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IEHP DualChoice - Khiếu Nại, Quyết Định Bảo Hiểm và Quy Trình Kháng Nghị
ho Ban Dịch Vụ Hội Viên của IEHP theo số (877) 273-IEHP (4347) và xin cấp Biểu Mẫu Than Phiền Dành Cho Hội Viên. Nếu quý vị cần được hỗ trợ điền biểu mẫu, thì Dịch Vụ Hội Viên của IEHP có thể hỗ trợ quý vị. Quý vị có thể hoàn thành Biểu Mẫu Than Phiền Dành Cho Hội Viên trực tuyến. Quý vị có thể gửi biểu mẫu đã hoàn tất cho bất kỳ Nhà Cung Cấp nào của IEHP hoặc gửi biểu mẫu qua đường bưu điện đến: P.O Box 1800, Rancho Cucamonga, CA 91729-1800 Quý vị có thể gửi fax biểu mẫu đã điền đầy đủ thông tin đến (909) 890-5877. Quý vị có thể nộp đơn khiếu nại trực tuyến. Biểu mẫu này là dành cho IEHP DualChoice cũng như các chương trình khác của IEHP. Đối với một số loại vấn đề, quý vị cần sử dụng quy trình để đưa ra quyết định bảo hiểm và tiến hành kháng cáo. Đối với các loại vấn đề khác, quý vị cần sử dụng quy trình than phiền. Cả hai quy trình này đều đã được Medicare phê duyệt. Để đảm bảo tính công bằng và xử lý kịp thời các vấn đề của quý vị, mỗi quy trình đều có một bộ quy tắc, quy trình và thời hạn mà cả quý vị và chúng tôi đều phải tuân thủ. Các Dịch Vụ và Hỗ Trợ Dài Hạn: Nếu quý vị đăng gặp vấn đề với dịch vụ chăm sóc của mình, thì quý vị có thể gọi cho Chương Trình Thanh Tra Cal MediConnect theo số 1-888-452-8609 để được hỗ trợ. Đối với các vấn đề và mối quan ngại liên quan đến các quyết định hội đủ điều kiện, các đánh giá và dịch vụ chăm sóc được các trung tâm Chương Trình Cung Cấp Dịch Vụ Tại Cộng Đồng Dành Cho Người Trưởng Thành (CBAS), hoặc Cơ Sở Điều Dưỡng/Cơ Sở Chăm Sóc Bán Cấp Tính cung cấp, quý vị nên tuân thủ quy trình được nêu dưới đây. Chương Trình Cung Cấp Dịch Vụ Tại Cộng Đồng Dành Cho Người Trưởng Thành (CBAS) Quý vị có thể gọi cho Dịch Vụ Hội Viên của IEHP theo số (877) 273-IEHP (4347) và xin cấp Biểu Mẫu Than Phiền Dành Cho Hội Viên. Nếu quý vị cần được hỗ trợ điền biểu mẫu, thì Ban Dịch Vụ Hội Viên của IEHP có thể hỗ trợ quý vị. Quý vị có thể gửi biểu mẫu đã hoàn tất cho bất kỳ Nhà Cung Cấp nào của IEHP hoặc gửi biểu mẫu qua đường bưu điện đến: P.O Box 1800 Rancho Cucamonga, CA 91729-1800 Quý vị có thể gửi fax biểu mẫu đã điền đầy đủ thông tin đến (909) 890-5877. Quý vị có thể nộp đơn khiếu nại trực tuyến. Biểu mẫu này là dành cho IEHP DualChoice cũng như các chương trình khác của IEHP. Giúp Xử Lý Vấn Đề Quý vị có thể liên hệ với Medicare. Dưới đây là hai cách để nhận thông tin trực tiếp từ Medicare: Quý vị có thể gọi đến số (800) MEDICARE (800) 633-4227, 24 giờ một ngày, 7 ngày mỗi tuần, TTY (877) 486-2048. Quý vị có thể truy cập trang web của Medicare Bằng cách nhấp vào liên kết này, quý vị sẽ rời khỏi trang web của IEHP DualChoice. Nhận Hỗ Trợ từ Tổ Chức Chính Phủ Độc Lập Chúng tôi luôn sẵn sàng hỗ trợ quý vị. Nhưng trong một số tình huống, quý vị cũng có thể muốn nhận hỗ trợ hoặc hướng dẫn từ người nào đó không liên quan đến chúng tôi. Quý vị có thể liên hệ với Chương Trình Hỗ Trợ Bảo Hiểm Y Tế Tiểu Bang (SHIP) của quý vị bất kỳ lúc nào. Chương trình của chính phủ này có các cố vấn được đào tạo tại mỗi tiểu bang. Chương trình không liên quan đến chúng tôi hoặc bất kỳ công ty bảo hiểm hoặc chương trình bảo hiểm y tế nào. Các cố vấn trong chương trình này có thể giúp quý vị hiểu rõ quy trình nào quý vị nên sử dụng để xử lý vấn đề quý vị đang gặp phải. Họ cũng có thể giải đáp các thắc mắc của quý vị, cung cấp cho quý vị thêm thông tin và đưa ra hướng dẫn về những việc cần làm. Các cố vấn của SHIP sẽ cung cấp các dịch vụ miễn phí. Quý vị có thể gọi điện cho SHIP theo số 1-800-434-0222. Nhận Hỗ Trợ và Thông Tin từ DHCS Hãy gọi: (916) 445-4171 MCI từ TDD theo số (800) 735-2929 MCI từ Cuộc Gọi Thoại: (800) 735-2922 Sprint từ TDD theo số (800) 877-5378 Sprint từ Cuộc Gọi Thoại: (800) 877-5379 Gửi thư đến: Department of Health Care Services 1501 Capitol Ave., P.O. Box 997413 Sacramento, CA 95899-7413 Trang Web:www.dhcs.ca.gov Bằng cách nhấp vào liên kết này, quý vị sẽ rời khỏi trang web của IEHP DualChoice. Nhận Hỗ Trợ và Thông Tin từ Medi-Cal Chương Trình Thanh Tra có thể giải đáp các thắc mắc của quý vị và giúp quý vị hiểu rõ những việc cần làm để xử lý vấn đề của mình. Chương Trình Thanh Tra không được kết nối với chúng tôi hoặc với bất kỳ công ty bảo hiểm hoặc chương trình sức khỏe nào. Họ có thể giúp quý vị hiểu rõ quy trình cần sử dụng. Hãy gọi: 1-888-452-8609 (TTY 711) từ Thứ Hai đến Thứ Sáu, 9 giờ sáng đến 5 giờ chiều. Truy cập trang web: www.healthconsumer.org/ Bằng cách nhấp vào liên kết này, quý vị sẽ rời khỏi trang web của IEHP DualChoice. Nhận Hỗ Trợ và Thông Tin từ Livanta Tiểu bang của chúng tôi có một tổ chức gọi là Tổ chức Cải thiện Chất lượng Người thụ hưởng & Chăm sóc Trung tâm tại Gia đình (BFCC) Livanta (QIO). Đây là một nhóm các bác sĩ và các chuyên gia chăm sóc sức khỏe khác giúp cải thiện chất lượng chăm sóc cho những người có Medicare. Livanta không có quan hệ với chương trình của chúng tôi. Hãy gọi: (877) 588-1123, TTY (855) 887-6668 Dành cho kháng cáo: (855) 694-2929 Dành cho tất cả đánh giá khác: (844) 420-6672 Gửi thư đến: Livanta BFCC-QIO Program 10820 Guilford Road, Suite 202 Annapolis Junction, Maryland 20701 Trang Web: www.livanta.com Bằng cách nhấp vào liên kết này, quý vị sẽ rời khỏi trang web của IEHP DualChoice. Làm thế nào để có được tổng số các khiếu nại, kháng nghị và các trường hợp ngoại lệ được nộp cho IEHP DualChoice (HMO D-SNP)? Vui lòng gọi điện hoặc gửi thư cho Dịch Vụ Hội Viên của IEHP DualChoice. Hãy gọi: (877) 273-IEHP (4347). Các cuộc gọi đến số này đều được miễn phí. 8 giờ sáng - 8 giờ tối (Giờ Thái Bình Dương), 7 ngày một tuần, bao gồm cả ngày nghỉ lễ, TTY: (800) 718-4347. Số này cần có thiết bị điện thoại đặc biệt. Các cuộc gọi đến số này đều được miễn phí. Fax: (909) 890-5877 Gửi thư đến: IEHP DualChoice, P.O. Box 1800 Rancho Cucamonga, CA 91729-1800 Email: memberservices@iehp.org Đến trực tiếp: 10801 Sixth Street, Suite 120, Rancho Cucamonga, CA 91730 IEHP DualChoice (HMO D-SNP) là một Chương trình HMO có hợp đồng với Medicare. Việc ghi danh vào IEHP DualChoice (HMO D-SNP) phụ thuộc vào việc gia hạn hợp đồng. Đây không phải danh sách đầy đủ. Thông tin trên trang này được cập nhật từ ngày 1 Tháng Mười, 2022. H8894_DSNP_23_3241532_M Pending Accepted
Plan Updates - Correspondence
here.
TITLE
DATE
RECIPIENTS
September 2023
CORRECTION - Provider Website Redesign and Provider Portal Refresh
09/29
All IEHP Providers
New DHCS Drug Use Review (DUR) Board Educational Articles
09/29
All IEHP PCPs, All IEHP Pharmacy Providers
Required! Adult and Youth Screening and Transition of Care Tools Webinar - October 6th OR 9th
09/28
All BH Providers
Month-End IEHP Outbound 834 File Update
09/27
All 834 Trading Partners
2023 Global Quality P4P Program – Data Submission Deadlines!
09/26
Medi-Cal PCPs
Equity and Practice Transformation (EPT) Program FAQs, Links & PowerPoint
09/26
Medi-Cal PCPs
Access Standards – Appointment Availability - PCP & OB
09/25
All PCPs & OB/GYNs
2023 Member Language Demographics Survey Results - Free Interpreter Services Available
09/25
All Providers
REMINDER - 2023 Urgent Care + Wellness Quality Incentive Program – Kickoff Meeting!
09/25
Medi-Cal Urgent Care Providers
DHCS EVV Office Hours – October 5th, 10th & 27th
09/22
EVV Impacted Providers and Individual Nurse Providers
AB 1797: Providers Required to Enter All Immunizations & TB Tests in CAIR2
09/22
All PCPs & IPAs
Heartbeat! Provider Newsletter is Now Available Online
09/21
All IEHP Providers
Bicillin® L-A shortage in California
09/20
IEHP PCPs, OB/GYNs and Family Planning Providers
UPDATE - Provider Website Redesign and Provider Portal Refresh
09/20
All IEHP Providers
IEHP Text Campaign to Engage Members with their Primary Care Physicians
09/19
IEHP Direct PCPs
Dementia Care Aware – Cognitive Health Assessment Training on September 26th
09/19
All PCPs and IPAs
SoCalDocJobs.com Free Site for Providers to Post Jobs and Find Candidates
09/19
ALL PCPs & Specialists
IE-CHI Virtual Health Education Forum - September 19th
09/15
ALL PCPs & IPAs
Revised UM Authorization Guidelines
09/15
All IPAs
2023 Urgent Care + Wellness Quality Incentive Program – Kickoff Meeting!
09/15
Medi-Cal Urgent Care Providers
CORRECTION - Access Standards – Appointment Availability – Well Women
09/14
All Specialists
NOW AVAILABLE - Equity and Practice Transformation (EPT) Provider Directed Payment Program Application
09/13
IEHP Medi-Cal PCPs
Access Standards – Appointment Availability - Specialists
09/13
All Specialists
Access Standards – Appointment Availability - BH
09/13
All Behavioral Health Providers
REMINDER - Medication Reconciliation Letter Available in Provider Portal
09/11
All Medi-Cal PCPs
REMINDER - Dilated Retinal Exam (DRE) for Members who have Diabetes
09/11
All PCPs & Vision Providers
2023 Urgent Care + Wellness Quality Incentive Program Release
09/08
All Medi-Cal Urgent Care Providers
IPA Monthly Interim Provider Manual Changes
09/08
All IPAs
2023 Vision Provider Member List
09/08
Vision Providers
Invitation to Equity Practice & Transformation Payments Program – Information Session and Dinner
09/07
IEHP Medi-Cal PCPs
August 2023 Pharmacy and Therapeutics Update
09/06
All IEHP PCPs, All IEHP Pharmacy Providers
IEHP’s Annual DHCS Audit – Your Office May Be Visited by a DHCS Auditor
09/06
Medi-Cal PCPs & IPAs
Dementia Care Aware - Cognitive Health Assessment Training on September 14th and September 26th
09/05
ALL PCPs & IPAs
URGENT: Recalls, Market Withdrawals & Safety Alerts, August 2023
09/01
All IEHP PCPs, All IEHP Pharmacy Providers
August 2023
UM Department Availability
08/30
All PCPs, Specialists & BH Providers
REMINDER - 2023 Global Quality P4P Program – Best Practices Meeting!
08/29
GQ P4P Participating PCPs
DELAY - CMS Preclusion List - September
08/29
All Medicare IPAs
New DHCS Drug Use Review (DUR) Board Educational Articles
08/29
All PCPs, OBs & BH Providers
Labor Day Holiday – September 4th
08/28
All IEHP Providers & IPAs
DHCS EVV Office Hours – September 7th, 12th & 29th
08/28
EVV Impacted Providers and Individual Nurse Providers
Month-End IEHP Outbound 834 File Update
08/28
IEHP 834 Trading Partners
Correction: Care Management Medi-Cal Care Coordination File Review Tool
08/25
Medi-Cal IPAs
Member Services Appointment Center
08/25
All IEHP Medi-Cal PCPs
Correction - Continuity of Care - Notice of Authorization Letter Template
08/25
All Medicare IPAs
REVISED - UM Authorization Guidelines
08/25
All IPAs and Medical Directors
REMINDER: Provider Preventable Conditions (PPC) – Reporting Requirements
08/24
All Providers, IPAs, Contracted Hospitals, and Ambulatory Surgical Centers
Community Health Worker (CHW) Provider Incentive Webinar - September 13, 2023
08/23
All Medi-Cal PCPs
BenefitsCal.Com - New Hub For All State Benefits
08/22
All PCPs, Specialists & BH Providers
Claims Processing during State of Emergency
08/20
All IEHP Pharmacy Providers
Written Consent Required - Submitting Appeals On Behalf of a Medi-Cal Member
08/17
All Medi-Cal PCPs
Behavioral Symptoms in Dementia Webinar in August
08/17
All PCPs & IPAs
Updated: Continuity of Care- Notice of Authorization Letter Template
08/16
All Medicare IPAs
Medicare P4P IEHP Direct – Blood Pressure Control Billing Guidance
08/16
IEHP Direct DualChoice PCPs – Billing Department
NEW - IEHP Rx Pharma Data IPA File Formatting Changes
08/16
All IPAs & EDI Partners
NEW - IPA Medical Record Validation Audit Notification
08/15
All Medi-Cal IPAs
2023 Premiere Clinical Psychopharmacology Conference
08/14
All PCPs & Psychiatrists
REMINDER - Enhanced Care Management Available for Members
08/14
All Medi-Cal PCPs & IPAs
2023 Global Quality P4P Program – Best Practices Meeting on Sept. 6th
08/14
All Medi-Cal PCPs
Action Required - 2023 GQ P4P Program Provider Directory Verification
08/11
All Medi-Cal PCPs
Doula Services - Now a Covered Benefit for Members
08/11
All PCPs, OB/GYNs and BH Providers
NEW - Member Eligibility Now Includes SOGIE Data
08/11
All IEHP Providers
Health & Human Services Grants Available!
08/11
All PCP, Specialists, BH & IPAs
ACTION REQUIRED – New Interdisciplinary Care Plan Sharing Process
08/11
Medicare IPAs
New IEHP Inbound Encounter Data Validity and Inbound Timeliness Reports
08/11
IEHP Encounter Data Trading Partners
Care Management Medi-Cal Care Coordination File Review Tool
08/11
All Medi-Cal IPAs
Comprehensive Practice Optimization Workshop
08/09
Riverside County PCP's
URGENT - Corrected Claims Submitted via Provider Portal Denying as Duplicates
08/04
All Behavioral Health & Vision Providers
CORRECTION - Updated Medi-Cal Nondiscrimination Notice and Taglines
08/02
All Medi-Cal IPAs
URGENT: Recalls, Market Withdrawals & Safety Alerts, July 2023
08/01
All IEHP PCPs, All IEHP Pharmacy Providers
ACTION REQUIRED - Submit NEMT - PCS Forms for Dialysis Members
08/01
All Dialysis Center
IEHP Quality Hospice Network Update
08/01
PCPs, Hospitals, SNFs, Home Health, My Path Palliative Care Providers
URGENT - IEHP Outbound Monthly 834 File Delay
08/01
All EDI Partners
July 2023
REQUIRED - HIPAA Compliant Telehealth Platforms - Effective August 10th!
07/31
All PCPs, Specialists, BH, BHT Providers & IPAs
UPDATE - Navigating The New Preventive Care Reports
07/28
All Global Quality P4P PCP Participants
2023 Appointment Availability Survey
07/28
All Behavioral Health Providers
2023 Appointment Availability Survey
07/28
All PCPs & IPAs
2023 Appointment Availability Survey
07/28
All Specialists, Ancillary & IPAs
Reminder: Utilize Member Additional Contact Information for Medi-Cal Renewal Outreach!
07/28
All PCPs, Specialists & BH Providers
New DHCS Drug Use Review (DUR) Board Educational Articles
07/27
All Medi-Cal PCPs & Specialists
DHCS EVV Office Hours – August 7th, 25th and 30th
07/25
EVV Impacted Providers and Individual Nurse Providers
Month-End IEHP Outbound 834 File Update
07/25
IEHP 834 Trading Partners
Accessible Clinics Program 2023
07/24
All PCPs & Specialists
Cognitive Health Assessment Training - July 25th
07/24
All PCPs
Global Quality P4P Program (for PCPs) – 2023 Program Guide Update
07/20
IEHP – Global Quality P4P PCP Participants
Updated Nondiscrimination Notice and Taglines
07/18
All IPAs
Global Quality P4P Program (for IPAs) – 2023 Program Guide Update
07/18
All Medi-Cal IPAs
Three Wildfires in Riverside County – Possible Impact to Member Care
07/17
All Riverside County Providers
IPA Monthly Interim PM Changes
07/13
All IPAs
RESOLVED: DualChoice (HMO D-SNP): Known Billing Issue
07/07
All IEHP Pharmacy Providers
DualChoice (HMO D-SNP): Known Billing Issue
07/06
All IEHP Pharmacy Providers
Maintenance Alert - SFTP Not Accessible This Weekend July 7th - 9th
07/06
IPAs, Hospitals & Trading Partners
UPDATES: 2023 IEHP Direct Stars Incentive Program Guide
07/06
IEHP Direct D-SNP Primary Care Providers (PCPs)
New UM Authorization Guidelines
07/05
All IPAs and Medical Directors
Dementia Care Aware Cognitive Health Assessment Training
07/05
All PCPs and IPAs
June 2023
URGENT: Recalls, Market Withdrawals & Safety Alerts, June 2023
06/30
All IEHP PCPs, All IEHP Pharmacy Providers
I-MEDIC and CMS Alerts: Providers Potential Inappropriate Billing
06/30
All Medicare IPAs
Revised UM Authorization Guideline
06/30
All IPAs, Medical Directors and Behavioral Health Providers
ACTION REQUIRED - 2023 Provider Satisfaction Survey begins July 5th!
06/30
All PCPs, Specialists, BH and IPAs
Three (3) New Community Supports Available for Members on July 1, 2023!
06/29
All PCPs, Specialists, BH and IPAs
NEW! Enhanced Care Management Reports Added to Provider Portal
06/29
IEHP Enhanced Care Management Providers
NEW! Preventative Care Combined Rosters and Reports
06/29
All Global Quality P4P PCPs
NEW: Populations of Focus Criteria for Enhanced Care Management Benefit
06/27
All Medi-Cal PCPs & IPAs
DHCS EVV Office Hours – July 6th, 11th, & 17th
06/26
All EVV Impacted Providers & Individual Nurse Providers
AND July 4rdIndependence Day Holiday – July 3th
06/26
All IEHP Providers & IPAs
2023 Global Quality P4P Program – Provider Directory Verification
06/22
All Global Quality P4P PCPs
Medi-Cal Renewal Date Does NOT Override Member’s Eligibility Status
06/15
All Medi-Cal PCPs & IPAs
Community Supports & Enhanced Care Management Webinar – July 12th!
06/14
All Community Supports, PCPs, Specialists, BH Providers
REMINDER - 2023 Global Quality P4P Program - CAIR2 Participation Requirement
06/13
All Global Quality P4P PCPs
Global Quality P4P PCP– 2023 Program Guide Update
06/13
All Global Quality P4P PCPs
Global Quality P4P IPA – 2023 Program Guide Update
06/13
All Medi-Cal IPAs
Dementia Care Aware Cognitive Health Assessment Training
06/12
All PCPs & IPAs
Juneteenth Holiday – Monday June 19th
06/12
All IEHP Providers and IPAs
URGENT! Recalls, Market Withdrawals & Safety Alerts, May 2023
06/09
All IEHP PCPs, All IEHP Pharmacy Providers
URGENT! First Deadline for Medi-Cal Renewal is June 30th
06/09
All PCPs, Specialists, BH and Vision Providers
May 2023 Pharmacy & Therapeutics Update
06/09
IEHP Provider Network
2023 Underutilization Reports Available - Comp Diabetes Care HbA1c Testing Measure Replaced
06/07
All IPAs
ACTION REQUIRED - 2023 HIV/AIDS Specialist Survey
06/07
All IEHP Direct PCPs & Specialists
Updates to AB 1184 - Confidential Communication of Medical Information Involving Sensitive Services
06/05
All Medi-cal Providers & IPAs
IPA Monthly Interim PM Changes
06/05
All IPAs
REMINDER: DHCS APL 23-010 -Behavioral Health Treatment Coverage for Members Under the Age of 21
06/05
All BHT Providers
sFTP Critical Vulnerability Detected!
06/02
All IPAs, Hospitals & SNFs
New DHCS Drug Use Review (DUR) Board Educational Articles
06/02
All PCPs & OB/GYNs
REMINDER - AB 1184 Confidential Communication Request (CCR), Effective June 2, 2023
06/01
Medi-Cal IPAs
Updated IEHP sFTP Retention Policy
06/01
EDI Trading Partners
May 2023
REMINDER – Review the Early Start Roster the Portal
05/30
All Medi-Cal IPAs and PCPs
ACTION REQUESTED: Empowering Members, Resolving Non-Compliance: Provider - Patient Collaboration
05/26
All PCPs, OBGYNs, & Pediatricians
NCQA Health Equity Race and Ethnicity Data Collection
05/26
All PCPs, Specialists, BH, BHT & Vision Providers
SAVE THE DATE - DHCS EVV Office Hours - June 6th, 12th & 30th
05/26
All EVV Impacted Providers & Individual Nurse Providers
UPDATE - PASRR Requirements for SNFs
05/25
Skilled Nursing Facilities
Reminder: Utilize Member Alternate Contact Information for AER Outreach!
05/25
All PCPs, Specialists & BH Providers
Weekly Sessions: Achieve IEHPs P4P MX Connectivity Measure - Deadline Approaching
05/24
All Medi-Cal PCPs
Month-End IEHP Outbound 834 File Update
05/24
IEHP 834 Trading Partners
REMINDER - DHCS Quarterly Timely Access Survey
05/23
All Medi-Cal PCPs, Specialists, BH & Ancillary
UPDATE - Independent Medical Review (IMR) Forms
05/23
All Medi-Cal IPAs
Memorial Day Holiday
05/22
All IEHP Providers and IPAs
UPDATE - PASRR Requirements for GACHs
05/19
All General Acute Care Hospitals
Provider Portal – Sub User Account Types and Access Levels
05/19
All IEHP Providers
UPDATE - PASRR Requirements for SNFs
05/19
All Skilled Nursing Facilities
APL 23-005 EPSDT
05/19
All Medi-Cal PCPs
APL 23-005 EPSDT
05/19
All Medi-Cal IPAs
Termination - SNF COVID-19 Per Diem Rate
05/17
All Skilled Nursing Facilities
2023 GQ P4P PCP - MX Deadline Reminder
05/17
All GQ P4P PCP Providers
Medicare P4P IEHP Direct Blood Pressure Control Billing Guidance
05/16
All Direct DualChoice PCPs
REMINDER - 2023 Global Quality P4P Program - CAIR2 Participation Requirement
05/15
All Medi-Cal PCPs
Notice – APL 23-004 (Supersedes APL 22-018) – Skilled Nursing Facilities – Long Term Care Benefit Standardization and Transition of Members to Managed Care
05/12
All Skilled Nursing Facilities
Behavioral Health Training Webinar – June 14, 2023
05/12
All BH Providers
Behavioral Health Treatment Training Webinar - June 7, 2023
05/12
All BHT Providers
Manifest MedEx Provider Listening Session
05/10
All PCPs, Specialists & IPAs
Pharmacy Recalls, Withdrawals & Safety Alerts for April 2023
05/10
All IEHP PCPs, All IEHP Pharmacy Providers
UPDATE-Treatment Authorization Process
05/10
All Skilled Nursing Facilities
IPA Monthly Interim PM Changes
05/08
All IPAs
NEW - Behavioral Health Transition of Care Tool Requirement
05/05
All PCPs & BH Providers
New COVID-19 Vaccine Status Alerts Added to the Provider Portal
05/05
All PCPs
SAVE THE DATE - DHCS EVV Office Hours - May 10th, 24th, 26th
05/05
EVV Impacted Providers & Individual Nurse Providers
NEW: Annual Medi-Cal Eligibility Renewal (AER) Roster Now Available to Download Under CSV!
05/04
All Medi-Cal PCPs & IPAs
REMINDER: Initial Health Appointment (IHA) Roster
05/04
Medi-Cal PCPs & IPAs
Notice - Release of APL 22-032 “Continuity of Care”
05/04
All IPAs
Retired/Revised - UM Authorization Guidelines
05/03
All IPA Administrators & Medical Directors
Global Quality P4P PCP – NEW 2023 Interim Reports
05/03
Medi-Cal PCPs & IPAs
ACTION REQUIRED - AB 1184 Delegate Response Due by May 9, 2023
05/02
Medi-Cal IPAs & Delegates
Phase III – Lift 3 - Medi-Cal Rx Transition Policy Change
05/02
Medi-Cal PCPs & Specialists
Care Management Monthly Medicare Log Templates & Attachments
05/01
Medicare IPAs
Care Management Monthly Medi-Cal Log Templates & Attachments
05/01
Medi-Cal IPAs
Maternal Wellness Event
05/01
OB/GYNs, BH, Hospitals, Medi-Cal PCPs & IPAs
IEHP Outbound Monthly 834 File Delay
05/01
834 Trading Partners
April 2023
REMINDER - IEHP Interpreter Service Benefit for Members!
04/28
All Providers & IPAs
Month-End IEHP Outbound 834 File Update
04/26
834 Trading Partners
Weekly Sessions - Achieve IEHPs P4P MX Connectivity Measure
04/25
All Medi-Cal PCPs
New! 2023 IEHP Direct Stars Incentive Program – Reports and Rosters
04/25
All Direct DualChoice PCPs
UPDATES - Global Quality P4P - IPA 2023 Program Guide
04/25
All Medi-Cal IPAs
UPDATES - Global Quality P4P - PCP 2023 Program Guide
04/25
All Medi-Cal PCPs
EVV CODE Changes Effective April 20
04/18
EVV Impacted Providers, Home Infusion Providers & Individual Nurse Providers
SAVE THE DATE - DHCS EVV Office Hours - April 24th & 27th
04/18
EVV Impacted Providers and Individual Nurse Providers
Now Live! Annual Medi-Cal Eligibility Renewal (AER) Alerts and Roster!
04/17
All Medi-Cal PCPs & IPAs
UPDATE - 2023 IEHP Direct Stars Incentive Program Guide
04/17
All Direct DualChoice PCPs
Care Plans and Health Risk Assessments (HRAs) Reminder
04/14
All PCPs, Specialists, SNFs and CBAs
REMINDER: 2023 Global Quality P4P Program - CAIR2 Participation Requirement
04/12
Medi-Cal PCPs
Weekly Sessions - Achieve IEHPs P4P MX Connectivity Measure
04/12
Medi-Cal PCPs
Choice90Rx Optimization Program
04/11
All DualChoice PCPs
UPDATE to eAuth (eReferral) Form - Referral Determination Date Goes Live!
04/11
Direct PCPs
Pharmacy Recalls - Withdrawals - Safety Alerts - January to March 2023
04/10
All IEHP PCPs & Pharmacy Providers
Phase III – Lift 1 - Medi-Cal Rx Transition Policy Change
04/10
All Medi-Cal PCPs & Specialists
The ABCs of ACOs (Accountable Care Organizations)
04/07
Physicians & Practice Administrators
POSTPONED - Addition of Referral Determination Date to e-Auth Form
04/07
Direct PCPs
UPDATE to eAuth (eReferral) Form - Referral Determination Date
04/06
Direct PCPs
Phone Number CORRECTION: IEHP Eligibility Renewal Support Team First Round of Yellow Medi-Cal Renewal Packets Mailed to Members!
04/06
Medi-Cal PCPs & IPAs
IEHP Outbound Daily 834 Delta File Delay
04/06
834 Trading Partners
2023 IEHP Direct Stars Incentive Program Kick Off Meeting
04/04
All Direct DualChoice PCPs
2023 IEHP DualChoice (HMO D-SNP) Plan Benefits
04/03
Medicare PCPs, Specialists, Vision Providers & IPAs
March 2023
New DHCS Drug Use Review (DUR) Board Educational Articles
03/31
All Medi-Cal PCPs & Specialists
IEHP DualChoice (HMO D-SNP): Known Billing Issue
03/31
All IEHP Pharmacy Providers
Pharmacy Recalls - Withdrawals - Safety Alerts - March 1-15, 2023
03/31
All IEHP PCPs & Pharmacy Providers
Pharmacy Recalls - Withdrawals - Safety Alerts - Dec 2022 to Feb 2023
03/31
All IEHP PCPs & Pharmacy Providers
Access Standards - Appointment Availability - BH
03/29
All BH Providers
Achieve IEHPs P4P MX Connectivity Measure - Weekly Sessions
03/29
All Medi-Cal PCPs
CMS Signature Requirement Guidelines for Member Medical Records
03/28
All PCPs, Specialists, BH Providers & IPAs
The PHE is ending - How Will this Affect your IEHP Members?
03/27
All Medi-Cal PCPs & IPAs
Month-End IEHP Outbound 834 File Update
03/27
All IEHP 834 Trading Partners
REMINDER – Action Required by March 31st - Blood Lead Survey
03/23
All Pediatricians, Family Practice & Community Clinics
REMINDER - IEHP Contracts with Call the Car for Transportation
03/23
All Hospital Administrators, SNFs & Dialysis Center
REVISED – UM Authorization Guidelines
03/22
All IPA Administrators, Medical Directors & BH Providers
Reminder Coordination of Care Reports and Rosters
03/21
All IPAs
2023 IEHP Direct Stars Incentive Program Guide Release
03/17
All Direct DualChoice PCPs
PHA - Increased Enteric Disease Activity - Shigella
03/17
All PCPs
Manifest MedEx Seminar - Achieve IEHP's MX Connectivity Quality Process Measure
03/17
All Medi-Cal PCPs
Phase III – Lift 1 - Medi-Cal Rx Transition Policy Change
03/16
All Medi-Cal PCPs & Specialists
RESPONSE REQUIRED – Provider Newsletter and Communication Survey
03/15
All PCPs, Specialists, Vision, BH & BHT Providers
REMINDER - 2023 Global Quality P4P Program - CAIR2 Participation Requirement
03/15
All Medi-Cal PCPs
Comprehensive Practice Optimization Workshop
03/15
All Riverside County PCPs
Medical Assistants: Enhancing Patient Safety & Reducing Liability Risks
03/15
All Riverside County PCPs
IEHP Coordination of Benefits Agreement (COBA) Implementation – Update
03/13
All PCPs, Specialists, Ancillary, & Hospitals
ACTION REQUIRED - Blood Lead Survey
03/13
All Pediatricians, Family Practice & Community Clinics
Opioid Attestation for Coverage Determinations and Removal of X-Waiver
03/10
All DualChoice Providers
Social Determinants of Health - Community Supports Services Referral Process
03/10
All PCPs, Behavioral Health Providers & IPAs
Complex Case Management (CCM) Program – Severe Chronic Conditions
03/08
All Medi-Cal IPAs, PCPs, Specialists, & Behavioral Health Providers
UPDATE - IEHP Coordination of Benefits Agreement (COBA) Implementation
03/07
All FQHCs, IHCs, & RHCs
REMINDER - Clean Claim Tool Guide Available
03/07
All Skilled Nursing Facilities
GQ P4P PCP – 2023 Program Guide Update - Social Determinates of Health Measure
03/03
All Medi-Cal PCPs
GQ P4P IPA – 2023 Program Guide Update - Social Determinates of Health Measure
03/03
All Medi-Cal IPAs
Encouraging Sexual History Taking for Patient Care and Partner Services
03/03
All PCPs
Encounter Data Submission Enhancements – Live Now!
03/02
All Direct PCPs
IEHP Global Quality P4P Manifest MedEx (MX) FAQs
03/02
All Medi-Cal PCPs & IPAs
Riverside County Medical Association - Physician Burnout Webinar
03/02
All Riverside and San Bernardino County PCPs
Riverside County Medical Association's 19th Annual Cruisin' Thru CME
03/02
All Riverside County PCPs
February 2023
CMS Alert - Fraudulent Activities and Monitoring Recommendations
02/28
All Medicare IPAs
Update to D-SNP Letter Template
02/24
All Medicare IPAs
Alternate Contact Information for Members Now Available!
02/23
All PCPs
Alzheimer's and Dementia Seminar (ECHO) - Beginning March 29th
02/23
All PCPs
Month-End IEHP Outbound 834 File Update
02/23
834 Trading Partners
RESPONSE REQUESTED – Provider Newsletter and Communication Survey
02/21
All PCPs, Specialists, Vision, BH and BHT Providers
UPDATE - Referral Timeline Standards for IEHP DualChoice (HMO D-SNP) Members
02/21
All Medicare IPAs
Skinny Gene Project - Diabetes Prevention Program (DPP)
02/21
All PCPs
Protocols for Emergency and Post-Stabilization Care for IEHP Members
02/17
All Hospitals
REMINDER - 2023 Global Quality P4P Program - CAIR2 Participation Requirement- PCPs
02/16
All Medi-Cal PCPs
Last Phase - Medi-Cal Rx Reinstatement of PAs for 46 Drug Classes, Including Medical Supplies - Eff. February 24th
02/14
All Medi-Cal PCPs & Specialists
Presidents' Day Holiday
02/13
All IEHP Providers & IPAs
RESPONSE REQUIRED – Provider Newsletter and Communication Survey
02/13
All PCPs, Specialists, Vision, BH and BHT Providers
New Provider Portal Alert - Inpatient Discharges
02/09
All PCPs
Quality Bonus Services RA’s Now Available!
02/09
All Medi-Cal PCPs
Ask DHCS – Open Office Hours for EVV Home Health Care Services – February 17, 2023
02/03
All EVV Impacted Providers & Individual Nurse Practitioners
UPDATE – Initial Health Appointment and Retirement of IHEBA/SHA
02/02
All Medi-Cal PCPs & IPAs
Transition to 30-day Coverage Determination Backdating
02/02
All LTC & SNF Providers
Redlands Community Hospital – Behavioral Health Unit Closed
02/01
All PCPs & BH Providers
UPDATE - Independent Medical Review Form
02/01
All Medicare IPAs
January 2023
KidsVaxGrant 3.0 Deadline to Apply is February 17, 2023
01/31
All Pediatricians and Family Practice PCPs
Effective February 1, 2023 - Call The Car Will Replace American Logistics Company (ACL) for ALL Member Transportation
01/31
All PCPs, Specialists, BH & IPAs
Provider Manual Acknowledgement of Receipt (AOR) Winners
01/27
All Providers
Crisis Recovery Resource Guide and Toolkit Available
01/27
All Community Support Services
REMINDER - BHT Providers Must Submit Exit Reports and Exit Letters!
01/27
All BHT (QASP) Providers
D-SNP Model of Care Incentive Program - 2023 Program Guide Release
01/26
All Medicare IPAs
Help Protect Members - Flu Vaccine Reminder
01/25
All PCPs
2023 Global Quality P4P PCP Kick Off Meeting
01/25
All Medi-Cal PCPs
2023 Global Quality P4P IPA Kick Off Meeting
01/25
All IPAs
An ECHO Learning Opportunity - Alzheimer's And Dementia Care - Weekly Sessions Begin Feb 16th
01/24
All PCPs
REMINDER - 2023 Global Quality P4P Program - CAIR2 Participation Requirement- PCPs
01/23
All Medi-Cal PCPs
REMINDER - 2023 Global Quality P4P Program - CAIR2 Participation Requirement- IPAs
01/23
All Medi-Cal IPAs
Response Requested by Thursday, January 26! - CBAS Emergency Remote Services (ERS)
01/23
All CBAS Providers
Global Quality P4P PCP Program - 2023 Program Guide Release
01/19
All Medi-Cal PCPs
UPDATE! Medi-Cal Letter Templates
01/17
All Medi-Cal IPAs
Emergency Resource Guide and Services – Flooding Services Available!
01/17
All Community Support Services Providers
Medicare P4P IEHP Direct – Blood Pressure Control Billing Guidance
01/13
All DualChoice PCPs
NEW! Regulatory Submission Response Files – MAO-004 XWalk
01/13
All Medicare IPAs
ALERT! 837 SBR04 Encounter Data Requirement Changes
01/13
All Medicare IPAs
IEHP DualChoice (D-SNP) Model of Care Training Requirement
01/12
All DualChoice Hospitals
IEHP DualChoice (D-SNP) Model of Care Training Requirement
01/10
All Medicare IPAs
IEHP DualChoice (D-SNP) Model of Care Training Requirement
01/10
All DualChoice Providers
IEHP Outbound 834 File Update
01/10
All 834 Trading Partners
IEHP HOLIDAY - Martin Luther King Jr. Day
01/09
All IEHP Providers
CORRECTION to Changes to Quarterly Workplan Requirements
01/05
All Medicare IPAs
LAST CHANCE to Win a $50 Gift Card - Submit 2023 Provider Policy and Provider Manual Acknowledgement of Receipt (AOR)
01/04
All IEHP Providers
2023 Population Health Management Academy
01/04
All Riverside County PCPs
CORRECTION - 2022 GQ P4P PCP - Quality Bonus Services Code Update
01/03
All Medi-Cal PCPs
December 2022
Outbound Eligibility File Delay on January 1, 2023
12/29
All IPAs and Ancillary Providers
REMINDER - CoverMyMeds - Prior Authorization Submission Method for Dual Choice Members– Effective January 1, 2023
12/29
All Dual Choice PCPs & Specialists
REMINDER - Pharmacy Benefits Manager (PBM) Change for DualChoice (HMO D-SNP) - Member Outreach in Process
12/29
All Dual Choice PCPS and Medicare IPAs
Access Standards – Appointment Availability - BH Providers
12/28
All Behavioral Health Providers
Mandatory Managed Care Enrollment (MMCE) Phase II - January 1, 2023
12/27
All Medi-Cal PCPs & Specialists
Access Standards – Appointment Availability - PCPs & OB/GYNs
12/27
All PCPs & OB/GYNs
Access Standards – Appointment Availability - Specialists
12/27
All Specialists
NEW! State Fair Hearing and Independent Medical Review Forms added to D-SNP Letter Templates (Effective January 2, 2023)
12/27
All Medicare IPAs
REMINDER - Help Your Members Update Their Contact Information!
12/22
All PCPs
2022 GQ P4P PCP - Quality Bonus Services Code Update
12/22
All Medi-Cal PCPs & IPAs
UPDATED! D-SNP Letter Templates (Effective January 2, 2023)
12/21
All Medicare IPAs
Phase II Wave I– Prior Authorization Submission – January 20, 2023
12/21
Medi-Cal PCPs & Specialists
Crossing the Line - Examining Professional, Personal, & Ethical Boundaries
12/21
Riverside County PCPs & Specialists
IEHP Outbound Daily 834 Delta File Delay
12/20
All 834 Trading Partners
Revised UM Authorization Guidelines
12/19
All IPA Administrators & Medical Directors
REMINDER - IEHP DualChoice (HMO D-SNP) begins Jan 2023
12/19
All Medicare PCPs, Specialists & BH Providers
OB P4P Program - Early Postpartum Visit Update
12/19
All Medi-Cal OB/GYNs
My Life. My Choice. - An Online Advanced Care Planning Program
12/16
All Dual Choice PCPs
REMINDER - CoverMyMeds - Prior Authorization Submission Method for Dual Choice Members– Effective January 1, 2023
12/16
All Dual Choice PCPs & Specialists
IEHP 2022-2023 Holiday Hours
12/15
All Providers & IPAs
2022 Global Quality P4P Program – Data Submission Deadlines for PCPs!
12/15
All Medi-Cal PCPs
2022 Global Quality P4P Program – Data Submission Deadlines for IPAs!
12/15
All Medi-Cal IPAs
CORRECTION– New Fax Number for Physician Certification Statements for Non-Emergency Medical Transportation
12/09
All Hospitals and SNFs
Medicare Formulary Changes for 2023 IEHP DualChoice (HMO D-SNP)
12/08
All Medicare PCPs, Specialists & IPAs
Pharmacy Recalls, Withdrawals & Safety Alerts - November 2022
12/07
All PCPs
REMINDER - Physician Certification Statement (PCS) Requirement
12/06
All PCPs, Specialists, BH & IPAs
EVV Home Health Care Services Open Office Hours – December 16th
12/06
EVV Impacted Providers & Individual Nurse Practitioners
Mpox (formerly Monkeypox) Vaccine Available through Local Health Departments
12/05
All Medi-Cal PCPs & IPAs
IMPORTANT! DHCS Error – Members Will NOT be Disenrolled From IEHP
12/05
All Medicare PCPs & IPAs
Global Quality P4P PCP – 2022 Program Guide Update (Quality Bonus Services)
12/05
All Medi-Cal PCPs
The Alzheimer's Association Event - Resources for Improving Dementia Care in the Clinical Practice
12/02
All PCPs
CoverMyMeds - Prior Authorization Submission Method for Dual Choice Members– Effective January 1, 2023
12/02
All Dual Choice PCPs
REMINDER - IEHP Dual Choice (HMO D-SNP) begins Jan 2023
12/02
All Medicare PCPs, Specialists & BH Providers
Response Requested by December 6, 2022! - CBAS Emergency Remote Services - Reporting
12/02
All CBAS Providers
IEHP Formulary Changes - November P&T Update
12/02
All PCPs
November 2022 Pharmacy and Therapeutics Subcommittee Update
12/02
All PCPs
NEW! D-SNP Letter Templates - Claims (Effective January 2, 2023)
12/02
All Medicare IPAs
Effective Today! - IEHP Contracts with Call The Car For Transportation
12/01
All Hospitals & SNFs
COVID-19 Isolation in SNF
12/01
All SNFs
Living the Mission Awards Nomination Form
12/01
All IEHP Providers
November 2022
Inland Empire Community Health Assessment
11/30
All PCPs, IPAs, Specialists, & Behavioral Health Providers
Pharmacy Benefits Manager (PBM) Change for DualChoice (HMO D-SNP) - Member Outreach in Process
11/29
All DualChoice PCPs & Medicare IPAs
ID Cards with Errors Reissued to Dual Choice Members
11/23
Select Dual Choice PCPs
Inland Caregiver Resource Center Informational Webinar - ECHO
11/23
All PCPs
IEHP’s Quarterly Behavioral Health Provider Training
11/18
All Behavioral Health (BH) Providers
Thanksgiving Holiday
11/18
All IEHP Providers
IEHP Outbound Daily 834 Delta File Delay
11/18
All 834 Trading Partners
CoverMyMeds - Prior Authorization Submission Method for Dual Choice Members– Effective January 1, 2023
11/17
All IEHP DualChoice PCPs
IEHP DualChoice (HMO D-SNP) 2023 Vision Benefits
11/17
All Vision Providers
Riverside County Medical Association's Physician Holiday Social
11/17
All Riverside County PCPs & Specialists
RUHS - PHA - Early Respiratory Syncytial Virus (RSV) and Seasonal Influenza Activity
11/17
All Riverside County PCPs
Global Quality P4P PCP Meeting - 2023 Program Preview
11/16
All Medi-Cal PCPs
BHT (QASP) Provider Training
11/15
All BHT (QASP) Providers
Reminder - BH Emergency Instruction Standards
11/15
All BH Providers
Reminder - PCP and Specialist Emergency Instruction Standards
11/15
All PCPs & Specialists
UPDATE! D-SNP Letter Templates (Effective January 2, 2023)
11/15
All Medicare IPAs
UPDATE - Revised UM Authorization Guidelines to November 3, 2022 - UM-BH 08
11/14
All Medi-Cal IPAs & BHT Providers
Pharmacy Recalls, Withdrawals & Safety Alerts - October 2022
11/14
All PCPs
REMINDER: IEHP DualChoice (HMO D-SNP) begins Jan 2023
11/10
All Medicare PCPs, Specialists & BH Providers
REMINDER: Help Your Members Update Their Contact Information!
11/10
All IEHP PCPs
Maternal Wellness Event Flyer
11/09
All Medi-Cal PCPs, OB/GYNs, Peds, BH Providers & IPAs
Essure System - No Longer a Covered Benefit
11/09
All OB/GYNs
ACTION REQUIRED -Submit 2023 Provider Policy and Provider Manual Acknowledgement of Receipt (AOR) - Win a $50 Gift Card
11/08
All IEHP Providers
Veterans Day
11/04
All IEHP Providers & IPAs
Revised UM Authorization Guidelines
11/03
All BH Providers & IPAs
Pharmacy Recalls, Withdrawals & Safety Alerts - September 2022
11/02
All PCPs
October 2022
Medicare - Nondiscrimination Notice and Taglines Templates
10/31
All Medicare IPAs
REMINDER: IEHP Interpreter Services – A Covered Benefit!
10/31
All PCPs & IPAs
Continuous Glucose Monitors
10/28
All Medicare PCPs, Endocrinologists & IPAs
Health Education Classes Available in Riverside Area
10/27
All Riverside Area PCPs, Specialists & OBs
PHA - Outbreak of Ebola Virus Disease Due to Sudan Virus in Central Uganda
10/25
All Riverside County PCPs
834 Eligibility File Format Changes
10/25
All IHEP 834 Trading Partners
Global Quality P4P IPA Meeting – 2023 Program Preview
10/21
All Medi-Cal IPAs
REMINDER DHCS Hospice Rates – Prospective Calculation Based on Medicaid Rates
10/21
All Hospice Providers
NEW! D-SNP Letter Templates (Effective January 2, 2023)
10/21
All Medicare IPAs
Help Protect Your Members Against the Flu
10/20
All PCPs & IPAs
Public Health Emergency (PHE) Ending Soon – Help Your Members Reenroll!
10/19
All IEHP PCPs
REMINDER - Balance Billing of IEHP Members Not Permitted!
10/14
All IEHP Providers
ACTION REQUIRED - Correct Prioritization of Authorization Requests
10/14
All PCPs, Specialists & IPAs
Global Quality P4P PCP Meeting – 2023 Program Preview
10/13
All Medi-Cal PCPs
Flu Vaccine Notice -Access to Pharmacy Vaccine Network
10/13
All PCPs
Cal MediConnect Sunsets and IEHP Dual Choice (D-SNP) Begins
10/12
All PCPs
Academic Detailing Services Now Offered
10/11
All IEHP Providers & Pharmacies
REMINDER - ACTION REQUIRED - Electronic Visit Verification (EVV) Implementation Requirements – Self Registration Required by October 19, 2022
10/10
All Home Health Care Services (HHCS) Providers & Personal Care Services (PCS)
UPDATE - Independent Medical Review (IMR) Forms
10/10
All Medicare IPAs
UPDATE to September 8, 2022 Communication Authorization Timeframes
10/6
All Medi-Cal IPAs
Special Fraud Alert - Exercise Caution with Purported Telemedicine Companies
10/6
All IEHP Providers & IPAs
FAQs For Delegate Monitoring of Utilization Measures
10/5
All IPAs
September 2022
Global Quality P4P Programs – NEW 2022 Quality Bonus Services!
09/30
All Medi-Cal PCPs
Diversity Awareness Month - October 2022 - Please Join Us!
09/30
All IEHP Providers & IPAs
REMINDER - IEHP Coordination of Benefits Agreement (COBA) Implementation – Action Required!
09/30
All PCPs, Specialists, ANC & Hospitals
ICD-10-CM Risk Adjustment Code Changes for CMS HCC Code Capture
09/26
All Direct Dual Choice PCPs
UPDATE! – Continuous Glucose Monitoring (CGM) Systems (IPA)
09/23
All Medi-Cal IPAs
UPDATE! – Continuous Glucose Monitoring (CGM) Systems
09/22
All Medi-Cal PCPs & Endocrinologists
ACTION REQUIRED - Electronic Visit Verification (EVV) Implementation Requirements – Self Registration Required by October 19, 2022
09/22
All Home Health Care Services (HHCS) Providers & Personal Care Services (PCS)
UPDATED Medi-Cal Letter Templates
09/22
All Medi-Cal IPAs
URGENT ATTENTION: Phishing Email Alert
09/21
All IEHP Providers
Pharmacy Times - Medication Reconciliation
09/21
All Dual Choice PCPs
Grievance Process Updates - Grievance Summary Form - Due Date
09/15
All IPAs
Continuity of Care (COC) Rosters Now Available on SFTP
09/15
All IPAs
REMINDER - Enhanced Care Management Available for Members
09/15
All Medi-Cal ANC and Vision Providers
Coordination of Benefits Agreement (COBA) Implementation - Action Required
09/12
All PCPs, Specialists, ANC & Hospitals
REMINDER - Dilated Retinal Exam (DRE) for Diabetic Members
09/09
All PCPs & Vision Providers
Revised UM Authorization Guidelines
09/09
All IPA Administrators & Medical Directors
Annual BH&CM Medi-Cal IPA Training Survey
09/08
All Medi-Cal IPA Care Management Staff
IEHP Provider Portal Updates – Reports now Viewable by TIN
09/08
All Medi-Cal PCPs
NEW - Collecting Social Determinants of Health Data (SDOH)
09/08
All Medi-Cal PCPs, Specialists & BH Providers
Authorization Timeframes Notice of Action (NOA) Translation & Attachment
09/08
All Medi-Cal IPAs
Please Notify IEHP if Your Availability has Changed due to Area Fires
09/08
All Hemet and Big Bear Area Providers
Recalls, Withdrawals & Safety
09/08
All IEHP Providers & Pharmacies
IEHP Formulary Changes (P&T)
09/07
All IEHP PCPs
Access Standards - Appointment Availability - Specialists
09/02
All Specialists
Access Standards - Appointment Availability - PCP, Ob
09/02
All PCPs & Obs
Access Standards - Appointment Availability - BH
09/02
All Behavioral Health Providers
Vaccination Clinic and Resource Fair - September 10
09/02
All Direct PCPs
IEHP Medi-Cal Medical Benefit Formulary
09/02
All Medi-Cal PCPs, Specialists & Psychiatrists
August 2022 P&T Update
09/02
All IEHP Providers & Pharmacies
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 - 2023 Plan Benefits
ou will pay:
Benefits
Doctor Visit: $0
Vision Care: $350 limit every year for contact lenses and eyeglasses (frames and lenses) -->
Vision care: Up to $350 limit every twelve months for eyeglasses (frames). Lenses are separately reimbursable based on prior approval and medical necessity.
Contact Lenses are covered up to $350 every twelve months in lieu of eyeglasses (Lenses and Frames).
Inpatient Hospital Care: $0
Home Health Agency Care: $0
Ambulance Services: $0
Transportation: $0. Including bus pass. Call our transportation vendor Call the Car (CTC) at (866) 880-3654, for TTY users, call your relay service or California Relay Service at 711. For reservations call Monday-Friday, 7am-6pm (PST). Call at least 5 days before your appointment.
Diagnostic Tests, X-Rays & Lab Services: $0
Durable Medical Equipment: $0
Home and Community Based Services (HCBS): $0
Community Based Adult Services (CBAS): $0
Long Term Care that includes custodial care and facility: $0
Utilities allowance of $40 for covered utilities. You must qualify for this benefit.
You pay nothing for a one-month or long term-supply of drugs
With IEHP DualChoice, you pay nothing for covered drugs as long as you follow the plan’s rules.
Tier 1 drugs are: generic, brand and biosimilar drugs. They have a copay of $0.
After your coverage begins with IEHP DualChoice, you must receive medical services and prescription drug services in the IEHP DualChoice network.
To learn more about the plan’s benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook.
2023 Summary of Benefits (PDF)
2023 Annual Notice of Changes (PDF)
2023 IEHP DualChoice Member Handbook (PDF)
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy of Adobe Acrobat Reader.By clicking on this link, you will be leaving the IEHP DualChoice website.
Plan Premium
With "Extra Help," there is no plan premium for IEHP DualChoice.
Plan Deductible
There is no deductible for IEHP DualChoice.
Because you are eligible for Medi-Cal, you qualify for and are getting “Extra Help” from Medicare to pay for your prescription drug plan costs. You do not need to do anything further to get this Extra Help.
You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, you can contact:
1-800-MEDICARE (1-800-633-4227). , TTY users should call (877) 486-2048, 24 hours a day/7days a week
The Social Security Office at (800) 772-1213 between 7 a.m. and 7 p.m., Monday through Friday, TTY users should call (800) 325-0778; or
Your State Medicaid Office
How to get care coordination
Do you need help getting the care you need? A care team can help you. A care team may include your doctor, a care coordinator, or other health person that you choose. A care coordinator is a person who is trained to help you manage the care you need. You will get a care coordinator when you enroll in IEHP DualChoice. This person will also refer you to community resources, if IEHP DualChoice does not provide the services that you need.
To speak with a care coordinator, please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347.
Prior Authorization and Out of Network Coverage
What kinds of medical care and other services can you get without getting approval in advance from your Primary Care Provider (PCP) in IEHP DualChoice (HMO D-SNP)? You can get services such as those listed below without getting approval in advance from your Primary Care Provider (PCP).
Routine women’s health care, which includes breast exams, screening mammograms (X-rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider.
Flu shots as long as you get them from a network provider.
Emergency services from network providers or from out-of-network providers.
Urgently needed care from in-network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible, e.g., when you are temporarily outside of the plan’s service area.
Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area. (If possible, please call IEHP DualChoice Member Services before you leave the service area so we can help arrange for you to have maintenance dialysis while you are away.)
How to get care from specialists and other network providers
A specialist is a doctor who provides health care services for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples:
Oncologists care for patients with cancer.
Cardiologists care for patients with heart conditions.
Orthopedists care for patients with certain bone, joint, or muscle conditions.
You will usually see your PCP first for most of your routine healthcare needs such as physical checkups, immunization, etc. When your PCP thinks that you need specialized treatment or supplies, your PCP will need to get prior authorization (i.e., prior approval) from your Plan and/or medical group. This is called a referral. Your PCP will send a referral to your plan or medical group. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. If you don’t have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself. PCPs are usually linked to certain hospitals and specialists. When you choose a PCP, it also determines what hospital and specialist you can use.
What if a specialist or another network provider leaves our plan?
Sometimes a specialist, clinic, hospital or other network provider you are using might leave the plan. When a provider leaves a network, we will mail you a letter informing you about your new provider. If you prefer a different one, please call IEHP DualChoice Member Services and we can assist you in finding and selecting another provider.
How to get care from out-of-network providers
When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. In order to receive out-of-network services, your Primary Care Provider (PCP) or Specialist must submit a referral request to your plan or medical group. All requests for out-of-network services must be approved by your medical group prior to receiving services.
IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. This is not a complete list.
Information on this page is current as of October 1, 2022.
H8894_DSNP_23_3241532_M
IEHP DualChoice - Quyền Lợi của Chương Trình năm 2023
ou will pay:
Benefits
Doctor Visit: $0
Vision Care: a combined limit of $350 each year for contact lenses and/or eyeglasses (frames).
Inpatient Hospital Care: $0
Home Health Agency Care: $0
Ambulance Services: $0
Transportation: $0. Including bus pass. Call the Car (CTC) at 1-855-673-3195, 24 hours a day, 7 days a week. For TTY users, call your relay service or California Relay Service at 711. For reservations call Monday-Friday, 7am-6pm (PST). Call at least 5 days before your appointment.
Diagnostic Tests, X-Rays & Lab Services: $0
Durable Medical Equipment: $0
Home and Community Based Services (HCBS): $0
Community Based Adult Services (CBAS): $0
Long Term Care that includes custodial care and facility: $0
Utilities allowance of $65 for covered utilities. You must qualify for this benefit.
Over the Counter (OTC) items allowance of $40 per quarter (every 3 months) towards the purchase of certain Over the Counter (OTC) items.
You pay nothing for a one-month or long term-supply of drugs
With IEHP DualChoice, you pay nothing for covered drugs as long as you follow the plan’s rules.
Tier 1 drugs are: generic, brand and biosimilar drugs. They have a copay of $0.
After your coverage begins with IEHP DualChoice, you must receive medical services and prescription drug services in the IEHP DualChoice network.
To learn more about the plan’s benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook.
2024 Summary of Benefits (PDF)(Coming soon)
2024 Annual Notice of Changes (PDF)
2024 IEHP DualChoice Member Handbook (PDF) (Coming soon)
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here. By clicking on this link, you will be leaving the IEHP DualChoice website.
Plan Premium
There is a monthly premium of $0-$41.00 for IEHP DualChoice. You may qualify for “Extra Help” which can help reduce your monthly premium.
Plan Deductible
There is no deductible for IEHP DualChoice.
Because you are eligible for Medi-Cal, you qualify for and are getting “Extra Help” from Medicare to pay for your prescription drug plan costs. You do not need to do anything further to get this Extra Help.
You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, you can contact:
1-800-MEDICARE (1-800-633-4227). , TTY users should call (877) 486-2048, 24 hours a day/7days a week
The Social Security Office at (800) 772-1213 between 7 a.m. and 7 p.m., Monday through Friday, TTY users should call (800) 325-0778; or
Your State Medicaid Office
How to get care coordination
Do you need help getting the care you need? A care team can help you. A care team may include your doctor, a care coordinator, or other health person that you choose. A care coordinator is a person who is trained to help you manage the care you need. You will get a care coordinator when you enroll in IEHP DualChoice. This person will also refer you to community resources, if IEHP DualChoice does not provide the services that you need.
To speak with a care coordinator, please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347.
Prior Authorization and Out of Network Coverage
What kinds of medical care and other services can you get without getting approval in advance from your Primary Care Provider (PCP) in IEHP DualChoice (HMO D-SNP)? You can get services such as those listed below without getting approval in advance from your Primary Care Provider (PCP).
Routine women’s health care, which includes breast exams, screening mammograms (X-rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider.
Flu shots as long as you get them from a network provider.
Emergency services from network providers or from out-of-network providers.
Urgently needed care from in-network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible, e.g., when you are temporarily outside of the plan’s service area.
Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area. (If possible, please call IEHP DualChoice Member Services before you leave the service area so we can help arrange for you to have maintenance dialysis while you are away.)
How to get care from specialists and other network providers
A specialist is a doctor who provides health care services for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples:
Oncologists care for patients with cancer.
Cardiologists care for patients with heart conditions.
Orthopedists care for patients with certain bone, joint, or muscle conditions.
You will usually see your PCP first for most of your routine healthcare needs such as physical checkups, immunization, etc. When your PCP thinks that you need specialized treatment or supplies, your PCP will need to get prior authorization (i.e., prior approval) from your Plan and/or medical group. This is called a referral. Your PCP will send a referral to your plan or medical group. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. If you don’t have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself. PCPs are usually linked to certain hospitals and specialists. When you choose a PCP, it also determines what hospital and specialist you can use.
What if a specialist or another network provider leaves our plan?
Sometimes a specialist, clinic, hospital or other network provider you are using might leave the plan. When a provider leaves a network, we will mail you a letter informing you about your new provider. If you prefer a different one, please call IEHP DualChoice Member Services and we can assist you in finding and selecting another provider.
How to get care from out-of-network providers
When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. In order to receive out-of-network services, your Primary Care Provider (PCP) or Specialist must submit a referral request to your plan or medical group. All requests for out-of-network services must be approved by your medical group prior to receiving services.
IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. This is not a complete list.
Information on this page is current as of October 01, 2023.
H8894_DSNP_24_4164896_M Pending Accepted
IEHP DualChoice - Than Phiền
quan đến: Chất lượng dịch vụ chăm sóc y tế của quý vị Tôn trọng quyền riêng tư của quý vị Thiếu tôn trọng, dịch vụ khách hàng kém hoặc các hành vi tiêu cực khác Khả năng tiếp cận thực tế Thời gian chờ đợi Độ sạch Thông tin quý vị nhận được từ chương trình của chúng tôi Tiếp cận ngôn ngữ Thông báo từ chúng tôi Tính kịp thời cho các hành động tôi liên quan đến các quyết định bảo hiểm hoặc kháng nghị Cách nộp Đơn Khiếu Nại cho IEHP DualChoice (HMO D-SNP) 1. Liên hệ ngay với chúng tôi – gọi cho IEHP DualChoice theo số (877) 273-IEHP (4347), 8 giờ sáng - 8 giờ tối, 7 ngày một tuần, kể cả ngày nghỉ. Người dùng TTY xin gọi 1-800-718-4347. Quý vị có thể nộp đơn khiếu nại bất kỳ lúc nào trừ khi có liên quan đến thuốc Phần D. Nếu than phiền về thuốc Phần D, quý vị phải nộp đơn than phiền trong vòng 60 ngày theo lịch sau khi quý vị gặp vấn đề mà quý vị muốn than phiền. Nếu quý vị không muốn gọi điện (hoặc quý vị đã gọi nhưng không hài lòng), thì quý vị có thể viết đơn than phiền và gửi cho chúng tôi. Nếu quý vị viết đơn than phiền, thì chúng tôi sẽ phản hồi đơn than phiền của quý vị. Quý vị có thể sử dụng "Biểu Mẫu Than Phiền và Kháng Nghị dành cho Hội Viên". Tất cả các phòng khám của bác sĩ và nhà cung cấp dịch vụ của chúng tôi đều có biểu mẫu này hoặc chúng tôi có thể gửi biểu mẫu cho quý vị qua đường bưu điện. Quý vị có thể nộp đơn khiếu nại trực tuyến. Quý vị có thể nộp biểu mẫu hoàn chỉnh cho nhà cung cấp của Chương Trình hoặc gửi biểu mẫu cho chúng tôi theo địa chỉ dưới đây hoặc fax biểu mẫu hoàn chỉnh đến số fax dưới đây. Biểu mẫu này là dành cho IEHP DualChoice cũng như các chương trình khác của IEHP. IEHP DualChoice P.O. Box 1800 Rancho Cucamonga, CA 91729-1800 Fax: (909) 890-5877 Dù quý vị gọi điện hay viết thư, quý vị cần liên hệ ngay với Dịch Vụ Hội Viên IEHP DualChoice. 2. Chúng tôi sẽ xem xét đơn than phiền của quý vị và phản hồi lại cho quý vị. Chúng tôi sẽ phản hồi ngay nếu có thể. Nếu quý vị gọi điện cho chúng tôi để than phiền, thì chúng tôi có thể phản hồi quý vị ngay trong cuộc gọi đó. Nếu tình hình sức khỏe của quý vị cần phản hồi nhanh, thì chúng tôi sẽ thực hiện việc đó. Hầu hết các than phiền đều được phản hồi trong 30 ngày theo lịch. Nếu chúng tôi cần thêm thông tin và phản hồi chậm vì lợi ích tốt nhất của quý vị hoặc nếu quý vị cần thêm thời gian, thì chúng tôi có thể mất thêm 14 ngày (tổng cộng là 44 ngày) để phản hồi than phiền của quý vị. Nếu chúng tôi không đồng ý với một số hoặc tất cả than phiền của quý vị hoặc không có trách nhiệm với vấn đề quý vị đang than phiền, thì chúng tôi sẽ thông báo cho quý vị. Phản hồi của chúng tôi sẽ bao gồm lý do cho câu trả lời này. Chúng tôi phải phản hồi dù có đồng ý với than phiền của quý vị hay không. Khiếu Nại Nhanh Nếu quý vị nộp đơn than phiền vì chúng tôi từ chối yêu cầu “quyết định bảo hiểm nhanh” hoặc kháng nghị nhanh của quý vị, thì chúng tôi sẽ tự động xử lý than phiền “nhanh” cho quý vị. Nếu quý vị có than phiền “nhanh”, thì có nghĩa là chúng tôi sẽ phản hồi quý vị trong vòng 24 giờ. Ai có thể nộp đơn khiếu nại? Quý vị hoặc người quý vị chọn có thể nộp đơn khiếu nại. Người quý vị chọn sẽ là “người đại diện” cho quý vị. Quý vị có thể chọn người thân, bạn bè, luật sư, người biện hộ, bác sĩ hoặc bất kỳ ai khác làm người đại diện cho quý vị. Những người khác có thể đã được Tòa án hoặc theo luật của Tiểu Bang ủy quyền để đại diện cho quý vị. Nếu quý vị muốn ai đó đại diện cho mình mà người đó chưa được Tòa Án hoặc theo luật Tiểu Bang ủy quyền, thì quý vị và người đó phải ký tên và ghi rõ ngày tháng vào một tuyên bố cho phép người đó được phép làm người đại diện hợp pháp của quý vị. Để tìm hiểu cách chọn người đại diện, quý vị có thể gọi điện cho Ban Dịch Vụ Hội Viên IEHP DualChoice. Than Phiền Bên Ngoài Quý vị có thể thông báo cho Medicare về than phiền của quý vị Quý vị có thể gửi đơn than phiền của mình cho Medicare. Biểu Mẫu Than Phiền của Medicare có tại: https://www.medicare.gov/MedicareComplaintForm/home.aspx. Medicare sẽ xem xét cẩn thận than phiền của quý vị và sẽ sử dụng thông tin này để giúp cải thiện chất lượng chương trình của Medicare. Nếu quý vị có bất kỳ ý kiến phản hồi hoặc quan ngại nào khác, hoặc nếu quý vị cảm thấy chương trình không giải quyết được vấn đề của quý vị, vui lòng gọi đến số (800) MEDICARE (800) 633-4227). TTY/TDD (877) 486-2048. Cuộc gọi được miễn phí. Quý vị có thể thông báo với Medi-Cal về than phiền của quý vị Văn Phòng Thanh Tra cũng giúp giải quyết các vấn đề từ quan điểm trung lập để đảm bảo rằng các hội viên của chúng tôi nhận được tất cả các dịch vụ được bao trả mà chúng tôi phải cung cấp. Văn Phòng Thanh Tra không liên quan đến chúng tôi hoặc bất kỳ công ty bảo hiểm hoặc chương trình bảo hiểm y tế nào. Số điện thoại của Văn Phòng Thanh Tra là 1-888-452-8609. Các dịch vụ được cung cấp miễn phí. Quý vị có thể thông báo cho Sở Chăm Sóc Sức Khỏe Có Quản Lý của California về than phiền của quý vị Sở Chăm Sóc Sức Khỏe Có Quản Lý của California (DMHC) có trách nhiệm quản lý các chương trình bảo hiểm y tế. Quý vị có thể gọi điện cho Trung Tâm Hỗ Trợ của DMHC để được hỗ trợ than phiền về các dịch vụ của Medi-Cal. Quý vị có thể liên hệ với DMHC nếu quý vị cần được hỗ trợ về than phiền liên quan đến một vấn đề khẩn cấp hoặc than phiền liên quan đến một mối đe dọa tức thời và nghiêm trọng đến sức khỏe của quý vị, quý vị không đồng ý với quyết định của chương trình chúng tôi về than phiền của quý vị hoặc chương trình của chúng tôi không giải quyết được than phiền của quý vị sau 30 ngày theo lịch. Dưới đây là hai cách để nhận hỗ trợ từ Trung Tâm Hỗ Trợ: Gọi đến số (888) 466-2219, TTY (877) 688-9891. Cuộc gọi được miễn phí. Truy cập trang web của Sở Chăm Sóc Sức Khỏe Có Quản Lý: http://www.dmhc.ca.gov/ Quý vị có thể nộp đơn than phiền cho Văn Phòng Quyền Công Dân Quý vị có thể gửi đơn than phiền đến Văn Phòng Quyền Công Dân của Sở Dịch Vụ Sức Khỏe và Nhân Sinh nếu quý vị cho rằng quý vị không được đối xử công bằng. Ví dụ: quý vị có thể nộp đơn than phiền về khả năng tiếp cận cho người khuyết tật hoặc hỗ trợ ngôn ngữ. Số điện thoại của Văn Phòng Quyền Công Dân là (800) 368-1019. Người dùng TTY nên gọi số (800) 537-7697. Quý vị cũng có thể truy cập https://www.hhs.gov/ocr/index.html để biết thêm thông tin. Quý vị cũng có thể liên hệ với Văn Phòng Quyền Công Dân tại: U.S. Department of Health and Human Services 90 7th Street, Suite 4-100 San Francisco, CA 94103 Điện thoại (800) 368-1019 TDD: (800) 537-7697 Fax: (415) 437-8329 Quý vị cũng có thể có các quyền theo Đạo Luật Người Khuyết Tật Hoa Kỳ. Quý vị có thể liên hệ với Văn Phòng Thanh Tra để được hỗ trợ. Số điện thoại là (888) 452-8609. Khi khiếu nại của quý vị là về chất lượng dịch vụ chăm sóc Quý vị có thêm hai lựa chọn: Quý vị có thể gửi đơn than phiền cho Tổ Chức Cải Tiến Chất Lượng. Nếu muốn, quý vị có thể than phiền trực tiếp về chất lượng dịch vụ chăm sóc mà quý vị nhận được với tổ chức này (mà không cần than phiền với chương trình của chúng tôi). Để tìm tên, địa chỉ và số điện thoại của Tổ Chức Cải Tiến Chất Lượng tại tiểu bang của quý vị, hãy xem Chương 2 của Cẩm Nang Hội Viên IEHP. Nếu quý vị than phiền với tổ chức này, thì chúng tôi sẽ phối hợp với họ để giải quyết than phiền của quý vị. Hoặc quý vị có thể than phiền đồng thời với cả hai. Nếu muốn, quý vị có thể than phiền về chất lượng dịch vụ chăm sóc với chương trình của chúng tôi và Tổ Chức Cải Tiến Chất Lượng. Để biết thêm thông tin về Khiếu Nại, hãy xem Chương 9 của Cẩm Nang Hội Viên IEHP DualChoice của quý vị. Xử lý các vấn đề về quyền lợi Medi-Cal của quý vị Nếu quý vị có Medi-Cal với IEHP và muốn biết thông tin về cách tiến hành kháng nghị và khiếu nại liên quan đến các dịch vụ được Medi-Cal bao trả, vui lòng gọi điện cho Ban Dịch Vụ Hội Viên IEHP DualChoice theo số (877) 273-IEHP (4347), TTY (800) 718-4347, 8 giờ sáng - 8 giờ tối (Giờ Chuẩn Thái Bình Dương [PST]), 7 ngày một tuần, bao gồm cả ngày lễ. IEHP DualChoice (HMO D-SNP) là một Chương trình HMO có hợp đồng với Medicare. Việc ghi danh tham gia IEHP DualChoice (HMO D-SNP) phụ thuộc vào quá trình gia hạn hợp đồng. Thông tin trên trang này được cập nhật từ ngày 1 Tháng Mười, 2022. H8894_DSNP_23_3241532_M Pending Accepted
Pharmacy Communications - Pharmacy Communications
to view the PDF files. You can download a free copy by clicking here. By clicking on this link, you will be leaving the IEHP website.
TITLE
DATE
RECIPIENTS
September 2023
New DHCS Drug Use Review (DUR) Board Educational Articles
09/29
All IEHP PCPs, All IEHP Pharmacy Providers
August 2023 Pharmacy and Therapeutics Update
09/06
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URGENT: Recalls, Market Withdrawals & Safety Alerts, August 2023
09/01
All IEHP PCPs, All IEHP Pharmacy Providers
August 2023
New DHCS Drug Use Review (DUR) Board Educational Articles
08/29
All PCPs, OBs & BH Providers
Claims Processing during State of Emergency
08/20
All IEHP Pharmacy Providers
URGENT: Recalls, Market Withdrawals & Safety Alerts, July 2023
08/01
All IEHP PCPs, All IEHP Pharmacy Providers
July 2023
New DHCS Drug Use Review (DUR) Board Educational Articles
07/27
All Medi-Cal PCPs & Specialists
RESOLVED - Dual Choice Member Billing Issue
07/07
All IEHP Pharmacy Providers
DualChoice (HMO D-SNP): Known Billing Issue
07/06
All IEHP Pharmacy Providers
June 2023
URGENT: Recalls, Market Withdrawals & Safety Alerts, June 2023
06/30
All IEHP PCPs, All IEHP Pharmacy Providers
URGENT! Recalls, Market Withdrawals & Safety Alerts, May 2023
06/09
All IEHP PCPs, All IEHP Pharmacy Providers
May 2023 Pharmacy & Therapeutics Update
06/09
IEHP Provider Network
New DHCS Drug Use Review (DUR) Board Educational Articles
06/02
All Medi-Cal PCPs & Specialists
May 2023
Pharmacy Recalls, Market Withdrawals Safety Alerts - April 2023
05/10
All IEHP PCP's, All IEHP Pharmacy Providers
April 2023
Pharmacy Recalls Withdrawals Safety Alerts - January to March 2023
04/10
All IEHP PCP's & Pharmacy Providers
March 2023
IEHP DualChoice (HMO D-SNP): Known Billing Issue
03/31
All IEHP Pharmacy Providers
Pharmacy Recalls - Withdrawals - Safety Alerts - March 1-15, 2023
03/31
All IEHP PCPs & Pharmacy Providers
Pharmacy Recalls - Withdrawals - Safety Alerts - Dec 2022 to Feb 2023
03/31
All IEHP PCPs & Pharmacy Providers
DualChoice Medicare Billing for Non-FDA Approved Medications
03/21
All IEHP Pharmacy Providers
Claim Processing during State of Emergency due to Snowstorm
03/03
All IEHP Pharmacy Providers
February 2023
Transition to 30-day Coverage Determination Backdating
02/02
All LTC & SNF Providers
January 2023
IEHP DualChoice (HMO D-SNP): Over-the-Counter Drugs
01/09-01/30
All IEHP Pharmacy Providers
IEHP DualChoice (HMO D-SNP): Medicare Part B Coinsurance Billing
01/05-01/13
All IEHP Pharmacy Providers
IEHP DualChoice (HMO D-SNP): PBM Update and Medicare Part B Coinsurance
01/02-01/20
All IEHP Pharmacy Providers
IEHP DualChoice (HMO D-SNP) Members - Medication Overrides
01/02
All IEHP Pharmacy Providers
December 2022
Cal MediConnect (CMC) to Medi-Cal Rx/HMO D-SNP Transition
12/22
All IEHP Pharmacy Providers
Claims Rejected in Error
12/19
All IEHP Pharmacy Providers
PBM Change & Prior Authorization Submission Method - for DualChoice (HMO D-SNP) Members (Effective January 1, 2023)
12/13-12/29
All IEHP Pharmacy Providers
Pharmacy Recalls, Withdrawals & Safety Alerts - November 2022
12/07
All IEHP Pharmacy Providers
CoverMyMeds - Prior Authorization Submission Method for DualChoice Members (Effective January 1, 2023)
12/01-12/12
All IEHP Pharmacy Providers
November 2022
Recalls, Withdrawals & Safety Alerts - October 2022
11/14
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts - September 2022
11/02
All IEHP Pharmacy Providers
COVID-19: Test to Treat Monoclonal Antibodies
11/01
All IEHP Pharmacy Providers
October 2022
Cal MediConnect to Medi-Cal Rx Transition (D-SNP)
10/28
All IEHP Pharmacy Providers
September 2022
Recalls, Withdrawals & Safety Alerts
09/08
All IEHP Pharmacy Providers
August 2022
2022-2023 Flu Vaccination for IEHP Members
08/31
All IEHP Pharmacy Providers
Reminder: Medi-Cal Rx Gradual Reinstatement of PAs - Phase 1
08/31
All IEHP Pharmacy Providers
30-Day Countdown: Reinstatement of PA Requirements for 11 Drug Classes
08/18
All IEHP Pharmacy Providers
30-Day Countdown: Reinstatement of PA Requirements for 11 Drug Classes
08/17
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts
08/10
All IEHP Pharmacy Providers
July 2022
Academic Detailing Services Now Offered
07/15
All IEHP Pharmacy Providers
DHCS Medi-Cal Rx Update: Postponement of Implementation of NCPDP Reject Code 80
07/13
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts
07/07
All IEHP Pharmacy Providers
June 2022
New DHCS DUR Board Educational Article
06/22
All IEHP Pharmacy Providers
MTM Medicare Pharmacy Mailing Campaign
06/08
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts
06/05
All IEHP Pharmacy Providers
Academic Detailing Services Now Offered
06/04
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: Blood Pressure Monitors and Cuffs
06/03
All IEHP Pharmacy Providers
Important Notice: COVID-19 Oral Antivirals Billing
06/01
All IEHP Pharmacy Providers
May 2022
Recalls, Withdrawals & Safety Alerts
05/05
All IEHP Pharmacy Providers
April 2022
Rejected Claims Due To Prescriber Error Codes
04/06
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts
04/05
All IEHP Pharmacy Providers
MTM COVID-19: Test to Treat
04/04
All IEHP Pharmacy Providers
March 2022
MTM Medicare Pharmacy Mailing Campaign
03/29
All IEHP Pharmacy Providers
New DHCS DUR Board Educational Article
03/16
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: How To Assist IEHP Members
03/28-03/31
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: How To Assist IEHP Members
03/21-03/25
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: How To Assist IEHP Members
03/14-03/18
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: How To Assist IEHP Members
03/07-03/11
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts
03/07
All IEHP Pharmacy Providers
IEHP Contracted DME Pharmacies: CGM, BP Monitor, Nebulizer
03/02
All IEHP Pharmacy Providers
February 2022
Medi-Cal Rx Transition: How To Assist IEHP Members
02/28-03/04
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: How To Assist IEHP Members
02/22-02/25
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: How To Assist IEHP Members
02/14-02/18
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: How To Assist IEHP Members
02/10-02/11
All IEHP Pharmacy Providers
Pharmacy Empowerment Program
02/08
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts
02/07
All IEHP Pharmacy Providers
New DHCS DUR Board Educational Article
02/02
All IEHP Pharmacy Providers
January 2022
Free OTC COVID-19 Antigen Test Kits Available
01/31
All IEHP Pharmacy Providers
Medi-Cal Rx Transition Implementation
01/17-01/21
All IEHP Pharmacy Providers
Medi-Cal Rx Transition Implementation
01/10-01/14
All IEHP Pharmacy Providers
Medi-Cal Rx Transition Implementation
01/07
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts
01/05
All IEHP Pharmacy Providers
Pharmacy Services - Formulary
most appropriate, high quality and cost-effective drug therapies.
The Inland Empire Health Plan Pharmacy and Therapeutics (P & T) Subcommittee develops and monitors the Formulary. The P & T is composed of the IEHP Chief Medical Officer, Medical Directors, Director of Pharmaceutical Services, physicians from various medical specialties, local communities, and clinical pharmacists. This panel reviews the medications in all therapeutic categories based on safety, clinical efficacy, and cost-effectiveness and selects the most appropriate drugs in each class.
Formulary development and maintenance is a dynamic process. The IEHP P & T Subcommittee is responsible for developing, managing, updating and administering the Formulary. The Subcommittee also ensures that the IEHP Formulary remains responsive to the needs of our members and providers.
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy by clicking Adobe Acrobat Reader. By clicking on this link, you will be leaving the IEHP website.
IEHP Medi-Cal Formulary Items:
DHCS Noncapitated Physician Administered Drugs (PADs)
Medi-Cal Medical Benefit PA (PDF)
Medi-Cal Medical Benefit Formulary (PDF)
Referral Form for Medi-Cal Benefit (PDF)
Exceptions to criteria or requests for coverage of drugs not on the Medi-Cal Drug Benefit Formulary may be submitted by prescribers on the Referral Form for Medi-Cal Benefit.
Starting January 1, 2022, all IEHP Medi-Cal pharmacy services will be transitioned from managed care (MC) to fee for service (FFS). The Medi-Cal pharmacy benefits and services administered by the Department of Health Care Services (DHCS) will be identified collectively as "Medi-Cal Rx."
Magellan Medicaid Administration, Inc. (MMA) will assume operations for Medi-Cal Rx on behalf of DHCS.
For further information on Medi-Cal Rx, please visit: https://www.iehp.org/en/providers/pharmacy-services?target=medi-cal-rx
For more information on the Medi-Cal Rx Covered Drug List (CDL), please visit: https://medi-calrx.dhcs.ca.gov/home/cdl
IEHP DualChoice (HMO D-SNP) - Medicare-Medicaid Plan Items:
IEHP DualChoice (HMO D-SNP) Formulary Book (PDF)
Grievance Coverage Determination and Appeals Process
IEHP DualChoice (HMO D-SNP) Formulary Search Tool
E-prescribing Tips (PDF)
Information on this page is current as of October 2, 2023
Provider Resources - Forms
liance
Delegation Oversight Audit (DOA)
Grievance
Growth Chart
Health and Wellness
Historical Data Form
Inland Regional Center
Medi-Cal Letter Templates
Medicare-Medicaid Plan Letter Templates
D-SNP Letter Templates
Medicare
Non-Contracted Providers
Perinatal
Pharmacy
Provider Preventable Conditions (PPC)
UM/CM
Vision
Other
Behavioral Health
ABA 6 Month and Exit Progress Report Template (Word)
ABA Exit Letter Template (Word)
ABA Service Hour Log (Word)
ABA School BHT Services Request Form (Word)
Authorization Release of Information Form - English (PDF)
Authorization Release of Information Form - Spanish (PDF)
Behavioral Health Authorization Request Form (PDF)
BHT Social Skills Template (Word)
Coordination of Care Treatment Plan Form (PDF)
No Further Treatment Request Form (PDF)
Psych Testing Battery Plan (for Psychologist use only) (PDF)
(For BH Providers Only) Transition of Care Tool (PDF)
Claims
For Integrated Denial Notices please click here.
Please select on the links below to obtain the revised CMS 1500 form (version 02/12) and the CMS 1500 Reference Instruction Manual.
Acknowledgement Letter (Word)
Capitation Data File Format (Word)
Capitation Payment Deduction (Word)
Cease and Desist Letter (Word)
Claims Project Spreadsheet (Excel)
Clean Claim Tool Guide - UB04 Inpatient Form (PDF)
Clean Claim Tool Guide - UB04 Outpatient Form (PDF)
CMS 1500 Reference Instruction Manual (PDF)
Demand For Payment Letter (Word)
Determination Letter (Word)
Encounter Data CAP Request Letter (Word)
Encounter Data Penalty Letter (Word)
Hospital Directed Payment Dispute Form (Word)
ICE - Claim Denial Reason Guide - IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid) (Word)
Irrevocable Letter of Credit (Word)
Manifest Report (Word)
Medi-Cal Universe Layout Instructions (Word)
Notice of CAP Deductions (Word)
Notice of Denial of Payment - English (Word)
Notice of Denial of Payment - Spanish (Word)
Notice of Dismissal of Appeal Request (PDF)
Part C Organization Determinations, Appeals, and Grievances (ODAG) (PDF)
Payment Attestation (Word)
Provider Identified Overpayment Form (PDF)
Provider Identified Overpayment Form (Multiple) (PDF)
Provider Dispute Resolution (PDR) (PDF)
Remittance Advice - Medicare DualChoice Annual Visit (PDF)
Revised CMS 1500 Health Insurance Claim Form (PDF)
Sample Capitation Report (PDF)
Waiver of Liability Statement - IEHP Dual Choice (HMO D-SNP) - effective January 2023 (PDF)
Table 3 Payment Organization Determinations and Reconsiderations (PYMT_C) (PDF)
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Compliance
DHCS Privacy Incident Report (PDF)
Notice of Privacy Practices (Word)
IEHP Code of Business Conduct and Ethics (PDF)
Member Incentive Forms
Focus Group Incentive Program (FGI) - Request for Approval Form (Word)
Focus Group Incentive (FGI) Program - Evaluation Form (Word)
Member Incentive (MI) Program - Request for Approval (Word)
Member Incentive (MI) Program - Evaluation Form (Word)
Survey Incentive (SI) - Request for Approval Form (Word)
Survey Incentive (SI) - Evaluation Form (Word)
Nondiscrimination Language
Nondiscrimination Language Access Notice:
Medi-Cal (PDF)
Medicare (PDF)
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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
Approved Referral Audit Tool (Excel)
California Specific - Reporting Requirements (PDF)
Care Coordinator to Member Ratio Template 5.1 (Excel)
Care Coordinator Training for Supporting Self-Direction (Excel)
Care Management California Children's Services Review Tool (PDF)
Care Transition Cases Log (Excel)
Credentialing and Recredentialing Report for Delegated Networks (Excel)
Credentialing and Recredentialing Report (Excel)
Delegation Oversight Audit Preparation Instructions - IEHP DualChoice (Word)
Delegation Oversight Audit Preparation Instructions - Medi-Cal (NCQA) (Word)
Delegation Oversight Audit Preparation Instructions - Medi-Cal (Word)
Denial Log Review Tool - IEHP DualChoice (Excel)
Denial Log Review Tool - IEHP Medi-Cal (Excel)
DOA CAP Response Form (Excel)
Enrollee Protections Reporting Template, CA2.1 (Excel)
IEHP ASM File Template (Excel)
IEHP Universe Expedited Auth MESAR Data Dictionary (PDF)
IEHP Universe Expedited Auth MESAR Template (Excel)
IEHP Universe M_Claims Data Dictionary (PDF)
IEHP Universe M_Claims Template (Excel)
IEHP Universe M_SAR Table 1 Standard and Expedited Service Authorization Requests (Excel)
IEHP Universe PYMT_C Table 3 Payment Organization Determinations and Reconsiderations (Excel)
IEHP Universe Standard Auth MSSAR Data Dictionary (PDF)
IEHP Universe Standard Auth MSSAR Template (Excel)
IPA Care Management Review Tool - IEHP DualChoice (PDF)
IPA Delegation Agreement - IEHP DualChoice (Word)
IPA Delegation Agreement - Medi-Cal (Word)
IPA Performance Evaluation Tool (Excel)
Medi-Cal Care Coordination Review Tool (PDF)
Medi-Cal Monthly Care Management Log (PDF)
Medi-Cal SPD Review Tool Data Dictionary (PDF)
MM Capitated Financial Alignment Model Reporting Requirements (PDF)
Monthly CCS Referral Log 2.0 (PDF)
Monthly Medicare Care Management Log 2.3 (PDF)
Monthly Medicare Plan Outreach Log 1.1 (PDF)
Practitioner Profile Template (Excel)
Precontractual Audit Preparation Instructions - IEHP DualChoice (Word)
Precontractual Audit Preparation Instruction - Medi-Cal (Word)
Program Description - Denial letter Sanction - IEHP DualChoice (PDF)
Referral Universe (Excel)
Request for UM Criteria Log (Word)
Response to Request for UM Criteria Letter (Word)
Second Opinion Tracking Log (Word)
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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)
Appeal Resolution Process - Medi-Cal - [English] (Word)
Appeal Resolution Process - Medi-Cal - [Spanish] (Word)
Grievance Resolution Process - Medi-Cal - [English] (Word)
Grievance Resolution Process - Medi-Cal - [Spanish] (Word)
Provider Fair Hearing Process (Word)
Provider Grievance Acknowledgement Letter (Word)
Provider Grievance Resolution Letter (Word)
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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)
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Health and Wellness
DPP Rx Pad (PDF)
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Historical Data Form
Historical Data Form (PDF)
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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
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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, 2023
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, 2023
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, 2023
Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated May 22, 2023
Notice of Action - Delay
English
Last Updated: 12/27/2022
Spanish
Last Updated: 12/27/2022
Chinese
Last Updated: 12/27/2022
Vietnamese
Last Updated: 12/27/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated May 22, 2023
Notice of Action - Deny
English
Last Updated: 12/27/2022
Spanish
Last Updated: 12/27/2022
Chinese
Last Updated: 12/27/2022
Vietnamese
Last Updated: 12/27/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated May 22, 2023
Notice of Action - Modify
English
Last Updated: 12/28/2022
Spanish
Last Updated: 12/28/2022
Chinese
Last Updated: 12/28/2022
Vietnamese
Last Updated: 12/28/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated May 22, 2023
Notice of Action - Terminate
English
Last Updated: 01/06/2023
Spanish
Last Updated: 01/06/2023
Chinese
Last Updated: 01/06/2023
Vietnamese
Last Updated: 01/06/2023
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated May 22, 2023
Other Health Care Coverage Requesting Provider Letter
English
Last Updated: 03/17/2021
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
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, 2023
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, 2023
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 14, 2023
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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
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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 July 14, 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 July 14, 2023
Continuity of Care - Notice of Authorization
English
Last Updated:08/24/2023
Spanish
Last Updated:08/24/2023
Chinese
Last Updated:08/24/2023
Vietnamese
Last Updated:08/24/2023
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 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 July 14, 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 July 14, 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 July 14, 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 July 14, 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 July 14, 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 July 14, 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 July 14, 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 July 14, 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 July 14, 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 July 14, 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 July 14, 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 July 14, 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 July 14, 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 July 14, 2023
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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)
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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.
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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)
California Prenatal Screening Program (PDF)
Contraceptive Informed Choice Form - English (Word)
Contraceptive Informed Choice Form - Spanish (Word)
Initial Perinatal Risk Assessment Form - English (Word)
Initial Perinatal Risk Assessment Form - Spanish (Word)
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Pharmacy
Click here for Pharmacy forms.
Part D Excluded Provider Letter - English (Word)
Part D Excluded Provider Letter - Spanish (Word)
Prescription Transition Notice - English (PDF)
Prescription Transition Notice - Spanish (PDF)
Request for Addition or Deletion of a Drug to the Formulary (PDF)
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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
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UM/CM
Acute Hospital Discharge Needs Request Form (PDF)
Acute Inpatient Data Sheet (Word)
Advance Health Care Directive - [English] (PDF)
Advance Health Care Directive - [Spanish] (PDF)
Advance Health Care Directive FAQs - [English] (Word)
Advance Health Care Directive FAQs - [Spanish] (Word)
Authorization or Refusal to Release Medical Record - Out of Network Family Planning - [English] (PDF)
Authorization or Refusal to Release Medical Record - Out of Network Family Planning - [Spanish] (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)
Behavioral Health Hospital Survey - Corrective Action Plan Tool (PDF)
Behavioral Health Hospital Survey Tool (PDF)
California Minor Consent and Confidentiality Laws (PDF)
Care Management Referral Form (PDF)
CCS-GHPP Client Service Auth Request - Established Case (PDF)
CCS-GHPP Client Service Auth Request - New Case (PDF)
Consent for HIV Test - English (PDF)
Consent for HIV Test - Spanish (PDF)
Consent for Special Procedure - English (Word)
Consent for Special Procedure - Spanish (PDF)
Corrective Action Plan Notification Tool (PDF)
Desert AIDS Project Enrollment Form (PDF)
DMHC Provider Appointment Availability Survey Methodology (PDF)
DMHC Provider Appointment Availability Survey Tools (PDF)
GHPP Application to Determine Eligibility (PDF)
Health Plan Referral Form for Out-of-Network and Special Services (Word)
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
IEHP Medical Record Review Survey Addendum (PDF)
Interim Facility Site Review (Assessment) Tool (PDF)
Interim Facility Site Review (On-Site) Tool (PDF)
Long Term Care Initial Review Form (Word)
Long Term Care (LTC) Follow-Up Review Form (Word)
Long Term Care (LTC) Data Sheet (PDF)
MC 171 Form and Instruction 05-07 (PDF)
Medi-Cal FFS-Approved Transplant Centers of Excellence (PDF)
Medicare Non-Covered Benefits (Word)
My Path Palliative Care Program CAP Form (PDF)
Non-Emergency Medical Transportation (NEMT) Physician Certification Statement (PCS) (PDF)
PCP Referral Tracking Log (Word)
Periodicity Schedule - Dental (PDF)
Provider Appointment Availability Survey Manual (PDF)
Referral Audit CAP Notification Letter (Word)
Referral Audit Corrective Action Plan Tool (Word)
Referral Form (PDF)
Reportable Diseases and Conditions - Riverside (PDF)
Reportable Diseases and Conditions - San Bernardino (PDF)
Service Request Form for Skilled Nursing Facilities (PDF)
Service Request for Skilled Nursing Facilities (PDF)
SNF Initial Review (PDF)
SNF Follow-up Review (PDF)
Specialty Office Service Authorization Sets Grid (Word)
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)
Transplant Team Referral Form (Word)
Transportation Requests Form (SNF & LTC) (PDF)
Transportation Requests Form (Hospital) (PDF)
UM Timeliness Standards - IEHP DualChoice (Word)
UM Timeliness Standards - Medi-Cal (Word)
Urgent Care CAP Complete Tool and Notification Letter (PDF)
Wound Assessment - Admission (PDF)
Wound Assessment - Follow - Up (PDF)
Wound Assessment - Addendum (PDF)
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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)
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Other
AEVS Alpha Codes (PDF)
Attachment I - Statement of Agreement by Supervising Provider (PDF)
Authorization of Release - Use & Disclosure of PHI - English (PDF)
Authorization of Release - Use & Disclosure of PHI - Spanish (PDF)
Bariatric Surgeon Case Volume Attestation (PDF)
BIC Card (Word)
Change in Hospital Affiliation Letter (Word)
Change in IPA Affiliation Letter (Word)
Chronic Care Improvement Program (CCIP) Planning & Reporting Document (Word)
Corrective Action Plan Notification Tool (Word)
CMS 1696 Appointment of Representative - English (PDF)
CMS 1696 Appointment of Representative - Spanish (PDF)
Compliant Termination Letter (Word)
Contract Maintenance Request Form (PDF)
Coverage Determination Form - Provider and Member - [Chinese] (Word)
Coverage Determination Form - Provider and Member - [Spanish] (Word)
Credentialing Subcommittee Termination Letter (PDF)
Death Master File Identity Attestation (PDF)
Delegation of Services Agreement and Supervising Physician Form (PDF)
DHCS MMCD Facility Site Review (FSR) Standards (PDF)
DHCS MMCD Facility Site Review (FSR) Tool (PDF)
DHCS MMCD FSR Attachment 0C - Physical Accessibility Review Survey (Word)
DHCS MMCD FSR Attachment 0D - Ancillary Physical Accessibility Review Survey (PDF)
DHCS MMCD FSR Attachment 0E - CBAS Physical Accessibility Review Survey (PDF)
DHCS MMCD Medical Record Review (MRR) Standards (PDF)
DHCS MMCD Medical Record Review (MRR) Tool (PDF)
Frozen Enrollment Change Status (Word)
Hospital Admitting Arrangement Attestation - Admitter (PDF)
Hospital Admitting Arrangement Attestation - Admitting Physician (PDF)
Hospital Admitting Arrangement Attestation - Hospitalist (PDF)
Hospital Admitting Privileges Reference by Specialty (PDF)
Hospital Geographic Service Areas (Word)
IEHP Addendum E (PDF)
IEHP ID Card - Medi-Cal (Word)
IEHP ID Card - DualChoice (PDF)
IEHP Interim Facility Site Review Tool (Word)
IEHP Medical Record Review Survey Addendum (PDF)
IEHP Urgent Care Center Evaluation Tool (PDF)
IEHP PCP Leave of Absence Coverage Form (Word)
IEHP Peer Review Level I and Credentialing Appeal (PDF)
IEHP Peer Review Process and Level II Appeal (PDF)
IPA Hospital Link Responsibility Grid - IEHP DualChoice (Excel)
IPA Hospital Link Responsibility Grid - Medi-Cal (PDF)
Licensed Midwife Attestation (PDF)
Limited Enrollment Change Status (Word)
Member PCP Termination Notification Letter - [English] (Word)
Member PCP Termination Notification Letter - [Spanish] (Word)
Non-Compliant Termination Letter (Word)
Over Enrollment Change Status (Word)
Patient Transfer Agreement (PDF)
Peer Review Termination Letter (PDF)
Persons with Disabilities Workgroup Application (Word)
Plan Choice Form - Riverside - English - Medi-Cal (PDF)
Plan Choice Form - Riverside - Spanish - Medi-Cal (PDF)
Plan Choice Form - SB - English - Medi-Cal (PDF)
Plan Choice Form - SB - Spanish - Medi-Cal (PDF)
Prescribing Arrangements for DEA and CDS Eligible Practitioners (PDF)
Provider Preventable Conditions (Word)
Provider Privilege Adjustment Request Form (PDF)
Specialty Network Review (PDF)
Specialty Network Review - IEHP Initial Findings Template (Excel)
Specialty Network Review - IPA Response Template (Excel)
The Code of Conduct of the Persons with Disabilities Workgroup (Word)
Transgender Questionnaire (PDF)
Urgent Care CAP Complete Tool and Notification Letter (Word)
Verification of Qualifications for HIV/AIDS Physician Specialists (PDF)
Work History Form Past Five (5) Years' Request (PDF)
2017 Model Output Report (MOR) Data File Layout (PDF)
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