搜尋結果： : " DIPLOMA IN ENVIRONMENTAL SCIE "

learn about different types of physical activities to improve heart health as well as learn how to control your blood pressure.  Click here to register for this in-person class Location IEHP Community Resource Center (Riverside) 3590 Tyler St Riverside, CA 92503

ill learn: What a heart attack is and how to recognize its warning signs/symptoms. The importance of seeking treatment quickly if someone has symptoms. Why people may delay calling 9-1-1. The benefits of calling 9-1-1. Click here to register for this in-person class.  Location: San Bernardino Community Seventh-day Adventist Church 1696 N. G St. San Bernardino, CA 92405  

ll learn: Why physical activity is good for their hart and overall health About different types of physical activity How much physical activity adults and children need Ways to fit physical activity into their schedule Click here to register for this in-person class Location San Bernardino Community Seventh-day Adventist Church 1696 N. G St. San Bernardino, CA 92405

(IEHP) Pay for Performance program, also known as P4P. IEHP’s P4P was designed to increase the provision of preventive health services to IEHP Members as well as improve HEDIS® results to ensure that all IEHP Direct DualChoice Members receive timely annual assessment visits with an emphasis on review and management of chronic illnesses. IEHP Direct PCPs will be reimbursed directly by IEHP through the DualChoice Annual Visit program. PCPs participating in IEHP's network through an IPA only are not eligible for this program: Overview (PDF) DualChoice Annual Visit (PDF) To learn more about P4P IEHP DualChoice Annual Visit, contact a Provider Services Representative at (909) 890-2054. Click on the following links to jump to that specific section: Provider Quality Incentives Brochure Medicare P4P IEHP Direct IEHP Direct Stars Incentive Program D-SNP Model of Care Incentive Program Global Quality P4P Program OB/GYN P4P Program Hospital P4P Program Provider Quality Incentives Brochure Inland Empire Health Plan (IEHP) is pleased to announce the 2023 Provider Quality Incentive Brochure. 2023 Provider Quality Incentive Brochure (PDF) | September 27, 2023 (Back to P4P Menu) Medicare P4P IEHP Direct Program Inland Empire Health Plan (IEHP) is pleased to announce the Medicare P4P IEHP Direct Program.  The goal of the program is designed to reward IEHP Direct Primary Care Providers (PCPs) for providing quality care to IEHP DualChoice Members. Medicare P4P IEHP Direct Program Guide (PDF) Published: February 16, 2023 (Back to P4P Menu) IEHP Direct Stars Incentive Program Inland Empire Health Plan (IEHP) is pleased to announce the IEHP Direct Stars Incentive Program for Primary Care Physicians (PCPs). The goal of the program is to reward PCPs who provide high-quality care to IEHP DualChoice (HMO D-SNP) members. IEHP Direct Stars Incentive Program Guide (PDF) Updated: June 29, 2023 (Back to P4P Menu) D-SNP Model of Care Incentive Program Inland Empire Health Plan (IEHP) is pleased to announce the D-SNP Model of Care Incentive Program for Independent Physicians Associations (IPAs). The goal of the program is to reward IPAs who provide high-quality care to IEHP DualChoice (HMO D-SNP) members. D-SNP Model of Care Incentive Program (PDF) Published: July 24, 2023 (Back to P4P Menu) Chronic Care Improvement Program Planning and Reporting Document The Chronic Care Improvement Program (CCIP) Planning and Reporting document can be used for the following D-SNP Model of Care Incentive Program activity: Chronic Care Improvement Program (CCIP) Activity. CCIP Planning and Reporting Document (Word Document) CCIP Planning and Reporting Document - Reference Guide (PDF) Global Quality P4P Program If you would like more information about IEHP’s GQ P4P Program or best practices to help improve quality scores and outcomes, visit our Secure Provider Portal, email the Quality Team at QualityPrograms@iehp.org or call the IEHP Provider Relations Team at (909) 890-2054. 2023 IEHP Global Quality P4P Program Guide PCP (PDF) Published: July 25, 2023 2023 IEHP Global Quality P4P Program Guide IPA (PDF) Published: July 25, 2023 2022 IEHP Global Quality P4P Program Guide PCP (PDF) Published: August 28, 2023 2022 IEHP Global Quality P4P Program Guide IPA (PDF) Published: July 25, 2023 2023 Provider Quality Resource Guide (PDF) Published: June 21, 2023 (Back to P4P Menu) Quality Improvement Activity Strategy Forms The Quality Improvement Activity (QIA) Strategy Forms can be used for the following 2023 and 2022 Global Quality P4P QIA Activities: Reducing Health Disparities and Potentially Avoidable Emergency Department Visits or Potentially Preventable Admissions. 2023 Equity Quality Improvement Activity #1 - Strategy Form (PDF) 2023 Quality Improvement Activity #2 - Strategy Form (PDF) 2022 Equity Quality Improvement Activity #1 - Strategy Form (PDF) 2022 Quality Improvement Activity #2 - Strategy Form (PDF) (Back to P4P Menu) Potentially Avoidable Emergency Department (ED) Visits: Potentially Preventable Diagnosis Code The Potentially Preventable Diagnosis Code List includes diagnosis codes for visits to an ED in which the condition could be treated by a Physician or other health care Provider in a non-emergency setting or conditions that are potentially preventable or are ambulatory care sensitive. Potentially Preventable Diagnosis List (PDF) Published: February 04, 2022   Patient Experience This toolkit is full of proven tips and successful strategies based on the kinds of questions your IEHP Members could be asked to answer regarding their Provider's service. Your Provider Relations Team has targeted nine specific topics in this toolkit to help Providers and their staff continue to achieve the highest marks in Patient experience from their IEHP Members. Serve Well Customer Service Toolkit (PDF) Well Child 2021 Recommendations for Preventive Pediatric Health Care from the American Academy of Pediatrics (PDF) Immunizations IEHP provides vaccine coverage based on the latest ACIP recommendation and guidelines. Please refer to the Immunization Update and "Summary of Recommendations" for both Child and Adolescents AND Adult Vaccines as follows: 2023 Immunization Timing Chart - English (PDF) 2023 Immunization Timing Chart - Spanish (PDF) 2023 Immunization Timing Chart - Chinese (PDF) 2023 Immunization Timing Chart - Vietnamese (PDF) 2023 Recommended Child and Adolescent Immunization Schedule (0-18 years) (PDF) 2023 Recommended Adult Immunization Schedule (19+ years) (PDF) Adult Vaccines are a covered benefit and do not require prior authorization (must adhere to CDC/ACIP Immunization Recommendation and/or FDA approved indication). Grow Well Childhood Immunization Toolkit for Providers (PDF) This toolkit contains commonly used immunization codes, best practices for reporting immunizations including information on registering with CAIR, tips on talking with parents and information on understanding vaccination hesitancy. CAIR2 Resource Guide (PDF) This guide contains helpful links and contact information for locations to register for CAIR2 or current users. Reimbursement process: Complete a CMS1500 form by including the appropriate CPT codes, quantity dispensed and billed amount. Mail: IEHP Claims Department P.O. Box 4349 Rancho Cucamonga, CA 91729-4349 For the latest updates and news regarding the vaccines, please visit CDC's ACIP website at: https://www.cdc.gov/vaccines/hcp/acip-recs/index.html Quality Bonus Services Dispute Form Please e-mail completed forms to QualityPrograms@iehp.org Quality Bonus Service Dispute Request Form (PDF) OB/GYN P4P Program Inland Empire Health Plan (IEHP) has released the OB/GYN P4P Program Guide which details the program requirements, performance measures, updated code sets, and payment timelines. OB/GYN P4P Program Guide (PDF) Published: January 01, 2023 OB P4P Frequently Asked Questions FAQs (PDF) Published: February 13, 2023 Postpartum Depression Screening (PDF) (Back to P4P Menu) Urgent Care + Wellness Quality Incentive Program Inland Empire Health Plan (IEHP) is pleased to announce the Urgent Care + Wellness Quality Incentive Program. The goal of the program is to reward urgent care providers for providing wellness services to IEHP Medi-Cal Members. Urgent Care + Wellness Quality Incentive Program Guide (PDF) Published: September 08, 2023 (Back to P4P Menu) Hospital P4P Program Inland Empire Health Plan (IEHP) is pleased to announce the Hospital Pay For Performance Program (Hospital P4P) for IEHP Medi-Cal contracted Hospitals servicing Riverside and San Bernardino Counties. The goal of the Hospital P4P Program is to provide substantial financial rewards to Hospitals that meet quality performance targets and demonstrate high-quality care to IEHP Members. 2023 Hospital P4P Program Guide (PDF) Published: September 21, 2023 P4P 2023 MX Data Contributions (PDF) Published: February 02, 2023 IEHP P4P 2023 Data Guidelines (PDF) Published: February 02, 2023 2022 Hospital P4P Program Guide (PDF) Published: March 20, 2023 P4P 2022 MX Data Contribution (PDF) Published: April 18, 2022 P4P 2022 MX Data Guidelines (PDF) Published: April 18, 2022 (Back to P4P Menu) Potentially Avoidable Emergency Department (ED) Visits: Potentially Preventable Diagnosis Code The Potentially Preventable Diagnosis Code List includes diagnosis codes for visits to an ED in which the condition could be treated by a Physician or other health care Provider in a non-emergency setting or conditions that are potentially preventable or are ambulatory care sensitive. Potentially Preventable Diagnosis List (PDF) Published: February 04, 2022 Substance Use Disorders and Mental Health Diagnosis Lists The Substance Use Disorders and Mental Health Diagnosis Lists includes diagnosis codes to identify substance use disorders, drug overdose, mental health or intentional self-harm diagnoses. Mental Health Diagnosis List (PDF) Published: June 23, 2023 Substance Use Disorders Diagnosis List (PDF) Published: June 23, 2023 You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here

居住在我們服務區域的民眾 (加州河濱郡與聖貝納迪諾郡的大部分居民) 成人 (無論是否撫養子女)、未成年人、老年人及殘障人士 符合收入標準和其他計劃要求者 50 歲以上的無證成年人 我要負擔多少費用？ 成人無須就 Medi-Cal 保險繳交任何月保險費。依據 Children’s Health Insurance Program (CHIP) 享有 Medi-Cal 保險的未成年人，僅須繳交少量月保險費。  我透過 IEHP 可以獲得 Medi-Cal 的哪些照護？ 您的計劃承保範圍包括：  門診 (非住院) 服務* 急診服務 跨性別服務* 臨終關懷與安寧照護* 住院治療* 產婦與新生兒照護 心理健康服務 處方藥 康復與復健服務及設備* 實驗室與放射線服務，如 X 光* 預防與健康服務以及慢性疾病管理 敏感性服務 物質使用障礙治療服務 兒科服務 視力服務* 非緊急醫療交通 (Non-Emergency Medical Transportation, NEMT) 非醫療交通 (Non-Medical Transportation, NMT) 長期服務與援助 (Long-Term Services and Supports, LTSS) 遠程醫療服務  上述部分服務僅於預先取得 IEHP 或您的 IPA 核准之情況下方適用。標示星號 (*) 的是可能需預先取得IEHP、您的IPA或醫療組的核准后，計劃所承保的服務。 如何申請 Medi-Cal：  請於週一至週五上午 8 點至下午 5 點致電 (866) 294-4347，與 IEHP 投保顧問聯繫。TTY 使用者請撥 (800) 720-4347。  您也可以致電 1-800-430-4263 與 Health Care Options 聯繫，或上網 www.healthcareoptions.dhcs.ca.gov。TTY 使用者請撥 1-800-430-7077。 IEHP Medi-Cal 會員重要注意事項 Medi-Cal 會員手冊 (PDF) - 說明如何取得 IEHP 照護及計劃承保的福利。 IEHP 會員手冊 Medi-Cal 福利指南 (PDF) - 本指南可協助您在IEHP會員手冊找到各項福利與服務的重要資訊。 Riverside縣Medi-Cal醫療服務提供者名錄(PDF) - 條列我們不斷壯大的醫療網絡，以及可快速取得所需照護的選項 – 全天無休。  San Bernardino縣 Medi-Cal醫療服務提供者名錄(PDF) - 條列我們不斷壯大的醫療網絡，以及可快速取得所需照護的選項 – 全天無休。 您需使用 Adobe Acrobat Reader 6.0 或更高版本，才能閲讀PDF 文檔。點選 Adobe Acrobat Reader 下載免費版本。     

題通常未獲得處理。Open Access Program 可透過加快獲得醫師看診的過程，讓您的子女更容易獲得持續醫療照護。無論您居住在加州內陸帝國的任何地方，您的子女都能夠約診網路內的任何 醫師。 此外，我們的計畫還能為您的子女提供一般 Medi-Cal 系統無法提供的許多服務。 Open Access 計畫如何使您的子女更容易獲得健康照護： 您的子女可預約我們龐大醫師網路內的任何 PCP 。 您可以隨時因任何原因更換醫師。IEHP 將協助您找到合適的醫師。請致電 1-800-440-IEHP (4347)/TTY 使用者請撥 (800) 718-4347。 此計畫會將您子女的健康記錄 (疫苗注射、用藥、檢查) 提供給醫師，以使其在看診時不須猜測。 若您忘了帶 IEHP 會員 ID 卡或保險受益人身份卡 (Beneficiary Identification Card, BIC)，Open Access 醫師可上網快速確認您子女的資格。 您與您的子女可免費獲取額外服務： 免費為您的子女提供 哮喘或糖尿病等健康項目。  讓您的子女保持安全與健康，並可享有父母專屬的額外福利，例如嬰兒汽車安全座椅、 兒童維他命及自行車安全帽。 我們設有專屬團隊，可協助您照護患有慢性疾病的子女。我們與您子女的醫師合作，致電給 您，確保您的子女獲得適當的照護。如果醫師看診、實驗室檢測或藥品配製工作塞車時，我們也可伸出援手。 重要資源 Riverside縣 Open Access 醫療服務提供者名錄(PDF) San Bernardino縣 Open Access醫療服務提供者名錄(PDF)   如欲深入瞭解 Open Access Program，請於週一至週五上午 8 點至下午 5 點致電 (800) 706-4347，與 IEHP 寄養照護專科醫師聯繫。 您需使用 Adobe Acrobat Reader 6.0 或更高版本，才能檢視 PDF 檔案。免費下載版本。點選 Adobe Acrobat Reader。 

通常是您暫時身處本計畫服務區域外)、區域外透析服務，以及 IEHP DualChoice (HMO D-SNP) 授權使用網絡外提供者的情況。 何謂網路內提供者？ 網路內提供者係指與我們簽訂合約，且接受我們的付款 為全額付款之醫師與其他健康照護專家、醫療團體、醫院與其他健康照護機構。我們安排這些提供者為本計畫會員提供給付的服務。 所有參與本計畫的提供者還會與我們簽訂合約，提供給付的 Medi-Cal 福利。 尋找醫師 請使用下列 IEHP DualChoice 提供者與藥局目錄，尋找網路內提供者： 2023 年 IEHP DualChoice 提供者與藥局目錄 (PDF) 初級照護提供者 (PCP) 是誰？他們在您的計畫中扮演什麼角色？ PCP 是指您的初級照護提供者。您的大部分例行性健康照護需求，都必須先找您的 PCP 看診。您的 PCP 也會協助您安排或協調您身為本計畫會員所享有的其他給付服務。「協調」您的服務包括與其他計畫提供者確認或諮詢您的照護內容與狀況。包括： X 光 實驗室檢測、治療 專科醫師提供的照護 醫院住院及後續照護 初級照護提供者 (PCP) 通常與特定醫院有所關聯。您在選擇 PCP 時，請記住下列事項： 您必須從提供者與藥局目錄選擇您的 PCP。若您在選擇或更換 PCP 時需要任何協助，請致電 IEHP DualChoice 會員服務中心。 選擇距離您的住家 10 英哩或 15 分鐘車程內的 PCP。 您所選擇的 PCP 只能夠為您辦理入住特定醫院。請儘量選擇距離您的住家 30 英哩或 45 分鐘車程內，且能夠讓您入住欲就診醫院的 PCP。 部分醫院設有「住院專科醫師」，負責於病患住院期間提供照護。若您入住任何此等醫院，「住院專科醫師」可能會在您入住期間擔任您的照護提供者。當您出院後，您的健康照護需求將恢復由您的 PCP 負責。 若您因任何原因需要變更 PCP，您的醫院與專科醫師也可能會變動。您的 PCP 應能夠講您的語言。然而，您的 PCP 也可在必要時隨時撥打語言專線服務，取得口譯人員的協助。 若您在加入 IEHP DualChoice 時未選擇 PCP，我們將為您選擇。我們會將您的 ID 卡與您的 PCP 資訊寄送給您。請記住，您可以隨時變更 PCP。 您可以基於任何原因更換您的 醫師 (及醫院) (每個月一次)。若  IEHP 在當月 25 日之前收到您的變更申請，則變更將從次月一日開始生效；若  IEHP 在當月 25 日之後收到您的變更申請，則變更將從下下個月一日開始生效 (部分提供者可能要求您提供 PCP 的轉介)。  如何取得專科醫師的照護 對於您的大部分例行性健康照護需求，如身體檢查、免疫接種等，通常需要先找您的初級照護提供者 (PCP) 看診。若 PCP 認為您需要專科治療或藥品，他/她將需要向您的計畫及/或醫療小組取得事先授權 (亦即：事先核准)。這稱為轉介。您的 PCP 會發送轉介資料給您的計畫或醫療小組。 最重要的是，您必須在前往計畫專科醫師或特定其他提供者看診前，向您的 PCP 取得轉介 (事先核准)。若您未在向專科醫師取得服務之前取得轉介 (事先核准)，您可能需要自行支付服務費用。 需要急症所需照護時，若您身處本計畫服務區域外該怎麼辦？ 假設您身處本計畫服務區域外，但仍在美國境內。若您需要急症所需照護，您可能無法找到或取得本計畫網路內的提供者。在此等情況下 (當您身處服務區域外且無法取得網路內提供者提供的照護時)，本計畫會給付任何提供者為您提供的急症所需照護。 若您在美國以外地區接受照護，本計畫將無法給付該等急症所需服務或任何其他照護。 變更您的初級照護提供者 (PCP) 您可以隨時基於任何原因變更 PCP。此外，您的 PCP 可能會退出本計畫的提供者網路，屆時您必須尋找新的 PCP。在此等情況下，您將必須更換為本計畫網路內的另一個提供者。若您的 PCP 退出本計畫，我們將會通知並協助您選擇其他 PCP，以便您持續享有給付的服務。IEHP DualChoice 會員服務中心可協助您找尋與選擇其他提供者。您可以致電 IEHP DualChoice 會員服務中心更換您的醫師。請於 (太平洋標準時間) 每天上午 8 點至晚上 8 點致電 (877) 273-IEHP (4347) 聯繫 IEHP DualChoice 會員服務中心，假日亦提供服務。TTY 使用者請撥 (800) 718-4347。 如需進一步瞭解網路內提供者的相關資訊，請參閱 IEHP DualChoice 會員手冊第 1 章。 IEHP DualChoice (HMO D-SNP) 是與 Medicare 簽約的 HMO 計畫。投保 IEHP DualChoice (HMO D-SNP) 取決於合約續訂。此清單並非完整清單。  您需使用 Adobe Acrobat Reader 6.0 或更高版本，才能檢視 PDF 檔案。點選 Adobe Acrobat Reader 下載免費版本。  此頁面資訊為截至 2022 年 10 月 1 日的最新資訊 H8894_DSNP_23_3241532_M Pending Accepted

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) 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.

計畫，讓您透過我們的計畫取得承保的 Medicare 和 Medi-Cal 福利。 我們的計畫包括醫師、醫院、藥局、長期服務與支援提供者、行為健康服務提供者與其他提供者。該計畫還設有照護協調人員與照護團隊，可協助您管理所有提供者與服務。他們會合作為您提供所需的照護。 IEHP DualChoice (HMO D-SNP) 有助於讓您的 Medicare 和 Medi-Cal 福利配合運作更順利，為您提供更好的服務。其中一些優點包括： 您可以透過與我們合作，滿足您所有的醫療保健需求。 您擁有一個由您協助建構的照護團隊。您的照護團隊可包括您自身、您的護理人員、醫師、護士、顧問或其他健康專業人員。 您可以聯繫照護協調員。照護協調員與您、我們的計畫以及您的照護團隊共同協助制定護理計畫。 您的照護團隊和照護協調員與您一起制定護理計畫，以滿足您的健康需求。照護團隊幫助協調您所需的服務。舉例來說，這表示您的護理團隊會確保： 您的醫師知悉您服用的所有藥物，因此他們可以確保您服用正確的藥物，並得以減少您可能因藥物而產生的任何副作用。 視情況而定，將與您全部的醫師和其他提供者共享您的檢驗結果。  哪些人符合 IEHP DualChoice 的資格？ IEHP DualChoice 同時適用 Medicare (A 與 B 部分) 與 Medi-Cal 會員。下列資訊說明哪些人符合 IEHP DualChoice (HMO D-SNP) 的資格。 包含對象： 強制投保 Medi-Cal 福利，包括長期服務與支援 (LTSS) 福利，以及 Medicare 福利。  若您符合下列條件，則您可以加入我們的計畫： 居住在我們的服務區域內（被監禁者即使實際位於該地理服務區域，也不被視為居住於該服務區域），以及 投保時年滿 21 歲，且  擁有 Medicare A 部分和 Medicare B 部分；且 目前符合獲得 Medi-Cal 的資格，且  您是全福利的雙重合格受益人，並且為您的 Medicare 福利投保 IEHP DualChoice，為您的 Medi-Cal 福利投保 Inland Empire Health Plan (IEHP)。 這被稱為獨家一致投保 (Exclusively Aligned Enrollment)，且 為美國公民或在美國合法居留 服務區域  只有居住在我們服務區域的民眾才能加入 IEHP DualChoice。我們的服務區域包括河濱郡與聖貝納迪諾郡所有地區。  如何投保 如需投保，請致電聯繫： 請於太平洋標準時間每天上午 8 點至晚上 8 點致電 (800) 741-IEHP (4347) 聯繫 IEHP DualChoice Medicare 團隊，假日亦提供服務；TTY 使用者請撥 (800) 718-4347 造訪我們的投保頁面以瞭解更多資訊。  IEHP DualChoice 是與 Medicare 簽約的 HMO 計畫，投保 IEHP DualChoice (HMO D-SNP) 取決於合約續訂。 此頁面資訊為截至 2022 年 10 月 1 日的最新資訊。 H8894_DSNP_23_3241532_M Pending Accepted

EHP's contracted Providers understand how IEHP functions and understand the rules and regulations IEHP must comply with, as governed by the California Department of Health Care Services (DHCS), California Department of Managed Health Care (DMHC), the Centers for Medicare and Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA). The Delegate or Provider has the responsibility to ensure review, understanding, and attestation of the information contained in the Manual. Acknowledgement of Receipt (AOR) 2024 Providers: 2024 Provider eAOR Providers are encouraged to attest electronically using the following recommended browsers: Google Chrome, Microsoft Edge, Mozilla Firefox 2024 Hospital & IPA AORs For more information regarding 2024 Manuals, click here. 2023 Providers: 2023 Provider eAOR Providers are encouraged to attest electronically using the following recommended browsers: Google Chrome, Microsoft Edge, Mozilla Firefox 2023 Hospital & IPA AORs For more information regarding 2023 Manuals, click here.

決定，以取得醫療、行為健康或特定長期服務與支援（MSSP、CBAS 或 NF 服務）  如欲要求做出給付決定，請致電、來信或傳真給我們，或讓您的代表或醫師聯絡我們並要求做出給付決定。  您可以致電我們：(877) 273-IEHP (4347) 聯絡我們，服務時間為 (太平洋標準時間) 每天上午 8 點至晚上 8 點，假日亦提供服務，TTY 使用者請撥 (800) 718-4347。  您可以傳真至：(909) 890-5877  您可以來信至： IEHP DualChoice P.O.Box 1800 Rancho Cucamonga, CA 91729-1800。 C 部分服務的給付決定需要多長時間？ 在您提出請求後，處理時間通常需要最多 14 個曆日。若我們未於 14 個曆日內做出決定，您可以提出上訴。 有時我們需要更多時間做出決定，在此情況下，我們會寄信通知您，我們需要額外 14 個曆日的處理時間。信函會說明需要延長處理時間的原因。 我可以快點取得 C 部分服務的給付決定嗎？ 有。如果您因為健康情況而需要取得快速答覆，應要求我們做出「快速給付決定」。 若我們核准您的要求，我們會在 72 小時內告知您我們的給付決定。然而，有時我們需要更多時間做出決定，在此情況下，我們會寄信通知您，我們需要額外 14 個曆日的處理時間。 要求做出快速給付決定： 若您要求做出快速給付決定，可致電或傳真至本計畫，要求我們給付您想要的照護。  您可以致電 (877) 273-IEHP (4347) 與 IEHP DualChoice 聯繫，服務時間為太平洋標準時間每天上午 8 點至晚上 8 點，假日亦提供服務。TTY 使用者請撥 (800) 718-4347，或傳真至 (909) 890-5877。 您也可以要求您的醫師或代表致電我們。 以下為申請快速給付決定的規則：  您必須符合下列兩項要求才能獲得快速給付決定：  只有當您針對尚未取得的照護或用品提出給付要求時，才能獲得快速給付決定。(若您的要求是針對已取得的照護或用品，您將無法獲得快速給付決定。) 唯有當標準 14 個曆日截止期限可能會對您的健康造成嚴重傷害或損害您的身體機能時，才能獲得快速給付決定。  若您的醫師認為您需要快速給付決定，我們將自動為您做出快速給付決定。 如果您未取得醫師的支持即申請快速給付決定，將由我們決定您是否能獲得快速給付決定。  若我們認定您的健康狀況不符合快速給付決定之規定，我們會寄信通知您。我們仍將採用標準 14 個曆日截止期限。 該信函會告知您，如果您的醫師提出快速給付決定要求，我們將會自動做出快速給付決定。 該信函亦會說明，針對我們的快速給付決定並非您所要求的快速給付決定，您可以如何提出「快速上訴」。 如果給付決定為「核准」，那什麼時候可以取得服務或用品？ 您將能夠在提出申請後的 14 個曆日（標準給付決定）或 72 小時（快速給付決定）內取得服務或用品。如果我們延長了做出給付決定所需的期間，則將會在延長期間結束前提供給付。 如果給付決定為「拒絕」，我會如何得知？  如果給付決定為「拒絕」，我們會寄信通知您，並說明拒絕的理由。 如果我們拒絕，您有權提出上訴，要求我們改變決定。提出上訴即代表要求我們審查拒絕給付的決定。 如果您決定提出上訴，表示您將進入第 1 階段上訴程序。 上訴 何謂上訴？ 上訴是您認為我們的決定有誤時，要求我們審查並變更給付決定的正式途徑。舉例來說，我們可能決定您所要求的任何服務、用品或藥品並未納入或已排除在 Medicare 或 Medi-Cal 給付範圍內。如果您或您的醫師不同意該決定，您可以提出上訴。 在大部分情況下，您都必須從第 1 階段上訴開始。若您不希望先就 Medi-Cal 服務計畫提出上訴，在特殊情況下，您可申請進行「獨立醫療審核」。若在上訴過程中需要協助，您可以致電 1-888-452-8609 與監察專員辦公室聯繫。監察專員辦公室與我方無關，也與任何保險公司或健康計畫無關。 C 部分服務的第 1 階段上訴是什麼？ 第 1 階段上訴係指對我們的計畫提出的第一次上訴。我們將審查給付決定，判定是否正確。審查人員將是未做出原始給付決定的人員。完成審查後，我們將以書面形式通知您裁決結果。如果我們在審查後，告知您該等服務或用品不在給付範圍內，則您可以提出第 2 階段上訴。  其他人可以代替我對 C 部分服務提出上訴嗎？ 有。您的醫師或其他提供者可以代替您提出上訴。另外，您的醫師或其他提供者以外的人員也可以代替您提出上訴，不過您必須先填寫「委任代表」表單。 該表單可授權其他人作為您的代表。 如果上訴是由您或您的醫師或其他提供者以外的人提出，我們必須先收到填寫完整的「委任代表」表單才能審查上訴。 如何對 C 部分服務提出第 1 階段上訴？ 若要開始上訴，您、您的醫師或其他提供者或您的代表必須與我們聯絡。您可以致電 (877) 273-IEHP (4347) 與 IEHP DualChoice 會員服務中心聯繫，服務時間為 (太平洋標準時間) 每天上午 8 點至晚上 8 點，假日亦提供服務。TTY 使用者請撥 (800) 718-4347。如需瞭解如何向我們提出上訴的其他詳細資訊，請參閱 IEHP DualChoice 會員手冊第 9 章。 您可以申請「標準上訴」或「快速上訴」。 如果您申請標準上訴或快速上訴，請以書面形式提出上訴並寄送至： IEHP DualChoice P.O.Box 1800 Rancho Cucamonga, CA 91729-1800 傳真：(909) 890-5748 您可以致電 (877) 273-IEHP (4347) 與 IEHP DualChoice 會員服務中心聯繫，提出上訴。服務時間為 (太平洋標準時間) 每天上午 8 點至晚上 8 點，假日亦提供服務。TTY 使用者請撥 (800) 718-4347。 我們將在收到您的上訴後 5 個曆日內發送信函給您，告知我們已收到您的上訴。 對 C 部分服務提出上訴的時間限制為何？ 您必須在我們向您發出告知決定的信函之日起 60 天內申請上訴。 如果您錯過此截止期限且可提供合理的理由，我們可能會給您更多時間提出上訴。以下是一些合理的理由範例：您當時患重病，或是我們為您提供了錯誤的申請上訴截止期限資訊。 我可以取得我的案例檔案副本嗎？ 有。若要申請副本，請致電 (877) 273-IEHP (4347) 與會員服務中心聯繫。TTY 使用者請撥 (800) 718-4347。 我的醫師可以提供有關我的 C 部分服務上訴的詳細資訊嗎？ 可以，您和您的醫師都可以提供佐證上訴的詳細資訊。 本計畫如何做出上訴裁決？  我們會仔細審查有關您醫療照護給付申請的所有資訊。接著，我們會確認我們在拒絕您的申請時，是否遵守所有規定。審核人員將是未做出原始給付決定的人員。如果我們需要更多資訊，會要求您或您的醫師提供。  何時可以知道 C 部分服務「標準」上訴裁決結果？ 我們必須在接獲您的上訴後 30 個曆日內予以答覆。如果您的健康狀況需要，我們會儘快通知您我們的決定。 但是，若您要求更多時間，或我們需要收集更多資訊，則可能額外需要 14 個曆日的處理時間。如果我們認定需要多一些時間來做出決定，將會透過信函通知您。 如果您認為我們不應延長決定時間，您可以針對我們的決定提出「快速申訴」。若您提出「快速申訴」，我們將在 24 小時內就您的上訴予以答覆。 如果我們未在 30 個曆日內或延長期間 (如果採用) 結束後答覆您，且您的問題是與 Medicare 服務或用品有關，我們會自動將您的案例送交第 2 階段上訴程序。倘若發生此類情況，您將會收到通知。若您的問題是與 Medi-Cal 服務或用品有關，您將須自行提出第 2 階段上訴。詳情請參閱下列說明。  如果我們核准您的部分或全部要求，我們必須在收到您的上訴後 30 個曆日內核准或提供給付。 如果我們對於您所提要求的最後裁決是部分或全部拒絕，我們將會寄通知信函給您。若您的問題是與 Medicare 服務或用品有關，我們的信函將會通知您已將您的案例交付獨立審查單位進行第 2 階段上訴。若您的問題是與 Medi-Cal 服務或用品有關，我們的信函將告知您如何自行提出第 2 階段上訴。詳情請參閱下列說明。 如果申請快速上訴，會發生什麼？ 如果您申請快速上訴，我們會在收到您的上訴後 72 小時內予以答覆。如果您的健康狀況需要盡快取得裁決結果，我們會提早予以答覆。 但是，若您要求更多時間，或我們需要收集更多資訊，則可能額外需要 14 個曆日的處理時間。如果我們認定需要多一些時間來做出決定，將會透過信函通知您。 如果您認為我們不應延長決定時間，您可以針對我們的決定提出「快速申訴」。若您提出「快速申訴」，我們將在 24 小時內就您的上訴予以答覆。 如果我們未在 72 小時內或延長期間 (如果採用) 結束後答覆您，且您的問題是與 Medicare 服務或用品有關，我們會自動將您的案例送交第 2 階段上訴程序。倘若發生此類情況，您將會收到通知。若您的問題是與 Medi-Cal 服務或用品有關，您將須自行提出第 2 階段上訴。詳情請參閱下列說明。 如果我們核准您的部分或全部要求，我們必須在收到您的上訴後 72 小時內核准或提供給付。  如果我們對於您所提要求的最後裁決是部分或全部拒絕，我們將會寄通知信函給您。若您的問題是與 Medicare 服務或用品有關，我們的信函將會通知您已將您的案例交付獨立審查單位進行第 2 階段上訴。若您的問題是與 Medi-Cal 服務或用品有關，我們的信函將告知您如何自行提出第 2 階段上訴。詳情請參閱下列說明。 在第 1 階段上訴期間，我是否可繼續享有福利？如果我們決定變更或停止先前核准的任何服務或用品之給付，我們會在採取相關行動之前發送通知給您。如果您不同意該行動，可以提出第 1 階段上訴，並要求我們繼續為您提供相關服務或用品的福利。您必須在下列日期 (以發生時間較晚者為準) 之前提出申請，才能繼續享有福利： 在我們郵寄行動通知之日後 10 日內；或 行動的預計生效日期。 若您在前述截止期限內提出申請，則您在上訴期間仍可獲得爭議服務或用品的給付。 第 2 階段上訴 如果本計畫駁回我的第 1 階段上訴，接下來會發生什麼？如果我們對於您第 1 階段上訴的最後裁決是部分或全部拒絕，我們將會寄通知信函給您。該信函會告知您，相關服務或用品是否通常可獲得 Medicare 或 Medi-Cal 給付。 若您的問題是與 Medicare 服務或用品有關，我們會在第 1 階段上訴結束後，儘快自動將您的案例送交第 2 階段上訴程序。 若您的問題是與 Medi-Cal 服務或用品有關，您將須自行提出第 2 階段上訴。該信函會告知您如何進行。相關資訊也請參閱下方。 第 2 階段上訴是什麼？第 2 階段上訴係指第二次上訴，且係由與計畫無關的獨立組織進行。   我的問題與 Medi-Cal 服務或用品有關。我要如何提出第 2 階段上訴？針對 Medi-Cal 服務與用品提出第 2 階段上訴有兩種方式：1) 獨立醫療審核或 2) 州聽證會。 1)   獨立醫療審核 您可以向加州管理式醫療保健部 (California Department of Managed Health Care, DMHC) 協助中心申請獨立醫療審核 (IMR)。IMR 適用具醫療性質之所有 Medi-Cal 給付服務或用品。IMR 是由非本計畫成員之醫師審核您的案例。若 IMR 的裁決是您勝訴，則我們必須提供您所要求的服務或用品。您不須就 IMR 支付任何費用。 若本計畫符合下列條件，則您可以申請 IMR： 因本計畫認定不具醫療必要性，而駁回、變更或延遲提供 Medi-Cal 服務或治療 (不包括 IHSS)。 不就適用嚴重醫療狀況之實驗性或研究性 Medi-Cal 治療提供給付。 不支付您已經取得之緊急或急症 Medi-Cal 服務費用。 未於提出標準上訴後 30 個曆日內或於提出快速上訴後 72 小時內，解決您就 Medi-Cal 服務提起之第 1 階段上訴。 如果您還要求召開州聽證會，則您可以申請 IMR，惟僅限您未就相同問題召開過州聽證會。 在多數情況下，您必須在申請 IMR 之前提出上訴。如果您不同意我們的決定，您可要求 DMHC 協助中心進行 IMR。 若您的治療因為屬於實驗或研究性質而遭駁回，則您在申請 IMR 之前，不須參加我們的上訴程序。 如果您的問題具急迫性，且對您的健康具有迫在眉睫的嚴重威脅，您可以立即向 DMHC 提出申請。在特殊且急迫的狀況下，DMHC 得豁免您遵守我方上訴程序的規定。 您必須在我們書面通知您上訴裁決後 6 個月內申請 IMR。DMHC 可能在認定相關情況導致您無法準時提出申請時，接受您在前述 6 個月期間屆滿後提出的申請。 如欲申請 IMR： 請填寫獨立醫療審核/申訴表，網址為：http://www.dmhc.ca.gov/FileaComplaint/SubmitanIndependentMedicalReviewComplaintForm.aspx，或致電 (888) 466-2219 與 DMHC 協助中心聯繫。TDD 使用者請撥 (877) 688-9891。 請檢附我們駁回服務或用品申請之信函或其他文件 (若有)。如此可加快 IMR 流程。請寄送文件副本，而非正本。協助中心將不會退還任何文件。 如果您是由他人代表申請 IMR，請填寫「授權協助表」(Authorized Assistant Form)。此表格可於下列網址下載：http://www.dmhc.ca.gov/FileaComplaint/SubmitanIndependentMedicalReviewComplaintForm.aspx，或請致電 (888) 466-2219 與 DMHC 協助中心聯繫。TDD 使用者請撥 (877) 688-9891。 請郵寄或傳真您的表格及所有附件至：  Help Center Department of Managed Health Care 980 Ninth Street, Suite 500 Sacramento, CA 95814-2725 傳真：916-255-5241 若您符合 IMR 資格，DMHC 將會在 7 個曆日內審核您的案例，並寄信通知您符合 IMR 規定。在從您的計畫收到您的申請表與佐證文件之後，IMR 將在 30 個曆日內做出決定。您應該會在提交完整申請資料後 45 個曆日內收到 IMR 裁決。 若您的案例具急迫性且您符合 IMR 資格，DMHC 將會在 2 個曆日內審核您的案例，並寄信通知您符合 IMR 規定。在從您的計畫收到您的申請表與佐證文件之後，IMR 將在 3 個曆日內做出決定。您應該會在提交完整申請資料後 7 個曆日內收到 IMR 裁決。 若您對 IMR 的裁決不滿意，仍可以要求召開州聽證會。  若 DMHC 認定您的案例不符合 IMR 規定，DMHC 將會透過一般消費者投訴程序審核您的案例。 2)   州聽證會 您可就 Medi-Cal 給付服務與用品申請召開州聽證會。若您的醫師或其他提供者要求提供我們不會核准的服務或用品，或我們不再繼續提供您已取得的服務或用品，且我們駁回您的第 1 階段上訴，則您有權申請召開州聽證會。 在大部分情況下，您有權在收到「您的聽證權利」通知後 120 天內，申請召開州聽證會。  注意：如果您申請召開州聽證會是由於我們告知您目前享有的服務即將變更或終止，而且您想要在召開州聽證會期間繼續享有該服務，則您提出申請的天數將縮減。有關詳細資訊，請參閱會員手冊第 9 章「在第 2 階段上訴期間，我是否可持續享有福利」。 申請召開州聽證會的方法有兩種： 您可以填寫行動通知背面的「申請召開州聽證會」。您應提供所有必要資訊，如您的全名、地址、電話號碼、計畫名稱或您遭採取行動之郡縣、相關補助計畫以及您希望申請召開聽證會的詳細理由。接著，您可以透過下列任一方式提交申請： 寄送至通知所載地址之郡縣福利部門。 寄送至 California Department of Social Services： State Hearings Division P.O.Box 944243, Mail Station 9-17-37 Sacramento, California 94244-2430 傳真至州聽證部門，號碼為 916-651-5210 或 916-651-2789。 您可以致電加州社會服務部，電話為 (800) 952-5253。TDD 使用者請撥 (800) 952-8349。若您決定透過電話申請召開州聽證會，您應瞭解該電話線路非常忙碌。 在第 2 階段上訴期間，我是否可繼續享有福利？若您的問題是與 Medicare 給付服務或用品有關，則在您向獨立審查單位提起第 2 階段上訴期間，您就服務或用品所享有的福利將不再繼續適用。 若您的問題是與 Medi-Cal 給付服務或用品有關，且您申請召開州公平聽證會，則在做出聽證決定之前，您就該服務或用品所享有的 Medi-Cal 福利將繼續適用。您必須在下列日期 (以發生時間較晚者為準) 之前申請召開聽證會，才能繼續享有福利： 在我們通知您已做出不適用福利裁決 (第 1 階段上訴裁決) 之郵寄日起 10 天內；或 行動的預計生效日期。 若您在前述截止期限內提出申請，則您在聽證會裁決做出之前仍可獲得爭議服務或用品的給付。 要如何得知裁決結果？若您的第 2 階段上訴為州聽證會，加州社會服務部將會寄函給您，說明裁決結果。  若州聽證會裁決為核准您申請的部分或全部項目，我們就必須遵守該裁決。我們必須在收到裁決副本之日起 30 個曆日內，完成規定之行動。 若州聽證會裁決為拒絕您申請的部分或全部項目，則表示其同意第 1 階段上訴裁決。我們可停止提供您所取得的任何暫時補助金。  若您的第 2 階段上訴為獨立醫療審核，管理式醫療保健部將會寄函給您，說明裁決結果。  若獨立醫療審核裁決為核准您申請的部分或全部項目，我們就必須提供服務或治療。 若獨立醫療審核裁決為拒絕您申請的部分或全部項目，則表示其同意第 1 階段上訴裁決。您仍可申請召開州聽證會。 若您的第 2 階段上訴係由 Medicare 獨立審查單位負責，該單位將會寄函給您，說明裁決理由。 若獨立審查單位的裁決為核准您申請的部分或全部項目，我們會在收到 IRE 裁決後的 72 小時內核准醫療照護給付，或在 14 個曆日內提供服務或用品。  若獨立審查單位的裁決為拒絕您申請的部分或全部項目，則表示其同意第 1 階段上訴裁決。此稱為「維持原裁決」；亦稱為「駁回上訴」。 如果裁決為拒絕我申請的全部或部分項目，我可以再次提出上訴嗎？若您的第 2 階段上訴為州聽證會，您可以在收到裁決後 30 天內申請複審。您也可以在收到裁決後一年內，向高等法院提交訴狀，申請對州聽證會駁回裁決進行司法審查 (依據民事訴訟法第 1094.5 條)。  若您的第 2 階段上訴為獨立醫療審核，您可以申請召開州聽證會。  若您的第 2 階段上訴係由 Medicare 獨立審查單位負責，則僅於您所申請服務或用品之價值符合特定最低金額門檻時，方可再次上訴。IRE 寄送給您的信函，將會說明您可能擁有的其他上訴權利。 付款問題 我們不允許網路內提供者向您收取給付服務與用品的費用。即使我們支付給提供者的金額低於提供者就給付服務或用品所收取的費用，也是如此。您絕對不需要支付任何帳單的差額。您唯一須支付的金額為規定應共付之服務、用品及/或藥品類別的共付額。若您收到的帳單金額高於您就給付服務與用品應支付的共付額，請將帳單寄給我們。您不應自行支付該帳單。我們會直接聯絡提供者並解決問題。 如果我支付了本計畫應付的醫療服務或用品分攤費用，如何向計畫申請退款？請記住，若您收到的帳單金額高於您就給付服務與用品應支付的共付額，您不應自行支付該帳單。但如果您支付了帳單，且您遵守服務和用品的取得規定，則您可以要求退款。  如果您要申請返款，就是申請給付裁決。我們將確認您所支付的服務或用品是否在給付範圍內，且我們將確認您是否遵守使用給付的規定。 如果您已付款的服務或用品屬於給付範圍，且您遵守所有規定，我們將會在收到您的申請後 60 個曆日內，將我們應支付的服務或用品分攤費用退還給您。 或者，如果您尚未支付該等服務或用品之費用，我們將會直接付款給您的提供者。若我們寄發款項，等同於我們同意您的給付裁決要求。 如果服務或用品不在給付範圍內，或是您未遵守所有規定，我們會郵寄信函通知您我們不會支付服務或用品費用並說明原因。 如果計畫表明不會付款，該怎麼辦？如果您不同意我們拒絕付款的決議，您可以提出上訴。遵循上訴程序。遵循這些指示時，請注意： 若您提出報銷上訴，我們必須在接獲上訴後 60 個曆日內回覆。 若您要求我們返還您已自費接受之醫療照護的費用，則不得申請快速上訴。  若我們對您上訴的答覆為「拒絕」，且該等服務或用品通常可獲得 Medicare 給付，我們將自動將您的案例發送給獨立審查單位。若有此情況，我們會寄通知函給您。 若 IRE 駁回我方裁決並認定我們應付款，則我們必須於 30 個日曆日內付款給您或提供者。如果您的上訴在第 2 階段上訴程序後的任何階段中獲得核准，我們必須在 60 個日曆日內寄發您要求的款項給您或提供者。 若 IRE 駁回您的上訴，表示他們同意我們的裁決，即不批准您的要求。(這稱為「維持原裁決」；亦稱為「駁回上訴」)。您所收到的信函，將會說明您可能擁有的其他上訴權利。僅於您所申請服務或用品之價值符合特定最低金額門檻時，方可再次上訴。 若我們對您上訴的答覆為「拒絕」，且該等服務或用品通常可獲得 Medi-Cal 給付，則您可自行提出第 2 階段上訴 (請參閱上文)。 IEHP DualChoice (HMO D-SNP) 是與 Medicare 簽約的 HMO 計畫。投保 IEHP DualChoice (HMO D-SNP) 取決於合約續訂。 此頁面資訊為截至 2022 年 10 月 1 日的最新資訊。 H8894_DSNP_23_3241532_M Pending Accepted

HP 臨床藥師團隊負責生產您的藥物，確保您所使用的藥物劑量符合您的健康狀況。若您是符合 MTM 計畫資格的會員，我們將會發送一封信函給您。除非您選擇不加入，否則您將自動投保計畫。符合資格的會員投保計畫無需花費任何費用。 誰可能符合資格？  本計畫的部分合格會員可能僅享有 IEHP 的 Medi-Cal 給付，   或者可能已經投保 IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid 計畫)。該等會員必須符合相關條件，且將會獲得 Medicare MTM 計畫的服務。(請參閱下列說明。)  MTM 服務包括哪些？  IEHP 的  MTM 服務包括 下列核心要素： 藥物治療審查 藥物教育 - 包括藥物行動計畫 疾病管理 我們的 IEHP 臨床藥師團隊會審查會員的藥物、家族病史、疾病狀態與藥物治療目標。該團隊會依據完整審查結果，為會員與提供者提供建議。  持照藥劑師與技師團隊將會與您的醫師 (或其他提供者) 及藥局合作提供完整照護。我們也會與照護管理團隊合作，為會員提供「全方位健康」照護。 Medicare MTM 計畫 IEHP 臨床藥師團隊為符合下列條件的 IEHP DualChoice 會員提供 MTM 服務，不另收取費用： 患有多種疾病； 使用許多處方藥； 需支付高額藥物費用 加入此計畫後，您將收到一份包含詳細資訊的郵寄資料包。此資料包也會提供如何退出計畫的相關資訊，以便您選擇不加入計畫時使用。若您決定不參與計畫，您獲得 IEHP DualChoice 給付的狀態及相關資格將不會有任何變化。誠摯希望您在符合資格時能夠加入，此計畫完全免費，還可協助您更好地管理您的藥物。  MTM 計畫包括年度綜合用藥審查 (CMR) 及針對性用藥審查 (TMR)。以下為 MTM 服務的部分內容： 綜合用藥審查  (CMR) IEHP 臨床藥劑師將透過電話為您提供年度綜合用藥審查服務。藥劑師會逐一確認您的藥物，以確保您所使用的藥物符合您的健康狀況，並協助您避免藥物相互作用等。  在完成您的 CMR 後，我們會將您的藥物行動計畫 (Medication Action Plan, MAP) 及個人藥物清單 (Personal Medication List, PML) 郵寄給您。您可致電會員服務中心並要求與臨床藥師團隊通話，以取得相關 MTM 服務文件及個人藥物清單的副本。 針對性用藥審查  (TMR) IEHP 臨床藥師團隊也會在一年當中提供 TMR 服務，審查參與計畫之 IEHP DualChoice 會員的藥物。該團隊會每三個月為所有保險受益人進行一次 TMR。保險受益人會透過郵件收到 TMR 建議，其初級照護提供者則可能會透過傳真收到相關建議 (若 IEHP 臨床藥師團隊認定有必要)。 符合 CMR 或 TMR 服務資格的 IEHP DualChoice 會員如需瞭解詳細資訊，可致電 1-877-273-IEHP (4347)，服務時間為 (太平洋標準時間) 每天早上 8 點至下午 8 點，假日亦提供服務。TTY 使用者請撥 1-800-718-4347。  按一下此處獲取空白個人藥物清單。 資格條件 該等 MTM 計畫服務可能有一些適用的資格條件，且不屬於福利。MTM 計畫服務適用於符合下列條件的會員： 1.會員罹患至少三 (3) 種下列疾病： 骨骼疾病 - 關節炎 - 骨質疏鬆症 骨骼疾病 - 關節炎 - 類風濕性關節炎 慢性心臟衰竭 (Chronic Heart Failure, CHF) 糖尿病 血脂異常 末期腎臟病 (End-Stage Renal Disease, ESRD) 高血壓 心理健康慢性疾病/殘障心理健康疾病 呼吸系統疾病 – 哮喘 呼吸系統疾病 – 慢性阻塞性肺病 (Chronic Obstructive Pulmonary Disease, COPD) 2. 醫師為會員開立至少五 (5) 種不同的處方藥，以治療下列疾病： 血管緊張素 I 型轉化酶抑制劑 血管緊張素 II 型受體阻斷劑 (Angiotensin II Receptor Blocker, ARB) 抗憂鬱劑 降血脂藥 降血壓藥 抗精神病藥物 乙型阻斷劑 支氣管擴張劑 鈣通道阻斷劑 疾病調節抗風濕藥物 (Disease-Modifying Anti-Rheumatic Drug, DMARD) 利尿劑 胰島素 口服降血糖藥 選擇性血清素再吸收抑制劑 (Selective Serotonin Reuptake Inhibitor, SSRI) 腫瘤壞死因子 (Tumor Necrosis Factor, TNF) 吸入式皮質類固醇 擬鈣製劑 強心配糖體 聚落刺激因子 昇糖素類似胜肽 糖皮質激素 腦啡肽酶抑制劑 非類固醇消炎止痛藥 (NSAID) 磷酸鹽結合劑 維生素 D 類似物  3.前三個月可能須支付 1,174 美元 (4,696 美元的四分之一) 的藥物費用。 如欲進一步瞭解 MTM，請致電  IEHP DualChoice 會員服務中心，電話：1-877-273-IEHP (4347)。服務時間為 (太平洋標準時間) 每天早上 8 點至晚上 8 點，假日亦提供服務。TTY 使用者 請 撥 1-800-718-4347。 此頁面資訊為截至 2021 年 10 月 8 日的資訊。 H5355_CMC_22_2246727  

表。若您需要填寫表單方面的協助，IEHP 會員服務中心可以提供協助。 您可以線上填寫會員申訴表。 您可以將填寫完成的表單提供給任何 IEHP 提供者，或郵寄至： P.O Box 1800, Rancho Cucamonga, CA 91729-1800 您可以將填寫完成的表單傳真至 (909) 890-5877。您可以線上提出申訴。此表單適用 IEHP DualChoice 及其他 IEHP 計畫。  針對某些類型的問題，您需遵行給付範圍決定和上訴程序。 而針對其他類型的問題則需遵行提出申訴的程序。以上兩種程序皆經 Medicare 核準。為確保問題處理流程的公正性與時效性，每種流程各有一套規定、程序及期限，我方與您都必須確實遵守。 長期服務與支援： 如果您對於照護有任何疑問，請致電 1-888-452-8609 尋求監察專員辦公室協助。  若屬我們簽約社區成人服務 (Community Based Adult Services, CBAS) 據點 或護理機構/亞急性照護機構之資格認定、評估與照護相關的問題與疑慮，請依據下列流程提出。 社區成人服務 (CBAS) 您可以致電 (877) 273-IEHP (4347) 與 IEHP 會員服務中心聯繫，並索取會員申訴表。若您需要填寫表單方面的協助，IEHP 會員服務中心可以提供協助。 您可以將填寫完成的表單提供給任何 IEHP 提供者，或郵寄至： P.O Box 1800 Rancho Cucamonga, CA 91729-1800 您可以將填寫完成的表單傳真至 (909) 890-5877。您可以線上提出申訴。此表單適用 IEHP DualChoice 及其他 IEHP 計畫。 協助處理問題 您可以聯絡 Medicare。您可以透過下列兩種方式直接向 Medicare 索取資訊： 您可以致電 24 小時全年無休專線 (800) MEDICARE (800) 633-4227，TTY 使用者請撥 (877) 486-2048。 您可以造訪 Medicare 網站 點選此連結，您將會離開 IEHP DualChoice 網站。 向獨立政府組織求助 我們非常樂意為您提供服務。不過，在某些情況下，建議您透過與我方無關的人士獲得協助或指導。您可隨時聯繫您的 State Health Insurance Assistance Program (SHIP)。此政府計畫在各州都設有受過訓練的顧問。此計畫與我方無關，也與任何保險公司或健康計畫無關。此計畫的顧問可以協助您瞭解處理問題時應採用的流程。此外，他們也可以解答您的問題、提供更多資訊，以及輔導您進行後續處理。SHIP 顧問的服務並不收費。您可以致電 1-800-434-0222 與 SHIP 聯繫。 向 DHCS 取得協助與相關資訊 電話：(916) 445-4171 MCI，TDD 請撥 (800) 735-2929 MCI，語音電話：(800) 735-2922 Sprint，TDD 請撥 (800) 877-5378 Sprint，語音電話：(800) 877-5379 致函： Department of Health Care Services 1501 Capitol Ave., P.O. Box 997413 Sacramento, CA 95899-7413 網站：www.dhcs.ca.gov 點選此連結，您將會離開 IEHP DualChoice 網站。 向 Medi-Cal 取得協助與相關資訊 監察專員辦公室可以解答您的疑問，並協助您瞭解需要做哪些事才能解決您的問題。監察專員辦公室與我方無關，也與任何保險公司或健康計畫無關。此計畫可協助您瞭解應採用哪項流程。 電話：請於週一至週五上午 9 點至下午 5 點致電 1-888-452-8609 (TTY 711) 造訪其網站：www.healthconsumer.org/ 點選此連結，您將會離開 IEHP DualChoice 網站。 向 Livanta 取得協助與相關資訊 本州有一個名為 Livanta Beneficiary & Family Centered Care (BFCC) 品質改進組織 (Quality Improvement Organization, QIO) 的組織。這是一個由醫生和其他健康照護專業人員組成的團體，他們協助改善 Medicare 患者的護理品質。Livanta 與我們的計畫無關。 電話：(877) 588-1123，TTY 使用者請撥 (855) 887-6668 如欲提出上訴：(855) 694-2929 如欲申請所有其他審核：(844) 420-6672 致函： Livanta BFCC-QIO Program 10820 Guilford Road, Suite 202 Annapolis Junction, Maryland 20701 網站：www.livanta.com 點選此連結，您將會離開 IEHP DualChoice 網站。 如何取得向 IEHP DualChoice (HMO D-SNP) 提出的申訴、上訴與例外處理的總數？ 請致電或寫信至 IEHP DualChoice 會員服務中心。 電話：(877) 273-IEHP (4347)。此為免付費專線。服務時間為 (太平洋標準時間) 每天上午 8 點至晚上 8 點，假日亦提供服務，TTY 使用者請撥：(800) 718-4347。此號碼須使用特殊電話設備。此為免付費專線。 傳真：(909) 890-5877 致函： IEHP DualChoice, P.O. Box 1800 Rancho Cucamonga, CA 91729-1800 電子郵件：memberservices@iehp.org 親自造訪：10801 Sixth Street, Suite 120, Rancho Cucamonga, CA 91730 IEHP DualChoice (HMO D-SNP) 是與 Medicare 簽約的 HMO 計畫。投保 IEHP DualChoice (HMO D-SNP) 取決於合約續訂。此清單並非完整清單。  此頁面資訊為截至 2022 年 10 月 1 日的最新資訊。 H8894_DSNP_23_3241532_M Pending Accepted

的 24 小時護士諮詢熱線。 請務必完成您的健康風險評估 (Health Risk Assessment, HRA)。 當您首次加入我們的計畫時，您會在投保生效日期前後 90 天內獲得健康風險評估 (HRA)。  我們必須為您完成 HRA。這份 HRA 是您的照護計畫的基礎。HRA 包括用於確定您的醫療、LTSS 和行為健康及功能需求的問題。  我們會與您溝通以完成 HRA。我們可以透過親臨現場、致電或郵寄完成 HRA。在您投保該計畫後，我們將向您寄送有關該 HRA 的更多資訊。  如果您是本計畫的新保戶，而您目前的醫師不在我們的網絡內，您可以繼續使用您目前的醫師所提供的服務一段時間。我們稱其為照護持續性。如果他們不在我們的網絡內，若符合以下所有條件，您可以保留您投保時既有的醫療服務提供者和服務授權，最長可達 12 個月：  您、您的代表或您的提供者要求我們讓您繼續使用您目前的提供者。  我們確定您與初級或專科護理提供者存在既有關係，但有一些例外。當我們提及「既有關係」時，是指您在首次投保我們計畫日期前的 12 個月內，至少獲得一次網絡外醫療服務提供者所提供的非急診服務。 我們透過查閱您的可用健康資訊，或您提供給我們的資訊來確定既有關係。 我們有 30 天的時間回覆您的請求。您可以要求我們更快做出決定，而我們必須在 15 天內做出回應。 您或您的提供者必須出示證明既有關係的文件，並在您提出請求時同意某些條款。 註：您只能針對耐用醫療設備 (Durable Medical Equipment, DME) 服務、交通運輸或其他未包含於我們計畫內的輔助服務提出此請求。您不能向 DME 提供者、交通運輸提供者或其他輔助提供者提出此請求。 照護持續期結束後，除非我們與您的網絡外醫師達成協議，您將需要使用 IEHP DualChoice 網絡中隸屬於您的初級照護提供者醫療團體的醫師和其他提供者。網絡內提供者是與健康計畫合作的提供者。我們計畫的 PCP 隸屬於醫療團體或獨立醫師協會 (Independent Physicians Associations, IPA)。當您選擇您的 PCP 時，您也在選擇附屬醫療團體。這意味著您的 PCP 會將您轉介給隸屬於其醫療團體的專家和服務。醫療團體或 IPA 是一個由醫生、專家和其他為 IEHP 會員提供醫療服務的提供者所組成的團體。您的 PCP 與醫療團體或 IPA 共同為您提供醫療護理。這包括獲得專科醫師看診或醫療服務的授權，例如實驗室檢測、X 光檢查和/或住院治療。在某些情況下，IEHP 是您的醫療團體或 IPA。有關獲得照護的詳細資訊，請參閱您的會員手冊第 3 章 為重要的健康決定做好準備 現在就取得 My Life.My Choice. 應用程式。它將您所有的預立照護規劃文件儲存於網路上的一個地方。預立照護規劃 (Advance care planning, ACP) 涉及醫病共享決策，以在預先照護指示中寫下一個人對其未來醫療護理的願望。ACP 和預先醫療照護指示可以在某人失去自己做決定的能力時，彌合他們所希望的照護和所得到的照護之間的差距。使用此應用程式，您或擁有授權書的指定人員可以隨時運用家用電腦或智慧型手機取得您的預先醫療照護指示。 透過我們的安全會員入口網站註冊免費應用程式。 IEHP DualChoice (HMO D-SNP) 是與 Medicare 簽約的 HMO 計畫。投保 IEHP DualChoice (HMO D-SNP) 取決於合約續訂。此清單並非完整清單。 此頁面資訊為截至 2022 年 10 月 1 日的最新資訊。 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: 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

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

HP DualChoice 網站) IEHP DualChoice 隱私權通知說明您的醫療資訊的使用與披露方式，以及您如何取得此資訊。 IEHP DualChoice 隱私權通知 (PDF) Medicare 暨 Medicaid 服務中心 下列連結會將您帶往 Medicaid 暨 Medicare 服務中心網站，且您可透過下列連結檢視 CMS 最佳證據政策 (CMS Best Available Evidence Policy)：CMS 最佳證據政策。點選此連結，您將會離開 IEHP DualChoice 網站。 您需使用 Adobe Acrobat Reader  6.0 或更高版本，才能檢視 PDF 檔案。點選此處下載免費版本。點選此連結，您將會離開 IEHP DualChoice 網站。 IEHP DualChoice (HMO D-SNP) 是與 Medicare 簽約的 HMO 計畫。投保 IEHP DualChoice (HMO D-SNP) 取決於合約續訂。 此頁面資訊為截至 2022 年 10 月 1 日的最新資訊。 H8894_DSNP_23_3241532_M Pending Accepted

得的資訊 語言協助 我方通信 關於給付決定或上訴相關措施的時效性 如何向 IEHP DualChoice (HMO D-SNP) 提出申訴 1.請立即與我們聯繫 ─ 請致電 (877) 273-IEHP (4347) 與 IEHP DualChoice 聯繫，服務時間為每天上午 8 點至晚上 8 點，假日亦提供服務，TTY/TDD 使用者請撥 1-800-718-4347。您可以隨時提出申訴，除非係與 D 部分藥品有關。若申訴內容係與 D 部分藥品有關，您必須在申訴問題發生後 60 個曆日內提出。 如果您不想透過電話提出 (或者您致電過，但未獲得滿意答覆)，您可以將要申訴的問題寫下來，然後郵寄給我們。如果您是透過書面形式提出申訴，我們也會透過書面形式回覆您的申訴。  您可以使用我們的「會員上訴與申訴申請表」。我們的所有醫師診間與服務提供者皆備有該表單，或者我們也可郵寄表單給您。您可以線上提出申訴。您可將填妥的表單提供給我們的計畫提供者，或寄送至下列地址，也可將填妥的表單傳真至下列號碼。此表單適用 IEHP DualChoice 及其他 IEHP 計畫。 IEHP DualChoice  P.O. Box 1800 Rancho Cucamonga, CA 91729-1800 傳真：(909) 890-5877 無論是致電或致函，您都應立即聯繫 IEHP DualChoice 會員服務中心。 2.我們會審核您的申訴，然後給您答覆 我們會盡可能立即回覆您。當您透過電話提出申訴，我們會儘量在當次通話中答覆您。若您的健康狀況需要我們盡快答覆，我們會按照您的要求辦理。 大部分申訴可在 30 個曆日內得到答覆。如果我們需要更多資訊，且認定延遲是基於您的最大利益 (或者您自己要求更多時間)，則我們可將申訴的答覆時間最多延長 14 天 (共 44 天)。 如果我們否決您的部分或全部申訴，或是我們不負責您所申訴的問題，則我們會告知您。我們會在回應時說明拒絕的理由。我們必須回覆是否同意您的申訴。 快速申訴 若您係因我們拒絕您的「快速給付裁決」或「快速上訴」申請而提出申訴，則我們會自動視同「快速」申訴處理。當您提出「快速」申訴時，則表示我們會在 24 小時內給您答覆。 哪些人可以提出申訴？ 您或您指定之人可以提出申訴。您所指定之人即為您的「代表」。 您可以指定親戚、朋友、律師、倡權者、醫師或任何其他人作為您的代表。其他人可能已經獲得法院許可或依據州法可代表您提出申訴。如果您要指定擔任您代表的人士尚未獲得法院許可或不符合州法規定，則您與該人士必須簽署一份聲明並標註日期，以茲授予該人士擔任您代表的權利。如欲進一步瞭解如何指定代表，您可以致電 IEHP DualChoice 會員服務中心。 外部申訴 您可以向 Medicare 提出申訴 您可以將申訴發送給 Medicare。Medicare 申訴表可透過下列網址下載： https://www.medicare.gov/MedicareComplaintForm/home.aspx。 Medicare 會仔細審理您的申訴，並且會運用這項資訊改善 Medicare 計畫的品質。 若您有任何其他意見或疑慮，或者您認為本計畫未解決您的問題，請致電 (800) MEDICARE (800) 633-4227)。TTY/TDD 使用者請撥 (877) 486-2048。此為免付費電話。 您也可以向 Medi-Cal 提出申訴 監察專員辦公室也可從中立角度協助解決問題，以確保我們的會員獲得我們須提供的所有給付服務。監察專員辦公室與我方無關，也與任何保險公司或健康計畫無關。  監察專員辦公室的電話為 1-888-452-8609。這些服務是免費的。 您可以向加州管理式醫療保健部提出您的申訴 加州管理式醫療保健部 (DMHC) 負責管理各項健康計畫。您可以致電 DMHC 協助中心，取得有關 Medi-Cal 服務申訴方面的協助。若您在申訴緊急問題、涉及對您的健康造成立即嚴重危害之問題、您不同意我方計畫對您申訴的裁決，或我方計畫並未於 30 個曆日內解決您的申訴等方面需要協助，您可以聯繫 DMHC。 您可以透過下列兩種方式取得協助中心的協助： 致電 (888) 466-2219，TTY 使用者請撥 (877) 688-9891。此為免付費電話。 造訪管理式醫療保健部網站： http://www.dmhc.ca.gov/ 您可以向民權局提出申訴 如果您認為遭受到不公平對待，您可以向衛生與公眾服務部 (Department of Health and Human Services) 民權局提出申訴。例如，您可以提出無障礙設施或語言協助等相關申訴。民權局的電話為 (800) 368-1019。TTY 使用者請撥 (800) 537-7697。您也可以造訪 https://www.hhs.gov/ocr/index.html 瞭解詳細資訊。 您也可以聯絡當地的民權辦事處，地址是： U.S. Department of Health and Human Services 90 7th Street, Suite 4-100 San Francisco, CA 94103 電話：(800) 368-1019 TDD：(800) 537-7697 傳真：(415) 437-8329 您也受《美國殘障人士法案》(Americans with Disabilities Act) 之保護。您可以聯繫監察專員辦公室取得協助。電話號碼為 (888) 452-8609。 若您的申訴是與照護品質有關 您還有下列兩個選擇： 您可以向品質改善組織 (Quality Improvement Organization) 提出申訴。如果您願意，可以直接向該組織提出與您所獲得照護品質有關的申訴 (而非向我方計畫提出申訴)。如欲搜尋您所在州的品質改善組織名稱、地址與電話號碼，請參閱  IEHP DualChoice 會員手冊第 2 章。若您向該組織提出申訴，我們將與其共同解決您的申訴。 或者，您可以同時向雙方提出申訴。您可以視需求，同時向我們和品質改善組織提出與照護品質相關的申訴。 詳細資訊請參閱 IEHP DualChoice 會員手冊第 9 章。 處理您的 Medi-Cal 福利問題 若您向 IEHP 投保 Medi-Cal，並希望瞭解就 Medi-Cal 給付服務提出上訴與申訴的相關資訊，請致電 IEHP DualChoice 會員服務部，電話為 (877) 273-IEHP (4347)，TTY 使用者請撥 (800) 718-4347。服務時間為太平洋標準時間每天上午 8 點至晚上 8 點，假日亦提供服務。 IEHP DualChoice (HMO D-SNP) 是與 Medicare 簽約的 HMO 計畫。投保 IEHP DualChoice (HMO D-SNP) 取決於合約續訂。 此頁面資訊為截至 2022 年 10 月 1 日的最新資訊。 H8894_DSNP_23_3241532_M Pending Accepted

有關的資訊。 受到尊重與殷勤對待。IEHP DualChoice 尊重您的尊嚴及隱私權利  。 接受一視同仁的服務，而無論種族、種性、國籍、宗教、性別、年齡、精神或身體殘疾或醫療狀況、性傾向、理賠次數、醫療記錄、可保性證明 (包括因家庭暴力行為而產生之情況)、殘障、基因資訊或款項來源。  以您能理解的方式獲取與 IEHP DualChoice、其計畫與服務、醫師、提供者、健康照護機構以及您的藥品給付與費用有關的資訊。 享有負責協調您的照護的初級照護提供者。 即使您更換初級照護提供者，您的 IEHP DualChoice 福利與需支付的共付額將維持不變。 除共付額外，您的 IEHP DualChoice 醫師不得向您收取給付健康照護服務的費用。 要求取得特定醫療狀況的第二意見。 在您需要的時間與地點接受緊急照護。 準時到計畫提供者看診、取得給付服務以及領取處方藥。 獲取與臨床計畫有關的資訊，包括工作人員資格、要求變更治療選擇、參與您的健康照護決定，以及取得須自行管理之健康照護問題相關資訊。 若您已取得健康照護提供者的照護服務，您可能有權在一段時間內繼續接受其服務。 若您因急症、嚴重慢性疾病、懷孕、絕症、新生兒照護或排定手術而接受醫師的照護，您可以要求繼續由當前醫師提供照護。如欲提出前述要求，或若您對照護持續性有任何疑慮，請致電 IEHP DualChoice 會員服務中心，電話 1-877-273-IEHP (4347)。 以各種格式收取會員知情資料，包括點字、大字列印與音訊。 與取得服務事先授權、品質保證及退保之程序有關的資訊，以及與影響 IEHP DualChoice 會員之其他程序有關的資訊。 IEHP DualChoice 將保障您已獲得核准之各項服務。若您有任何授權待核准，或您正在等待治療，或您目前的醫師已為您排定專科醫師照護，請聯繫 IEHP 以在此過渡期間協助您安排照護事宜。致電 1-877-273-IEHP (4347) 聯繫 IEHP DualChoice，服務時間為太平洋標準時間每天上午 8 點至晚上 8 點，假日亦提供服務。TTY 使用者請致電 1-800-718-4347。 及時檢視、要求變更與取得您的醫療記錄副本。 免費取得口譯員服務。 若您的語言需求未獲得滿足，請通知 IEHP。 就 IEHP DualChoice 會員權利與責任政策提供建議。 瞭解預立指示、生前遺囑與授權書等相關規定，以及取得與既有法律變動有關之資訊。 預先決定您在發生威脅生命之疾病或傷害事件時，希望如何獲得照護。 免於遭受任何形式的限制或排擠，以作為壓迫、懲戒、便宜行事或報復的手段 對 IEHP DualChoice、其提供者或您的照護提出申訴。IEHP DualChoice 將在申訴程序方面為您提供協助。您有權選擇某人在上訴或申訴程序中作為您的代表，以及協助您的申訴 及上訴儘快獲得審核，並瞭解所需的時間。 依據 Medicare 指南申請召開申訴聽證會並獲得解決； 向 IEHP DualChoice 申請取得照護品質申訴資料。 就 IEHP DualChoice 做出的任何決定提出上訴，包括但不限於拒絕、終止、支付或減少服務。這包括在服務提供後拒絕支付服務費用 (服務後)，或於服務提供前拒絕給付服務 (服務前)。 申請快速复議； 向 IEHP DualChoice 申請與取得上訴資料； 在上訴交付獨立審查單位 (IRE) 時收取通知； 於 IEHP DualChoice 全部或部分維持其初始不利判決時，自動送交 IRE 复議； 若獨立審查單位全部或部分維持初始不利判決，且剩餘爭議金額達 100 美元或以上，送交行政法官 (ALJ) 裁決； 若 ALJ 裁決全部或部分不利於會員，可申請由上訴委員會 (Departmental Appeals Board, DAB) 審查； 若 ALJ 聽證會及/或 DAB 審核全部或部分不利於會員，且剩餘爭議金額達 1,000 美元或以上，將聽證會裁決送交司法審核； 依據 QIO 程序提出照護品質申訴； 申請由 QIO 審核不給付住院患者醫院照護費用之決定； 申請由 QIO 審核不給付專業護理機構、居家健康機構與綜合性門診復健機構費用之決定； 依據患者資訊機密相關聯邦與州法律，及時索要您的案件檔案副本； 質疑當地與全國 Medicare 給付判定標準。 作為 IEHP DualChoice 會員，您有責任： 檢視您的會員手冊，並在不瞭解給付與福利時致電 IEHP DualChoice 會員服務中心 將您的醫療狀況與疑慮告知您的醫師。 遵循您的醫師認為必要的治療計畫 進行必要的例行性與疾病照護安排，並在您無法按預定時間看診時通知您的醫師。 瞭解您的健康需求並維持健康的生活習慣。 盡所有努力參與 IEHP DualChoice 為您提供的健康照護計畫。 如需進一步瞭解會員權利與責任相關資訊，請參閱 IEHP DualChoice 會員手冊第 8 章。 退保時的權利與責任 終止您的 IEHP DualChoice (HMO D-SNP) 會員資格可能是自願的（您自己的選擇），也可能是非自願的（並非您自己的選擇） 您可能因個人原因而退出我們的計畫。 此外，在少數情況下，雖然您並未選擇退出計畫，但我們必須終止您的會員資格。您的 IEHP DualChoice 會員手冊 第 10 章說明了我們必須終止您的會員資格的情況。 何時可以終止您的計畫會員資格？ 若您是因 Medi-Cal 協助而加入，您可以隨時終止您的 IEHP DualChoice 會員。 您的會員資格通常會在我們收到您要求變更計畫的申請後次月一日終止。您投保的新計畫也將在同一日生效。 如何自願終止您的計畫會員資格？ 若您希望從我們的計畫轉換為其他 Medicare Advantage 計畫，只須投保新的 Medicare Advantage 計畫即可。一旦您的新計畫給付開始生效，您將自動從 IEHP DualChoice 退保。 若您希望從我們的計畫轉換為 Original Medicare 計畫，但您尚未另外選擇 Medicare 處方藥計畫。您必須申請退保 IEHP DualChoice。您可透過下列兩種方式申請退保： 如欲退保，請致電 1-844-580-7272 與 Health Care Options (HCO) 聯繫，服務時間為 (太平洋標準時間) 週一至週五上午 8 點至下午 6 點。TTY/TDD 使用者請撥 1-800-430-7077。有關詳細資訊，請造訪 DHCS 網站。點選此連結，您將會離開 IEHP DualChoice 網站。 您也可以聯繫 Medicare，電話 1-800-MEDICARE (1-800-633-4227)，此專線 24 小時全天候提供服務。TTY 使用者請撥 1-877-486-2048。 在您的會員資格終止前，您仍是我們計畫的會員。 若您申請退保 IEHP DualChoice，您的會員資格可能要一段時間才會終止，然後您的新 Medicare 給付才會生效。(請參閱    IEHP DualChoice  會員手冊 第 10 章，瞭解與您的新給付生效時間有關的資訊。)在這段期間內，您必須繼續透過我們的計畫取得醫療照護與處方藥。 在您的計畫會員資格終止前，您必須繼續在我們的網路內藥局領取處方藥。一般而言，只有在網路內藥局 (含郵購藥局服務) 所領取之處方藥才會予以給付。 您在會員資格終止當日住進醫院，本計畫通常也會給付您的住院費用，直到您出院為止 (即使您的出院時間是在新健康給付生效之後)。 若您不再符合 Medi-Cal 給付資格，或您的情況有所變動，導致您不再符合 Dual Special Needs Plan 給付資格，您可繼續從 IEHP DualChoice 取得兩個月的福利。此延長期限可讓您在認定自己符合相關資格時，協助您更正您的資格資訊。您將會收到一封與您的資格變更有關的信函，該信函上將載明如何更正您的資格資訊。 如欲繼續成為 IEHP DualChoice 會員，您必須在前述兩個月期間的最後一日再次符合資格。 若您於前述兩個月期間屆滿時仍不符合資格，您將從 IEHP DualChoice 退保。 非自願終止會員資格 如果發生下列任一情況，則 IEHP DualChoice 必須終止您的計畫會員資格： 如果您未繼續投保 Medicare 的 A 部分和 B 部分。 如果您搬遷至我方服務區域外超過六個月時間。        如果您入監服刑。 如果您投保其他有給付處方藥的保險計畫，但您提供虛假資料或隱瞞不報。 如果您在投保本計畫時，故意提供不正確的資訊，且這些資訊會影響您投保本計畫的資格。 如果您持續做出干擾行為，導致我們難以為您及本計畫其他會員提供醫療照護。 如果您讓其他人使用您的會員卡以取得醫療照護。 如欲成為 IEHP DualChoice 會員，您須維持 Medi-Cal 與 Medicare 的資格。若您喪失零費用分攤全額保障 Medi-Cal 資格，您將會在次月第一日從我們的計畫 (或您的 Medicare 福利) 退保，並 將由 Original Medicare 給付。 州政府或 Medicare 可能會在認定您不再符合計畫資格時將您退保。 IEHP DualChoice (HMO D-SNP) 是與 Medicare 簽約的 HMO 計畫。投保 IEHP DualChoice (HMO D-SNP) 取決於合約續訂。 此頁面資訊為截至 2022 年 10 月 1 日的最新資訊。 H8894_DSNP_23_3241532_M Pending Accepted