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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

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.

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

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

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

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 All IEHP PCPs, All IEHP Pharmacy Providers 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  

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

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) (Back to top) 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) (Back to top) Delegation Oversight Audit (DOA) Biographical Information Sheet Credentialing DOA Audit Tool HIPAA Security - Medi-Cal DOA HIPAA Security - Medicare Medi-Cal DOA Tool UM/CM/QI Medicare DOA Tool UM/CM/QI Medi-Cal UM Referral Template Sub-Contracted Facility/Agency Services and Delegated Functions 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) (Back to top) Grievance The Grievance Forms below are for your Member's use when filing a complaint, or has an appeal regarding any aspect of care or service provided by you. Please select the Appeal and Grievance form appropriate for their use: Medi-Cal Form      English (PDF)      Spanish (PDF)      Chinese (PDF)      Vietnamese (PDF) Medicare Form      English (PDF)      Spanish (PDF)      Chinese (PDF)      Vietnamese (PDF) The following IEHP DualChoice (HMO D-SNP) Letters will be effective January 1, 2023:      English (PDF)      Spanish (PDF)      Chinese (PDF)      Vietnamese (PDF) 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) (Back to top) Growth Chart Inland Empire Health Plan (IEHP) offers you easy access to useful reference materials and forms you may need. It's just one click away. Select the growth chart form that you need by clicking on the link below: (0-36 months): Head Circumference-For-Age And Weight- For-Length Percentiles           Boys (PDF)          Girls (PDF) (0-36 months): Length and Weight-For-Age Percentiles           Boys (PDF)          Girls (PDF) (2-20 years): Stature and Weight-For-Age-Percentiles           Boys (PDF)         Girls (PDF) (2-20 years): Body Mass Index For-Age Percentiles           Boys (PDF)          Girls (PDF) (Back to top) Health and Wellness DPP Rx Pad (PDF) (Back to top)   Historical Data Form Historical Data Form (PDF) (Back to top) Inland Regional Center Early Start (0-36 months) Referral (PDF) Early Start Online Application Eligibility and Intake IRC Referrals (3-99+ years): San Bernardino County: For Providers - (909) 890-4711 // Intake - (909) 890-3148 Riverside County: For Providers - (909) 890-4763 // Intake - (951) 826-2648 (Back to top) Medi-Cal Letter Templates A complete template includes all documents listed under each template in the order specified listed. Changes can only be made to highlighted areas, any changes made outside of the highlighted areas are strictly prohibited by DHCS. Click on the title to expand the menu and download desired document. Member Authorization Letter English Last Updated: 09/20/2022 Spanish Last Updated: 09/20/2022   Chinese Last Updated: 09/20/2022   Vietnamese Last Updated: 09/20/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 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 (Back to top) Medicare-Medicaid Plan Letter Templates A complete template includes all documents listed under each template in the order specified listed. Changes can only be made to highlighted areas, any changes made outside of the highlighted areas are strictly prohibited by CMS. Click on the title to expand the menu and download desired document. Carve-Out Information Letter English Last Updated: 11/12/2017   Spanish Last Updated: 10/31/2017   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Denial Reason Matrix English Last Updated: 07/03/2018   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Detailed Explanation of Non-Coverage English Last Updated: 12/17/2021   Spanish Last Updated: 12/17/2021   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Detailed Notice of Discharge English Last Updated: 12/17/2021   Spanish Last Updated: 12/17/2021   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Expedited Criteria Not Met English Last Updated: 10/31/2017   Spanish Last Updated: 10/31/2017   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Extension Needed for Additional Information English Last Updated: 10/31/2017   Spanish Last Updated: 10/31/2017   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Integrated Denial Notice - Part B Drugs - 7 day appeal - IPA English Last Updated: 02/14/2022   Spanish Last Updated: 02/14/2022   Chinese Last Updated: 02/14/2022   Vietnamese Last Updated: 02/14/2022   Independent Medical Review - [English] [Spanish] [Chinese] [Vietnamese] Updated October 7, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Integrated Denial Notice - Part C - 30 day appeal - IPA English Last Updated: 03/08/2022   Spanish Last Updated: 02/14/2022   Chinese Last Updated: 02/14/2022   Vietnamese Last Updated: 02/14/2022   Independent Medical Review - [English] [Spanish] [Chinese] [Vietnamese] Updated October 7, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Integrated Denial of Payment Notice - 7 day appeal - IPA English Last Updated: 03/17/2021   Spanish Last Updated: 10/18/2021   Independent Medical Review - [English] [Spanish] [Chinese] [Vietnamese] Updated October 7, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Integrated Denial of Payment Notice - 30 day appeal - IPA English Last Updated: 03/17/2021   Spanish Last Updated: 04/12/2017   Independent Medical Review - [English] [Spanish] [Chinese] [Vietnamese] Updated October 7, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Notice of Authorization of Services English Last Updated: 10/31/2017   Spanish Last Updated: 10/31/17   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Notice of Dismissal of Coverage English Last Updated:03/10/2022   Spanish Last Updated:03/10/2022   Chinese Last Updated:03/10/2022   Vietnamese Last Updated:03/10/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Notice of Medicare Non-Coverage English Last Updated: 10/31/2017   Spanish Last Updated: 10/31/2017   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Notice of Reinstatement of Coverage English Last Updated: 10/31/2017   Spanish Last Updated: 10/31/2017   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 (Back to top) NEW D-SNP Letter Templates These templates should not be used until the effective date of January 2, 2023. Please continue using the current Medicare DualChoice letter templates currently seen on this webpage for the remainder of 2022. A complete template includes all documents listed under each template in the order specified listed. Changes can only be made to highlighted areas, any changes made outside of the highlighted areas are strictly prohibited by CMS. Click on the title to expand the menu and download desired document. AOR Dismissal Letter English Last Updated: 09/26/2022   Spanish Last Updated:09/26/2022   Chinese Last Updated:09/26/2022   Vietnamese Last Updated:09/26/2022   Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated 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   (Back to top) Medicare Certificates of Medical Necessity (CMN) & DME Information Forms (DIF) Positive Airway Pressure Devices for Obstructive Sleep Apnea (PDF) Enteral and Parenteral Nutrition (PDF) External Infusion Pump (PDF) Osteogenesis Stimulators (PDF) Oxygen (PDF) Seat Lift Mechanisms (PDF) Continuation Form (PDF) Transcutaneous Electrical Nerve Stimulator (TENS) (PDF) Pneumatic Compression Device (PDF) (Back to top) Non-Contracted Providers To submit a referral to IEHP, please fill out the referral form below, include all clinical notes and fax it to IEHP. If you are referring back to yourself, please indicate such. If you need IEHP to direct the referral, please indicate that on the form. Referral Authorization Request Form - Non-Contracted Providers (PDF) If you are interested in becoming a network Provider, please click here. (Back to top) Perinatal IEHP provides standard risk assessment forms that can be used by all Providers of obstetrical (OB) services. Please refer to IEHP Provider Policy 10D1, "Obstetrical Services, Guidelines for Obstetrical Services" for further detail. To obtain copies, simply click on the links below. Edinburgh Postnatal Depression Screening Tool - English (PDF) Edinburgh Postnatal Depression Screening Tool - Spanish (PDF) ACOG Antepartum Record (PDF) 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) (Back to top) 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) (Back to top) Provider Preventable Conditions (PPC) By clicking on these links, you will be leaving the IEHP website. On May 23,2017, the Department of Healthcare Services (DHCS) released All Plan Letter (APL) 17-009, reporting requirements related to Provider Preventable Conditions. In conjunction, DHCS released Dual Plan Letter (DPL) 17-002. As part of these instructions, the Health Plan, Network Providers, Delegates, Contracted Hospitals, and ambulatory surgical centers must report using PPC Form on DHCS secure online portal for both Medicare and Medi-Cal lines of business. Further information is available on the following pages: Instructions for Completing Online Reporting of PPCs Medi-Cal Guidance on Reporting Provider-Preventable Conditions Frequently Asked Questions All Plan Letter (APL) 17-009 Duals Plan Letter (DPL) 17-002 PPC Form Medicare and Medi-Cal lines of business must follow the instructions below: Providers are REQUIRED to send a copy of the completed PPC submission from the DHCS secure online portal to IEHP by fax at (909) 890-5545 within five (5) business days of reporting to DHCS; IEHP does not pay Provider claims nor reimburse a Provider for a PPC, in accordance with 42 CFR Section 438.3(g) and IEHP's three-way Cal MediConnect contract. Per IEHP policy and the Coordinated Care Initiative 3-Way Contract, IEHP reserves the right to recover or recoup any claim related to a PPC; As outlined in both the APL/DPL - Reporting Requirements related to Provider Preventable Conditions, the following classify as PPCs and must be reported: Category 1 - HCACs (For Any Inpatient Hospital Setting in Medicaid) Any unintended foreign object retained after surgery A clinically significant air embolism An incidence of blood incompatibility A stage III or stage IV pressure ulcer that developed during the patient's stay in the hospital A significant fall or trauma that resulted in fracture, dislocation, intracranial injury, crushing injury, burn, or electric shock A catheter-associated urinary tract infection Vascular catheter-associated infection Any of the following manifestations of poor glycemic control: diabetic ketoacidosis; nonketotic hyperosmolar coma; hypoglycemic coma; secondary diabetes with ketoacidosis; or secondary diabetes with hyperosmolarity A surgical site infection following: Coronary artery bypass graft (CABG) - mediastinitis Bariatric surgery; including laparoscopic gastric bypass, gastroenterostomy, laparoscopic gastric restrictive surgery Orthopedic procedures; including spine, neck, shoulder, elbow Cardiac implantable electronic device procedures Deep vein thrombosis/pulmonary embolism following total knee replacement or hip replacement with pediatric and obstetric exceptions Latrogenic pneumothorax with venous catheterization A vascular catheter-associated infection Category 2 - Other Provider Preventable Conditions (For Any Health Care Setting) Wrong surgical or other invasive procedure performed on a patient Surgical or other invasive procedure performed on the wrong body part Surgical or other invasive procedure performed on the wrong patient (Back to top) UM/CM Acute Hospital Discharge Needs Request Form (PDF) 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) (Back to top) Vision Ophthalmologist Referral Form (PDF) Vision Exception Request (VER) Form (PDF) PCP Vision Report Form (PDF) IEHP Lab Form (PDF) Medi-Cal Non-Covered Services/Materials Waiver Form-English (PDF) Medi-Cal Non-Covered Services/Materials Waiver Form-Spanish (PDF) Medi-Cal Non-Covered Services/Materials Waiver Form-Chinese (PDF) Medi-Cal Non-Covered Services/Materials Waiver Form-Vietnamese (PDF) The following IEHP DualChoice (HMO D-SNP) Letters will be effective January 1, 2023: IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-English (PDF) IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-Spanish (PDF) IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-Chinese (PDF) IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-Vietnamese (PDF) (Back to top) Other 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) (Back to top) You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.