搜尋結果： : " UNIVERSITEIT NYENOORD PHYSICS "

加此 Webex 課程   課程編號： 177 291 8574 下載適用於  Apple 使用者的 Webex 下載適用於  Android 使用者的 Webex 下載適用於 電腦使用者的 Webex

下載適用於  Apple 使用者的 Webex 下載適用於  Android 使用者的 Webex 下載適用於 電腦使用者的 Webex  

標籤，做好糖尿病照護。此外，您還能學到一些外食秘訣。  請按這裡報名參加此 Webex 課程   課程編號： 177 060 1705  下載適用於  Apple 使用者的 Webex 下載適用於  Android 使用者的 Webex 下載適用於 電腦使用者的 Webex

時較適合選擇的食物 (和脂肪)。此外，您也可以學習減少攝取脂肪和膽固醇的秘訣。   請按這裡報名參加此 Webex 課程   課程編號： 177 060 1705 下載適用於  Apple 使用者的 Webex 下載適用於  Android 使用者的 Webex 下載適用於 電腦使用者的 Webex

尿病。  請按這裡報名參加此 Webex 課程   課程編號：  177 060 1705 下載適用於  Apple 使用者的 Webex 下載適用於  Android 使用者的 Webex 下載適用於 電腦使用者的 Webex

betes needs to stay healthy, how to take care of your feet and address barriers.  Click here to register for this Webex class   Session Number: 24686247890 Download Webex for Apple users Download Webex for Android users Download Webex for PC users

按這裡報名參加此 Webex 課程   課程編號： 177 511 7594 下載適用於  Apple 使用者的 Webex 下載適用於  Android 使用者的 Webex 下載適用於 電腦使用者的 Webex

地點 IEHP 社區資源中心（維克多維爾） 12353 Mariposa Rd Suites C-2 & C-3 Victorville, CA 92395

夥伴網路會議 以深入瞭解。請聯絡我們的 社區開拓服務團隊 以取得協助。  若您的組織有興趣成為 IEHP 社區合作夥伴，請在此註冊。  如何在我的社區尋找資源？ ConnectIE 是新的一站式互動網站，讓人們能透過 Inland Empire 更輕鬆地取得社區資源。 請造訪 ConnectIE 以瞭解更多詳情！  

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

部分藥品」。部分藥品不在 Medicare D 部分給付範圍內，但 Medi-Cal 可能會給付。 我可以針對 D 部分處方藥要求給付裁決或提出上訴嗎？ 可以。以下為您可向我們提出 D 部分藥品給付裁決要求的範例。  您要求我們做出例外安排，例如： 要求我們給付不在本計畫「給付藥品清單 (處方集)」中的 D 部分藥品 要求我們免除計畫對藥品給付的限制 (例如可取得藥品的數量) 您向我們詢問某一藥品是否在您的給付範圍內 (例如，您的藥品列於本計畫的處方集中，但我們規定您必須先獲得核准，我們才會給付該藥品)。 請注意：如果藥局告知您可能無法領取所需的處方藥，您將會收到一份通知，說明如何與我們聯繫以申請給付裁決。 您可以要求我們支付您已購買的處方藥費用。亦即要求關於付款的給付裁決。 如果您不同意我們所做的給付決定，可以針對我們的決議提出上訴。 例外狀況是指什麼？ 例外情況是指允許給付通常不在給付藥品清單中的藥物，或是允許在不需遵守特定規定與限制的情況下使用藥物。若藥物未列於我們的給付藥品清單中，或者給付條件與您的期望不符，您可以要求我們以「例外情況」處理。 若您提出例外申請，您的醫師或其他開立處方者須說明您需要該例外的醫療原因。 以下範例說明您、您的醫師或其他開立處方者可提出的例外申請：  給付未列於給付藥品清單 (處方集) 中的 D 部分藥品。 如果我們同意做出例外安排，並給付未列於處方集中的藥品，您將需要支付適用於藥物的藥品分攤費用。 您不得就我方要求您支付的藥品共同負擔費用或共同保險費用金額提出例外要求。 解除給付限制。我們處方集上的某些特定藥品必須遵守額外的規定或限制。 針對特定藥品的額外給付規定和限制包括： 須使用藥品的學名藥，而非原廠藥。 在我們同意為您給付該藥品前，事先取得計畫核准。(有時稱為「事先授權」)。 在我們同意為您給付要求的藥品前，需先嘗試另外一種藥品。(有時稱為「分階段療法」)。 數量限制。計畫有時會針對某些藥品限制您可以取得的藥品數量。 如果我們同意做出例外安排並免除對您的限制，您可以針對我們要求您支付的藥品共同負擔費用金額提出例外申請。 提出破例申請的重要須知 您的醫師或其他開立處方者必須向我們提供聲明，解釋提出破例申請的醫療因素。若您在提出例外申請時隨附開立處方者提供的這項資訊，可以更快知道例外裁決的結果。 通常，我們的處方集包含一種以上用於治療特定病症的藥品。這些不同的選擇稱為「替代」藥品。若替代藥品和您所申請的藥品具有相同療效，並且也不會引發更多副作用或其他健康問題，我們通常不會核准您的例外申請。 我們將核准或拒絕您的例外申請。 若我們核准您的例外申請，則例外處理的有效期限通常持續到當曆年的年底。只要您的醫師持續為您開立該藥品的處方，且該藥品可持續安全有效地治療您的症狀，情況即不會發生改變。 如果我們拒絕您的例外申請，您可以提出上訴，要求針對我們的決議進行審查。 給付決定 具體做法 申請您所需要的給付決定類型。以致電、寄信或傳真方式向我們提出申請。您、您的代表或您的醫師（或其他開立處方者）皆可提出申請。   您可以致電我們：電話 (877) 273-IEHP (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。TTY 使用者請致電 1-800-718-4347。 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 您、您的醫師 (或其他開立處方者) 或您的代表皆可申請給付決定。您也可以委由律師代表您提出申請。 您的醫師或其他開立處方者不需要您的書面授權即可代表您向我們申請給付裁定。 若您提出例外申請，請提供「佐證聲明」。您的醫師或其他開立處方者必須向我們提供聲明，說明提出藥品例外申請的醫療原因。我們稱之為「佐證聲明」。  您的醫師或其他開立處方者可以將聲明傳真或郵寄給我們。您的醫師或其他開立處方者亦可先來電告知我們，然後再將聲明傳真或郵寄給我們。 申請 Medicare 處方藥給付裁定 (PDF) 此表單亦可透過 CMS 網站取得： Medicare 處方藥裁定申請表（適用於投保人與提供者） 點選此連結，您將會離開 IEHP DualChoice 網站。 您尚未取得之藥品的「標準給付決定」截止期限 若我們採用標準截止期限，我們必須在收到您的申請後 72 小時內回覆；若您申請例外，則在我們收到您的醫師或開立處方者的佐證聲明後 72 小時內回覆。如果您的健康狀況需要，我們會儘快予以回覆。 若我們無法滿足此截止期限，我們會將您的申請送交第 2 階段上訴程序。在第 2 階段上訴程序中，將由獨立審查單位審查我們的決定。 如果我們核准您的部分或全部要求，我們必須在您提出申請後 72 小時內批准或給付；若您申請例外，則我們必須在收到您的醫師或開立處方者的佐證聲明後 72 小時內處理。  如果我們拒絕您的部分或全部要求，我們會寄信通知您，並說明駁回原因。通知函中亦會註明如何針對我們的裁決提出上訴。 您已購買之藥品的「標準給付決定」截止期限 我們必須在收到您的申請後 14 個曆日內答覆您。 若我們無法滿足此截止期限，我們會將您的申請送交第 2 階段上訴程序。在第 2 階段上訴程序中，將由獨立審查單位審查我們的決定。 如果我們核准您的部分或全部要求，我們會在 14 個曆日內付款給您。 如果我們拒絕您的部分或全部要求，我們會寄信通知您，並說明駁回原因。通知函中亦會註明如何針對我們的裁決提出上訴。 如果您的健康狀況需要，可以要求我們做出「快速給付決定」 除非我們已同意採用「快速截止期限」，否則我們會以「標準截止期限」為準。 標準給付決定表示我們將在收到您的醫師聲明後的 72 小時內給您答覆。 快速給付決定表示我們將在收到您的醫師聲明後的 24 小時內給您答覆。 唯有在您針對尚未領取的藥品提出申請的情況下，才能獲得快速給付決定。(若您是要求我們返還您已支付的藥品費用，則無法申請快速給付決定)。 唯有當採用標準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。 如果您的醫師或其他開立處方者告知我們，您的健康情況需取得「快速給付決定」，我們將自動同意做出快速給付決定，並將寄送信函通知您。 如果您自行提出快速給付決定申請 (未提供您的醫師或其他開立處方者的聲明)，我們將決定您是否適用快速給付決定。 如果我們決定您的醫療狀況不符合快速給付決定要求，我們將採用標準截止期限。 我們會郵寄信函通知您。信函將說明您如何針對我們的標準給付決定提出申訴。 您可以提出「快速申訴」，24 小時內即可得知結果。 「快速給付決定」的截止期限 如果我們採用快速截止期限，就必須在 24 小時內給您答覆。亦即在我們收到您的申請後 24 小時內。若您申請例外，則我們將在收到您的醫師或開立處方者的聲明後 24 小時內答覆您。如果您的健康狀況需要，我們會儘快答覆您。 若我們無法滿足此截止期限，我們會將您的申請送交第 2 階段上訴程序。在第 2 階段上訴程序中，將由外部獨立組織審核您的申請及我們的決定。 如果我們核准您的部分或全部要求，我們必須在收到您的申請或您的醫師或開立處方者的佐證聲明後 24 小時內答覆您。 如果我們拒絕您的部分或全部要求，我們會寄信通知您，並說明駁回原因。通知函中亦會註明如何針對我們的裁決提出上訴。 D 部分藥品第 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。 如果要申請標準上訴，您可透過發送書面申請的方式提出上訴。您亦可致電 1-877-273-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/TDD 使用者請撥 1-800-718-4347。 若要申請快速上訴，可以透過寫信或致電的方式申請。 您必須在我們發出給付決定通知之日起 60 個曆日內提出上訴。若有正當理由未在該截止期限內提出申請，我們可以延長提出上訴的時間。 舉例來說，錯過截止期限的正當理由可能包含：您當時患重病而無法聯絡我們，或是我們提供的申請上訴截止期限資訊不正確或不完整。 您可以申請一份上訴資訊副本並新增更多資訊。 您有權要求我們提供有關您上訴的資料副本。  若有意願，您及您的醫師或其他開立處方者可向我們提供附加資訊以支援您上訴。 您可以使用下列表單提出上訴： 給付裁決表單 (PDF) 其他人可以代替我提出上訴嗎？可以。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。  「標準上訴」的截止期限 若我們採用標準截止期限，必須在收到上訴申請後 7 個曆日內答覆您，如果您的健康狀況需要，也可以提早答覆。若對您的健康有必要，請申請「快速上訴」。若您要求我們就您已購買之藥品退款給您，我們必須在收到您的上訴後 14 個曆日內答覆您。 若我們未在 7 個曆日 (或若您要求我們就您已購買之藥品退款給您，則為 14 個曆日) 內答覆您，我們會將您的申請送交第 2 階段上訴程序。在第 2 階段上訴程序中，將由獨立審查單位審查我們的決定。 若對您的健康有必要，請申請「快速上訴」 如果您針對我們就您尚未取得之藥品給付決定提出上訴，您與您的醫師或其他開立處方者需決定您是否需要「快速上訴」。 申請「快速上訴」的要求同於申請「快速給付決定」。  我們的計畫將審核您的上訴並做出裁決 我們會再次仔細審查與您的給付申請相關的所有資訊。我們會確認在拒絕您的申請時是否遵守所有規定。我們可能會聯絡您、您的醫師或其他開立處方者以獲得更多資訊。 「快速上訴」的截止期限 若我們採用快速截止期限，會在收到上訴申請後 72 小時內答覆您，如果您的健康狀況需要，也可以提早答覆。 若我們未在 72 小時內答覆您，我們會將您的申請 送交第 2 階段上訴程序。在第 2 階段上訴程序中，將由獨立審查單位審查您的上訴。 如果我們核准您的部分或全部要求，必須在收到上訴申請後 72 小時內進行給付。 如果我們拒絕您的部分或全部要求，我們會寄信通知您，並說明駁回原因。 D 部分藥品第 2 階段上訴 如果我們駁回您的上訴，您可以選擇接受裁決或再次提起上訴。若您決定提出第 2 階段上訴，將會由獨立審查單位審查我們的裁決。 若您希望由獨立審查機構審查您的案例，必須以書面方式提出上訴。  請在您收到裁決通知後的 60 天內提出上訴。如果您錯過此截止期限，但只要能提供合理解釋，仍可提出上訴。 您、您的醫師或其他開立處方者或您的代表都可以提出第 2 階段上訴。 若您向獨立審查單位提出上訴，我們會將您的案例相關檔案寄給對方。您有權要求我們提供一份案例檔案的副本給您。您有權向獨立審查單位提供其他對上訴有利的資訊。獨立審查單位是由 Medicare 聘僱的獨立機構，與本計畫無關聯，且非政府機構。獨立審查單位的審查人員會仔細審查所有與上訴相關的資訊。之後，該機構會寄函給您，說明其裁決結果。 若我們在重新判定後仍維持拒絕裁定，您有權申請复議。請參閱下列表單： 复議申請表 (PDF) 第 2 階段上訴之「快速上訴」截止期限如果您的健康狀況需要，可要求獨立審查單位進行「快速上訴」。 若審查機構同意進行「快速上訴」，其必須在接獲上訴申請後 72 小時內回覆關於第 2 階段上訴的結果。 若獨立審查單位核准您的部分或全部要求，我們必須於接獲裁決後 24 小時內授權或給付您所申請的藥品。 第 2 階段「標準上訴」的截止期限若您申請第 2 階段標準上訴，獨立審查單位必須在收到上訴申請後 7 個曆日內回覆關於第 2 階段上訴的結果。 若獨立審查單位核准您的部分或全部要求，我們必須於接獲裁決後 72 小時內授權或給付您所申請的藥品。  若獨立審查單位核准返還您已購買之藥品費用的要求，我們會在收到裁決後 30 個曆日內付款。 如果獨立審查單位駁回您的第 2 階段上訴會怎樣？駁回表示獨立審查單位同意我們不核准您的申請的決定。此稱為「維持原裁決」；亦稱為「駁回上訴」。 若您申請給付的藥品價值符合特定最低金額門檻，您可提出第 3 階段上訴。獨立審查單位寄給您的信函中，將會說明繼續提出上訴所須符合的金額門檻。第 3 階段上訴是由行政法官負責受理。 如需詳細資訊，請參閱您的 IEHP DualChoice 會員手冊第 9 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

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 website. TITLE DATE RECIPIENTS March 2023     DualChoice Medicare Billing for Non-FDA Approved Medications 03/21 All IEHP Pharmacy Providers Claim Processing during State of Emergency due to Snowstorm 03/03 All IEHP Pharmacy Providers February 2023     Transition to 30-day Coverage Determination Backdating 02/02 All LTC & SNF Providers January 2023     IEHP DualChoice (HMO D-SNP): Over-the-Counter Drugs 01/09-01/30 All IEHP Pharmacy Providers IEHP DualChoice (HMO D-SNP): Medicare Part B Coinsurance Billing 01/05-01/13 All IEHP Pharmacy Providers IEHP DualChoice (HMO D-SNP): PBM Update and Medicare Part B Coinsurance 01/02-01/20 All IEHP Pharmacy Providers IEHP DualChoice (HMO D-SNP) Members - Medication Overrides 01/02 All IEHP Pharmacy Providers December 2022     Cal MediConnect (CMC) to Medi-Cal Rx/HMO D-SNP Transition 12/22 All IEHP Pharmacy Providers Claims Rejected in Error 12/19 All IEHP Pharmacy Providers PBM Change & Prior Authorization Submission Method - for DualChoice (HMO D-SNP) Members (Effective January 1, 2023) 12/13-12/29 All IEHP Pharmacy Providers Pharmacy Recalls, Withdrawals & Safety Alerts - November 2022 12/07 All IEHP Pharmacy Providers CoverMyMeds - Prior Authorization Submission Method for DualChoice Members (Effective January 1, 2023) 12/01-12/12 All IEHP Pharmacy Providers November 2022     Recalls, Withdrawals & Safety Alerts - October 2022 11/14 All IEHP Pharmacy Providers Recalls, Withdrawals & Safety Alerts - September 2022 11/02 All IEHP Pharmacy Providers COVID-19: Test to Treat Monoclonal Antibodies 11/01 All IEHP Pharmacy Providers October 2022     Cal MediConnect to Medi-Cal Rx Transition (D-SNP) 10/28 All IEHP Pharmacy Providers September 2022     Recalls, Withdrawals & Safety Alerts 09/08 All IEHP Pharmacy Providers August 2022     2022-2023 Flu Vaccination for IEHP Members 08/31 All IEHP Pharmacy Providers Reminder: Medi-Cal Rx Gradual Reinstatement of PAs - Phase 1 08/31 All IEHP Pharmacy Providers 30-Day Countdown: Reinstatement of PA Requirements for 11 Drug Classes 08/18 All IEHP Pharmacy Providers 30-Day Countdown: Reinstatement of PA Requirements for 11 Drug Classes 08/17 All IEHP Pharmacy Providers Recalls, Withdrawals & Safety Alerts 08/10 All IEHP Pharmacy Providers July 2022     Academic Detailing Services Now Offered 07/15 All IEHP Pharmacy Providers DHCS Medi-Cal Rx Update: Postponement of Implementation of NCPDP Reject Code 80 07/13 All IEHP Pharmacy Providers Recalls, Withdrawals & Safety Alerts 07/07 All IEHP Pharmacy Providers June 2022     New DHCS DUR Board Educational Article 06/22 All IEHP Pharmacy Providers MTM Medicare Pharmacy Mailing Campaign 06/08 All IEHP Pharmacy Providers Recalls, Withdrawals & Safety Alerts 06/05 All IEHP Pharmacy Providers Academic Detailing Services Now Offered 06/04 All IEHP Pharmacy Providers Medi-Cal Rx Transition: Blood Pressure Monitors and Cuffs 06/03 All IEHP Pharmacy Providers Important Notice: COVID-19 Oral Antivirals Billing 06/01 All IEHP Pharmacy Providers May 2022     Recalls, Withdrawals & Safety Alerts 05/05 All IEHP Pharmacy Providers April 2022     Rejected Claims Due To Prescriber Error Codes 04/06 All IEHP Pharmacy Providers Recalls, Withdrawals & Safety Alerts 04/05 All IEHP Pharmacy Providers MTM COVID-19: Test to Treat 04/04 All IEHP Pharmacy Providers March 2022     MTM Medicare Pharmacy Mailing Campaign 03/29 All IEHP Pharmacy Providers New DHCS DUR Board Educational Article 03/16 All IEHP Pharmacy Providers Medi-Cal Rx Transition: How To Assist IEHP Members 03/28-03/31 All IEHP Pharmacy Providers Medi-Cal Rx Transition: How To Assist IEHP Members 03/21-03/25 All IEHP Pharmacy Providers Medi-Cal Rx Transition: How To Assist IEHP Members 03/14-03/18 All IEHP Pharmacy Providers Medi-Cal Rx Transition: How To Assist IEHP Members 03/07-03/11 All IEHP Pharmacy Providers Recalls, Withdrawals & Safety Alerts 03/07 All IEHP Pharmacy Providers IEHP Contracted DME Pharmacies: CGM, BP Monitor, Nebulizer 03/02 All IEHP Pharmacy Providers February 2022     Medi-Cal Rx Transition: How To Assist IEHP Members 02/28-03/04 All IEHP Pharmacy Providers Medi-Cal Rx Transition: How To Assist IEHP Members 02/22-02/25 All IEHP Pharmacy Providers Medi-Cal Rx Transition: How To Assist IEHP Members 02/14-02/18 All IEHP Pharmacy Providers Medi-Cal Rx Transition: How To Assist IEHP Members 02/10-02/11 All IEHP Pharmacy Providers Pharmacy Empowerment Program 02/08 All IEHP Pharmacy Providers Recalls, Withdrawals & Safety Alerts 02/07 All IEHP Pharmacy Providers New DHCS DUR Board Educational Article 02/02 All IEHP Pharmacy Providers January 2022     Free OTC COVID-19 Antigen Test Kits Available 01/31 All IEHP Pharmacy Providers Medi-Cal Rx Transition Implementation 01/17-01/21 All IEHP Pharmacy Providers Medi-Cal Rx Transition Implementation 01/10-01/14 All IEHP Pharmacy Providers Medi-Cal Rx Transition Implementation 01/07 All IEHP Pharmacy Providers Recalls, Withdrawals & Safety Alerts 01/05 All IEHP Pharmacy Providers  

您控制糖尿病。  請按這裡報名參加此 Webex 課程   課程編號： 177 409 5237 下載適用於  Apple 使用者的 Webex 下載適用於  Android 使用者的 Webex 下載適用於 電腦使用者的 Webex

血糖控制時較適合選擇的食物 (和脂肪)。此外，您也可以學習減少攝取脂肪和膽固醇的秘訣。   請按這裡報名參加此 Webex 課程   課程編號： 177 409 5237  下載適用於  Apple 使用者的 Webex 下載適用於  Android 使用者的 Webex 下載適用於 電腦使用者的 Webex

整體健康還需要哪些檢測。  請按這裡報名參加此 Webex 課程   課程編號： 177 409 5237 下載適用於  Apple 使用者的 Webex 下載適用於  Android 使用者的 Webex 下載適用於 電腦使用者的 Webex

treach program for our providers and pharmacies. We perform phone and one-on-one outreaches with physicians, nurse practitioners, physician assistants, and pharmacy staff. Our goal is to transform the prescriber and pharmacy practice and enhance the provider, pharmacist and member experience. Clinical Drug Education Clinical Drug Education provides materials that focus on a specific drug, drug class, and/or disease state. These materials contain pharmacological and clinical practice information to assist providers and pharmacies in their practice. As new drug information is available, it is important to stay up to date on clinical research findings to assist with member care and medication-use decisions.   Practice Development Practice development education provides materials that focus on enhancing provider and member experience. The materials contain guidance on Formulary Utilization and PA submissions as well as insights regarding electronic prescribing and electronic health records. It is our commitment to provider practice optimization tools and resources to enhance member care.   You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy by clicking Adobe Acrobat Reader.  By clicking on this link, you will be leaving the IEHP website. Biosimilars A growing trend in healthcare is the use of biosimilar drugs. The following information will assist you and your practice on prescribing biosimilars. What is a Biosimilar? (PDF) Biosimilars: Are They the Same Quality? (PDF) Biological Product Definitions (PDF) Prescribing Biosimilar Products (PDF) Prescribing Interchangeable Products (PDF) Opioid and Chronic Pain Management In collaboration with Riverside University Health System (RUHS) and Centers for Disease Control and Prevention (CDC), IEHP would like to provide the following information to assist you and your practice on prescribing opioids for chronic pain management. CURES CURES FAQ (PDF) CURES 2.0 User Guide (PDF) CURES tips and tricks (PDF) Naloxone Naxolone Drug facts (PDF) Naxolone instructions for use (PDF) First Responder Naxolone administration fact sheet (PDF) Opioid Prescribing Guidelines Medication Assisted Treatment (MAT) and Opioid Treatment Program (OTP) FAQ (PDF) CDC Guideline Infographic (PDF) CDC Guidelines Factsheet (PDF) TurnTheTide Pocket Guide for Prescribing Opioids for Chronic Pain (PDF) CDC Guideline at a Glance  Opioid Tapering Clinical Pocket Guide to Tapering (PDF) Tapering Resource-AAFP (PDF) Opioid Tapering Resource pack (PDF) Pharmacy Medication Assisted Treatment (MAT) for Substance Abuse (PDF) Urine Drug Testing CDC Clinical Practice Guideline for Prescribing Opioids for Pain UDT for monitoring opioid therapy-AAFP (PDF) X-Waiver  X-Waiver resources Removal of DATA Waiver (X-Waiver) Requirement https://www.samhsa.gov/medications-substance-use-disorders/removal-data-waiver-requirement All prescriptions for buprenorphine will now only require a standard DEA registration number. For additional information on the removal of the DATA-Waiver requirement, see the Removal of DATA Waiver (X-Waiver) Requirement. Practice Optimization   Electronic Prescribing (e-Rx) Electronic prescribing is a growing standard in the healthcare industry. Most electronic health record systems offer electronic prescription capabilities. The information below will provide insight to the practice of e-prescribing. Benefits of e-Rx brochure (PDF) Formulary Utilization The IEHP Formulary offers a variety of drugs based on safety and efficacy for any condition. The information below will help you find out how to access and interpret the formulary Medicare FAQ (PDF) The process of submitting a prior authorization may be cumbersome for your practice. The information below will help you understand this process and assist with receiving a proper decision in a timely manner.   For any questions regarding Pharmacy Academic Detailing Training please contact: PharmacyAcademicDetailing@iehp.org     You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy by clicking Adobe Acrobat Reader. By clicking on this link, you will be leaving the IEHP website. Information on this page is current as of January 1. 2022  

e. IEHP has created UM Subcommittee Approved Authorization Guidelines to serve as one of the sets of criteria for medical necessity decisions. Our goal in creating this page is to provide you with easily accessible electronic versions of IEHP’s UM guidelines. IEHP utilizes a variety of sources in developing our UM guidelines which include: Medicare and Medi-Cal’s coverage policy statements Evidence in the peer-reviewed published medical literature Technology assessments and structured evidence reviews Evidence-based consensus statements Expert opinions of healthcare Providers Evidence-based guidelines from nationally recognized professional healthcare organizations and public health agencies. IEHP is also licensed to use MCG Guidelines, Apollo Medical Review Criteria, and InterQual to guide in utilization management decisions. Since medical technology is constantly evolving, our clinical guidelines are subject to change without prior notification. Additional UM Subcommittee Guidelines may be developed as needed or may be withdrawn from use. Please note that benefits may vary based on Member’s line of business; therefore, certain services discussed in the UM Subcommittee Guidelines may not be a covered benefit. Table of Contents (PDF) Providers may obtain information about criteria, either in general or relating to specific UM decisions, from IEHP upon request by contacting the IEHP UM Department. Please contact the IEHP Provider Relations Team at (909) 890-2054 to be connected to the UM Department.  Behavioral Health Behavioral Health Treatment (BHT) Criteria (PDF) Criteria for Multidisciplinary Diagnostic Treatment (PDF) Community Supports Services Community Transition Services Nursing Facility Transition to a Home (PDF) Nursing Facility Transition-Diversion to Assisted Living (PDF) Housing Deposits (PDF) Housing Transition Navigation Services (PDF) Housing Tenancy and Sustaining Services (PDF) Asthma Remediation (PDF) Environmental Accessibility Adaptations (Home Modifications) (PDF) Medically Tailored Meals (PDF) Sobering Centers (PDF) Recuperative Care (PDF) Short-Term Post-Hospitalization Housing (PDF) Diagnostic Testing Elastography (PDF) Inflammatory Bowel Disease Serology (PDF) Vestibular Autorotation Test (PDF) Gynecology and Obstetrics Fetal Non-Stress Testing (PDF) Neurology Bone Marrow Transplant in Treatment of Multiple Sclerosis (PDF) Pain Management Pain Management - Centers of Excellence (COE) (PDF) Referrals to Pain Management Specialist (PDF) Pharmacy Biosimilar Products (PDF) CAR-T Therapy (PDF) Surgical Procedures Adolescent Bariatric Consultation and Surgery (PDF) Natural Orifice Transluminal Endoscopic Surgery (PDF) Transgender Services (PDF) Other Allocation of Limited Critical Care Resources During a Public Health Emergency (PDF) Complementary and Alternative Medicine or Holistic Therapies (PDF) Congregate Living Health Facilities (PDF) Criteria for Custodial Care: Medi-Cal (PDF) Enhanced Care Management (PDF) Hair Removal Guideline (PDF) My Path (A Palliative Care Approach) (PDF) Tertiary Care Center Referral Requests (PDF) Transitional Care Medicine (PDF) Transportation Criteria (PDF)   You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

s for Contracted and Non-Contracted Providers Emergency and Post-Stabilization Care for IEHP Members IEHP DualChoice (HMO D-SNP) Model of Care Training for Non-Contracted Providers Provider Dispute Resolution Process for Contracted and Non-Contracted Providers   Definition of a Provider Dispute A provider dispute is a written notice from the provider to Inland Empire Health Plan (IEHP) that: Challenges, appeals, or appeals, or requests reconsideration of a claim (including a bundled group of similar claims) that has been denied, adjusted, or contested Challenges a request for reimbursement for an overpayment of a claim Seeks resolution of a billing determination or other contractual dispute   What is not Considered to be a Provider Dispute Claims denied for missing or additional documentation requirements such as consent forms, invoices, Explanation of Benefits from primary carrier, or itemized bills are not considered Provider Disputes Corrected Claims Pre-Service Authorization Denials   Provider Dispute Time Frame IEHP accepts disputes from providers if they are submitted within 365 days of receipt of IEHPs decision (for example, IEHPs Remittance Advice (RA) indicating a claim was denied or adjusted).   Submission of Provider Disputes When submitting a provider dispute, a provider should use a Provider Dispute Resolution Request form. If the dispute is for multiple, substantially similar claims, complete the spreadsheet on page 2 of the Provider Dispute Resolution Request Form All Provider Disputes and supporting information must be submitted to: IEHP Claims Appeal Resolution Unit PO BOX 4319 Rancho Cucamonga, CA 91729-4349   Acknowledgement of Provider Dispute IEHP acknowledges receipt of each provider dispute, regardless of whether the dispute is complete, within 15 business days of receipt.   Resolution Timeframe IEHP resolves each provider dispute within 45 business days following receipt of the dispute, and provides the provider with a written determination stating the reasons for determination.   PDR Determination Resulting in Additional Payment If IEHP determines to pay additional monies based on information originally provided and/or available at the time the claim was first presented to IEHP for adjudication, or a result of a processing error IEHP will automatically include the appropriate interest amount if payment is not issued within required regulatory timeframes.   Non-Contracted Provider Disputes Resolution Process for IEHP DualChoice (HMO D-SNP) A non-contracted provider, on his or her own behalf, is permitted to file a standard appeal for a denied claim only if the non-contracted provider completes a waiver of liability statement, which provides that the non-contracted provider will not bill IEHP DualChoice (HMO D-SNP) Plan Members.   Who to Call with Questions on IEHPs PDR Process Contracted providers may visit our online secure provider portal at www.iehp.org for more information. Providers may also call the IEHP Provider Call Center at (909) 890-2054 or (866) 223-4347 Monday-Friday, 8:00 am to 5pm PST.   (Back to Non-Contracted Providers Menu) Emergency and Post-Stabilization Care for IEHP Members   Triage and Advice Systems IEHP provides Members triage, screening, and advice services by telephone 24 hours a day, 7 days a week through its Nurse Advice Line (NAL). By calling the NAL, Members receive assistance with access to urgent or emergency services from an on-call physician, or licensed triage personnel. IEHP Members can reach this 24/7 Nurse Advice Line at (888)-244-IEHP (4347) or 711 (TTY).   Post-Stabilization Care IEHP requires contracted and non-contracted hospitals to obtain prior authorization for post-stabilization care for Members (patients). IEHP requests the patient’s diagnosis as indicated by the treating physician or surgeon and any other information reasonably necessary for the Plan to decide on whether to authorize post-stabilization care or to assume management of the patient’s care by prompt transfer to another facility. The hospital should request prior authorization from IEHP’s Utilization Management (UM) Department by: Phone at (866) 649-6327; or Fax at (909) 477-8553 to send clinical notes for medical necessity review.   IEHP makes every effort to respond to requests for necessary post-stabilization care within thirty (30) minutes of receipt. The services are considered approved if IEHP does not respond within this timeframe. All subsequent hospital day are subject to review for medical necessity. IEHP will inform the provider of the Plan’s decision and will coordinate the transfer of the Member if IEHP denies the request for authorization of post-stabilization care and elects to transfer the Member to another health care provider.   Non-Emergency Services If a Member presents at the emergency department for non-emergency services, please refer the Member to their IEHP Member Handbook, section 3 (How to Get Care), which outlines the process for obtaining a referral.   Claims Reimbursement Complete facility claims for authorized health care services must be sent to: Inland Empire Health Plan Attn: Claims Department – IEHP Direct PO BOX 4349 Rancho Cucamonga, CA 91729-4349 Complete professional claims for authorized health care services must be sent to: For IEHP-Direct Members, please send to address above. For IEHP Members assigned to an IPA, please click for here for more information on how to send to the appropriate IPA.   Billing IEHP Members Providers under the Medi-Cal program must not submit claims to, demand or otherwise collect reimbursement from a Medi-Cal beneficiary, or from other persons on behalf of the beneficiary, for any service included in the Medi-Cal program’s scope of benefits in addition to a claim submitted to the Medi-Cal program for that service.   IEHP DualChoice (HMO D-SNP) Model of Care Training for Non-Contracted Providers   The Centers for Medicare & Medicaid Services (CMS), the Department of Health Care Services (DHCS), and National Committee for Quality Assurance (NCQA) requirement that out-of-network providers routinely seen by IEHP DualChoice (HMO D-SNP) Members, receive training on IEHPs Model of Care for our D-SNP Members:   IEHP DualChoice (HMO D-SNP) Model of Care Training (PDF) IEHP DualChoice (HMO D-SNP) Model of Care Training (HTML)   *We recommend opening file in: Mozilla Firefox, MS Edge, Chrome or MS Internet Explorer 2023 IEHP DualChoice (HMO D-SNP) Model of Care Non-Contracted Provider AOR (PDF) Report an Issue To report any issues with this system or process or for any questions, please send an email to DGHospitalRelationsServiceTeam@iehp.org   (Back to Non-Contracted Providers Menu)   You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

here. TITLE DATE RECIPIENTS March 2023     I-MEDIC and CMS Alerts - Provider Potentially Inappropriate Billing 03/24 All Medicare IPAs 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 August 2022     2022 - 2023 Flu Vaccination for IEHP Members  08/31 All IEHP Providers & Pharmacies REMINDER: Medi-Cal Rx Gradual Reinstatement of PAs – Phase 1 08/31 All Medi-Cal PCPs & Specialists Labor Day Holiday 08/30 All IEHP Providers & IPAs REMINDER: Enhanced Care Management Available for Members 08/30 All Medi-Cal PCPs & IPAs Final REMINDER: Submit the 2022 Provider Satisfaction Survey 08/29 All PCPs, Specialists & BH Providers REMINDER: Community Supports Services Available for Members 08/29 All PCPs, Specialists & BH Providers Medication Reconciliation Program 08/29 All IEHP Providers & Pharmacies NOTICE: DHCS Approved Letter – Prior Authorization Not Required 08/26 All Medi-Cal IPAs NOTICE: DHCS Approved Letter – Prior Authorization Not Required 08/26 All Medi-Cal PCPs, Specialists & Ambulatory Surgery Centers REMINDER: Aug 2022 Provider Educational Series: “How to Navigate Rosters & Reports” 08/24 All Direct Medi-Cal PCPs NEW: Health Education Classes Offered in Desert Hot Springs and Mecca 08/24 All Coachella Valley PCPs ADVISORY: Updated Monkeypox Guidance 08/23 All Riverside County PCPs San Bernardino County Public Health - Monkeypox Guidance 08/23 All San Bernardino County PCPs & Specialists REMINDER: Medication Reconciliation 08/22 All IEHP Providers REMINDER: 2022 Provider Satisfaction Survey 08/22 All PCPs, Specialists, & BH Providers REMINDER: DHCS Quarterly Timely Access Survey 08/22 All Medi-Cal PCPs, Specialists, BH & Ancillary Providers Medication Reconciliation Program 08/22 All IEHP Providers & Pharmacies Reinstatement of PA Requirements for 11 Drug Classes 08/17 All Medi-Cal PCPs REMINDER: Appropriate Billing for Dispensing of Vision Materials 08/17 All Vision Providers REMINDER: Provider Directory Verification Form due August 26th 08/17 Select PCPs & Specialists Medication Reconciliation Program 08/15 All IEHP Providers & Pharmacies REMINDER: Timely Provision of Denial Packets 08/12 All Medicare IPAs Member Grievance Updates: Medical Record Requests 08/12 All Direct PCPs, Specialists, & Ancillary 2022 Global Quality P4P Program Guide Updates - SDOH Rate Measure 08/12 All Medi-Cal PCPs & IPAs Medi-Cal Letter Templates 08/11 All Medi-Cal IPAs Recalls, Withdrawals & Safety 08/10 All IEHP Providers & Pharmacies UPDATE: IEHP’s Network is Open to New QASP Providers 08/08 All BHT Providers 2022 Provider Educational Series – How to Navigate Rosters & Reports 08/08 All Direct Medi-Cal PCPs Proposition 56 – Don’t Miss Out on Available Supplemental Payments 08/05 All Medi-Cal PCPs 2022 Provider Quality Resource Guide 08/05 All PCPs Changes to Quarterly Workplan Requirements 08/03 All IPAs REMINDER: Provider Preventable Conditions - Reporting Requirements 08/03 All IEHP Providers, Ambulatory Surgical Centers & IPAs Webinar: COVID-19 In the Black and Brown Community and the Post Long-Term Effects 08/01 All PCPs & IPAs Medication Reconciliation Program 08/01 All IEHP Providers & Pharmacies July 2022     NEW DATE: Medi-Cal Rx Gradual Reinstatement of Prior Auths (PAs) – Phase 1 – September 16, 2022 07/29 All Med-Cal PCPs & Specialists Practitioner Reporting Requirements - UB-04 Claim Form 07/29 All SNFs, Hospitals, & Ancillary Free Webinar: It Takes a Village to Manage COVID-19 07/27 All PCPs & IPAs REMINDER: Medi-Cal Rx Gradual Reinstatement of PAs – Phase 1 – August 1, 2022 07/25 All Medi-Cal PCPs & Specialists ALERT: Hospice Policy and Procedures 07/25 Select Contract and Non-Contracted Hospice Providers Inappropriate Treatment Delays and Denials for HIV PrEP and PEP 07/22 All Medi-Cal PCPs & Specialists UPDATED: Telehealth Services FAQs 07/21 All PCPs, Specialists, BH, BHT Providers & IPAs 2022 Global Quality P4P Program – Provider Directory Verification 07/20 All Medi-Cal PCPs NEW: Riverside County Public Health: Updated Monkeypox Guidance 07/20 All Riverside County PCPs & Specialists DHCS Plan Data Feed Project – Files Available on SFTP 07/19 All IPAs 2022 Global Quality P4P PCP Program Guide- UPDATES 07/18 All Medi-Cal PCPs 2022 Global Quality P4P IPA Program Guide- UPDATES 07/18 All Medi-Cal IPAs 2022 Appointment Availability Survey – Fax Survey 07/15 All PCPs & IPAs 2022 Appointment Availability Survey – Fax Survey 07/15 All BH Providers 2022 Appointment Availability Survey – Fax Survey 07/14 All Specialists, Ancillary & IPAs UPDATE: Diabetic Vision Outreach Campaign – EXTENDED to July 22, 2022 07/14 All Vision Providers Medi-Cal Rx Gradual Reinstatement of PAs – Phase 1 07/11 All Medi-Cal PCPs & Specialists 2022 Global Quality P4P (GQ P4P) Interim Reports Data Refresh 07/11 All Medi-Cal PCPs & IPAs Update: Risk Adjustment Telehealth and Telephone Services 07/11 All Dual Choice PCPs, Specialists & BH Providers Cal MediConnect Sunsets and IEHP Dual Choice (D-SNP) Begins 07/08 All Medicare PCPs, Specialists & BH Providers 2022 Provider Satisfaction Survey 07/07 All PCPs, Specialists & BH Providers 2022 Provider Educational Series - Provider Directory Verification Process (Virtual) 07/07 All Medi-Cal PCPs Recalls, Withdrawals & Safety 07/07 All IEHP Providers & Pharmacies IEHP Medi-Cal Medical Benefit Formulary 07/01 All Medi-Cal PCPs, Specialists & Psychiatrists IEHP Providers Can Post Jobs and Find Candidates for Free on SoCalDocJobs.com 07/01 All PCPs June 2022     ALERT: No Prior Authorization for Biomarker Testing for Stage 3 and 4 Metastatic Cancers 06/29 All PCPs, Specialists & IPAs REMINDER – KidVaxGrant Application Deadline Approaching 06/29 All Medi-Cal PCPs REMINDER - 2022 Provider Educational Series: Provider Directory Verification Process 06/28 All Direct Medi-Cal PCPs DHCS Plan Data Feed Project 06/27 All IPAs  Alzheimer’s and Dementia Care: A FREE CME Project Echo Opportunity 06/27 All IEHP Family Practice & Internal Medicine Providers Independence Day Holiday 06/27 All IEHP Providers & IPAs Standards for Determining Threshold Languages, Nondiscrimination Requirements, and Language Assistance Service 06/27 All Medi-Cal IPAs UPDATED - Telehealth Services POS Code Updates 06/26 All PCPs, Specialists & BH Providers Clinical Practice Guidelines 06/24 All PCPs & IPAs Access Standards – Appointment Availability for Specialists 06/24 All Specialists NOTICE: No Prior Authorizations for Preventive Services - IPAs 06/23 All Medi-Cal IPAs NOTICE: No Prior Authorizations for Preventive Services - Providers 06/23 Direct Medi-Cal PCPs & Specialists Billing of IEHP Members Guidance 06/22 All IEHP Providers & IPAs May 2022 P&T Update 06/22 All IEHP Providers & Pharmacies REMINDER - 2022 Provider Educational Series: Provider Directory Verification Process 06/21 All Direct Medi-Cal PCPs Access Standards – Appointment Availability for PCPs and OB Providers 06/21 All PCPs & OB Providers Access Standards – Appointment Availability for BH Providers 06/21 All Behavioral Health Providers REMINDER – Authorizations Required for All Follow-up Visits! 06/17 All BH & BHT Providers REMINDER: 2022 Global Quality P4P Program – CAIR2 Participation Requirement 06/17 All Medi-Cal PCPs Member Campaign on Preventive Care Services 06/17 All Medi-Cal PCPs & IPAs Updates/Amendments to AB 1184: Confidential Communication of Medical Information Involving Sensitive Services 06/16 All Medi-Cal Providers & IPAs IEHP Alternative Format Requirement Overview 06/14 All IEHP Providers & IPAs Juneteenth Holiday 06/13 All IEHP Providers & IPAs REMINDER - Authorizations Required for Vision Services 06/10 All Vision Providers Alcohol and Drug Screening Assessment Brief Interventions and Referral to Treatment (SABIRT) 06/10 All PCPs & IPAs 2022 Provider Educational Series - Provider Directory Verification Process 06/10 All Direct Medi-Cal PCPs Navigating the Formula Crisis Webinar 06/08 All Medi-Cal PCPs & OB/GYN MTM Medi-Cal Provider Mailing Campaign 06/08 All IEHP Providers & Pharmacies MTM Medicare Provider Mailing Campaign 06/08 All IEHP Providers & Pharmacies  Recalls, Withdrawals & Safety 06/05 All IEHP Providers & Pharmacies  Academic Detailing Services Now Offered 06/04 All IEHP Providers & Pharmacies Medi-Cal Rx Billing Policy for Physician Administered Drugs (PADs) 06/03 All Medi-Cal PCPs, Specialists & IPAs New and Revised UM Authorization Guidelines 06/03 All IPA & BHT Providers UPDATES COMING SOON – Changes to UM Semi-Annual and Annual Reporting Requirements 06/01 All IPAs UPDATE - Facility Site Review (FSR) and Medical Record Review (MRR) Tools and Standards – Effective July 1, 2022 06/01 All PCPs & IPAs May 2022     IEHP’s Bi-Annual BHT Provider Training 05/27 All Behavioral Health Treatment (BHT) Providers Memorial Day Holiday 05/23 All Providers & IPAs REMINDER: CMC Transition to D-SNP - Model of Care Early Preview Meeting - June 13, 2002 05/23 All IPA CM & Quality Staff 2022 Global Quality P4P Program - NEW 2022 Interim Reports 05/20 All Medi-Cal PCPs IEHP UM Department Availability 05/20 All PCPs, Specialists & BH Care Coordination REMINDER – Review the Early Start Roster on IEHP’s Portal 05/17 All Medi-Cal PCPs & IPAs CMC Transition to D-SNP - Model of Care Early Preview Meeting - June 13, 2002 05/16 All IPA CM & Quality Departments REMINDER: 2022 Global Quality P4P Program – CAIR2 Participation Requirement 05/16 All Medi-Cal PCPs REMINDER: 2022 Global Quality P4P Program – Manifest MedEx Connectivity 05/16 All Medi-Cal PCPs  eReferral Submission to IEHP now available for IPA assigned Medi-Cal Members: Transplants (MOT) and Community Support Services 05/13 All Medi-Cal PCPs & IPAs Applied Changes for Medicare Members on the 835 Files 05/10 IEHP Trading Partners Sunsetting of Proposition 56: Value Based Payment Program 05/09 All Medi-Cal PCPs, Specialists, BH & IPAs HIV/AIDS Specialist Survey 05/06 All Specialists UPDATED FAQs: Members with Other Health Coverage (OHC) 05/06 All Providers & IPAs Revised/Retired UM Authorization Guidelines 05/06 All Medi-Cal IPAs & BH Community Supports Services Modifier Guidance 05/06 All Medi-Cal PCPs, Specialists, BH & IPAs  Recalls, Withdrawals & Safety Alerts 05/05 All IEHP Providers & Pharmacies Providers REMINDER: No Prior Authorizations Needed for Preventive Services 05/03 All IPAs Alzheimer’s and Dementia Care: A Project Echo Opportunity 05/03 All PCPs Webinar - IWIN COVID and the Community 05/02 San Bernardino County PCPs April 2022     2022 Global Quality P4P Program - Manifest MedEx Connectivity Reminder 04/29 All Medi-Cal PCPs Maternal Wellness Events - May 2022 - IEHP Community Resource Centers 04/28 All Medi-Cal PCPs, OB/GYN, Peds, BH & IPAs Letter to Primary Care Providers RE-Response to GSF 04/27 All Medi-Cal PCPs Letter to Providers RE-Response to GSF 04/26 All Medi-Cal IPAs & Specialists Initial Health Assessment (IHA) Roster 04/22 All Medi-Cal PCPs & IPAs REMINDER: IEHP Interpreter Services – Benefit for Members! 04/20 All PCPs & IPAs REMINDER - 2022 Global Quality P4P Program – CAIR2 Participation Requirement 04/15 All Medi-Cal PCPs COVID-19 “Test to Treat” Initiative 04/13 All PCPs & IPAs Revised UM Authorization Guideline 04/12 All Medi-Cal IPA Administrators and Medical Directors & BH Providers Public Health Service (PHS) 340B Participating Provider Billing Reminder 04/12 All FQHCs and DSHs Care Plans and Health Risk Assessments (HRAs) Reminder 04/08 All PCPs, Specialists, SNFs & CBAS 2nd Round of Free At-Home COVID-19 Test Kits Available 04/08 All Medi-Cal PCPs Misdirected Claims Testing – Meeting Request 04/07 IEHP Trading Partners Alzheimer’s and Dementia Care: A Project Echo Opportunity 04/06 All IEHP PCPs Standing Orders Enrollment - Respond Today! 04/06 All Medicare PCPs Medicare P4P IEHP Direct – Blood Pressure Control Billing Guidance 04/05 All Direct DualChoice PCPs Important Notice: Proton Pump Inhibitor Overutilization 04/05 All IEHP Providers & Pharmacies Recalls, Withdrawals & Safety Alerts 04/05 All IEHP Providers & Pharmacies March 2022     CORRECTION - Standing Orders Enrollment- Respond Today! 03/31 All Medi-Cal PCPs Complex Case Management (CCM) Program – Severe Chronic Conditions 03/30 All Medi-Cal PCPs, Specialists, BH Providers & IPAs Major Organ Transplants (MOT) and TAR Approval DATE Impact 03/29 All Medi-Cal IPAs & COEs Standing Orders Enrollment - Respond Today! 03/29 All Medi-Cal PCPs MTM Medi-Cal Provider Mailing Campaign 03/29 All IEHP Providers & Pharmacies MTM Medicare Provider Mailing Campaign 03/29 All IEHP Providers & Pharmacies Initial Health Assessment (IHA) 03/28 All Medi-Cal PCPs REMINDER - 2022 OB P4P Kickoff Meeting – March 31, 2022! 03/28 All Medi-Cal OB/GYNs CMS Signature Requirement Guidelines for Member Medical Records 03/25 All IPAs, PCPs, Specialists & BH Providers REMINDER: IEHP Claims, Appeals/Disputes and Audit Recovery Mailing Addresses 03/25 All Direct PCPs, Specialists & BH Providers 2021 GQ P4P Program- Data Submission Extension Until March 31, 2022 03/22 All Medi-Cal PCPs REMINDER: IEHP Wants to Know Your Interest in Pilot Program to Implement a Community Electronic Health Record (EHR) 03/22 All Medi-Cal PCPs REMINDER - American Rescue Plan Act – Extension of Postpartum Care Coverage 03/21 All Medi-Cal PCPs, OBs & IPAs Behavioral Health Access Standards – Appointment Availability 03/16 All Behavioral Health Providers New DHCS DUR Board Educational Article 03/16 All IEHP Providers & Pharmacies IEHP Wants to Know: Interest in Pilot Program to Implement a Community Electronic Health Record (EHR)? 03/15 All Medi-Cal PCPs REMINDER - 2022 Global Quality P4P Program – CAIR2 Participation Requirement 03/14 All Medi-Cal PCPs & IPAs Riverside County Legionnaires' Disease Advisory 03/14 All PCPs & IPAs Coordination of Benefits with Other Health Coverage (OHC) – Medi-Medi Coverage Added to Provider Portal 03/11 All IEHP Providers & IPAs Notice of Dismissal of Coverage Letter Updates & Attestation Form 03/11 All Medicare IPAs Process for IEHP Medi-Cal Members: Continuous Glucose Monitors (CGM) 03/10 All Medi-Cal PCPs UPDATED Integrated Denial Notice Medicare Letter Templates 03/08 All Medicare IPAs Process for IEHP Medi-Cal Members: Blood Pressure Monitors and Nebulizers 03/07 All Medi-Cal PCPs Recalls, Withdrawals & Safety Alerts 03/07 All IEHP Providers & Pharmacies IEHP’s Quarterly BH Provider Training 03/04 All Behavioral Health Providers Update: Enhanced Care Management Roster Available on Provider Portal 03/01 All Medi-Cal PCPs & IPAs You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

th us to offer our members the highest quality care and service they need. Facility Site Reviews are the required standards by the California Department of Health Care Services (DHCS)/Medi-Cal Managed Care Division (MMCD) for all primary care provider (PCP) sites. Below you will find various resources in regards to DHCS information, Physical Accessibility Reviews (PARS), Facility Site Review (FSR), and Medical Record Reviews (MRR) as well as IEHP’s addendum tools for your reference. Facility Site Review Training Index: Department of Health Care Services (DHCS) IEHP Addendum Tools PARS Facility Site Review Medical Record Review Department of Health Care Services (DHCS) 2022 Facility Site Review Standards (FSR) (PDF) 2022 Facility Site Review Tool  (FSR) (PDF) 2022 Medical Record Review Standards (MRR) (PDF) 2022 Medical Record Review Tool (MRR) (PDF) APL 22-017 - Facility Site Review and Medical Record Review (PDF) DPL 14-005 - FSR Physical-Accessibility Reviews (PDF) PL 12-006 - Revised FSR Tool (PDF) (Back to Index) IEHP Addendum Tools Att 06 - IEHP Urgent Care Evaluation Tool (PDF) IEHP Interim Review (PDF) (Back to Index) PARS APL with PARS C (PDF) APL with PARS D & CBAS (PDF) PAR-FSR-C_PARS - Survey (PDF) PAR-FSR-D_PARS - Ancillary (PDF) PAR-FSR-E_PARS - CBAS (PDF) (Back to Index) Facility Site Review Menu Click on the following links to jump to that specific section: Facility Site Review Audit Tool Sections Additional Documents Medical Record Review Audit Tool Sections Additional Documents (Back to Index) Access/Safety Facility Site Review Pre-filled Emergency Medications Dosage Chart (PDF) Emergency Exit Routes Factsheet (PDF) Evacuation Routes (PDF) Glucometer Log (PDF) Hemocue Log (PDF) Medical Emergency, Earthquake, Fire Protocols (PDF) Sample of Sizes of Ambu Bags (PDF) Sample Oxygen Tank Set (PDF) Workplace Violence (PDF) (Back to FSR Menu) Adult Preventive Medical Record Review ACES Screening (PDF) Adult Health History (PDF) Adult Sterilization & Special Consent P&P (PDF) Alcohol Resources (PDF) AUDIT-C (PDF) Brief Addiction Monitor (BAM) (PDF) Comprehensive Pediatric and Adult Health Assessment Forms (PDF) CRAFFT-2.0 Clinician Interview (PDF) Hepatitis Risk Assessment Tool (PDF) Intimate Partner Violence (IPV) Screening Tools (PDF) Intimate Partner Violence (IPV) and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings (PDF) PHQ-2 - Sample (PDF) PHQ-9 - Sample (PDF) Required Documentation Checklist for Adult (PDF) Social Needs Screening Tool (PDF) TB Risk Assessment Adult (PDF) (Back to FSR Menu) Clinical Services Facility Site Review Checklist for Safe Vaccine Storage and Handling (PDF) Clean and Dirty Sign (PDF) Controlled Substance Distribution Log (PDF) Controlled Substance Narcotic Log (PDF) Monthly Expiration Date & Verification Log (PDF) P&P Distribution of Sample Medications (PDF) Patient Distribution Log for Samples (PDF) Plan for Vaccine Protection in Case of Power Outage (PDF) Radiology - Notice to Employees (PDF) Sample Radiology Inspection Report (PDF) Vaccine Information Sheet (VIS) Protocol (PDF) Vaccine Storage (PDF) (Back to FSR Menu) Coordination of Care Medical Record Review Adult Progress Note - Sample (PDF) Missed Appointment Log - Sample (PDF) Pediatric Progress Note - Sample (PDF) (Back to FSR Menu) Documentation Medical Record Review Adult General Consent to Treat (PDF) Advance Health Care Directive Acknowledgement Form (PDF) CAIR Sharing Request (PDF) General Consent to Treat Minor (PDF) Medical Record Release (PDF) Sample Medication List (PDF) Signature Page - IEHP (PDF) (Back to FSR Menu) Format Medical Record Review Acknowledgment of Receipt of Notice of Privacy Practice (PDF) (Back to FSR Menu) Infection Control Facility Site Review AAP Infection Prevention and Control in Pediatric Ambulatory Settings - COVID (PDF) Autoclave Log (PDF) Biohazardous Sign (PDF) Bloodborne Pathogens & Post Exposure Plan - Fillable (PDF) Cleaning Schedule (PDF) Communicable Disease (ISOLATION) Protocol (PDF) Infection Control, Biohazardous Waste and Disposition of Patients with Contagious Disease (PDF) Instrument Transportation Log (PDF) Isolation & Transmissions Based Precautions (PDF) OSHA Employee Injury Report Form (PDF) P&P Autoclave (PDF) P&P Autoclaving Instruments in Peel (PDF) P&P Chemical Disinfection (PDF) P&P Cold Sterilization (PDF) P&P Transport for Reusable Instruments (PDF) Reusable Sharps Container (PDF) Safety Needle Fact Sheet (PDF) Sharps Injury Log Sample (PDF) Transfer Stations and Treatment Facilities (PDF) (Back to FSR Menu) OB/CPSP Preventive Medical Record Review CPSP Initial and Trimester Assessment and Care Plan (PDF) CPSP Postpartum Assessment and Care Plan (PDF) Edinburgh Postnatal Depression Scale (EPDS) (PDF) Required Documentation Checklist for OB (PDF) (Back to FSR Menu) Office Management Facility Site Review Access Standards (PDF) After Hour Script (PDF) CLAS Standards (PDF) Confidentiality Form (PDF) Fax Sheet (PDF) Medical Emergency, Earthquake, Fire Protocols (PDF) Medical Record Release (PDF) Office Hours Sample Form (PDF) On-Call Provider Schedule (PDF) PCP Referral Tracking Log (PDF) Referral Process (PDF) Sample Office Hours (PDF) Wait Time Survey Tool (PDF) (Back to FSR Menu) Pediatric Preventive Medical Record Review AAP Infection Prevention and Control in Pediatric Ambulatory Settings - COVID (PDF) AAP Schedule (PDF) AAP Supplemental Information (PDF) Alcohol Resources (PDF) AUDIT-C (PDF) Brief Addiction Monitor (BAM) (PDF) CDC BMI Growth Chart - Boys (PDF) CDC BMI Growth Chart - Girls (PDF) CDC Growth Chart Head Circumference - Boys (PDF) CDC Growth Chart Head Circumference - Girls (PDF) CDC Growth Chart Weight for Age - Boys (PDF) CDC Growth Chart Weight for Age - Girls (PDF) Child Health History - English (PDF) Child Health History - Spanish (PDF) Comprehensive Pediatric and Adult Health Assessment Forms (PDF) CRAFFT-2.0 Clinician Interview (PDF) Edinburgh Postnatal Depression Scale (EPDS) (PDF) General Consent to Treat Minor (PDF) Hepatitis Risk Assessment Tool (PDF) Intimate Partner Violence (IPV) Screening Tools (PDF) Intimate Partner Violence (IPV) and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings (PDF) PEARLS Assessment (PDF) PEARLS Teen Self-Assessment (PDF) PHQ-2 - Sample (PDF) PHQ-A - Sample (PDF) Required Documentation Checklist for Pediatric (PDF) Social Needs Screening Tool (PDF) TB Risk Assessment Pediatrics (PDF) What Do You Eat (8-19 years) - English (PDF) What Do You Eat (8-19 years) - Spanish (PDF) What Does Your Child Eat (Birth - 8 years) - English (PDF) What Does Your Child Eat (Birth - 8 years) - Spanish (PDF) Youth Nutrition and Activity Assessment (8 - 19 years) (PDF) (Back to FSR Menu) Personnel Facility Site Review Accessibility Obligations of Medical Practices (PDF) Bloodborne Pathogens & Post Exposure Plan - Fillable (PDF) Domestic Violence (PDF) Electronic Resources for Required Employee Training (PDF) Employee File Checklist (PDF) IEHP Cultural and Linguistics Training (PDF) IEHP Evidence of Staff Training (PDF) IEHP Grievance Resolution Process - English (PDF) IEHP Grievance Resolution Process - Spanish (PDF) IEHP P&P Child Abuse Reporting (PDF) IEHP P&P Elder or Adult Abuse Reporting (PDF) IEHP P&P Sensitive Services-Access Standards (PDF) Medical Assistant Letter of Competency - Fillable (PDF) Medical Assistant Venipuncture Form (PDF) Medication Administration Procedures (PDF) Mid-level Supervision of Medical Assistant (PDF) Notice to Consumer PA Sign - English (PDF) Notice to Consumer PA Sign - Spanish (PDF) Notice to Consumer Sign - English (PDF) Notice to Consumer Sign - Spanish (PDF) SB697 Practice Agreement (PDF) SOC 341 (PDF) Standardized Procedures for Nurse Practitioner (PDF) Suspected Child Abuse Report (PDF) (Back to FSR Menu) Preventive Services Facility Site Review Pure Tone Audiometer (PDF) Sample Eye Chart (PDF) (Back to FSR Menu) Additional Documents Facility Site Review IEHP Phone List (PDF) (Back to FSR Menu) Additional Documents Medical Record Review Online Resources for Medical Record Review (PDF) (Back to FSR Menu) You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.