搜尋結果： : " UNIVERSITY OF BIRMINGHAMBIRMIN "

e alternatives that MCPs may offer in place of services or settings covered under the California Medicaid State Plan. Beginning January 1, 2022, IEHP will be offering 11 of the 14 DHCS Preapproved Community Supports services. Please click on the service for additional details. Asthma Remediation Environmental Asthma Trigger Remediations are physical modifications to a home environment that are necessary to ensure the health, welfare, and safety of the individual, or enable the individual to function in the home and without which acute asthma episodes could result in the need for emergency services and hospitalization. Community Transition Services/Nursing Facility Transition to a Home Assist members to live in the community and avoid further institutionalization. These services are non-recurring set-up expenses for individuals who are transitioning from a licensed facility to a living arrangement in a private residence where the person is directly responsible for his or her own living expenses. Environmental Accessibility Adaptations (Home Modifications) Environmental Accessibility Adaptations (EAAs also known as Home Modifications) are physical adaptations to a home that are necessary to ensure the health, welfare, and safety of the individual, or enable the individual to function with greater independence in the home: without which the Member would require institutionalization. Housing Deposits Housing Deposits assist with identifying, coordinating, securing, or funding one-time services and modifications necessary to enable a person to establish a basic household that do not constitute room and board. Housing Tenancy & Sustaining Services This service provides tenancy and sustaining services, with a goal of maintaining safe and stable tenancy once housing is secured. Housing Transition Navigation Services Housing transition services assist Members with obtaining housing. Medically Supportive Food/Meals/Medically Tailored Meals Malnutrition and poor nutrition can lead to devastating health outcomes, higher utilization, and increased costs, particularly among Members with chronic conditions. Meals help individuals achieve their nutrition goals at critical times to help them regain and maintain their health. Results include improved Member health outcomes, lower hospital readmission rates, a well-maintained nutritional health status, and increased Member satisfaction. Nursing Facility Transition/Diversion to Assisted Living Facilities Nursing Facility Transition/Diversion services assist individuals to live in the community and/or avoid institutionalization when possible. The goal is to both facilitate nursing facility transition back into a home-like, community setting and/or prevent skilled nursing admissions for Members with an imminent need for nursing facility level of care (LOC). Individuals have a choice of residing in an assisted living setting as an alternative to long-term placement in a nursing facility when they meet eligibility requirements. Recuperative Care (Medical Respite) Recuperative care, also referred to as medical respite care, is short-term residential care for individuals who no longer require hospitalization, but still need to heal from an injury or illness (including behavioral health conditions) and whose condition would be exacerbated by an unstable living environment. An extended stay in a recovery care setting allows individuals to continue their recovery and receive post-discharge treatment while obtaining access to primary care, behavioral health services, case management and other supportive social services, such as transportation, food, and housing. Short-Term Post-Hospitalization Housing Short-Term Post-Hospitalization housing provides Members who do not have a residence and who have high medical or behavioral health needs with the opportunity to continue their medical/psychiatric/substance use disorder recovery immediately after exiting an inpatient hospital (either acute or psychiatric or Chemical Dependency and Recovery hospital), residential substance use disorder treatment or recovery facility, residential mental health treatment facility, correctional facility, nursing facility, or recuperative care and avoid further utilization of State plan services. Sobering Centers (Riverside County) Sobering centers are alternative destinations for individuals who are found to be publicly intoxicated (due to alcohol and/or other drugs) and would otherwise be transported to the emergency department or jail. Sobering centers provide these individuals, primarily those who are homeless or those with unstable living situations, with a safe, supportive environment to become sober. IEHP Direct and Delegated Providers can submit referrals for Community Supports via the Provider Portal. For questions on how to submit a referral or more information relating to the above services, Providers can call the Provider Call Center at (909) 890-2054 or (866) 223-4347. Please continue to direct IEHP Members needing additional information on Community Supports Services to IEHP Member Services at (800) 440-4347, Monday - Friday, 8am - 5pm. TTY users should call (800) 718-4347. If you have programmatic questions, please email DGCommunitySupportTeam@iehp.org Community Supports Provider Brochure - English (PDF) | Spanish (PDF) | Chinese (PDF) | Vietnamese (PDF) Community Supports FAQs (PDF) Medi-Cal Community Supports or In Lieu of Services (ILOS) Policy Guide (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.

fornia Physician Orders for Life Sustaining Treatment (POLST) Registry (CPR) to connect a digital POLST network throughout the Inland Empire Healthcare System which includes independent physicians, hospitals, skilled nursing facilities, and the Health Information Exchange (HIE). The goal of this initiative is to provide a more effective means of documenting, communicating, and ensuring Member desired Treatment at the end of life is being honored.  By clicking on these links, you will be leaving the IEHP website. To login, visit Working Toward a Statewide POLST Registry in California | POLST (capolst.org) To sign up, simply go to POLST for Healthcare Providers | POLST (capolst.org) CPR Correspondence (PDF) CPR FAQ (PDF) For any questions, please contact Care Directives at (888) 621-4383 or email support@caredirectives.org. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

mecast.com/s/Xe1jCJ6xqQCBo4gtnovWOE?domain=dhcs.ca.gov。 營業時間：週一至週五上午 8 點至中午 12 點，下午 1 點至下午 5 點。週末與假日不營業。 郵寄地址： Department of Health Care Services Third Party Liability and Recovery Division Casualty Insurance Section – MS 4720 P.O.Box 997425 Sacramento, CA 95899-7425 IEHP DualChoice (HMO D-SNP) Medicare-Medicaid 計畫 會員 如果您是 Medicare 會員並且想要報告可能的債務清償、判決、裁定或是您收到的其他款項，或要求取得您的「受保護健康資訊」，請按一下此處以下載揭露授權書 (PDF)。  

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) Behavioral Health Home Based Services (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) Bronchial Thermoplasty (PDF) Natural Orifice Transluminal Endoscopic Surgery (PDF) Transgender Services (PDF) Other Allocation of Limited Critical Care Resources During a Public Health Emergency (PDF) Care Plan Option (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.

isciplinary Care Team (ICT) Dual Choice Medicare CM IPA Training Alzheimer's and Dementia Care Specialty Mental Health Care Coordination Staying Healthy Assessment (SHA) Training National LGBT Health Education Webinars Online Cultural Competency Training Interdisciplinary Care Team (ICT) Fact Sheet (PDF) Healthcare Provider Toolkit: Assisting Patients with Requests for Workplace Accommodations or Leaves of Absence (PDF) Dual Choice Medicare CM IPA Training 2021 Care Management Delegation Oversight Medi-Cal IPA Training (MP4 Video) - December 08, 2021 Discussion Topics: Health Risk Assessments (HRA) Individual Care Plans (ICP) Interdisciplinary Care Team (ICT) Coordination of Care Delegated IPA Reporting Requirements   2021 Care Management Delegation Oversight Medi-Cal IPA Training (MP4 Video) - February 16, 2021 Alzheimer's and Dementia Care Project ECHO Opportunities From The Alzheimer's Association For Inland Empire Primary Care Clinics Alzheimer’s Association / UCSF Memory and Aging Center Alzheimer’s and Dementia Care ECHO Faculty partners: UCSF Memory and Aging Center faculty When: Thursdays beginning February 16, 2023 until July 20, 2023 from 12:00 pm - 1:00 pm PT via Zoom Who can be involved: All California based Primary care practice teams (including MD/DO, NP, PA, social work, MA) UCSF/Inland Empire ECHO 2023 Flyer (PDF) To register, please contact Kelsey Burnham at kburnham@alz.org  UCLA ADC ECHO Faculty partners: UCLA Alzheimer’s and Dementia Care (ADC) program faculty When: Wednesdays beginning March 29, 2023 until September 6, 2023 from 11:00 am - 12:00 pm PT via Zoom Who can be involved: Nationwide teams interested in adding to their own knowledge and skills and those interested in learning about or implementing the highly effective UCLA ADC program ADC ECHO 2023 Flyer (PDF) To register, please contact Rachel Goldberger at rbgoldberger@alz.org Specialty Mental Health Care Coordination The Centers for Medicare and Medicaid Services (CMS) is requiring IEHP and its IPAs to document and report the efforts made to coordinate the care of IEHP DualChoice (HMO D-SNP)  Members receiving specialty mental health services through the County Mental Health Plans.   As of June 1, 2018, IEHP has put policies and procedures in place to comply with these process and reporting requirements: On the first (1st) of each month, IEHP will provide IPAs and County MH Clinics a list of IEHP DualChoice (HMO D-SNP) Members known to be receiving specialty mental health services through the County MH Plans. IPAs are expected to outreach to these Members and their County MH Clinic Provider, as well as, document their outreach attempts and outcomes as outlined in Policy 25C2, “Care Management Requirements – Delegated IPA Responsibilities.” IPAs are required to provide data elements specific to this measure, as outlined in Policy 25F1, “Encounter Data Reporting - Medicare MMP Reporting Requirements – IEHP DualChoice (HMO D-SNP)" and Attachment, “Medicare Provider Reporting Requirements Schedule” in Section 25. IEHP, through its Delegation Oversight process, will monitor the IPAs’ compliance with documentation and reporting requirements, as outlined in Policy 25A2, “Delegation Oversight Audit.” To access the On-Site training material presented to IPAs and County Mental Health Clinics, click here (PDF). National LGBT Health Education Webinars IEHP has put together a list of webinars, provided by a third party, to provide educational programs, resources, and consultation to health care organizations with the goal of optimizing quality, cost-effective health care for lesbian, gay, bisexual, transgender, and all sexual and gender minority (LGBT) people. The National LGBT Health Education Center is part of the Division of Education and Training at The Fenway Institute, Fenway Health. The Fenway Institute (TFI) is an interdisciplinary center for research, training, education, and policy development that works to ensure access to quality, culturally affirming medical and mental health care for traditionally underserved communities, including LGBTQIA+ people and those affected by HIV/AIDS. The mission of Fenway Health is to enhance the wellbeing of the LGBTQIA+ community as well as people in our neighborhoods and beyond through access to the highest quality health care, education, research, and advocacy. Fenway Health is one of the largest providers of LGBTQIA+ health care and HIV primary care in the country; as such, it is a leader in the field of LGBTQIA+ health and informs much of the promising practices and innovative models that the Education Center disseminates to health centers nationwide. By clicking on these links, you will be leaving the IEHP website. The National LGBT Health Education Center Webinars  Courses Include:  HIV Prevention/PrEP at Health Centers: An Overview and Current Best Practices What’s new in PrEP and STIs? Cases From a Sexual Health Clinic Insurance Considerations for Navigating Gender-affirming Care Building Your Family: LGBTQ Reproductive Options Behavioral Health Assessments and Referral for Gender-Affirming Surgery Navigating Gender Affirming Care Collecting Sexual Orientation and Gender Identity (SO/GI) Data In Electronic Health Records Providing Mental Health Assessments for Gender Affirming Surgery Referral Letters Online Cultural Competency Training AHRQ Health Literacy Modules Available for Continuing Education (CE) and Maintenance of Certification (MOC) Credit  Physicians and nurses can earn CE credits while learning about the challenges in caring for patients with low health literacy as well as strategies to improve overall patient communication and care. OptumHealth Education is issuing continuing education credit for taking the AHRQ-developed Health Literacy Knowledge Self-Assessment. No fees are charged for the two CE activities: By clicking on these links, you will be leaving the IEHP website. 1. An Updated Overview of Health Literacy Link (optumhealtheducation.com) 2. Improving Health Literacy by Improving Communication Skills Link (optumhealtheducation.com) Pediatricians and family physicians can earn credit for re-certification (MOC Part 2) as well as CE by taking the Health Literacy Knowledge Self-Assessment through the American Board of Pediatrics and the American Academy of Family Physicians, respectively. To learn about AHRQ’s tools to address health literacy, visit Health Literacy Topics at:  https://www.ahrq.gov/health-literacy/index.html To find out about other free AHRQ continuing education opportunities, go to: https://www.ahrq.gov/patient-safety/education/continuing-ed/index.html To contact AHRQ, visit https://www.ahrq.gov/contact/index.html   Office of Minority Health - https://cccm.thinkculturalhealth.hhs.gov/ CDC - www.cdc.gov U.S. Department of Health and Human Service, Health Resources and Services Administration - www.hrsa.gov You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

reventable Conditions. Visit Reporting of Provider Preventable Conditions for DHCS instructions for online reporting. By clicking on these links, you will be leaving the IEHP website. Medicare Outpatient Observation Notice (MOON) In the event any Medicare recipient has been in a status of outpatient observation for greater than 24 hours, Acute Hospitals are required to provide Medicare Members with a Medicare Outpatient Observation Notice (MOON). Medicare recipients must receive the MOON within 36 hours of admission to observation level of care. Please refer to the following website for further details on MOON requirements at https://www.federalregister.gov/articles/2016/08/22/2016-18476/medicare-program-hospital-inpatient-prospective-payment-system-for-acute-care-hospitals-etc.  By clicking on this link, you will be leaving the IEHP website. Document Catalog: MOON FAQs (PDF) MOON Instruction Summary (PDF) CMS Manual System 10611_Pub 100-04 Medicare Claims Processing MOON Instructions (PDF) MOON Forms MOON English (PDF) MOON Spanish (PDF) MOON Correspondence (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.

most appropriate, high quality and cost-effective drug therapies.   The Inland Empire Health Plan Pharmacy and Therapeutics (P & T) Subcommittee develops and monitors the Formulary. The P & T is composed of the IEHP Chief Medical Officer, Medical Directors, Director of Pharmaceutical Services, physicians from various medical specialties, local communities, and clinical pharmacists. This panel reviews the medications in all therapeutic categories based on safety, clinical efficacy, and cost-effectiveness and selects the most appropriate drugs in each class.   Formulary development and maintenance is a dynamic process. The IEHP P & T Subcommittee is responsible for developing, managing, updating and administering the Formulary. The Subcommittee also ensures that the IEHP Formulary remains responsive to the needs of our members and providers.   You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy by clicking Adobe Acrobat Reader. By clicking on this link, you will be leaving the IEHP website.   IEHP Medi-Cal Formulary Items: DHCS Noncapitated Physician Administered Drugs (PADs) Medi-Cal Medical Benefit PA (PDF) Medi-Cal Medical Benefit Formulary (PDF) Referral Form for Medi-Cal Benefit (PDF) Exceptions to criteria or requests for coverage of drugs not on the Medi-Cal Drug Benefit Formulary may be submitted by prescribers on the Referral Form for Medi-Cal Benefit. Starting January 1, 2022, all IEHP Medi-Cal pharmacy services will be transitioned from managed care (MC) to fee for service (FFS). The Medi-Cal pharmacy benefits and services administered by the Department of Health Care Services (DHCS) will be identified collectively as "Medi-Cal Rx." Magellan Medicaid Administration, Inc. (MMA) will assume operations for Medi-Cal Rx on behalf of DHCS. For further information on Medi-Cal Rx, please visit: https://www.iehp.org/en/providers/pharmacy-services?target=medi-cal-rx For more information on the Medi-Cal Rx Covered Drug List (CDL), please visit: https://medi-calrx.dhcs.ca.gov/home/cdl   IEHP DualChoice (HMO D-SNP) - Medicare-Medicaid Plan Items: IEHP DualChoice (HMO D-SNP) Formulary Book(PDF) Grievance Coverage Determination and Appeals Process IEHP DualChoice (HMO D-SNP) Formulary Search Tool        10 Reasons Why You Should Be E-prescribing Brochure (PDF) E-prescribing Tips (PDF)   Information on this page is current as of March 01, 2023

will now be held at the following address: Dr. Bradley P. Gilbert Center for Learning & Innovation 9500 Cleveland Ave. Rancho Cucamonga, CA 91730 Click here to view the meeting room map. Any Member of the public may observe the scheduled proceedings by using the link listed below. March 6, 2023 - 9 a.m. Click here to join the virtual meeting. March 2023 Agenda Board Report Under $200k Summary Report January 2023 Agenda Board Report Under $200k Summary Report

ly contracted provider. PLEASE NOTE, IEHP is currently not accepting new: DME Hospice Specialty Pharmacy Clinical Laboratories Please check monthly for updates on Network Availability. Prior to extending a contract, we must receive the following documents: 1. Ancillary Provider Network Participation Request Form (PDF) 2. W-9 Form A current Taxpayer Identification Number and Certification Form 3. Liability Insurance Certificate Professional general liability in the minimum amount of One Million Dollars ($1,000,000) per occurrence. Three Million Dollars ($3,000,000) aggregate per year for professional liability. 4. Ownership Information (PDF) Name, Title and Percentage of Ownership 5. Provider Accreditation Certificate 6. CMS/DHCS Passing Site Survey (Approval Letter) Required for each facility 7. California State License (if applicable) Required for each facility 8. Urgent Care Minimum Qualifications (if applicable) All Ages (PDF) Pediatrics (PDF) 9. Medi-Cal Number Ancillary Providers need to successfully enroll in the State's Medi-Cal Program 10. Provider Acknowledgment of Receipt (AOR) (PDF) IEHP is required by State and Federal regulators to maintain an AOR form on file for our Providers signifying your receipt and review of the Policy & Procedure manuals, including annual updates 11. Electronic Remittance Advice (ERA) Form (PDF) Ancillary Providers must complete the ERA form   Contracts Maintenance Request Form can be found here (PDF). Any delay in receiving the above stated documents will affect the effective date of the contract that will be mailed to you.  The contract collateral and other supporting contract documents should be e-mailed to contract@iehp.org. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

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     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  

2016, now includes proposed supplemental payments for physicians participating in Medi-Cal Fee-For-Service (FFS) and Medi-Cal Managed Care. Proposition 56 FAQs SFY 19/20 (PDF) Published: February 18, 2020 Click on the following links to jump to that specific section: Electronic Payments Ground Emergency Medical Transport (GEMT) Payment Adverse Childhood Experiences Screening (ACES) Services HYDE Developmental Screening Services Proposition 56 and GEMT Payment Schedule Family Planning Services Proposition 56 Payment Dispute Process Electronic Payments With the current public health situation that our country is experiencing, it is necessary for IEHP to take additional precautions to ensure the health and well-being of our community. These precautions are being reviewed, and discussed daily, by our Executive leadership team and will be implemented as deemed necessary.  Future COVID-19 precautions may include reduced on-site staffing and prioritization of electronic payments over printed checks. To minimize any disruption or delay in payment, we recommend that you sign up for electronic payments as soon as possible if you have not done so already. Our team is available to assist you with the necessary paperwork required to make this change or to answer any questions you may have. The team can be reached by e-mailing vendormaintenance@iehp.org or by calling (909) 294-3928 and selecting Option 1. Our priority remains keeping our Members, Providers, Vendors, and Team Members safe while doing what we can to minimize the potential spread of the virus. We will continue to work hard to provide you with the level of service you have come to expect during this uncertain time. (Back to Prop 56 Menu) Adverse Childhood Experiences Screening (ACES) Services Proposition 56 Adverse Childhood Experience Screening (ACES) Services (PDF)  Published: May 15, 2020 FAQs on Proposition 56 Payment - Adverse Childhood Experience Screening (ACES) Services (PDF) Published: October 14, 2021 PSA Videos: Do More Ask Resilience (Back to Prop 56 Menu) Developmental Screening Services Proposition 56 Developmental Screening Services (PDF) Published: March 19, 2020 FAQs on Proposition 56 - Developmental Screening Services (PDF) Published: October 14, 2021 (Back to Prop 56 Menu) Family Planning Services Proposition 56 - Family Planning Services (PDF) Published: June 1, 2022 FAQs on Proposition 56 - Family Planning Screening Services (PDF) Published: October 13, 2022 (Back to Prop 56 Menu) Ground Emergency Medical Transport (GEMT) Payment The Department of Health Care Services (DHCS) has established a Ground Emergency Medical Transport (GEMT) Quality Assurance Fee (QAF) program. In accordance with 42 USC Section 1396u-2(b)(2)(D), Title 42 of the Code of Federal Regulations part 438.114(c), and WIC Sections 14129-14129.7, Medi-Cal Managed Care Health Plans must provide increased reimbursement rates for specified GEMT services to non-contracted GEMT providers. SPA 18-004 implements a one-year QAF program and reimbursement add-on for GEMT provided by emergency medical transportation providers effective for State Fiscal Year (SFY) 2018-19 from July 1, 2018, to June 30, 2019. GEMT Program Overview (PDF) FAQs on GEMT (PDF) GEMT Dispute Request Form (PDF) Please email completed forms to Prop56Inquiry@iehp.org or fax to (909) 296-3550. (Back to Prop 56 Menu) HYDE Proposition 56 HYDE Services (PDF) Published: May 15, 2020 FAQs on Proposition 56 - HYDE Services (PDF) Published: October 14, 2021 (Back to Prop 56 Menu) Proposition 56 and GEMT Payment Schedule Proposition 56 and GEMT Supplemental Payment Schedule CY2023 Updated: January 6, 2023 (Back to Prop 56 Menu) Proposition 56 Payment Dispute Process Proposition 56 - Paid Claims Dispute Request Form (PDF) Proposition 56 - Encounter Dispute Request Form (PDF) Please email completed forms to Prop56Inquiry@iehp.org or fax to (909) 296-3550. (Back to Prop 56 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.

ns, NCD) 係透過基於證據的流程決定。以下為各 NCD 的簡要說明。以下程序可能須遵守資格或限制規定。 有關各 NCD 的詳細資訊，包括限制與資格，請點選各 NCD 後方連結，或聯繫 IEHP DualChoice 會員服務中心。請於 (太平洋標準時間) 每天上午 8 點至晚上 8 點期間致電 (877) 273-IEHP (4347)，假日亦提供服務；或TTY/TDD 使用者請撥 (800) 718-4347 1.B 型肝炎病毒 (HBV) 感染篩檢 (生效日期：2016 年 9 月 28 日)  (施行日期：2017 年 10 月 2 日 – 設計與編碼；2018 年 1 月 1 日 – 測試與施行) CMS 依據美國預防服務工作組 (USPSTF) 建議，發佈了全國給付判定標準 (NCD)，擴大給付範圍以包括 HBV 感染篩檢。過去，HBV 篩檢與二次篩檢僅適用於孕婦。  B 型肝炎病毒 (HBV) 係透過體液傳播。此病毒會攻擊肝臟並導致發炎。感染者可能會出現噁心、食慾不振、疲勞、發燒與腹痛等症狀，或可能無症狀。感染者可能發展成急性 HBV 感染，並導致威脅生命的併發症。 USPTF 發現，HBV 篩檢可提早預防並有助於降低染病及病毒傳播，並可透過治療改善感染者的中間結果評估。 給付項目有哪些？ 自 2016 年 9 月 28 日起，CMS 將 HBV 感染篩檢納入給付範圍。 適用對象為何？ 符合下列任一條件的 Medicare 保險受益人皆適用： 被認定屬感染高風險族群；或 已懷孕。 點選此處進一步瞭解 HBV 篩檢。 2.腰椎管狹窄症 (LSS) 影像引導經皮穿刺脊椎減壓術 (PILD) (生效日期：2016 年 12 月 7 日)  (施行日期：2017 年 6 月 27 日) CMS 擴大了「腰椎管狹窄症影像引導經皮穿刺脊椎減壓術 (PILD for LSS)」全國給付判定標準 (NCD) 的適用範圍，現已涵蓋參加經 CMS 核准的前瞻性縱向研究的保險受益人。過去，PILD for LSS 僅適用依據「依實證發展給付」(CED) 範式，參加經 CMS 核准的前瞻性隨機對照試驗 (RCT) 的保險受益人。現在，NCD 將 PILD for LSS 同時納入 RCT 與縱向研究給付範圍。 LSS 係指背部下方椎孔狹窄症狀。PILD 是透過間接影像引導進行腰椎後路減壓手術，而不對手術區域進行任何目視檢查。此手術會切除部份椎弓以縮減黃韌帶，從而擴大受影響區域的椎管。 給付項目有哪些？ 自 2016 年 12 月 7 日起，Medicare 將對依據 CED 參加獲核准臨床試驗且罹患 LSS 的保險受益人提出的理賠，給付 PILD 費用。 適用對象為何？ 罹患 LSS 且參加獲核准臨床試驗的 Medicare 保險受益人。 點選此處進一步瞭解 PILD for LSS 篩檢。 3.無導線心臟節律器   (生效日期：2017 年 1 月 18 日)  (施行日期：2017 年 8 月 29 日 – MAC 當地編輯；2018 年 1 月 2 日 – MCS 分享編輯) CMS 發佈一份全國給付判定標準 (NCD)，將在獲 CMS 核准給付的「依實證發展給付」(CED) 研究的手術中使用之無導線心臟節律器納入給付範圍。  無導線心臟節律器係透過導管送至心臟，其功能與其他經靜脈植入單腔心臟節律器類似。無導線心臟節律器不須使用傳統節律裝置所不可或缺的儀器袋及植入導線。去除此等裝置，可消除傳統節律器可能發生的重大併發症，同時還可提供類似功能。無導線心臟節律器係透過導管送至心臟，其功能與其他經靜脈植入單腔心臟節律器類似。2017 年 1 月 18 日之前，對此並無任何全國給付判定標準 (NCD)。 給付項目有哪些？ 自 2017 年 1 月 18 日起，Medicare 將對依據 CED 參加獲 CMS 核准研究的患者提出的理賠，給付無導線心臟節律器費用。 適用對象為何？ 需要節律器且參加獲核准臨床試驗的 Medicare 保險受益人。 點選此處進一步瞭解無導線心臟節律器。 4.高壓氧 (HBO) 治療 (C 節，氧氣的局部施用)  (生效日期：2017 年 4 月 3 日)  (施行日期：2017 年 12 月 18 日) CMS 修改了氧氣的局部施用 第 1 章第 20.29 節 C 小節，刪除了排除此治療方法的規定。 其更新了給付判定標準，允許當地承包商可於治療慢性傷口時，局部施用氧氣。     給付項目有哪些？ 局部施用氧氣治療慢性傷口。 適用對象為何？ 確認適用給付判定標準的 Medicare 保險受益人可獲得此給付。 點選此處進一步瞭解氧氣的局部施用。 5.症狀性外周動脈疾病 (Symptomatic Peripheral Artery Disease, PAD) 患者監督運動治療 (Supervised Exercise Therapy, SET) (生效日期：2017 年 5 月 25 日) (施行日期：2018 年 7 月 2 日) CMS 於第 1 章增列了第 20.35 節，名為「症狀性外周動脈疾病患者監督運動治療」。 依據 CMS 意見，高品質研究的結果顯示 SET 比其他更具侵入性的治療方案更有效，且罹患「間歇性跛行」(PAD 的常見症狀) 的保險受益人可因此獲得初步治療。 給付項目有哪些？ 合格保險受益人有權在負責 PAD 治療的醫師看診並提供轉介之後，於 12 週內參與 36 次治療。  SET 計畫必須： 包括歷時 30-60 分鐘的療程，包括 PAD 的治療性運動訓練計畫； 此等療程可於醫院門診或醫師辦公室進行； 此等療程應由通過 PAD 運動治療訓練的合格輔助人員協助進行，以確保運動所帶來的益處高於傷害；且 在醫師直接監督的情況下進行。 適用對象為何？ 經診斷罹患症狀性外周動脈疾病且可從此等治療受益的 Medicare 保險受益人。 點選此處進一步瞭解症狀性外周動脈疾病 (PAD) 患者監督運動治療 (SET)。 6.核磁共振成像 (MRI) (生效日期：2017 年 4 月 10 日) (施行日期：2018 年 12 月 10 日) CMS 於《Medicare 全國給付判定標準手冊》第 1 章第 4 部分增列了第 220.2 節，名為「核磁共振成像」(MRI)。依據 FDA MRI 環境標示規定，保險受益人於特定情況下將可享有 MRI 給付保障。 給付項目有哪些？ 自 2018 年 4 月 10 日起，在依據 FDA MRI 環境標示規定使用的前提下，保險受益人將可獲得 MRI 給付。 若不依據 FDA MRI 環境標示規定使用，則僅於特定情況下方可獲得給付，包括： 在正常操作模式下，MRI 的磁場強度達到 1.5 Tesla 植入式節律器 (PM)、植入式复律除顫器 (ICD)、心臟再同步化治療節律器 (CRT-P) 以及心臟再同步化治療除顫器 (CRT-D) 系統，必須無任何破裂、心外膜或棄置的導線 已採用特定檢查表的相關機構 適用對象為何？ 安裝植入式節律器 (PM)、植入式复律除顫器 (ICD)、心臟再同步化治療節律器 (CRT-P) 以及心臟再同步化治療除顫器 (CRT-D) 的 Medicare 保險受益人。 點選此處進一步瞭解 MRI 給付。 7.植入式心臟除顫器 (ICD) (生效日期：2018 年 2 月 15 日) (施行日期：2019 年 3 月 26 日) CMS 更新了《Medicare 全國給付判定標準手冊》第 1 章第 1 部分第 20.4 節，為心室性心搏過速 (VT) 病患的植入式心臟除顫器 (ICD) 提供額外的給付標準。 給付項目有哪些？ ICD 是用於診斷與治療危及生命的心室性心搏過速 (VT) 的電子裝置，且經實驗證明可改善特定病患的存活率及降低心源性死亡率。Medicare 暨 Medicaid 服務中心 (CMS) 將對 2018 年 2 月 15 日之後提出的理賠進行給付。 適用對象： 經認定符合給付條件的保險受益人。 ICD 給付適用符合下列條件的病患： 個人曾發生持續 VT 或因心室顫動 (VF) 而心跳停止的情況 過去曾有心肌梗塞 (MI) 症狀且左心室射血分數 (LVEF) 小於或等於 0.03 的病患 患嚴重缺血性擴張型心肌病，但無持續 VT 或因 VF 而心跳停止病史，以及具有紐約心臟協會 (New York Heart Association, NYHA) II 類或 III 類心臟衰竭症狀，且 LVEF 小於或等於 35% 患嚴重非缺血性擴張型心肌病，但無心跳停止或持續 VT、NYHA II 類或 III 類心臟衰竭病史，且 LVEF 小於或等於 35%，並持續接受最佳藥物治療至少三 (3) 個月 有記錄的家族或遺傳疾病，同時存在可能危及生命的心律加快症狀的高風險族群，惟不限於長 QT 症候群或肥厚性心肌症 既有 ICD 因電池壽命、選擇性替換指標 (ERI) 或故障而須更換 有關詳細給付標準，請參閱 NCD 手冊第 20.4 節。 點選此處進一步瞭解  ICD 給付。 8. 罹患種系 (先天性) 癌症的 Medicare 保險受益人的次世代定序 (NGS) (生效日期：2020 年 1 月 27 日)  (施行日期：2020 年 11 月 13 日) CMS 更新了《Medicare 全國給付判定標準手冊》第 1 章第 2 部分第 90.2 節，將符合特定要求的種系 (先天性) 癌症之 NGS 檢測納入給付範圍，並更新了體細胞 (後天性) 癌症的給付標準。 給付項目： 自 2020 年 1 月 27 日起，CMS 認定診斷性實驗室檢測 NGS 屬合理且必要的，並適用罹患種系 (先天性) 癌症的病患，只要係依據主治醫師要求、符合特定要求且於「美國臨床實驗室改善修正法」(CLIA) 認證的實驗室進行。 適用對象： 罹患種系 (先天性) 癌症或體細胞 (後天性) 癌症的保險受益人，但檢測須依據主治醫師要求、符合下列所有要求且於「美國臨床實驗室改善修正法」(CLIA) 認證的實驗室進行： 體細胞 (後天性) 癌症： 符合下列條件的保險受益人： 復發性、難以治療、轉移性或第 III 期或第 IV 期末期癌症；及 先前未針對相同癌症基因內容，使用與 NGS 相同的檢測方法接受檢測；及 決定尋求進一步癌症治療 (如：治療性化學療法)。 採用 NGS 的診斷性實驗室檢測必須擁有： 經食品藥物管理局 (FDA) 核准或許可作為輔助體外診斷；及 經 FDA 核准或許可可作為病患癌症的指標；及 採用載明治療選項的報告範本，將結果提供給主治醫師以進行病患管理。 種系 (先天性) 癌症 符合下列條件的保險受益人： -卵巢癌或乳癌；及 種系 (先天性) 癌症的臨床適應症，顯示罹患遺傳性乳癌或卵巢癌； 種系 (先天性) 乳癌或卵巢癌的風險因子；及 -先前未針對相同癌症基因內容，使用與 NGS 相同的檢測方法接受檢測。 採用 NGS 的診斷性實驗室檢測必須擁有： FDA 核准或許可；及 採用載明治療選項的報告範本，將結果提供給主治醫師以進行病患管理。 Medicare 管理承包商 (Medicare Administrative Contractors, MAC) 可於符合其他特定條件的情況下，將 NGS 認定為診斷性檢查納入給付範圍。 點選此處瞭解次世代定序給付的相關資訊。 9.經皮氣球血管擴張術 (PTA)    (生效日期：2019 年 2 月 19 日)  (施行日期：2019 年 2 月 19 日)  CMS 更新了《Medicare 全國給付判定標準手冊》第 1 章第 1 部分第 20.7 節，提供了關於 PTA 的更多資訊。  給付項目： 在下列情況，經皮氣球血管擴張術 (PTA) 將納入給付範圍，以改善病變血管段的血流狀況，並擴張外周動脈、腎臟動脈與冠狀動脈受損的部分。  適用對象： PTA 給付適用下列情況：  1.治療動脈粥樣硬化阻塞病變  2.與食品藥物管理局 (FDA) 的頸動脈支架置入術一併進行 – 獲核准的 B 類臨床研究用醫療器材豁免 (IDE) 試驗  3.與 FDA 核准的後核准研究頸動脈支架置入術一併進行  4.與高風險頸動脈內膜切除術 (CEA) 病患的頸動脈支架置入術一併進行 5.與 FDA 核准的 B 類 IDE 臨床研究的顱內支架置入術一併進行 點選此處進一步瞭解 PTA 給付。 10.經導管主動脈瓣置換術 (TAVR) (生效日期：2019 年 6 月 21 日) (施行日期：2020 年 6 月 12 日) CMS 更新了《Medicare 全國給付判定標準手冊》第 1 章第 20.32 節。在符合特定要求的情況下，Medicare 暨 Medicaid 服務中心 (CMS) 將給付依據「依實證發展給付」(CED) 進行的經導管主動脈瓣置換術 (TAVR)。 給付項目： 自 2019 年 6 月 21 日起，對於依據 CED 進行的 TAVR 手術，除符合 NCD 手冊規定的給付標準外，若係與治療症候性主動脈瓣狹窄有關、符合食品藥物管理局 (FDA) 核准之適應症規定且使用獲核准裝置，或符合臨床試驗條件，則 CMS 將予以給付。 適用對象： 當 TAVR 用於治療症候性主動脈瓣狹窄、符合 FDA 核准之適應症規定，且符合下列條件時，此服務將獲得給付： 相關手術與植入系統已獲得 FDA 上市前核准 (PMA)，得用於 FDA 核准之適應症 病患係由心臟團隊負責照護，包括心臟外科醫師、介入性心臟醫師以及多個提供者、護士與研究人員 心臟團隊的介入性心臟醫師與心臟外科醫師必須共同參與 TAVR 的相關方面 進行 TAVR 的醫院必須符合多項資格並實施計畫 登記處須收集必要資料並備妥書面分析計畫，以因應各種問題。 若 TAVR 未明文列示為獲 FDA 核准之適應症，但在臨床研究中進行並符合下列條件，則此服務包含在給付範圍內： 心臟團隊的介入性心臟醫師與心臟外科醫師必須共同參與 TAVR 的相關方面 臨床研究必須嚴格評估各病患在 TAVR 前後的生活品質至少一年時間，同時必須負責處理其他各項問題 臨床研究必須遵守所有科學誠信準則，以及與 Medicare 社群有關的規定。 點選此處進一步瞭解 NGS 給付。 11.動態血壓監測 (ABPM) (生效日期：2019 年 7 月 2 日) (施行日期：2020 年 6 月 16 日) CMS 更新了《Medicare 全國給付判定標準手冊》第 1 章第 20.19 節。Medicare 暨 Medicaid 服務中心 (CMS) 將在符合特定要求的情況下，給付動態血壓監測 (ABPM) 費用。 給付項目： 自 2019 年 7 月 2 日起，若保險受益人疑似罹患白袍高血壓或隱性高血壓，則除 NCD 手冊給付標準外，CMS 將給付動態血壓監測 (ABPM) 費用。 適用對象： 當動態血壓監測 (ABPM) 係用於在疑似罹患白袍高血壓或隱性高血壓時診斷高血壓，且符合下列條件，則此服務將獲得給付： ABPM 裝置必須： 能夠生成 24 小時標準化血壓量測圖，包括日間、夜間以及正常血壓區塊； 向病患提供口頭與書面指示，並於醫師辦公室進行測試；及 由主治醫師或非執業醫師的治療醫藥從業人員解讀相關結果。 其他 ABPM 適應症的給付由 Medicare 管理承包商全權決定。 點選此處進一步瞭解動態血壓監測給付。 12.慢性下背痛針灸 (cLBP) (生效日期：2020 年 1 月 21 日) (施行日期：2020 年 10 月 5 日) CMS 更新了《Medicare 全國給付判定標準手冊》第 1 章第 30.3.3 節。Medicare 暨 Medicaid 服務中心 (CMS) 將在符合特定要求的情況下，給付慢性下背痛針灸 (cLBP) 費用。 給付項目： 自 2020 年 1 月 21 日起，除 NCD 手冊所列給付標準外，CMS 將給付 90 天內最多 12 次慢性下背痛針灸 (cLBP) 費用，對於接受治療而背痛有改善的保險受益人，將給付額外 8 次療程的費用。 適用對象： 僅在符合下列條件時，經診斷罹患慢性下背痛 (cLBP) 的保險受益人可獲得此服務的給付： 就此決定而言，cLBP 係指： 持續 12 週或更長時間； 非特異性，亦即無可識別的背痛原因 (即：與新陳代謝、炎症、感染等疾病無關)； 與手術無關；且 與懷孕無關。 症狀有所改善的病患，將可額外享有 8 次療程的給付保障。 每年的針灸治療次數不得超過 20 次。 若病患疼痛狀況無改善或加重，則應停止治療。 就 cLBP 以外任何病症進行的所有類型的針灸，包括乾針療法，皆不在 Medicare 給付範圍內。 點選此處進一步瞭解慢性下背痛針灸的給付。 13.迷走神經刺激 (VNS) (生效日期：2020 年 2 月 15 日) (施行日期：2020 年 7 月 22 日) CMS 更新了《Medicare 全國給付判定標準手冊》第 1 章第 160.18 節。Medicare 暨 Medicaid 服務中心 (CMS) 將在符合特定要求的情況下，給付抗憂鬱症的迷走神經刺激 (VNS) 治療費用。 給付項目：  自 2020 年 2 月 15 日起，除《全國給付判定標準手冊》所列給付條件外，CMS 將為依據「依實證發展給付」(CED) 參加獲 CMS 核准臨床試驗的保險受益人，給付獲 FDA 核准之抗憂鬱症的迷走神經刺激 (VNS) 器治療費用。 適用對象： 參加獲 CMS 核准臨床試驗、使用迷走神經刺激 (VNS) 器進行抗憂鬱症治療並符合下列要求的保險受益人： 相關治療係透過「依實證發展給付」(CED) 作為獲 CMS 核准臨床試驗一部分而提供。詳細臨床試驗條件請參閱《全國給付判定標準手冊》第 160.18 節。 相關臨床試驗必須回答《全國給付判定標準手冊》第 160.18 節所有研究問題，以瞭解與對照組相比，接受 VNS 治療的病患在進行抗憂鬱症療法後的健康改善程度。 病患標準：    須使用下列標準來確認可接受抗憂鬱症療法的保險受益人： 保險受益人罹患重性憂鬱症的時間必須至少兩年，或至少曾四次發病，包括最近一次。 病患的憂鬱症必須至少有過四次治療失敗，並符合為本目的所設計工具所衡量的足夠藥物劑量和持續時間。 在植入 VNS 器前 45 日內，病患經歷重性憂鬱症發作情況，此狀況透過兩次訪視並以推薦的憂鬱程度評估工具加以量測決定。 在植入儀器之前，病患必須穩定用藥至少四周。 若病患同時罹患躁鬱症，則須仔細描述相關病情。 病患不得： 當前或過去曾有任何重性憂鬱症的精神病病徵； 當前或過去曾有精神分裂症或情感思覺失調症； 當前或過去曾有任何其他精神疾病； 當前或過去曾有快速循環躁鬱症； 當前有精神錯亂、失智、失憶或其他認知障礙等次要診斷； 當前有自殺意圖；或 接受其他試驗性裝置或試驗性藥物治療。 CMS 會審核相關研究資料，以確認病患是否符合《全國給付判定標準手冊》第 160.18 節的標準。 全國非給付適應症 當在 CMS 核准之 CED 研究之外提供時，則用於治療 TRD 的 VNS 費用將不予給付。 治療憂鬱症的其他 VNS 適應症，皆不在全國給付範圍內。 為治療 TRD 而植入 VNS 器的病患，在儀器電池壽命終止或發生任何其他儀器相關故障時，可能會接受更換 VNS 器的治療。 點選此處進一步瞭解迷走神經刺激。  14.嵌合抗原受體 (CAR) T 細胞治療 (生效日期：2019 年 8 月 7 日) (施行日期：2021 年 9 月 20 日) CMS 更新了《Medicare 全國給付判定標準手冊》第 110.24 節，於符合特定要求的情況下，將嵌合抗原受體 (CAR) T 細胞治療納入給付範圍。 給付項目： 自 2019 年 8 月 7 日起，CMS 將為於食品藥物管理局 (FDA)《風險評估暨降低風險策略》(Risk Evaluation and Mitigation Strategies, REMS) 註冊健康照護機構接受治療，並符合特定要求的保險受益人，給付至少一次嵌合抗原受體 (CAR) T 細胞癌症自體治療。 適用對象： 保險受益人在符合所有下列條件時，將可獲得至少一次嵌合抗原受體 (CAR) T 細胞癌症自體治療： 自體治療適用 T 細胞至少擁有一個嵌合抗原受體 (CAR) 的癌症；及 治療係於 FDA 註冊之健康照護機構進行；及 治療係用於具醫療可接受性之適應症，亦即依據其產品說明係用於 FDA 核准之適應症，或其使用符合一份或多份獲 CMS 核准之概略。 非給付用途： 使用非 FDA 核准擁有至少一個 CAR 之自體 T 細胞，或不符合給付規定，皆不在給付範圍內。 點選此處進一步瞭解嵌合抗原受體 (CAR) T 細胞治療給付。  15.大腸癌 (CRC) 篩檢 - 血液生物標記檢測 (生效日期：2021 年 1 月 19 日)  (施行日期：2021 年 10 月 4 日)  給付項目： 自 2021 年 1 月 19 日起，CMS 認定在符合特定規定的情況下，血液生物標記檢測為 Medicare 保險受益人每 3 年應接受的適當大腸癌篩檢。  適用對象： Medicare 保險受益人於取得主治醫師同意並符合下列條件時，其每 3 年一次的血液大腸癌篩檢費用將可獲得給付： 相關程序係由獲「美國臨床實驗室改善修正法」(CLIA) 認證的實驗室進行 病患為：  年齡介於 50-85 歲；及 無症狀 (無直腸癌疾病之跡象或症狀，包括但不限於下消化道疼痛、糞便帶血、糞便潛血檢測呈陽性或糞便免疫化學檢測呈陽性)；及 存在罹患大腸癌的平均風險 (無個人腺瘤性瘜肉、大腸癌或發炎性腸道疾病史，包括克隆氏症與潰瘍性結腸炎；無大腸癌或腺瘤性息肉家族病史、家族性腺瘤性息肉或遺傳性非息肉性大腸癌) 篩檢測試必須符合下列所有規定： 食品藥物管理局 (FDA) 上市授權，且適應症包括大腸癌篩檢；及 依據 FDA 標示的關鍵研究，血液篩檢測試經證明效能良好，包括敏感度大於或等於 74%，且與公認標準相比之大腸癌偵測率大於或等於 90% (目前已接受結腸鏡檢查)。 不給付項目： 上述法規或全國給付判定標準未明確規定的所有其他大腸癌篩檢適應症。其中包括： 2008 年 4 月 28 日至 2014 年 10 月 8 日期間進行的所有 sDNA 篩檢檢測。自 2014 年 10 月 9 日起，上述規定未明確說明的所有其他 sDNA 篩檢檢測，仍不在全國給付範圍內。 電腦斷層掃描結腸成像 (CTC) 篩檢，自 2009 年 5 月 12 日起生效。 點選此處進一步瞭解 NGS 給付。 16.心室輔助裝置 (VAD) (生效日期：2020 年 12 月 1 日) (施行日期：2021 年 7 月 27 日) 給付項目： 自 2020 年 12 月 1 日起，CMS 更新了《全國給付判定標準手冊》第 20.9.1 節，在符合特定要求的情況下，於 CMS 核准組織所驗證的機構使用心室輔助裝置之費用，將可獲得給付。 適用對象： 接受植入心室輔助裝置 (VAD) 治療的保險受益人，須符合下列規定且： 該裝置係於心臟切開術後 (心臟切開手術後期間) 使用，以協助血液流動。 該裝置必須通過食品藥物管理局 (FDA) 核准用於此目的；或 心臟衰竭的保險受益人符合下列規定，且取得獲 FDA 核准用於短期或長期機械式循環輔助之左心室輔助裝置 (LVAD)： 罹患紐約心臟協會 (NYHA) 第 IV 類心臟衰竭；且 左心室射血分數 (LVEF) ≤ 25%；且 須使用強心劑 (inotrope)，或心臟指數 (Cardiac Index, CI) < 2.2 L/min/m2，而不完全依賴強心劑，並符合下列任一條件： 依據當期適用心臟衰竭處置指南，在過去 60 天內至少 45 天曾進行適當的醫療管理，但仍無法達到療效；或 在過去 14 天內曾發生嚴重心臟衰竭，且須使用主動脈內氣球幫浦 (intra-aortic balloon pump, IABP) 或使用類似暫時性機械式循環輔助至少 7 天。 保險受益人必須由符合《全國給付判定標準手冊》最低標準之醫療專家團隊負責管理。 相關機構必須通過 CMS 核准組織認證。 非給付用途： 未在手冊中列示之所有其他 VAD 適應症仍不在給付範圍內，除係 B 類臨床研究用醫療器材豁免試驗 (42 CFR 405)，或係《全國給付判定標準手冊》第 310.1 節所定義之例行性臨床試驗成本。 點選此處進一步瞭解心室輔助裝置 (VAD) 給付之詳細資訊。 17.慢性不癒合傷口的血液衍生產品 (生效日期：2021 年 4 月 13 日) (施行日期：2022 年 2 月 14 日) 給付項目： 自 2021 年 4 月 13 日起，CMS 更新了《全國給付判定標準手冊》第 270.3 節，在符合特定要求的情況下，為自體 (取自同一個人) 高濃度血小板血漿 (PRP) 提供給付。 適用對象： 接受為期 20 週的慢性不癒合糖尿病傷口治療的保險受益人，且治療裝置由美國食品藥物管理局 (FDA) 認可，用於治療影響皮膚的滲出 (出血、分泌、滲出等) 傷口。 非給付用途： 下列用途不在給付範圍內： 使用自體血小板衍生生長因子 (Platelet-Derived Growth Factor, PDGF) 治療慢性、不癒合、皮膚性 (影響皮膚) 的傷口，及 貝卡普明 (Becaplermin)，適用於慢性、不癒合、皮下 (皮膚下面) 傷口的非自體生長因子，及 直接適用於縫合傷口，或裂開或撕裂的傷口時，對急性外科傷口進行自體高濃度血小板血漿 (Autologous Platelet-Rich Plasma, PRP) 治療。 其他： 對於超過 20 週的治療，或其他所有慢性不癒合傷口的給付範圍，將由當地 Medicare 管理承包商 (Medicare Administrative Contractors) 裁定。 點選此處進一步瞭解適用於慢性不癒合傷口的血液衍生產品的給付資訊。 18.適用於二尖瓣閉鎖不全的經導管緣對緣修復 [TEER] (生效日期：2021 年 1 月 19 日) (施行日期：2021 年 10 月 8 日) 給付項目： 自 2021 年 1 月 19 日起，CMS 更新了《全國給付判定標準手冊》第 20.33 節，在符合特定要求的情況下，為適用於二尖瓣閉鎖不全的經導管緣對緣修復 (TEER) 提供給付。 適用對象： 接受經導管緣對緣修復 (TEER) 治療且符合以下任一條件的保險受益人： 針對患者仍有症狀時的中等到嚴重二尖瓣閉鎖不全 (MR) 症狀的治療，無論最大耐受指引導向藥物治療 (GDMT) 與心臟再同步化治療的穩定劑量如何，在適當情況下且符合以下條件時： 治療為獲美國食品藥物管理局 (FDA) 核准之適應症， 手術使用已從 FDA 獲得上市前核准的二尖瓣 TEER 系統。 保險受益人正接受符合以下條件之心臟團隊的術前或術後照護： 符合裁決所列要求的心臟外科醫師。 符合裁決所列要求的介入性心臟醫師。 符合裁決所列要求的介入性心臟超音波醫師。 具有治療晚期心臟衰竭患者經驗的心臟衰竭醫師。 來自其他小組的提供者，包括患者執業人員、護士、研究人員與管理人員。 患者必須接受修復適當性評估，且必須記錄下來，並提供給符合此裁決要求的心臟團隊成員使用。 手術必須由介入性心臟醫師或心臟外科醫師進行。< 介入性心臟超音波醫師必須在手術期間進行經食道心臟超音波。 所有參與手術的醫師都必須接受裝置製造商的專項裝置訓練。 手術必須在基礎設施與經驗均符合此裁決要求的醫院中進行。 心臟團隊必須參與符合此裁決要求的全國性註冊與追蹤結果。> 若其他用途未明文列示為獲 FDA 核准之適應症，但在臨床研究中進行並符合下列條件，則二尖瓣 TEER 包含在給付範圍內： 手術必須由介入性心臟醫師或心臟外科醫師進行。 介入性心臟超音波醫師必須在手術期間進行經食道心臟超音波。> 所有參與手術的醫師都必須接受裝置製造商的專項裝置訓練。 臨床研究必須評估此裁決中必要的十二個問題。 臨床研究必須評估患者在此前後至少一年時間裡的生活品質，並回答此裁決中的至少一個問題。 臨床研究必須遵守科學誠信準則，以及與此裁決中描述的 Medicare 社群有關的規定。 將所需研究資訊提交給 CMS 進行核准。 非給付用途： 下列用途不在給付範圍內： 對同時患有多種無法從手術中獲益之疾病的患者的治療。 對於未經治療的嚴重主動脈瓣狹窄患者的治療。 其他： 此裁決將於生效日期後十年到期 (若在此期間未進行覆議)。 到期後，給付範圍將由當地 Medicare 管理承包商 (MAC) 裁定。 點選此處進一步瞭解適用於二尖瓣閉鎖不全的經導管緣對緣修復 [TEER] 的給付資訊。 19.使用正子電腦斷層造影 NaF-18 (NaF-18 PET) 判定癌症的骨轉移 - 僅限手冊更新  (生效日期：2017 年 12 月 15 日) (施行日期：2022 年 1 月 17 日)  服務日期自 2017 年 12 月 15 日或之後生效，CMS 已更新《全國給付判定標準手冊》第 220.6.19 節，釐清正子電腦斷層造影 NaF-18 (NaF-18 PET) 不適用於全國給付。 非給付用途： 2017 年 12 月 15 日或之後，規定用於判定癌症骨轉移之正子電腦斷層造影 NaF-18 (NaF-18 PET) 服務不適用於全國給付範圍。 其他 以其他 PET 放射性藥物追蹤劑用於根據美國食品藥物管理局 (FDA) 核准之癌症適應症時，可由 Medicare 管理承包商 (Medicare Administrative Contractor, MAC) 酌情決定是否支付。 按一下此處，了解關於使用正子電腦斷層造影 NaF-18 (NaF-18 PET) 判定癌症骨轉移的更多資訊。 此頁面資訊為截至 2021 年 12 月 28 日的最新資訊 H5355_CMC_22_2746205 Accepted 20.居家用氧  （生效日期：2021 年 9 月 27 日） （施行日期：2023 年 1 月 3 日） 給付項目： 自 2021 年 9 月 27 日起，CMS 更新了《全國給付判定標準手冊》第 240.2 節，以給付患者出現低氧血症時，運用於急性和慢性疾病的短期或長期的家用氧氣治療和氧氣設備。CMS 已經更新《全國給付判定標準手冊》第 240.2 節，將 NCD 240.2 節 D 部分的患者初始承保期從 120 天改為 90 天，以與 90 天的法定期限保持一致。 適用對象： 當符合以下所有（A、B 和 C）條件時，呈現低氧血症（血液中的氧氣含量低）的受益人：  A. 低氧血症是依據病患的主治醫生指示和評估的臨床測試結果，符合以下任何一項條件： a.測量動脈血中氧分壓 (pressure of oxygen, PO2) 的臨床試驗。 i.可以透過耳朵或脈搏血氧儀獲得 PO2 測量值。 ii.PO2 可由主治醫師或合格的實驗室服務提供者或供應商執行。 b.提供動脈血液氣體測量的臨床試驗。 i.如果 PO2 和動脈血液氣體結果相互矛盾，則優先以動脈血液氣體結果為依據來確定醫療需求。 B. 臨床試驗必須在需要時進行： a.當推定在居家環境進行氧氣治療將改善患者的病情時，則表明是需要的時間。 i.對於住院患者，需要的時間是出院後 2 天內。 ii.如果最初的氧氣處方並非於患者住院期間開立，則當主治醫師確定可透過居家氧氣治療緩解低氧血症的體徵和症狀時，即出現需要的時間。 C. 受益人的診斷符合下列定義的群體之一： a.群體 I： i.在靜息狀態下呼吸室內空氣進行測試，動脈 PO2 等於或低於 55 mm Hg，或動脈血氧飽和度等於或低於 88%，或； ii.當患者動脈 PO2 等於或低於 55 mm Hg，或患者於睡眠期間測試顯示 PO2 等於或低於 56 mm Hg 時，動脈血氧飽和度等於或低於 88%，或； iii.清醒時動脈血氧飽和度為 89% 或以上；或睡眠時氧氣水準下降超過正常水準，呈現動脈 PO2 下降超過 10 mmHg 或動脈血氧飽和度下降超過 5%。 a.患者還必須呈現低氧血症的體徵和症狀，如夜間煩躁不安、失眠或認知過程障礙。 2.在這些活動中，睡眠中的氧氣是唯一會被給付的單位類型。 3.攜帶式氧氣不屬於給付範圍。 iv.在患者的功能表現或正式運動中測試，動脈 PO2 在 55 mm Hg 或以下，或動脈血氧飽和度在 88% 或以下， 1.對於靜息和白天呈現動脈 PO2 等於或高於 56 mm Hg，或動脈血氧飽和度等於或高於 89% 的患者。 2.在這些事件中，如果使用氧氣得以改善患者在運動期間呼吸室內空氣時呈現的低氧血症，則在運動期間提供補充氧氣。 b.群體 II： i.動脈血氧飽和度在 56-59 mm Hg 之間或動脈血氧飽和度為 89% 的患者，有以下任何一種狀況： 1.下垂性水腫（由於液體過多引起的與重力相關的腫脹）提示鬱血性心臟衰竭；或， 2.透過測量肺動脈壓、門控血池掃描、心臟超音波或心電圖上的「P」型肺病（標準導程 II、III 或 AVFL 中的 P 波大於 3 mm）確定肺動脈高壓或肺性心臟病（肺動脈高血壓）；或， 3.紅血球過多症（紅血球增多），血比容大於 56%。 c.醫療保險管理承包商 (Medicare Administrative Contractors, MAC) 將檢視上述動脈 PO2 水準，並考量各種可能由患者年齡、患者皮膚色素沉著、海拔高度和患者攜氧能力下降等因素造成的氧氣測量值。 非給付用途： 以下醫療狀況非屬於居家環境中的氧氣療法和氧氣設備的給付範圍內： 非屬於低氧血症狀況的心絞痛（胸痛）；或， 沒有肺性心臟病或低氧血症證據的呼吸困難；或， 嚴重的週邊血管疾病導致一個或多個肢體出現臨床上明顯的飽和度下降；或， 絕症，除非其影響患者的呼吸能力。 其他： MAC 可以為不符合上述標準的患者確定居家氧氣治療的必要給付範圍。對患者經歷非屬於上述情況的初始承保，可以限制為少於 90 天的處方，或少於醫生處方上標明的天數。如果認為有醫學上的必要性，MAC 可以延長氧氣治療時間。 MAC 還可以批准在家中活動並會因單獨使用該裝置或與固定氧氣系統結合使用而得到好處的受益人運用攜帶式氧氣系統。 如需進一步瞭解居家用氧給付範圍，請點選此處。 21. 180.1 - 醫學營養治療 (Medical Nutrition Therapy, MNT) (生效日期：2022 年 1 月 1 日） （施行日期：2022 年 7 月 5 日） 給付項目： 自 2022 年 1 月 1 日起，CMS 更新了《全國給付判定標準手冊》第 180.1 節，以給付診斷為腎臟病或糖尿病（如 42 CFR 410.130 之定義）的患者在一年的醫學營養治療 (MNT) 期間的三個小時的給藥時間。對於被診斷患有腎臟病或糖尿病的患者，未來幾年的給付範圍為兩小時。 如果醫師確認治療有醫學上的必要性，並且只要糖尿病門診患者自我管理教育 (Diabetes Outpatient Self-Management Training, DSMT) 和 MNT 未於同一日期提供，則 Medicare 將在最初和其後的幾年內給付 MNT 和 DSMT。 營養專家和營養師將決定每天施用多少單位，並且必須符合本 NCD 以及 42 CFR 410.130 – 410.134 的要求。如果醫生確定患者的醫療狀況、診斷或治療方案發生變化，需要調整 MNT 指令或增加照護時間，則額外的治療時間將被認為有醫學上的必要性。 適用對象： 被診斷患有 42 CFR 410.130 中定義的腎臟病或糖尿病的受益人。 如需進一步瞭解醫學營養治療 (MNT) 給付，請點選此處。 22.  重新考量—使用低劑量電腦斷層掃描 (Low Dose Computed Tomography, LDCT) 篩檢肺癌 (生效日期：2022 年 2 月 10 日） （施行日期：2022 年 10 月 3 日）  給付項目： 對於服務日期為 2022 年 2 月 10 日或之後的索賠，CMS 將給付 Medicare B 部分肺癌篩檢諮詢和醫病共享決策。如果符合特定的資格標準，將可以使用 LDCT 進行肺癌年度篩檢。  在受益人進行第一次肺癌 LDCT 篩檢之前，受益人必須接受符合特定標準的諮詢和完成醫病共享決策看診。 適用對象： 會員必須符合以下所有資格標準：  年齡為 50 – 77 歲； 無症狀（沒有肺癌的跡象或症狀）； 具有至少 20 包-年抽菸史（1 包-年 = 每天一包、持續抽菸 1 年，1 包 = 20 支香煙）； 目前仍為吸菸者或是在近 15 年內戒菸者。 收到使用 LDCT 進行肺癌篩檢的指示。 請按此處以取得關於 LDCT 給付的更多資訊。  23. (用於對抗類澱粉蛋白以治療阿茲海默症 (Alzheimer's Disease, AD) 的單株抗體) (生效日期：2022 年 4 月 7 日) (實施日期：2022 年 12 月 12 日) 承保範圍： Medicare 與 Medicaid 服務中心 (CMS) 已更新全國承保裁決 (National Coverage Determination, NCD) 手冊第 200.3 節，以在符合以下承保標準時承保食品藥物管理局 (Food and Drug Administration, FDA) 所核准用於對抗類澱粉蛋白以治療阿茲海默症 (Alzheimer's Disease, AD) 的單株抗體，生效日期為 2022 年 4 月 7 日。 承保對象： 符合以下條件 (A 或 B) 時，患有阿茲海默症 (Alzheimer's Disease, AD) 的受益人可能取得治療承保： 相關治療是以替代性指標的變化 (例如類澱粉蛋白減少) 所產生之療效為基礎。相關治療被合理認為可能預測臨床益處，並依據研究性新藥申請規定在隨機對照試驗中 施用。 相關治療是以 Medicare 與 Medicaid 服務中心 (CMS) 核准的事前比較研究中直接衡量臨床益處所產生之療效為基礎。Medicare 與 Medicaid 服務中心 (CMS) 核准的事前比較研究之研究資料可透過登記簿進行收集。 對於 Medicare 與 Medicaid 服務中心 (CMS) 核准的研究，計畫書 (包括分析計畫) 必須符合本全國承保裁決 (NCD) 中列出的規定。 經 Medicare 與 Medicaid 服務中心 (CMS) 核准將單株抗體用於對抗類澱粉蛋白 (經食品藥物管理局 FDA核准可用於以直接衡量臨床益處所產生之療效實證為基礎的阿茲海默症 AD治療) 的研究必須解決本全國承保裁決第 B.4 節中列出的所有問題。 Medicare 與 Medicaid 服務中心 (CMS) 核准的研究還必須遵守健康護理研究及品質機構 (Agency for Healthcare Research and Quality, AHRQ) 在本全國承保裁決 (NCD) 第 5 節中確立的科學誠信標準。 如需深入瞭解研究設計和基本原理要求，請前往這裡。 非承保用途： 在食品藥物管理局 (FDA) 核准的隨機對照試驗、Medicare 與 Medicaid 服務中心 (CMS) 核准的研究或國家衛生院 (NIH) 支持的研究之外所提供用於對抗類澱粉蛋白以治療阿茲海默症 (AD) 的單株抗體。 其他： 不適用(N/A)。 如需深入瞭解用於對抗類澱粉蛋白以治療阿茲海默症 (Alzheimer's Disease, AD) 的單株抗體，請點選這裡。 24. 結腸直腸癌篩查 (生效日期：2023 年 1 月 1 日) (實施日期：2023 年 2 月 27 日) 承保範圍： 自 2023 年 1 月 1 日起，Medicare 與 Medicaid 服務中心 (Centers for Medicare and Medicaid Services, CMS) 已更新全國承保裁決 (National Coverage Determination, NCD) 手冊的第 210.3 節，透過 Medicare B 部分為結腸直腸癌 (Colorectal Cancer, CRC) 篩查提供承保。 承保對象： 至少已年滿 45 歲以上的受益人若滿足本全國承保裁決中的所有 Medicare 標準，便可接受下列篩查： 糞便潛血檢查 (Fecal Occult Blood Test, gFOBT)，每 12 個月一次 Cologuard™ – 多目標糞便 DNA (Stool DNA, sDNA) 檢查，每 3 年一次 血液生物標記檢查，每 3 年一次 不屬於承保範圍的使用： 《社會安全法》、法規或前文中沒有另外規定的所有其他結腸直腸癌篩檢的適應症在全國仍不屬於承保範圍。不屬於承保範圍的檢查具體包含下列項目： 所有sDNA篩查檢測 ，生效日期為 2008 年 4 月 28 日至 2014 年 10 月 8 日。針對服務日期在 2014 年 10 月 9 日當日或之後的檢查，前文沒有另外規定的所有其他sDNA 篩查檢測在全國仍不屬於承保範圍。 電腦斷層掃描結腸造影 (Computed Tomographic Colonography, CTC) 篩檢，自 2009 年 5 月 12 日起生效。 如需有關動態腦電圖監控和結腸直腸癌篩查的進一步資訊，請點選此處。 本頁面的資訊截至 2023 年 2 月 14 日為止為最新資訊 H8894_DSNP_23_3820564_M_CH 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)  Claims For Integrated Denial Notices please click here. Please select on the links below to obtain the revised CMS 1500 form (version 02/12) and the CMS 1500 Reference Instruction Manual. Provider Identified Overpayment Form (PDF) Provider Identified Overpayment Form (Multiple) (PDF) Provider Dispute Resolution (PDR) (PDF) Claims Project Spreadsheet (Excel) Clean Claim Tool Guide - UB04 Inpatient Form (PDF) Clean Claim Tool Guide - UB04 Outpatient Form (PDF) Waiver of Liability Statement - IEHP Dual Choice (HMO D-SNP) - effective January 2023 (PDF) Revised CMS 1500 Health Insurance Claim Form (PDF) CMS 1500 Reference Instruction Manual (PDF) (Back to top) Compliance Member Incentive Forms Focus Group Incentive (FGI) - Request for Approval Form (PDF) Focus Group Incentive (FGI) - Evaluation Form (PDF) Member Incentive (MI) Program - Request for Approval (PDF) Member Incentive (MI) Program - Annual Update/End of Program Evaluation (PDF) Survey Incentive (SI) - Request for Approval Form (PDF) Survey Incentive (SI) - Evaluation Form (PDF) Nondiscrimination Language Nondiscrimination Language Access Notice: Medi-Cal (PDF) Medicare (PDF) (Back to top) Delegation Oversight Audit (DOA) Biographical Information Sheet Credentialing DOA Audit Tool HIPAA Security - Medi-Cal DOA HIPAA Security - Medicare Medi-Cal DOA Tool UM/CM/QI Medicare DOA Tool UM/CM/QI Medi-Cal UM Referral Template Sub-Contracted Facility/Agency Services and Delegated Functions (Back to top) Grievance The Grievance Forms below are for your Member's use when filing a complaint, or has an appeal regarding any aspect of care or service provided by you. Please select the Appeal and Grievance form appropriate for their use: Medi-Cal Form      English (PDF)      Spanish (PDF)      Chinese (PDF)      Vietnamese (PDF) Medicare Form      English (PDF)      Spanish (PDF)      Chinese (PDF)      Vietnamese (PDF) The following IEHP DualChoice (HMO D-SNP) Letters will be effective January 1, 2023:      English (PDF)      Spanish (PDF)      Chinese (PDF)      Vietnamese (PDF) (Back to top) Growth Chart Inland Empire Health Plan (IEHP) offers you easy access to useful reference materials and forms you may need. It's just one click away. Select the growth chart form that you need by clicking on the link below: (0-36 months): Head Circumference-For-Age And Weight- For-Length Percentiles           Boys (PDF)          Girls (PDF) (0-36 months): Length and Weight-For-Age Percentiles           Boys (PDF)          Girls (PDF) (2-20 years): Stature and Weight-For-Age-Percentiles           Boys (PDF)         Girls (PDF) (2-20 years): Body Mass Index For-Age Percentiles           Boys (PDF)          Girls (PDF) (Back to top) Health and Wellness DPP Rx Pad (PDF) (Back to top)   Historical Data Form Historical Data Form (PDF) (Back to top) Inland Regional Center Early Start (0-36 months) Referral (PDF) Early Start Online Application Eligibility and Intake IRC Referrals (3-99+ years): San Bernardino County: For Providers - (909) 890-4711 // Intake - (909) 890-3148 Riverside County: For Providers - (909) 890-4763 // Intake - (951) 826-2648 (Back to top) Medi-Cal Letter Templates A complete template includes all documents listed under each template in the order specified listed. Changes can only be made to highlighted areas, any changes made outside of the highlighted areas are strictly prohibited by DHCS. Click on the title to expand the menu and download desired document. Member Authorization Letter English Last Updated: 09/20/2022 Spanish Last Updated: 09/20/2022   Chinese Last Updated: 09/20/2022   Vietnamese Last Updated: 09/20/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 Continuity of Care Authorization Letter English Last Updated: 09/20/2022   Spanish Last Updated: 09/20/2022   Chinese Last Updated: 09/20/2022   Vietnamese Last Updated: 09/20/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 Notice of Action – Carve Out English Last Updated: 12/29/2022   Spanish Last Updated: 12/29/2022   Chinese Last Updated: 12/29/2022   Vietnamese Last Updated: 12/29/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 Notice of Action - Delay English Last Updated: 12/27/2022   Spanish Last Updated: 12/27/2022   Chinese Last Updated: 12/27/2022   Vietnamese Last Updated: 12/27/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 Notice of Action - Deny English Last Updated: 12/27/2022   Spanish Last Updated: 12/27/2022   Chinese Last Updated: 12/27/2022   Vietnamese Last Updated: 12/27/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 Notice of Action - Modify English Last Updated: 12/28/2022   Spanish Last Updated: 12/28/2022   Chinese Last Updated: 12/28/2022   Vietnamese Last Updated: 12/28/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 Notice of Action - Terminate English Last Updated: 01/06/2023   Spanish Last Updated: 01/06/2023   Chinese Last Updated: 01/06/2023   Vietnamese Last Updated: 01/06/2023   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 Other Health Care Coverage Requesting Provider Letter English Last Updated: 03/17/2021   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 Continuity of Care Terminate Letter English Last Updated: 09/20/2022   Spanish Last Updated: 09/20/2022   Chinese Last Updated: 09/20/2022   Vietnamese Last Updated: 09/20/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 Specialist Termination Letter English Last Updated: 09/20/2022   Spanish Last Updated:09/20/2022   Chinese Last Updated:09/20/2022   Vietnamese Last Updated:09/20/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 Prior Authorization Not Required English Last Updated: 09/20/2022   Spanish Last Updated:09/20/2022   Chinese Last Updated:09/20/2022   Vietnamese Last Updated:09/20/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2022 (Back to top) Medicare-Medicaid Plan Letter Templates A complete template includes all documents listed under each template in the order specified listed. Changes can only be made to highlighted areas, any changes made outside of the highlighted areas are strictly prohibited by CMS. Click on the title to expand the menu and download desired document. Carve-Out Information Letter English Last Updated: 11/12/2017   Spanish Last Updated: 10/31/2017   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Denial Reason Matrix English Last Updated: 07/03/2018   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Detailed Explanation of Non-Coverage English Last Updated: 12/17/2021   Spanish Last Updated: 12/17/2021   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Detailed Notice of Discharge English Last Updated: 12/17/2021   Spanish Last Updated: 12/17/2021   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Expedited Criteria Not Met English Last Updated: 10/31/2017   Spanish Last Updated: 10/31/2017   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Extension Needed for Additional Information English Last Updated: 10/31/2017   Spanish Last Updated: 10/31/2017   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Integrated Denial Notice - Part B Drugs - 7 day appeal - IPA English Last Updated: 02/14/2022   Spanish Last Updated: 02/14/2022   Chinese Last Updated: 02/14/2022   Vietnamese Last Updated: 02/14/2022   Independent Medical Review - [English] [Spanish] [Chinese] [Vietnamese] Updated October 7, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Integrated Denial Notice - Part C - 30 day appeal - IPA English Last Updated: 03/08/2022   Spanish Last Updated: 02/14/2022   Chinese Last Updated: 02/14/2022   Vietnamese Last Updated: 02/14/2022   Independent Medical Review - [English] [Spanish] [Chinese] [Vietnamese] Updated October 7, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Integrated Denial of Payment Notice - 7 day appeal - IPA English Last Updated: 03/17/2021   Spanish Last Updated: 10/18/2021   Independent Medical Review - [English] [Spanish] [Chinese] [Vietnamese] Updated October 7, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Integrated Denial of Payment Notice - 30 day appeal - IPA English Last Updated: 03/17/2021   Spanish Last Updated: 04/12/2017   Independent Medical Review - [English] [Spanish] [Chinese] [Vietnamese] Updated October 7, 2022 Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Notice of Authorization of Services English Last Updated: 10/31/2017   Spanish Last Updated: 10/31/17   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Notice of Dismissal of Coverage English Last Updated:03/10/2022   Spanish Last Updated:03/10/2022   Chinese Last Updated:03/10/2022   Vietnamese Last Updated:03/10/2022   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Notice of Medicare Non-Coverage English Last Updated: 10/31/2017   Spanish Last Updated: 10/31/2017   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 Notice of Reinstatement of Coverage English Last Updated: 10/31/2017   Spanish Last Updated: 10/31/2017   Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022 (Back to top) NEW D-SNP Letter Templates These templates should not be used until the effective date of January 2, 2023. Please continue using the current Medicare DualChoice letter templates currently seen on this webpage for the remainder of 2022. A complete template includes all documents listed under each template in the order specified listed. Changes can only be made to highlighted areas, any changes made outside of the highlighted areas are strictly prohibited by CMS. Click on the title to expand the menu and download desired document. AOR Dismissal Letter English Last Updated: 09/26/2022   Spanish Last Updated:09/26/2022   Chinese Last Updated:09/26/2022   Vietnamese Last Updated:09/26/2022   Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated February 21, 2023 AOR Request Letter English Last Updated: 09/26/2022   Spanish Last Updated:09/26/2022   Chinese Last Updated:09/26/2022   Vietnamese Last Updated:09/26/2022   Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated February 21, 2023 Continuity of Care - Notice of Authorization English Last Updated: 09/26/2022   Spanish Last Updated:09/26/2022   Chinese Last Updated:09/26/2022   Vietnamese Last Updated:09/26/2022   Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated February 21, 2023 Continuity of Care – Notice of Termination English Last Updated: 09/26/2022   Spanish Last Updated:09/26/2022   Chinese Last Updated:09/26/2022   Vietnamese Last Updated:09/26/2022   Nondiscrimination Notice, Tagline, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated February 21, 2023 Detailed Explanation of Non-Coverage English Last Updated: 09/26/2022   Spanish Last Updated:09/26/2022   Chinese Last Updated:09/26/2022   Vietnamese Last Updated:09/26/2022   Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated February 21, 2023 Detailed Notice of Discharge English Last Updated: 12/20/2022   Spanish Last Updated:12/20/2022   Chinese Last Updated:12/20/2022   Vietnamese Last Updated:12/20/2022   Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated February 21, 2023 Expedited Criteria Not Met English Last Updated: 09/26/2022   Spanish Last Updated: 09/26/2022   Chinese Last Updated: 09/26/2022   Vietnamese Last Updated: 09/26/2022   Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated February 21, 2023 Extension Needed for Additional Information English Last Updated: 09/26/2022   Spanish Last Updated: 09/26/2022   Chinese Last Updated: 09/26/2022   Vietnamese Last Updated: 09/26/2022   Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated February 21, 2023 Informational Letter to Beneficiary and PCP English Last Updated: 09/26/2022   Spanish Last Updated: 09/26/2022   Chinese Last Updated: 09/26/2022   Vietnamese Last Updated: 09/26/2022   Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated February 21, 2023 Notice of Authorization of Services English Last Updated: 09/27/2022   Spanish Last Updated: 09/27/2022   Chinese Last Updated: 09/27/2022   Vietnamese Last Updated: 09/27/2022   Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated February 21, 2023 Notice of Dismissal of Coverage Request English Last Updated: 09/26/2022   Spanish Last Updated: 09/26/2022   Chinese Last Updated: 09/26/2022   Vietnamese Last Updated: 09/26/2022   Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated February 21, 2023 Notice of Medicare Non-Coverage English Last Updated:09/27/2022   Spanish Last Updated:09/27/2022   Chinese Last Updated:09/27/2022   Vietnamese Last Updated:09/27/2022   Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated February 21, 2023 Cancelled Relocation Letter English Last Updated: 09/22/2022   Spanish Last Updated:09/22/2022   Chinese Last Updated:09/22/2022   Vietnamese Last Updated:09/22/2022   Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated February 21, 2023 Long-Term Care IPA and PCP Change Letter English Last Updated: 09/26/2022   Spanish Last Updated:09/26/2022   Chinese Last Updated:09/26/2022   Vietnamese Last Updated:09/26/2022   Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated February 21, 2023 Coverage Decision Letter Part B - 7 Day Appeal English Last Updated: 10/03/2022   Spanish Last Updated:10/03/2022   Chinese Last Updated:10/03/2022   Vietnamese Last Updated:10/03/2022   *Additional Information for IPAs: Please include the integrated Coverage Decision Letter, the most recent IMR form, application instructions, DMHC’s toll-free telephone number, and an envelope addressed to DMHC. Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated February 21, 2023 Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated January 01, 2023 State Fair Hearing Form - [English] [Spanish] [Chinese] [Vietnamese] Updated September 01, 2021 Coverage Decision Letter Medical – 30 Day Appeal English Last Updated: 10/03/2022   Spanish Last Updated:10/03/2022   Chinese Last Updated:10/03/2022   Vietnamese Last Updated:10/03/2022   *Additional Information for IPAs: Please include the integrated Coverage Decision Letter, the most recent IMR form, application instructions, DMHC’s toll-free telephone number, and an envelope addressed to DMHC. Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated February 21, 2023 Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated January 01, 2023 State Fair Hearing Form - [English] [Spanish] [Chinese] [Vietnamese] Updated September 01, 2021 Coverage Decision Letter - Claims English Last Updated: 11/22/2022   Spanish Last Updated:11/22/2022   Chinese Last Updated:11/22/2022   Vietnamese Last Updated:11/22/2022   Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated February 21, 2023   (Back to top) Medicare Certificates of Medical Necessity (CMN) & DME Information Forms (DIF) Positive Airway Pressure Devices for Obstructive Sleep Apnea (PDF) Enteral and Parenteral Nutrition (PDF) External Infusion Pump (PDF) Osteogenesis Stimulators (PDF) Oxygen (PDF) Seat Lift Mechanisms (PDF) Continuation Form (PDF) Transcutaneous Electrical Nerve Stimulator (TENS) (PDF) Pneumatic Compression Device (PDF) (Back to top) Non-Contracted Providers To submit a referral to IEHP, please fill out the referral form below, include all clinical notes and fax it to IEHP. If you are referring back to yourself, please indicate such. If you need IEHP to direct the referral, please indicate that on the form. Referral Authorization Request Form - Non-Contracted Providers (PDF) If you are interested in becoming a network Provider, please click here. (Back to top) Perinatal IEHP provides standard risk assessment forms that can be used by all Providers of obstetrical (OB) services. Please refer to IEHP Provider Policy 10D1, "Obstetrical Services, Guidelines for Obstetrical Services" for further detail. To obtain copies, simply click on the links below. Edinburgh Postnatal Depression Screening Tool - English (PDF) Edinburgh Postnatal Depression Screening Tool - Spanish (PDF) ACOG Antepartum Record (PDF) (Back to top) Pharmacy Click here for Pharmacy forms. (Back to top) Provider Preventable Conditions (PPC) By clicking on these links, you will be leaving the IEHP website. On May 23,2017, the Department of Healthcare Services (DHCS) released All Plan Letter (APL) 17-009, reporting requirements related to Provider Preventable Conditions. In conjunction, DHCS released Dual Plan Letter (DPL) 17-002. As part of these instructions, the Health Plan, Network Providers, Delegates, Contracted Hospitals, and ambulatory surgical centers must report using PPC Form on DHCS secure online portal for both Medicare and Medi-Cal lines of business. Further information is available on the following pages: Instructions for Completing Online Reporting of PPCs Medi-Cal Guidance on Reporting Provider-Preventable Conditions Frequently Asked Questions All Plan Letter (APL) 17-009 Duals Plan Letter (DPL) 17-002 PPC Form Medicare and Medi-Cal lines of business must follow the instructions below: Providers are REQUIRED to send a copy of the completed PPC submission from the DHCS secure online portal to IEHP by fax at (909) 890-5545 within five (5) business days of reporting to DHCS; IEHP does not pay Provider claims nor reimburse a Provider for a PPC, in accordance with 42 CFR Section 438.3(g) and IEHP's three-way Cal MediConnect contract. Per IEHP policy and the Coordinated Care Initiative 3-Way Contract, IEHP reserves the right to recover or recoup any claim related to a PPC; As outlined in both the APL/DPL - Reporting Requirements related to Provider Preventable Conditions, the following classify as PPCs and must be reported: Category 1 - HCACs (For Any Inpatient Hospital Setting in Medicaid) Any unintended foreign object retained after surgery A clinically significant air embolism An incidence of blood incompatibility A stage III or stage IV pressure ulcer that developed during the patient's stay in the hospital A significant fall or trauma that resulted in fracture, dislocation, intracranial injury, crushing injury, burn, or electric shock A catheter-associated urinary tract infection Vascular catheter-associated infection Any of the following manifestations of poor glycemic control: diabetic ketoacidosis; nonketotic hyperosmolar coma; hypoglycemic coma; secondary diabetes with ketoacidosis; or secondary diabetes with hyperosmolarity A surgical site infection following: Coronary artery bypass graft (CABG) - mediastinitis Bariatric surgery; including laparoscopic gastric bypass, gastroenterostomy, laparoscopic gastric restrictive surgery Orthopedic procedures; including spine, neck, shoulder, elbow Cardiac implantable electronic device procedures Deep vein thrombosis/pulmonary embolism following total knee replacement or hip replacement with pediatric and obstetric exceptions Latrogenic pneumothorax with venous catheterization A vascular catheter-associated infection Category 2 - Other Provider Preventable Conditions (For Any Health Care Setting) Wrong surgical or other invasive procedure performed on a patient Surgical or other invasive procedure performed on the wrong body part Surgical or other invasive procedure performed on the wrong patient (Back to top) UM/CM Acute Hospital Discharge Needs Request Form (PDF) Authorization for Use and/or Disclosure of Patient Health Information - English (PDF) Authorization for Use and/or Disclosure of Patient Health Information - Spanish (PDF) Care Management Referral Form (PDF) Consent for HIV Test - English (PDF) Consent for HIV Test - Spanish (PDF) Health Risk Assessment (HRA) - IEHP DualChoice (CMC) - English (PDF) Health Risk Assessment (HRA) - IEHP DualChoice  (CMC)- Spanish (PDF) Health Risk Assessment (HRA) - IEHP DualChoice (HMO D-SNP) - English (PDF) - effective 1/1/2023 Health Risk Assessment (HRA) - IEHP DualChoice (HMO D-SNP) - Spanish (PDF) - effective 1/1/2023 Health Risk Assessment (HRA) - IEHP DualChoice (HMO D-SNP) - Chinese (PDF) - effective 1/1/2023 Health Risk Assessment (HRA) - IEHP DualChoice (HMO D-SNP) - Vietnamese (PDF) - effective 1/1/2023 HIV Testing Sites - Riverside and San Bernardino (PDF) Home Health Check Off List (PDF) Home Modification Consent Form (PDF) Long Term Care (LTC) Data Sheet (PDF) Non-Emergency Medical Transportation (NEMT) Physician Certification Statement (PCS) (PDF) Referral Form (PDF) Service Request for Skilled Nursing Facilities (PDF) SNF Initial Review (PDF) SNF Follow-up Review (PDF) Standing Referral and Extended Access Referral to Specialty Care (PDF) Sterilization Consent Form PM-330 PM-330 Form - Tips and Example (PDF) PM-330 Form - English (PDF) PM-330 Form - Spanish (PDF) Transportation Requests Form (SNF & LTC) (PDF) Transportation Requests Form (Hospital) (PDF) Wound Assessment - Admission (PDF) Wound Assessment - Follow - Up (PDF) Wound Assessment - Addendum (PDF) (Back to top) Vision Ophthalmologist Referral Form (PDF) Vision Exception Request (VER) Form (PDF) PCP Vision Report Form (PDF) IEHP Lab Form (PDF) Medi-Cal Non-Covered Services/Materials Waiver Form-English (PDF) Medi-Cal Non-Covered Services/Materials Waiver Form-Spanish (PDF) Medi-Cal Non-Covered Services/Materials Waiver Form-Chinese (PDF) Medi-Cal Non-Covered Services/Materials Waiver Form-Vietnamese (PDF) The following IEHP DualChoice (HMO D-SNP) Letters will be effective January 1, 2023: IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-English (PDF) IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-Spanish (PDF) IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-Chinese (PDF) IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-Vietnamese (PDF) (Back to top) Other Authorization of Release - Use & Disclosure of PHI - English (PDF) Authorization of Release - Use & Disclosure of PHI - Spanish (PDF) CMS 1696 Appointment of Representative - English (PDF) CMS 1696 Appointment of Representative - Spanish (PDF) Contracts Maintenance Request Form (PDF) Provider Services Materials Request Form (PDF) 2017 Model Output Report (MOR) Data File Layout (PDF) (Back to top) You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

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

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

diabetes needs to stay healthy, how to take care of your feet and address barriers. Click here to register for this in-person class Location IEHP Community Resource Center (San Bernardino) 805 W 2nd St San Bernardino, CA 92410

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

(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 2022 Provider Quality Incentive Brochure. 2022 Provider Quality Incentive Brochure (PDF) | June 22, 2022 (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) Published: March 16, 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: January 23, 2023 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) (Back to P4P Menu) 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: March 14, 2023 2023 IEHP Global Quality P4P Program Guide IPA (PDF) Published: March 14, 2023 2022 IEHP Global Quality P4P Program Guide PCP (PDF) Published: December 21, 2022 2022 IEHP Global Quality P4P Program Guide IPA (PDF) Published: December 16, 2022 2022 Provider Quality Resource Guide (PDF) Published: July 14, 2022 (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 Codes 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: 2022 Immunization Timing Chart - English (PDF) 2022 Immunization Timing Chart - Spanish (PDF) 2022 Immunization Timing Chart - Chinese (PDF) 2022 Immunization Timing Chart - Vietnamese (PDF) Immunization Updates (PDF) 2021 Recommended Child and Adolescent Immunization Schedule (0-18 years) (PDF) 2021 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. By clicking on this link, you will be leaving the IEHP website. (Back to P4P Menu) Quality Bonus Services Dispute Form Please e-mail completed forms to QualityPrograms@iehp.org Quality Bonus Service Dispute Request Form (PDF) (Back to P4P Menu) 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) 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: February 07, 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: January 31, 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 Codes 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 (Back to P4P Menu) 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: February 02, 2022 Substance Use Disorders Diagnosis List (PDF) Published: February 02, 2022 (Back to P4P 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

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) 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) 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 Electronic 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.

ffer in place of services or settings covered under the Medicaid State Plan. These services should be medically appropriate and cost-effective alternatives. Beginning January 1, 2022, Inland Empire Health Plan (IEHP) is offering 11 of the 14 DHCS Preapproved Community Supports services: Asthma Remediation Community Transition Services/Nursing Facility Transition to a Home Home Modifications Housing Deposits Housing Tenancy and Sustaining Services Housing Transition Navigation Services Medically Supportive Food/Meals/Medically Tailored Meals Nursing Facility Transition/Diversion to Assisted Living Facilities, such as Residential Care Recuperative Care (Medical Respite) Short-Term Post-Hospitalization Housing Sobering Centers (Riverside County) Tentative Upcoming Services Day Habilitation (Date TBD) Personal Care and Homemaker Services (Date TBD) Respite Services (Date TBD) Community Supports FAQs (PDF) Please return the completed Community Supports Service Provider Assessment (PDF) via email at DGCommunitySupportTeam@iehp.org.   You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.