- Click here to visit the Skinny Gene Project online, or
- Call Skinny Gene Project at (909) 922- 0022, Monday - Friday 8am – 5pm., or
- Email hello@skinnygeneproject.org
For Providers
Educational Resources
2021 Population Needs Assessment (PNA) Report
IEHP’s Population Needs Assessment (PNA) identifies Member health status and behaviors, Member health education priorities, cultural/linguistics needs, health disparities, and gaps in service related to these issues. The findings of the PNA may help Providers better understand and serve our Members.
For questions, please contact IEHP Health Education Department at healthed@iehp.org
Loving Support Program
- IEHP supports and sponsors the Loving Support Program that is run by Riverside University Health System (RUHS). Loving Support is a program committed to helping mothers achieve their breastfeeding goals. This service offers help and support with the first days at home, return to work, support groups, and timely answers to challenges nursing mothers face.
Members can directly contact the Loving Support 24/7 Helpline at 888-451-2499. No referral is necessary. English and Spanish-speaking certified lactation specialists and Internationally Board Certified Lactation Consultants (IBCLCs) are available 24 hours a day, 7 days a week to answer questions. Messages are recorded after hours and promptly addressed.
Member Education Resources
The following websites are good sources of easy-to-read patient information that can be downloaded, printed, or ordered. By clicking on these links, you will be leaving the IEHP website.
| RESOURCE | DESCRIPTION |
|---|---|
| Medline Plus |
A service of the US National Library of Medicine and the National Institutes of Health. Easy to read information and audio tutorials on many health topics in English and Spanish. Topics are available in multiple languages. |
| Food and Drug Administration - Office of Women's Health |
Easy-to-read handouts in English, Spanish and other languages on nutrition, diabetes, depression, and other topics related to women’s health. |
| Learning About Diabetes, Inc. |
Easy to read “Handouts and Visual Aids” in color on diabetes care and nutrition to help patients eat the right foods to control blood sugar. |
| Weight Control Information Network |
An extensive list of health education materials about healthy weight and physical activity in English and Spanish. Materials can be printed or ordered. |
| Health Information Translations | Easy-to-read educational handouts on many health topics and in multiple languages. |
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.
Provider 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
- 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.
POLST Registry
By clicking on these links, you will be leaving the IEHP website.
To login, visit Working Toward a Statewide POLST Registry in California | POLST (capolst.org)
To sign up, simply go to POLST for Healthcare Providers | POLST (capolst.org)
For any questions, please contact Care Directives at (888) 621-4383 or email support@caredirectives.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.Pharmacy Services
Here, you will find links to the Pharmacy Program Manual, Communications, DTM Program, Prior Authorization Criteria, Clinical Practice Guidelines, Forms, IEHP Formulary, and Safety Resources with drug recall information.
If you have any questions regarding services provided by the Pharmaceutical Services Department, please feel free to contact the IEHP Pharmacy Department at (909) 890-2049.
Clinical Practice Guidelines
The tools provided on this page are meant to be used as resources to assist primary care providers in delivering care in accordance with IEHP standards. Resources are reviewed regularly and updated to reflect changes from a regulatory and clinical standpoint.
Preventive Care Guidelines
- American College of Obstetricians and Gynecologists (ACOG)
- American Academy of Pediatricians (AAP) / Bright Futures
- Comprehensive Perinatal Services Program (CPSP)
Clinical Practice Guidelines Library
The guidelines contained on this page are recommended by IEHP with the intent to enhance Member care. IEHP’s Clinical Practice Guidelines topics are organized using the following categories:
- United States Preventive Services Task Force (USPSTF);
- IEHP Internal Library;
- Healthcare Effectiveness Data Information Set (HEDIS); and
- Managed Care Accountability Set (MCAS)
Links or documents embedded within the Internal Library category indicate literature that has been published by leading, formal organizations and have been endorsed/approved by IEHP’s Medical Directors and Quality Committee. IEHP produced information relevant to the topic will also be listed in this category. We have also indicated any HEDIS/ MCAS measures that are pertinent to the topic. Additionally, IEHP accepts USPSTF guidelines to help primary care clinicians identify clinical preventive services that are appropriate for their patients. IF there is a USPSTF guideline relevant to the topic, we have identified it below.
Library Catalog
Click on a letter to jump to that specific section:
A
USPSTF
IEHP Internal Library
HEDIS
Asthma Medication Ratio (AMR)
Medication Management for People with Asthma (MMA)
MCAS
B
IEHP Internal Library
HEDIS
MCAS
C
USPSTF
IEHP Internal Library
HEDIS
MCAS
IEHP Internal Library
HEDIS
MCAS
HEDIS
Statin Therapy for Patients with Cardiovascular Disease-Adherence (SPC)
Statin Therapy for Patients with Cardiovascular Disease – Statin Therapy (SPC)
MCAS
USPSTF
IEHP Internal Library
HEDIS
Pharmacology Management of COPD Exacerbation – Systemic Corticosteroids (PCE)
Pharmacology Management of COPD Exacerbations – Bronchodilators (PCE)
Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR)
MCAS
USPSTF
IEHP Internal Library
HEDIS
MCAS
D
HEDIS
Antidepressant Medication Management Acute Phase (AMM)
Antidepressant Medication Management Continuation Phase (AMM)
MCAS
Antidepressant Medication Management Acute (AMM-Acute)
Antidepressant Medication Management Continuation (AMM-Cont)
HEDIS
Statin Therapy for Patients with Diabetes – Adherence (SPD)
Statin Therapy for Patients with Diabetes – Statin Therapy (SPD)
Comprehensive Diabetes Care – HbA1C Testing (CDC)
Comprehensive Diabetes Care - HbA1C Control (<=9) (CDC)
Comprehensive Diabetes Care (<8) (CDC)
Comprehensive Diabetes Care - Eye Exam (CDC)
Comprehensive Diabetes Care – Monitoring for Nephropathy (CDC)
Comprehensive Diabetes Care – Blood Pressure Control (<140/90) (CDC)
MCAS
Comprehensive Diabetes Care HbA1C Testing (CDC HT)
Comprehensive Diabetes Care HbA1C Testing >9%) (CDC H9)
G
IEHP Internal Library
HEDIS
MCAS
H
IEHP Internal Library
HEDIS
MCAS
IEHP Internal Library
HEDIS
MCAS
IEHP Internal Library
HEDIS
MCAS
O
IEHP Internal Library
HEDIS
Weight Assessment and Counseling (WCC-BMI)
Adult Body Mass Index (ABA)
MCAS
Weight Assessment and Counseling (WCC-BMI)
Adult Body Mass Index (ABA)
IEHP Internal Library
HEDIS
MCAS
S
IEHP Internal Library
Centers for Disease Control Public Health Media Library – STD Treatment
You may also refer to individual topics as they appear in this library:
HEDIS
MCAS
IEHP Internal Library
HEDIS
MCAS
IEHP Internal Library
HEDIS
MCAS
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.
Additional Resources & Tools
Click on the following links to jump to that specific section:
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.
(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:
(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.
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Utilization Management Clinical Criteria
Welcome to the Utilization Management Clinical Criteria page. 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.
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
Gynecology and Obstetrics
Neurology
Pain Management
Pharmacy
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.