Tìm Kiếm Kết Quả Cho : " DIPLOMA IN ENVIRONMENTAL SCIE "

hần hai này, chúng tôi sẽ hướng dẫn quý vị cách chuẩn bị một đĩa ăn bổ dưỡng để quý vị có thể thưởng thức các món ăn mình yêu thích. Tìm hiểu cách chuẩn bị một đĩa ăn lành mạnh và cách đọc nhãn thực phẩm khi chăm sóc người mắc bệnh tiểu đường. Phần hai cũng giới thiệu các lời khuyên khi đi ăn hàng.  Nhấp vào đây để đăng ký lớp học trực tiếp này Địa Điểm Desert Hot Springs Family Resource Center 14-320 Palm Dr. Desert Hot Springs, CA 92240      

g lớp học này, học viên sẽ học về tầm quan trọng của việc chăm sóc trước khi sinh sớm và thường xuyên. Nhấp vào đây để đăng ký lớp học trực tiếp này Địa Điểm Trung Tâm Nguồn Lực Hỗ Trợ Cộng Đồng của IEHP (Victorville) 12353 Mariposa Rd Suites C-2 & C-3 Victorville, CA 92395    

n Suyễn của Quý vị - Tìm hiểu điều gì xảy ra trong phổi khi các triệu chứng hen suyễn bắt đầu, tìm hiểu về các yếu tố là tác nhân gây bệnh hen suyễn và cách tránh các cơn hen suyễn. Nhấp vào đây để đăng ký lớp học trực tiếp này Địa Điểm Desert Hot Springs Family Resource Center 14-320 Palm Dr. Desert Hot Springs, CA 92240      

huyết tật. Chủ Đề: Tìm Kiếm Thông Tin – Tìm hiểu địa điểm và cách thức tìm kiếm thông tin để giúp quý vị đạt được mục tiêu. Nhấp vào đây để đăng ký lớp học trực tiếp này Địa Điểm Trung Tâm Nguồn Lực Hỗ Trợ Cộng Đồng của IEHP (Victorville) 12353 Mariposa Rd Suites C-2 & C-3 Victorville, CA 92395      

Chuyển Dạ và Sinh Nở - Lớp học này tập trung vào một số điều quý vị có thể làm để  chuẩn bị cho quá trình chuyển dạ và sinh nở.  Nhấp vào đây để đăng ký lớp học này qua WebEx   Mã số Buổi học: 24657287956 Tải xuống phiên bản Webex cho người dùng thiết bị Apple Tải xuống phiên bản Webex cho người dùng thiết bị Android Tải xuống phiên bản Webex cho người dùng máy tính cá nhân

khuyết tật. Chủ Đề: Hoạt Động Thể Chất – Quý vị sẽ xem hiện tại quý vị đang hoạt động như thế nào và tăng cường hoạt động như thế nào để có nhiều năng lượng hơn và vận động linh hoạt hơn. Nhấp vào đây để đăng ký lớp học trực tiếp này Địa Điểm Trung Tâm Nguồn Lực Hỗ Trợ Cộng Đồng của IEHP (Riverside) 3590 Tyler St Riverside, CA 92503

động có thể vui cho cả gia đình!  Không cần mua thẻ tập gym đắt tiền. Tham gia với chúng tôi trong một lớp học vui vẻ nơi mọi người có thể thưởng thức hoạt động thể chất thông qua SPARK (Giải trí cho Trẻ em bằng Thể thao, Vui chơi, và Tích cực vận động). Chào đón mọi lứa tuổi và mức khả năng. Nhấp vào đây để đăng ký lớp học trực tiếp này Địa Điểm Desert Hot Springs Family Resource Center 14-320 Palm Dr. Desert Hot Springs, CA 92240    

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)  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 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 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 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 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 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 (CMC) - English (PDF) Health Risk Assessment (HRA) - IEHP DualChoice  (CMC)- 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.

dành cho người khuyết tật. Chủ đề: Hoạt Động Thể Chất – Quý vị sẽ xem hiện tại quý vị đang hoạt động như thế nào và tăng cường hoạt động như thế nào để có nhiều năng lượng hơn và vận động linh hoạt hơn. Nhấp vào đây để tham gia đăng ký lớp học này qua WebEx   Mã Số Buổi Học:  133 345 5010 Tải xuống phiên bản Webex cho người dùng thiết bị Apple Tải xuống phiên bản Webex cho người dùng thiết bị Android Tải xuống phiên bản Webex cho người dùng máy tính cá nhân

dành cho người khuyết tật. Chủ đề: Tìm Kiếm Thông Tin – Tìm hiểu địa điểm và cách thức tìm kiếm thông tin để giúp quý vị đạt được mục tiêu. Nhấp vào đây để tham gia đăng ký lớp học này qua WebEx   Mã Số Buổi Học:  1772609725 Tải xuống phiên bản Webex cho người dùng thiết bị Apple Tải xuống phiên bản Webex cho người dùng thiết bị Android Tải xuống phiên bản Webex cho người dùng máy tính cá nhân

thy ways to cope, and strategies to talk to your doctor.  Click here to register for this in-person class Location IEHP Community Resource Center (San Bernardino) 805 W 2nd St San Bernardino, CA 92410

iabetes needs to stay healthy, how to take care of your feet and address barriers.  Click here to register for this in-person class Location IEHP Community Resource Center (Riverside) 3590 Tyler St Riverside, CA 92503

ọng Đại – Chuyển Dạ và Sinh Nở - Lớp học này tập trung vào một số điều quý vị có thể làm để  chuẩn bị cho quá trình chuyển dạ và sinh nở.  Nhấp vào đây để đăng ký lớp học này qua WebEx   Mật Khẩu: 133 514 1650 Tải xuống phiên bản Webex cho người dùng thiết bị Apple Tải xuống phiên bản Webex cho người dùng thiết bị Android Tải xuống phiên bản Webex cho người dùng máy tính cá nhân

ức Cơ Bản về Nuôi Con Bằng Sữa Mẹ - Khi tham gia lớp học này, quý vị sẽ được tìm hiểu thông tin cơ bản về nuôi con bằng sữa mẹ như, khớp ngậm đúng, bế cho con bú và các dấu hiệu cho thấy trẻ muốn bú.  Nhấp vào đây để đăng ký lớp học này qua WebEx   Mật Khẩu: 133 514 1650 Tải xuống phiên bản Webex cho người dùng thiết bị Apple Tải xuống phiên bản Webex cho người dùng thiết bị Android Tải xuống phiên bản Webex cho người dùng máy tính cá nhân

basic breastfeeding information such as, proper latch, nursing holds, and feeding cues.  Click here to register for this WebEx class   Session Number: 24644973790 Download Webex for Apple users Download Webex for Android users Download Webex for PC users

: Healthy Communication – Learn how to communicate your needs clearly to your doctor or your support network. Click here to register for this in-person class Location IEHP Community Resource Center (Victorville) 12353 Mariposa Rd Suites C-2 & C-3 Victorville, CA 92395    

dành cho người khuyết tật. Chủ đề: Tìm Kiếm Thông Tin – Tìm hiểu địa điểm và cách thức tìm kiếm thông tin để giúp quý vị đạt được mục tiêu. Nhấp vào đây để tham gia đăng ký lớp học này qua WebEx   Mã Số Buổi Học:  1772609725 Tải xuống phiên bản Webex cho người dùng thiết bị Apple Tải xuống phiên bản Webex cho người dùng thiết bị Android Tải xuống phiên bản Webex cho người dùng máy tính cá nhân

dành cho người khuyết tật. Chủ đề: Hoạt Động Thể Chất – Quý vị sẽ xem hiện tại quý vị đang hoạt động như thế nào và tăng cường hoạt động như thế nào để có nhiều năng lượng hơn và vận động linh hoạt hơn. Nhấp vào đây để tham gia đăng ký lớp học này qua WebEx   Mã Số Buổi Học:  133 345 5010 Tải xuống phiên bản Webex cho người dùng thiết bị Apple Tải xuống phiên bản Webex cho người dùng thiết bị Android Tải xuống phiên bản Webex cho người dùng máy tính cá nhân

tance of reducing stress and being active during your pregnancy. Click here to register for this in-person class Location IEHP Community Resource Center (Victorville) 12353 Mariposa Rd Suites C-2 & C-3 Victorville, CA 92395      

hy ways to cope, and strategies to talk to your doctor.  Click here to register for this in-person class Location IEHP Community Resource Center (San Bernardino) 805 W 2nd St San Bernardino, CA 92410