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Pharmacy Services - Pharmacy Forms
BM) handles all Medicare pharmacy and provider prior authorization and pharmacy benefit related questions. Providers and pharmacies can call MedImpact Customer Contact Center at (800) 788-2949. Health care providers can submit prior authorizations via fax (858) 790-7100, or download forms at the MedImpact Website.
Request for Redetermination of Medicare Prescription Drug Denial- English (PDF)
Request for Redetermination of Medicare Prescription Drug Denial -
Spanish (PDF)
Coverage Determination Form - Retroactive prior authorization requests (PA requests dated before 1/1/2023) should be faxed to (909) 890-5766.
Drug Request
Supplemental PER Form for Compounded Prescription (PDF)
Medicare
Hospice Form for Medicare Part D Plans (PDF)
Medicare Prescription Drug Coverage and Your Rights - English (PDF)
Medicare Prescription Drug Coverage and Your Rights - Spanish (PDF)
Mail Order
Mail-Order Service Fax Form (PDF)
Other Pharmacy Provider Forms
Appointment of Representative - English (PDF)
Appointment of Representative - Spanish (PDF)
Nutritional Evaluation Form - Adult (PDF)
Nutritional Evaluation Form - Infant (PDF)
Opioid Edit Error Report Form (PDF)
WIC Program Forms (California Department of Public Health)
Pediatric Referral Form (PDF)
WIC Referral For Pregnant Women (PDF)
WIC Referral For Postpartum/Breastfeeding Women (PDF)
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy by clicking Adobe Acrobat Reader. By clicking on this link, you will be leaving the IEHP website.
Information on this page is current as of January 05, 2023.
即將舉行的活動 - With Every Heartbeat is Life: Control Your Blood Pressure (San Bernardino)
ll learn:
What blood pressure is and what level to aim for
What a stroke is and what the warning signs are
The dangers of eating too much salt and sodium
Steps to eat less salt and sodium
Click here to register for this in-person class
Location
San Bernardino Community Seventh-day Adventist Church
1696 N. G St.
San Bernardino, CA 92405
即將舉行的活動 - With Every Heartbeat is Life: Knowledge is Power - Know Your Risk for Heart Disease (San Bernardino)
ll:
Understand how the heart works and its importance.
Know lifestyle changes they can make to help reduce their risk of heart disease.
Understand their risks of developing heart disease.
Click here to register for this in-person class
Location:
San Bernardino Community Seventh-day Adventist Church
1696 N. G St.
San Bernardino, CA 92405
即將舉行的活動 - Healthy Heart : Get Energized! Say Yes to Physical Activity + Control Your Blood Pressure (Riverside)
即將舉行的活動 - With Every Heartbeat is Life: React in Time to Heart Attack Signs (San Bernardino)
ill learn:
What a heart attack is and how to recognize its warning signs/symptoms.
The importance of seeking treatment quickly if someone has symptoms.
Why people may delay calling 9-1-1.
The benefits of calling 9-1-1.
Click here to register for this in-person class.
Location:
San Bernardino Community Seventh-day Adventist Church
1696 N. G St.
San Bernardino, CA 92405
即將舉行的活動 - With Every Heartbeat is Life: Get Energized! Say Yes to Physical Activity (San Bernardino)
ll learn:
Why physical activity is good for their hart and overall health
About different types of physical activity
How much physical activity adults and children need
Ways to fit physical activity into their schedule
Click here to register for this in-person class
Location
San Bernardino Community Seventh-day Adventist Church
1696 N. G St.
San Bernardino, CA 92405
P4P - Proposition 56 - GEMT - Pay for Performance (P4P)
(IEHP) Pay for Performance
program, also known as P4P. IEHP’s P4P was designed to increase the provision of preventive health
services to
IEHP Members as well as improve HEDIS® results to ensure that all IEHP Direct DualChoice
Members
receive timely annual assessment visits with an emphasis on review and management of chronic illnesses.
IEHP Direct PCPs will be reimbursed directly by IEHP through the
DualChoice Annual Visit program. PCPs participating in IEHP's network through an IPA only are not eligible for
this
program:
Overview
(PDF)
DualChoice Annual Visit (PDF)
To learn more about P4P IEHP DualChoice Annual Visit, contact a Provider Services
Representative at (909) 890-2054.
Click on the following links to jump to that specific section:
Provider Quality Incentives Brochure
Medicare P4P IEHP Direct
IEHP Direct Stars Incentive Program
D-SNP Model of Care Incentive Program
Global Quality P4P Program
OB/GYN
P4P
Program
Hospital P4P Program
Provider Quality Incentives Brochure
Inland Empire Health Plan (IEHP) is pleased to announce the 2023 Provider Quality Incentive Brochure.
2023 Provider Quality Incentive Brochure (PDF) | September 27, 2023
(Back to P4P Menu)
Medicare P4P IEHP Direct Program
Inland Empire Health Plan (IEHP) is pleased to announce the Medicare P4P IEHP Direct Program. The goal
of
the program is designed to reward IEHP Direct Primary Care Providers (PCPs) for providing quality care to
IEHP
DualChoice Members.
Medicare P4P IEHP Direct Program Guide
(PDF)
Published: February 16, 2023
(Back to P4P Menu)
IEHP Direct Stars Incentive Program
Inland Empire Health Plan (IEHP) is pleased to announce the IEHP Direct Stars Incentive Program for Primary
Care
Physicians (PCPs). The goal of the program is to reward PCPs who provide high-quality care to IEHP
DualChoice
(HMO D-SNP) members.
IEHP Direct Stars Incentive Program Guide
(PDF) Updated: June 29, 2023
(Back to P4P Menu)
D-SNP Model of Care Incentive Program
Inland Empire Health Plan (IEHP) is pleased to announce the D-SNP Model of Care Incentive Program for
Independent
Physicians Associations (IPAs). The goal of the program is to reward IPAs who provide high-quality care to
IEHP
DualChoice (HMO D-SNP) members.
D-SNP Model of Care Incentive Program
(PDF) Published: July 24, 2023
(Back to P4P Menu)
Chronic Care Improvement Program Planning and Reporting Document
The Chronic Care Improvement Program (CCIP) Planning and Reporting document can be used for the following
D-SNP
Model of Care Incentive Program activity: Chronic Care Improvement Program (CCIP) Activity.
CCIP Planning and Reporting Document
(Word
Document)
CCIP Planning and Reporting
Document - Reference Guide (PDF)
Global Quality P4P Program
If you would like more information about IEHP’s GQ P4P Program or best practices to help improve quality
scores and outcomes, visit our Secure
Provider
Portal, email the Quality Team at QualityPrograms@iehp.org or call the IEHP Provider Relations Team at (909) 890-2054.
2023 IEHP Global Quality
P4P
Program Guide PCP (PDF) Published: July 25, 2023
2023 IEHP Global Quality
P4P
Program Guide IPA (PDF) Published: July 25, 2023
2022 IEHP Global Quality P4P Program Guide PCP (PDF) Published: August 28, 2023
2022 IEHP Global Quality
P4P
Program Guide IPA (PDF) Published: July 25, 2023
2023 Provider Quality Resource Guide (PDF) Published: June 21, 2023
(Back to P4P Menu)
Quality Improvement Activity Strategy Forms
The Quality Improvement Activity (QIA) Strategy Forms can be used for the following 2023 and 2022 Global Quality P4P
QIA
Activities: Reducing Health Disparities and Potentially Avoidable Emergency Department Visits or Potentially
Preventable
Admissions.
2023 Equity Quality
Improvement
Activity #1 - Strategy Form (PDF)
2023 Quality Improvement Activity #2
-
Strategy Form (PDF)
2022 Equity Quality
Improvement
Activity #1 - Strategy Form (PDF)
2022 Quality Improvement Activity #2 -
Strategy Form (PDF)
(Back to P4P Menu)
Potentially Avoidable Emergency Department (ED) Visits: Potentially Preventable Diagnosis Code
The Potentially Preventable Diagnosis Code List includes diagnosis codes for visits to an ED in which the
condition
could be treated by a Physician or other health care Provider in a non-emergency setting or conditions that are
potentially preventable or are ambulatory care sensitive.
Potentially Preventable Diagnosis List
(PDF) Published: February 04, 2022
Patient Experience
This toolkit is full of proven tips and successful strategies based on the kinds of questions your IEHP Members
could
be asked to answer regarding their Provider's service. Your Provider Relations Team has targeted nine specific
topics in this toolkit to help Providers and their staff continue to achieve the highest marks in Patient
experience
from their IEHP Members.
Serve Well Customer Service Toolkit (PDF)
Well Child
2021
Recommendations for Preventive Pediatric Health Care from the American Academy of Pediatrics (PDF)
Immunizations
IEHP provides vaccine coverage based on the latest ACIP recommendation and guidelines. Please refer to the
Immunization
Update and "Summary of Recommendations" for both Child and Adolescents AND Adult Vaccines as follows:
2023 Immunization Timing Chart - English
(PDF)
2023 Immunization Timing Chart - Spanish
(PDF)
2023 Immunization Timing Chart - Chinese
(PDF)
2023 Immunization Timing Chart - Vietnamese
(PDF)
2023 Recommended
Child and Adolescent Immunization Schedule (0-18 years) (PDF)
2023 Recommended Adult
Immunization
Schedule (19+ years) (PDF)
Adult Vaccines are a covered benefit and do not require prior authorization (must adhere to CDC/ACIP Immunization
Recommendation and/or FDA approved indication).
Grow Well Childhood Immunization
Toolkit for Providers (PDF)
This toolkit contains commonly used immunization codes, best practices for reporting immunizations including
information
on registering with CAIR, tips on talking with parents and information on understanding vaccination hesitancy.
CAIR2 Resource
Guide
(PDF)
This guide contains helpful links and contact information for locations to register for CAIR2 or current users.
Reimbursement process:
Complete a CMS1500 form by including the appropriate CPT codes, quantity dispensed and billed amount.
Mail:
IEHP Claims Department
P.O. Box 4349
Rancho Cucamonga, CA 91729-4349
For the latest updates and news regarding the vaccines, please visit CDC's ACIP website at:
https://www.cdc.gov/vaccines/hcp/acip-recs/index.html
Quality Bonus Services Dispute Form
Please e-mail completed forms to QualityPrograms@iehp.org
Quality Bonus Service Dispute Request Form
(PDF)
OB/GYN P4P Program
Inland Empire Health Plan (IEHP) has released the OB/GYN P4P Program Guide which details the program requirements,
performance measures, updated code sets, and payment timelines.
OB/GYN P4P
Program Guide (PDF) Published: January 01, 2023
OB
P4P Frequently Asked Questions FAQs (PDF) Published: February 13, 2023
Postpartum
Depression Screening (PDF)
(Back to P4P Menu)
Urgent Care + Wellness Quality Incentive Program
Inland Empire Health Plan (IEHP) is pleased to announce the Urgent Care + Wellness Quality Incentive Program. The goal of the program is to reward urgent care providers for providing wellness services to IEHP Medi-Cal Members.
Urgent Care + Wellness Quality Incentive Program Guide (PDF) Published: September 08, 2023
(Back to P4P Menu)
Hospital P4P Program
Inland Empire Health Plan (IEHP) is pleased to announce the Hospital Pay For Performance Program (Hospital P4P) for
IEHP
Medi-Cal contracted Hospitals servicing Riverside and San Bernardino Counties. The goal of the Hospital P4P Program
is
to provide substantial financial rewards to Hospitals that meet quality performance targets and demonstrate
high-quality
care to IEHP Members.
2023 Hospital P4P Program Guide (PDF) Published: September 21, 2023
P4P 2023 MX Data Contributions (PDF) Published:
February 02, 2023
IEHP P4P
2023 Data Guidelines (PDF) Published: February 02, 2023
2022
Hospital P4P Program Guide (PDF) Published: March 20, 2023
P4P 2022
MX
Data Contribution (PDF) Published: April 18, 2022
P4P 2022
MX
Data Guidelines (PDF) Published: April 18, 2022
(Back to P4P Menu)
Potentially Avoidable Emergency Department (ED) Visits: Potentially Preventable Diagnosis Code
The Potentially Preventable Diagnosis Code List includes diagnosis codes for visits to an ED in which the
condition
could be treated by a Physician or other health care Provider in a non-emergency setting or conditions that are
potentially preventable or are ambulatory care sensitive.
Potentially Preventable Diagnosis List
(PDF) Published: February 04, 2022
Substance Use Disorders and Mental Health Diagnosis Lists
The Substance Use Disorders and Mental Health Diagnosis Lists includes diagnosis codes to identify substance use
disorders, drug overdose, mental health or intentional self-harm diagnoses.
Mental
Health
Diagnosis List (PDF) Published: June 23, 2023
Substance Use Disorders Diagnosis List (PDF)
Published: June 23, 2023
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by
clicking here
Provider Manuals - General Information
EHP's contracted Providers understand how IEHP functions and understand the rules and regulations IEHP must comply with, as governed by the California Department of Health Care Services (DHCS), California Department of Managed Health Care (DMHC), the Centers for Medicare and Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA).
The Delegate or Provider has the responsibility to ensure review, understanding, and attestation of the information contained in the Manual.
Acknowledgement of Receipt (AOR)
2024
Providers:
2024 Provider eAOR
Providers are encouraged to attest electronically using the following recommended browsers: Google Chrome, Microsoft Edge, Mozilla Firefox
2024 Hospital & IPA AORs
For more information regarding 2024 Manuals, click here.
2023
Providers:
2023 Provider eAOR
Providers are encouraged to attest electronically using the following recommended browsers: Google Chrome, Microsoft Edge, Mozilla Firefox
2023 Hospital & IPA AORs
For more information regarding 2023 Manuals, click here.
IEHP DualChoice - C 部分問題
決定,以取得醫療、行為健康或特定長期服務與支援(MSSP、CBAS 或 NF 服務) 如欲要求做出給付決定,請致電、來信或傳真給我們,或讓您的代表或醫師聯絡我們並要求做出給付決定。 您可以致電我們:(877) 273-IEHP (4347) 聯絡我們,服務時間為 (太平洋標準時間) 每天上午 8 點至晚上 8 點,假日亦提供服務,TTY 使用者請撥 (800) 718-4347。 您可以傳真至:(909) 890-5877 您可以來信至: IEHP DualChoice P.O.Box 1800 Rancho Cucamonga, CA 91729-1800。 C 部分服務的給付決定需要多長時間? 在您提出請求後,處理時間通常需要最多 14 個曆日。若我們未於 14 個曆日內做出決定,您可以提出上訴。 有時我們需要更多時間做出決定,在此情況下,我們會寄信通知您,我們需要額外 14 個曆日的處理時間。信函會說明需要延長處理時間的原因。 我可以快點取得 C 部分服務的給付決定嗎? 有。如果您因為健康情況而需要取得快速答覆,應要求我們做出「快速給付決定」。 若我們核准您的要求,我們會在 72 小時內告知您我們的給付決定。然而,有時我們需要更多時間做出決定,在此情況下,我們會寄信通知您,我們需要額外 14 個曆日的處理時間。 要求做出快速給付決定: 若您要求做出快速給付決定,可致電或傳真至本計畫,要求我們給付您想要的照護。 您可以致電 (877) 273-IEHP (4347) 與 IEHP DualChoice 聯繫,服務時間為太平洋標準時間每天上午 8 點至晚上 8 點,假日亦提供服務。TTY 使用者請撥 (800) 718-4347,或傳真至 (909) 890-5877。 您也可以要求您的醫師或代表致電我們。 以下為申請快速給付決定的規則: 您必須符合下列兩項要求才能獲得快速給付決定: 只有當您針對尚未取得的照護或用品提出給付要求時,才能獲得快速給付決定。(若您的要求是針對已取得的照護或用品,您將無法獲得快速給付決定。) 唯有當標準 14 個曆日截止期限可能會對您的健康造成嚴重傷害或損害您的身體機能時,才能獲得快速給付決定。 若您的醫師認為您需要快速給付決定,我們將自動為您做出快速給付決定。 如果您未取得醫師的支持即申請快速給付決定,將由我們決定您是否能獲得快速給付決定。 若我們認定您的健康狀況不符合快速給付決定之規定,我們會寄信通知您。我們仍將採用標準 14 個曆日截止期限。 該信函會告知您,如果您的醫師提出快速給付決定要求,我們將會自動做出快速給付決定。 該信函亦會說明,針對我們的快速給付決定並非您所要求的快速給付決定,您可以如何提出「快速上訴」。 如果給付決定為「核准」,那什麼時候可以取得服務或用品? 您將能夠在提出申請後的 14 個曆日(標準給付決定)或 72 小時(快速給付決定)內取得服務或用品。如果我們延長了做出給付決定所需的期間,則將會在延長期間結束前提供給付。 如果給付決定為「拒絕」,我會如何得知? 如果給付決定為「拒絕」,我們會寄信通知您,並說明拒絕的理由。 如果我們拒絕,您有權提出上訴,要求我們改變決定。提出上訴即代表要求我們審查拒絕給付的決定。 如果您決定提出上訴,表示您將進入第 1 階段上訴程序。 上訴 何謂上訴? 上訴是您認為我們的決定有誤時,要求我們審查並變更給付決定的正式途徑。舉例來說,我們可能決定您所要求的任何服務、用品或藥品並未納入或已排除在 Medicare 或 Medi-Cal 給付範圍內。如果您或您的醫師不同意該決定,您可以提出上訴。 在大部分情況下,您都必須從第 1 階段上訴開始。若您不希望先就 Medi-Cal 服務計畫提出上訴,在特殊情況下,您可申請進行「獨立醫療審核」。若在上訴過程中需要協助,您可以致電 1-888-452-8609 與監察專員辦公室聯繫。監察專員辦公室與我方無關,也與任何保險公司或健康計畫無關。 C 部分服務的第 1 階段上訴是什麼? 第 1 階段上訴係指對我們的計畫提出的第一次上訴。我們將審查給付決定,判定是否正確。審查人員將是未做出原始給付決定的人員。完成審查後,我們將以書面形式通知您裁決結果。如果我們在審查後,告知您該等服務或用品不在給付範圍內,則您可以提出第 2 階段上訴。 其他人可以代替我對 C 部分服務提出上訴嗎? 有。您的醫師或其他提供者可以代替您提出上訴。另外,您的醫師或其他提供者以外的人員也可以代替您提出上訴,不過您必須先填寫「委任代表」表單。 該表單可授權其他人作為您的代表。 如果上訴是由您或您的醫師或其他提供者以外的人提出,我們必須先收到填寫完整的「委任代表」表單才能審查上訴。 如何對 C 部分服務提出第 1 階段上訴? 若要開始上訴,您、您的醫師或其他提供者或您的代表必須與我們聯絡。您可以致電 (877) 273-IEHP (4347) 與 IEHP DualChoice 會員服務中心聯繫,服務時間為 (太平洋標準時間) 每天上午 8 點至晚上 8 點,假日亦提供服務。TTY 使用者請撥 (800) 718-4347。如需瞭解如何向我們提出上訴的其他詳細資訊,請參閱 IEHP DualChoice 會員手冊第 9 章。 您可以申請「標準上訴」或「快速上訴」。 如果您申請標準上訴或快速上訴,請以書面形式提出上訴並寄送至: IEHP DualChoice P.O.Box 1800 Rancho Cucamonga, CA 91729-1800 傳真:(909) 890-5748 您可以致電 (877) 273-IEHP (4347) 與 IEHP DualChoice 會員服務中心聯繫,提出上訴。服務時間為 (太平洋標準時間) 每天上午 8 點至晚上 8 點,假日亦提供服務。TTY 使用者請撥 (800) 718-4347。 我們將在收到您的上訴後 5 個曆日內發送信函給您,告知我們已收到您的上訴。 對 C 部分服務提出上訴的時間限制為何? 您必須在我們向您發出告知決定的信函之日起 60 天內申請上訴。 如果您錯過此截止期限且可提供合理的理由,我們可能會給您更多時間提出上訴。以下是一些合理的理由範例:您當時患重病,或是我們為您提供了錯誤的申請上訴截止期限資訊。 我可以取得我的案例檔案副本嗎? 有。若要申請副本,請致電 (877) 273-IEHP (4347) 與會員服務中心聯繫。TTY 使用者請撥 (800) 718-4347。 我的醫師可以提供有關我的 C 部分服務上訴的詳細資訊嗎? 可以,您和您的醫師都可以提供佐證上訴的詳細資訊。 本計畫如何做出上訴裁決? 我們會仔細審查有關您醫療照護給付申請的所有資訊。接著,我們會確認我們在拒絕您的申請時,是否遵守所有規定。審核人員將是未做出原始給付決定的人員。如果我們需要更多資訊,會要求您或您的醫師提供。 何時可以知道 C 部分服務「標準」上訴裁決結果? 我們必須在接獲您的上訴後 30 個曆日內予以答覆。如果您的健康狀況需要,我們會儘快通知您我們的決定。 但是,若您要求更多時間,或我們需要收集更多資訊,則可能額外需要 14 個曆日的處理時間。如果我們認定需要多一些時間來做出決定,將會透過信函通知您。 如果您認為我們不應延長決定時間,您可以針對我們的決定提出「快速申訴」。若您提出「快速申訴」,我們將在 24 小時內就您的上訴予以答覆。 如果我們未在 30 個曆日內或延長期間 (如果採用) 結束後答覆您,且您的問題是與 Medicare 服務或用品有關,我們會自動將您的案例送交第 2 階段上訴程序。倘若發生此類情況,您將會收到通知。若您的問題是與 Medi-Cal 服務或用品有關,您將須自行提出第 2 階段上訴。詳情請參閱下列說明。 如果我們核准您的部分或全部要求,我們必須在收到您的上訴後 30 個曆日內核准或提供給付。 如果我們對於您所提要求的最後裁決是部分或全部拒絕,我們將會寄通知信函給您。若您的問題是與 Medicare 服務或用品有關,我們的信函將會通知您已將您的案例交付獨立審查單位進行第 2 階段上訴。若您的問題是與 Medi-Cal 服務或用品有關,我們的信函將告知您如何自行提出第 2 階段上訴。詳情請參閱下列說明。 如果申請快速上訴,會發生什麼? 如果您申請快速上訴,我們會在收到您的上訴後 72 小時內予以答覆。如果您的健康狀況需要盡快取得裁決結果,我們會提早予以答覆。 但是,若您要求更多時間,或我們需要收集更多資訊,則可能額外需要 14 個曆日的處理時間。如果我們認定需要多一些時間來做出決定,將會透過信函通知您。 如果您認為我們不應延長決定時間,您可以針對我們的決定提出「快速申訴」。若您提出「快速申訴」,我們將在 24 小時內就您的上訴予以答覆。 如果我們未在 72 小時內或延長期間 (如果採用) 結束後答覆您,且您的問題是與 Medicare 服務或用品有關,我們會自動將您的案例送交第 2 階段上訴程序。倘若發生此類情況,您將會收到通知。若您的問題是與 Medi-Cal 服務或用品有關,您將須自行提出第 2 階段上訴。詳情請參閱下列說明。 如果我們核准您的部分或全部要求,我們必須在收到您的上訴後 72 小時內核准或提供給付。 如果我們對於您所提要求的最後裁決是部分或全部拒絕,我們將會寄通知信函給您。若您的問題是與 Medicare 服務或用品有關,我們的信函將會通知您已將您的案例交付獨立審查單位進行第 2 階段上訴。若您的問題是與 Medi-Cal 服務或用品有關,我們的信函將告知您如何自行提出第 2 階段上訴。詳情請參閱下列說明。 在第 1 階段上訴期間,我是否可繼續享有福利?如果我們決定變更或停止先前核准的任何服務或用品之給付,我們會在採取相關行動之前發送通知給您。如果您不同意該行動,可以提出第 1 階段上訴,並要求我們繼續為您提供相關服務或用品的福利。您必須在下列日期 (以發生時間較晚者為準) 之前提出申請,才能繼續享有福利: 在我們郵寄行動通知之日後 10 日內;或 行動的預計生效日期。 若您在前述截止期限內提出申請,則您在上訴期間仍可獲得爭議服務或用品的給付。 第 2 階段上訴 如果本計畫駁回我的第 1 階段上訴,接下來會發生什麼?如果我們對於您第 1 階段上訴的最後裁決是部分或全部拒絕,我們將會寄通知信函給您。該信函會告知您,相關服務或用品是否通常可獲得 Medicare 或 Medi-Cal 給付。 若您的問題是與 Medicare 服務或用品有關,我們會在第 1 階段上訴結束後,儘快自動將您的案例送交第 2 階段上訴程序。 若您的問題是與 Medi-Cal 服務或用品有關,您將須自行提出第 2 階段上訴。該信函會告知您如何進行。相關資訊也請參閱下方。 第 2 階段上訴是什麼?第 2 階段上訴係指第二次上訴,且係由與計畫無關的獨立組織進行。 我的問題與 Medi-Cal 服務或用品有關。我要如何提出第 2 階段上訴?針對 Medi-Cal 服務與用品提出第 2 階段上訴有兩種方式:1) 獨立醫療審核或 2) 州聽證會。 1) 獨立醫療審核 您可以向加州管理式醫療保健部 (California Department of Managed Health Care, DMHC) 協助中心申請獨立醫療審核 (IMR)。IMR 適用具醫療性質之所有 Medi-Cal 給付服務或用品。IMR 是由非本計畫成員之醫師審核您的案例。若 IMR 的裁決是您勝訴,則我們必須提供您所要求的服務或用品。您不須就 IMR 支付任何費用。 若本計畫符合下列條件,則您可以申請 IMR: 因本計畫認定不具醫療必要性,而駁回、變更或延遲提供 Medi-Cal 服務或治療 (不包括 IHSS)。 不就適用嚴重醫療狀況之實驗性或研究性 Medi-Cal 治療提供給付。 不支付您已經取得之緊急或急症 Medi-Cal 服務費用。 未於提出標準上訴後 30 個曆日內或於提出快速上訴後 72 小時內,解決您就 Medi-Cal 服務提起之第 1 階段上訴。 如果您還要求召開州聽證會,則您可以申請 IMR,惟僅限您未就相同問題召開過州聽證會。 在多數情況下,您必須在申請 IMR 之前提出上訴。如果您不同意我們的決定,您可要求 DMHC 協助中心進行 IMR。 若您的治療因為屬於實驗或研究性質而遭駁回,則您在申請 IMR 之前,不須參加我們的上訴程序。 如果您的問題具急迫性,且對您的健康具有迫在眉睫的嚴重威脅,您可以立即向 DMHC 提出申請。在特殊且急迫的狀況下,DMHC 得豁免您遵守我方上訴程序的規定。 您必須在我們書面通知您上訴裁決後 6 個月內申請 IMR。DMHC 可能在認定相關情況導致您無法準時提出申請時,接受您在前述 6 個月期間屆滿後提出的申請。 如欲申請 IMR: 請填寫獨立醫療審核/申訴表,網址為:http://www.dmhc.ca.gov/FileaComplaint/SubmitanIndependentMedicalReviewComplaintForm.aspx,或致電 (888) 466-2219 與 DMHC 協助中心聯繫。TDD 使用者請撥 (877) 688-9891。 請檢附我們駁回服務或用品申請之信函或其他文件 (若有)。如此可加快 IMR 流程。請寄送文件副本,而非正本。協助中心將不會退還任何文件。 如果您是由他人代表申請 IMR,請填寫「授權協助表」(Authorized Assistant Form)。此表格可於下列網址下載:http://www.dmhc.ca.gov/FileaComplaint/SubmitanIndependentMedicalReviewComplaintForm.aspx,或請致電 (888) 466-2219 與 DMHC 協助中心聯繫。TDD 使用者請撥 (877) 688-9891。 請郵寄或傳真您的表格及所有附件至: Help Center Department of Managed Health Care 980 Ninth Street, Suite 500 Sacramento, CA 95814-2725 傳真:916-255-5241 若您符合 IMR 資格,DMHC 將會在 7 個曆日內審核您的案例,並寄信通知您符合 IMR 規定。在從您的計畫收到您的申請表與佐證文件之後,IMR 將在 30 個曆日內做出決定。您應該會在提交完整申請資料後 45 個曆日內收到 IMR 裁決。 若您的案例具急迫性且您符合 IMR 資格,DMHC 將會在 2 個曆日內審核您的案例,並寄信通知您符合 IMR 規定。在從您的計畫收到您的申請表與佐證文件之後,IMR 將在 3 個曆日內做出決定。您應該會在提交完整申請資料後 7 個曆日內收到 IMR 裁決。 若您對 IMR 的裁決不滿意,仍可以要求召開州聽證會。 若 DMHC 認定您的案例不符合 IMR 規定,DMHC 將會透過一般消費者投訴程序審核您的案例。 2) 州聽證會 您可就 Medi-Cal 給付服務與用品申請召開州聽證會。若您的醫師或其他提供者要求提供我們不會核准的服務或用品,或我們不再繼續提供您已取得的服務或用品,且我們駁回您的第 1 階段上訴,則您有權申請召開州聽證會。 在大部分情況下,您有權在收到「您的聽證權利」通知後 120 天內,申請召開州聽證會。 注意:如果您申請召開州聽證會是由於我們告知您目前享有的服務即將變更或終止,而且您想要在召開州聽證會期間繼續享有該服務,則您提出申請的天數將縮減。有關詳細資訊,請參閱會員手冊第 9 章「在第 2 階段上訴期間,我是否可持續享有福利」。 申請召開州聽證會的方法有兩種: 您可以填寫行動通知背面的「申請召開州聽證會」。您應提供所有必要資訊,如您的全名、地址、電話號碼、計畫名稱或您遭採取行動之郡縣、相關補助計畫以及您希望申請召開聽證會的詳細理由。接著,您可以透過下列任一方式提交申請: 寄送至通知所載地址之郡縣福利部門。 寄送至 California Department of Social Services: State Hearings Division P.O.Box 944243, Mail Station 9-17-37 Sacramento, California 94244-2430 傳真至州聽證部門,號碼為 916-651-5210 或 916-651-2789。 您可以致電加州社會服務部,電話為 (800) 952-5253。TDD 使用者請撥 (800) 952-8349。若您決定透過電話申請召開州聽證會,您應瞭解該電話線路非常忙碌。 在第 2 階段上訴期間,我是否可繼續享有福利?若您的問題是與 Medicare 給付服務或用品有關,則在您向獨立審查單位提起第 2 階段上訴期間,您就服務或用品所享有的福利將不再繼續適用。 若您的問題是與 Medi-Cal 給付服務或用品有關,且您申請召開州公平聽證會,則在做出聽證決定之前,您就該服務或用品所享有的 Medi-Cal 福利將繼續適用。您必須在下列日期 (以發生時間較晚者為準) 之前申請召開聽證會,才能繼續享有福利: 在我們通知您已做出不適用福利裁決 (第 1 階段上訴裁決) 之郵寄日起 10 天內;或 行動的預計生效日期。 若您在前述截止期限內提出申請,則您在聽證會裁決做出之前仍可獲得爭議服務或用品的給付。 要如何得知裁決結果?若您的第 2 階段上訴為州聽證會,加州社會服務部將會寄函給您,說明裁決結果。 若州聽證會裁決為核准您申請的部分或全部項目,我們就必須遵守該裁決。我們必須在收到裁決副本之日起 30 個曆日內,完成規定之行動。 若州聽證會裁決為拒絕您申請的部分或全部項目,則表示其同意第 1 階段上訴裁決。我們可停止提供您所取得的任何暫時補助金。 若您的第 2 階段上訴為獨立醫療審核,管理式醫療保健部將會寄函給您,說明裁決結果。 若獨立醫療審核裁決為核准您申請的部分或全部項目,我們就必須提供服務或治療。 若獨立醫療審核裁決為拒絕您申請的部分或全部項目,則表示其同意第 1 階段上訴裁決。您仍可申請召開州聽證會。 若您的第 2 階段上訴係由 Medicare 獨立審查單位負責,該單位將會寄函給您,說明裁決理由。 若獨立審查單位的裁決為核准您申請的部分或全部項目,我們會在收到 IRE 裁決後的 72 小時內核准醫療照護給付,或在 14 個曆日內提供服務或用品。 若獨立審查單位的裁決為拒絕您申請的部分或全部項目,則表示其同意第 1 階段上訴裁決。此稱為「維持原裁決」;亦稱為「駁回上訴」。 如果裁決為拒絕我申請的全部或部分項目,我可以再次提出上訴嗎?若您的第 2 階段上訴為州聽證會,您可以在收到裁決後 30 天內申請複審。您也可以在收到裁決後一年內,向高等法院提交訴狀,申請對州聽證會駁回裁決進行司法審查 (依據民事訴訟法第 1094.5 條)。 若您的第 2 階段上訴為獨立醫療審核,您可以申請召開州聽證會。 若您的第 2 階段上訴係由 Medicare 獨立審查單位負責,則僅於您所申請服務或用品之價值符合特定最低金額門檻時,方可再次上訴。IRE 寄送給您的信函,將會說明您可能擁有的其他上訴權利。 付款問題 我們不允許網路內提供者向您收取給付服務與用品的費用。即使我們支付給提供者的金額低於提供者就給付服務或用品所收取的費用,也是如此。您絕對不需要支付任何帳單的差額。您唯一須支付的金額為規定應共付之服務、用品及/或藥品類別的共付額。若您收到的帳單金額高於您就給付服務與用品應支付的共付額,請將帳單寄給我們。您不應自行支付該帳單。我們會直接聯絡提供者並解決問題。 如果我支付了本計畫應付的醫療服務或用品分攤費用,如何向計畫申請退款?請記住,若您收到的帳單金額高於您就給付服務與用品應支付的共付額,您不應自行支付該帳單。但如果您支付了帳單,且您遵守服務和用品的取得規定,則您可以要求退款。 如果您要申請返款,就是申請給付裁決。我們將確認您所支付的服務或用品是否在給付範圍內,且我們將確認您是否遵守使用給付的規定。 如果您已付款的服務或用品屬於給付範圍,且您遵守所有規定,我們將會在收到您的申請後 60 個曆日內,將我們應支付的服務或用品分攤費用退還給您。 或者,如果您尚未支付該等服務或用品之費用,我們將會直接付款給您的提供者。若我們寄發款項,等同於我們同意您的給付裁決要求。 如果服務或用品不在給付範圍內,或是您未遵守所有規定,我們會郵寄信函通知您我們不會支付服務或用品費用並說明原因。 如果計畫表明不會付款,該怎麼辦?如果您不同意我們拒絕付款的決議,您可以提出上訴。遵循上訴程序。遵循這些指示時,請注意: 若您提出報銷上訴,我們必須在接獲上訴後 60 個曆日內回覆。 若您要求我們返還您已自費接受之醫療照護的費用,則不得申請快速上訴。 若我們對您上訴的答覆為「拒絕」,且該等服務或用品通常可獲得 Medicare 給付,我們將自動將您的案例發送給獨立審查單位。若有此情況,我們會寄通知函給您。 若 IRE 駁回我方裁決並認定我們應付款,則我們必須於 30 個日曆日內付款給您或提供者。如果您的上訴在第 2 階段上訴程序後的任何階段中獲得核准,我們必須在 60 個日曆日內寄發您要求的款項給您或提供者。 若 IRE 駁回您的上訴,表示他們同意我們的裁決,即不批准您的要求。(這稱為「維持原裁決」;亦稱為「駁回上訴」)。您所收到的信函,將會說明您可能擁有的其他上訴權利。僅於您所申請服務或用品之價值符合特定最低金額門檻時,方可再次上訴。 若我們對您上訴的答覆為「拒絕」,且該等服務或用品通常可獲得 Medi-Cal 給付,則您可自行提出第 2 階段上訴 (請參閱上文)。 IEHP DualChoice (HMO D-SNP) 是與 Medicare 簽約的 HMO 計畫。投保 IEHP DualChoice (HMO D-SNP) 取決於合約續訂。 此頁面資訊為截至 2022 年 10 月 1 日的最新資訊。 H8894_DSNP_23_3241532_M Pending Accepted
IEHP DualChoice - 申訴、給付裁決與上訴程序
表。若您需要填寫表單方面的協助,IEHP 會員服務中心可以提供協助。 您可以線上填寫會員申訴表。 您可以將填寫完成的表單提供給任何 IEHP 提供者,或郵寄至: P.O Box 1800, Rancho Cucamonga, CA 91729-1800 您可以將填寫完成的表單傳真至 (909) 890-5877。您可以線上提出申訴。此表單適用 IEHP DualChoice 及其他 IEHP 計畫。 針對某些類型的問題,您需遵行給付範圍決定和上訴程序。 而針對其他類型的問題則需遵行提出申訴的程序。以上兩種程序皆經 Medicare 核準。為確保問題處理流程的公正性與時效性,每種流程各有一套規定、程序及期限,我方與您都必須確實遵守。 長期服務與支援: 如果您對於照護有任何疑問,請致電 1-888-452-8609 尋求監察專員辦公室協助。 若屬我們簽約社區成人服務 (Community Based Adult Services, CBAS) 據點 或護理機構/亞急性照護機構之資格認定、評估與照護相關的問題與疑慮,請依據下列流程提出。 社區成人服務 (CBAS) 您可以致電 (877) 273-IEHP (4347) 與 IEHP 會員服務中心聯繫,並索取會員申訴表。若您需要填寫表單方面的協助,IEHP 會員服務中心可以提供協助。 您可以將填寫完成的表單提供給任何 IEHP 提供者,或郵寄至: P.O Box 1800 Rancho Cucamonga, CA 91729-1800 您可以將填寫完成的表單傳真至 (909) 890-5877。您可以線上提出申訴。此表單適用 IEHP DualChoice 及其他 IEHP 計畫。 協助處理問題 您可以聯絡 Medicare。您可以透過下列兩種方式直接向 Medicare 索取資訊: 您可以致電 24 小時全年無休專線 (800) MEDICARE (800) 633-4227,TTY 使用者請撥 (877) 486-2048。 您可以造訪 Medicare 網站 點選此連結,您將會離開 IEHP DualChoice 網站。 向獨立政府組織求助 我們非常樂意為您提供服務。不過,在某些情況下,建議您透過與我方無關的人士獲得協助或指導。您可隨時聯繫您的 State Health Insurance Assistance Program (SHIP)。此政府計畫在各州都設有受過訓練的顧問。此計畫與我方無關,也與任何保險公司或健康計畫無關。此計畫的顧問可以協助您瞭解處理問題時應採用的流程。此外,他們也可以解答您的問題、提供更多資訊,以及輔導您進行後續處理。SHIP 顧問的服務並不收費。您可以致電 1-800-434-0222 與 SHIP 聯繫。 向 DHCS 取得協助與相關資訊 電話:(916) 445-4171 MCI,TDD 請撥 (800) 735-2929 MCI,語音電話:(800) 735-2922 Sprint,TDD 請撥 (800) 877-5378 Sprint,語音電話:(800) 877-5379 致函: Department of Health Care Services 1501 Capitol Ave., P.O. Box 997413 Sacramento, CA 95899-7413 網站:www.dhcs.ca.gov 點選此連結,您將會離開 IEHP DualChoice 網站。 向 Medi-Cal 取得協助與相關資訊 監察專員辦公室可以解答您的疑問,並協助您瞭解需要做哪些事才能解決您的問題。監察專員辦公室與我方無關,也與任何保險公司或健康計畫無關。此計畫可協助您瞭解應採用哪項流程。 電話:請於週一至週五上午 9 點至下午 5 點致電 1-888-452-8609 (TTY 711) 造訪其網站:www.healthconsumer.org/ 點選此連結,您將會離開 IEHP DualChoice 網站。 向 Livanta 取得協助與相關資訊 本州有一個名為 Livanta Beneficiary & Family Centered Care (BFCC) 品質改進組織 (Quality Improvement Organization, QIO) 的組織。這是一個由醫生和其他健康照護專業人員組成的團體,他們協助改善 Medicare 患者的護理品質。Livanta 與我們的計畫無關。 電話:(877) 588-1123,TTY 使用者請撥 (855) 887-6668 如欲提出上訴:(855) 694-2929 如欲申請所有其他審核:(844) 420-6672 致函: Livanta BFCC-QIO Program 10820 Guilford Road, Suite 202 Annapolis Junction, Maryland 20701 網站:www.livanta.com 點選此連結,您將會離開 IEHP DualChoice 網站。 如何取得向 IEHP DualChoice (HMO D-SNP) 提出的申訴、上訴與例外處理的總數? 請致電或寫信至 IEHP DualChoice 會員服務中心。 電話:(877) 273-IEHP (4347)。此為免付費專線。服務時間為 (太平洋標準時間) 每天上午 8 點至晚上 8 點,假日亦提供服務,TTY 使用者請撥:(800) 718-4347。此號碼須使用特殊電話設備。此為免付費專線。 傳真:(909) 890-5877 致函: IEHP DualChoice, P.O. Box 1800 Rancho Cucamonga, CA 91729-1800 電子郵件:memberservices@iehp.org 親自造訪:10801 Sixth Street, Suite 120, Rancho Cucamonga, CA 91730 IEHP DualChoice (HMO D-SNP) 是與 Medicare 簽約的 HMO 計畫。投保 IEHP DualChoice (HMO D-SNP) 取決於合約續訂。此清單並非完整清單。 此頁面資訊為截至 2022 年 10 月 1 日的最新資訊。 H8894_DSNP_23_3241532_M Pending Accepted
Plan Updates - Correspondence
here.
TITLE
DATE
RECIPIENTS
September 2023
CORRECTION - Provider Website Redesign and Provider Portal Refresh
09/29
All IEHP Providers
New DHCS Drug Use Review (DUR) Board Educational Articles
09/29
All IEHP PCPs, All IEHP Pharmacy Providers
Required! Adult and Youth Screening and Transition of Care Tools Webinar - October 6th OR 9th
09/28
All BH Providers
Month-End IEHP Outbound 834 File Update
09/27
All 834 Trading Partners
2023 Global Quality P4P Program – Data Submission Deadlines!
09/26
Medi-Cal PCPs
Equity and Practice Transformation (EPT) Program FAQs, Links & PowerPoint
09/26
Medi-Cal PCPs
Access Standards – Appointment Availability - PCP & OB
09/25
All PCPs & OB/GYNs
2023 Member Language Demographics Survey Results - Free Interpreter Services Available
09/25
All Providers
REMINDER - 2023 Urgent Care + Wellness Quality Incentive Program – Kickoff Meeting!
09/25
Medi-Cal Urgent Care Providers
DHCS EVV Office Hours – October 5th, 10th & 27th
09/22
EVV Impacted Providers and Individual Nurse Providers
AB 1797: Providers Required to Enter All Immunizations & TB Tests in CAIR2
09/22
All PCPs & IPAs
Heartbeat! Provider Newsletter is Now Available Online
09/21
All IEHP Providers
Bicillin® L-A shortage in California
09/20
IEHP PCPs, OB/GYNs and Family Planning Providers
UPDATE - Provider Website Redesign and Provider Portal Refresh
09/20
All IEHP Providers
IEHP Text Campaign to Engage Members with their Primary Care Physicians
09/19
IEHP Direct PCPs
Dementia Care Aware – Cognitive Health Assessment Training on September 26th
09/19
All PCPs and IPAs
SoCalDocJobs.com Free Site for Providers to Post Jobs and Find Candidates
09/19
ALL PCPs & Specialists
IE-CHI Virtual Health Education Forum - September 19th
09/15
ALL PCPs & IPAs
Revised UM Authorization Guidelines
09/15
All IPAs
2023 Urgent Care + Wellness Quality Incentive Program – Kickoff Meeting!
09/15
Medi-Cal Urgent Care Providers
CORRECTION - Access Standards – Appointment Availability – Well Women
09/14
All Specialists
NOW AVAILABLE - Equity and Practice Transformation (EPT) Provider Directed Payment Program Application
09/13
IEHP Medi-Cal PCPs
Access Standards – Appointment Availability - Specialists
09/13
All Specialists
Access Standards – Appointment Availability - BH
09/13
All Behavioral Health Providers
REMINDER - Medication Reconciliation Letter Available in Provider Portal
09/11
All Medi-Cal PCPs
REMINDER - Dilated Retinal Exam (DRE) for Members who have Diabetes
09/11
All PCPs & Vision Providers
2023 Urgent Care + Wellness Quality Incentive Program Release
09/08
All Medi-Cal Urgent Care Providers
IPA Monthly Interim Provider Manual Changes
09/08
All IPAs
2023 Vision Provider Member List
09/08
Vision Providers
Invitation to Equity Practice & Transformation Payments Program – Information Session and Dinner
09/07
IEHP Medi-Cal PCPs
August 2023 Pharmacy and Therapeutics Update
09/06
All IEHP PCPs, All IEHP Pharmacy Providers
IEHP’s Annual DHCS Audit – Your Office May Be Visited by a DHCS Auditor
09/06
Medi-Cal PCPs & IPAs
Dementia Care Aware - Cognitive Health Assessment Training on September 14th and September 26th
09/05
ALL PCPs & IPAs
URGENT: Recalls, Market Withdrawals & Safety Alerts, August 2023
09/01
All IEHP PCPs, All IEHP Pharmacy Providers
August 2023
UM Department Availability
08/30
All PCPs, Specialists & BH Providers
REMINDER - 2023 Global Quality P4P Program – Best Practices Meeting!
08/29
GQ P4P Participating PCPs
DELAY - CMS Preclusion List - September
08/29
All Medicare IPAs
New DHCS Drug Use Review (DUR) Board Educational Articles
08/29
All PCPs, OBs & BH Providers
Labor Day Holiday – September 4th
08/28
All IEHP Providers & IPAs
DHCS EVV Office Hours – September 7th, 12th & 29th
08/28
EVV Impacted Providers and Individual Nurse Providers
Month-End IEHP Outbound 834 File Update
08/28
IEHP 834 Trading Partners
Correction: Care Management Medi-Cal Care Coordination File Review Tool
08/25
Medi-Cal IPAs
Member Services Appointment Center
08/25
All IEHP Medi-Cal PCPs
Correction - Continuity of Care - Notice of Authorization Letter Template
08/25
All Medicare IPAs
REVISED - UM Authorization Guidelines
08/25
All IPAs and Medical Directors
REMINDER: Provider Preventable Conditions (PPC) – Reporting Requirements
08/24
All Providers, IPAs, Contracted Hospitals, and Ambulatory Surgical Centers
Community Health Worker (CHW) Provider Incentive Webinar - September 13, 2023
08/23
All Medi-Cal PCPs
BenefitsCal.Com - New Hub For All State Benefits
08/22
All PCPs, Specialists & BH Providers
Claims Processing during State of Emergency
08/20
All IEHP Pharmacy Providers
Written Consent Required - Submitting Appeals On Behalf of a Medi-Cal Member
08/17
All Medi-Cal PCPs
Behavioral Symptoms in Dementia Webinar in August
08/17
All PCPs & IPAs
Updated: Continuity of Care- Notice of Authorization Letter Template
08/16
All Medicare IPAs
Medicare P4P IEHP Direct – Blood Pressure Control Billing Guidance
08/16
IEHP Direct DualChoice PCPs – Billing Department
NEW - IEHP Rx Pharma Data IPA File Formatting Changes
08/16
All IPAs & EDI Partners
NEW - IPA Medical Record Validation Audit Notification
08/15
All Medi-Cal IPAs
2023 Premiere Clinical Psychopharmacology Conference
08/14
All PCPs & Psychiatrists
REMINDER - Enhanced Care Management Available for Members
08/14
All Medi-Cal PCPs & IPAs
2023 Global Quality P4P Program – Best Practices Meeting on Sept. 6th
08/14
All Medi-Cal PCPs
Action Required - 2023 GQ P4P Program Provider Directory Verification
08/11
All Medi-Cal PCPs
Doula Services - Now a Covered Benefit for Members
08/11
All PCPs, OB/GYNs and BH Providers
NEW - Member Eligibility Now Includes SOGIE Data
08/11
All IEHP Providers
Health & Human Services Grants Available!
08/11
All PCP, Specialists, BH & IPAs
ACTION REQUIRED – New Interdisciplinary Care Plan Sharing Process
08/11
Medicare IPAs
New IEHP Inbound Encounter Data Validity and Inbound Timeliness Reports
08/11
IEHP Encounter Data Trading Partners
Care Management Medi-Cal Care Coordination File Review Tool
08/11
All Medi-Cal IPAs
Comprehensive Practice Optimization Workshop
08/09
Riverside County PCP's
URGENT - Corrected Claims Submitted via Provider Portal Denying as Duplicates
08/04
All Behavioral Health & Vision Providers
CORRECTION - Updated Medi-Cal Nondiscrimination Notice and Taglines
08/02
All Medi-Cal IPAs
URGENT: Recalls, Market Withdrawals & Safety Alerts, July 2023
08/01
All IEHP PCPs, All IEHP Pharmacy Providers
ACTION REQUIRED - Submit NEMT - PCS Forms for Dialysis Members
08/01
All Dialysis Center
IEHP Quality Hospice Network Update
08/01
PCPs, Hospitals, SNFs, Home Health, My Path Palliative Care Providers
URGENT - IEHP Outbound Monthly 834 File Delay
08/01
All EDI Partners
July 2023
REQUIRED - HIPAA Compliant Telehealth Platforms - Effective August 10th!
07/31
All PCPs, Specialists, BH, BHT Providers & IPAs
UPDATE - Navigating The New Preventive Care Reports
07/28
All Global Quality P4P PCP Participants
2023 Appointment Availability Survey
07/28
All Behavioral Health Providers
2023 Appointment Availability Survey
07/28
All PCPs & IPAs
2023 Appointment Availability Survey
07/28
All Specialists, Ancillary & IPAs
Reminder: Utilize Member Additional Contact Information for Medi-Cal Renewal Outreach!
07/28
All PCPs, Specialists & BH Providers
New DHCS Drug Use Review (DUR) Board Educational Articles
07/27
All Medi-Cal PCPs & Specialists
DHCS EVV Office Hours – August 7th, 25th and 30th
07/25
EVV Impacted Providers and Individual Nurse Providers
Month-End IEHP Outbound 834 File Update
07/25
IEHP 834 Trading Partners
Accessible Clinics Program 2023
07/24
All PCPs & Specialists
Cognitive Health Assessment Training - July 25th
07/24
All PCPs
Global Quality P4P Program (for PCPs) – 2023 Program Guide Update
07/20
IEHP – Global Quality P4P PCP Participants
Updated Nondiscrimination Notice and Taglines
07/18
All IPAs
Global Quality P4P Program (for IPAs) – 2023 Program Guide Update
07/18
All Medi-Cal IPAs
Three Wildfires in Riverside County – Possible Impact to Member Care
07/17
All Riverside County Providers
IPA Monthly Interim PM Changes
07/13
All IPAs
RESOLVED: DualChoice (HMO D-SNP): Known Billing Issue
07/07
All IEHP Pharmacy Providers
DualChoice (HMO D-SNP): Known Billing Issue
07/06
All IEHP Pharmacy Providers
Maintenance Alert - SFTP Not Accessible This Weekend July 7th - 9th
07/06
IPAs, Hospitals & Trading Partners
UPDATES: 2023 IEHP Direct Stars Incentive Program Guide
07/06
IEHP Direct D-SNP Primary Care Providers (PCPs)
New UM Authorization Guidelines
07/05
All IPAs and Medical Directors
Dementia Care Aware Cognitive Health Assessment Training
07/05
All PCPs and IPAs
June 2023
URGENT: Recalls, Market Withdrawals & Safety Alerts, June 2023
06/30
All IEHP PCPs, All IEHP Pharmacy Providers
I-MEDIC and CMS Alerts: Providers Potential Inappropriate Billing
06/30
All Medicare IPAs
Revised UM Authorization Guideline
06/30
All IPAs, Medical Directors and Behavioral Health Providers
ACTION REQUIRED - 2023 Provider Satisfaction Survey begins July 5th!
06/30
All PCPs, Specialists, BH and IPAs
Three (3) New Community Supports Available for Members on July 1, 2023!
06/29
All PCPs, Specialists, BH and IPAs
NEW! Enhanced Care Management Reports Added to Provider Portal
06/29
IEHP Enhanced Care Management Providers
NEW! Preventative Care Combined Rosters and Reports
06/29
All Global Quality P4P PCPs
NEW: Populations of Focus Criteria for Enhanced Care Management Benefit
06/27
All Medi-Cal PCPs & IPAs
DHCS EVV Office Hours – July 6th, 11th, & 17th
06/26
All EVV Impacted Providers & Individual Nurse Providers
AND July 4rdIndependence Day Holiday – July 3th
06/26
All IEHP Providers & IPAs
2023 Global Quality P4P Program – Provider Directory Verification
06/22
All Global Quality P4P PCPs
Medi-Cal Renewal Date Does NOT Override Member’s Eligibility Status
06/15
All Medi-Cal PCPs & IPAs
Community Supports & Enhanced Care Management Webinar – July 12th!
06/14
All Community Supports, PCPs, Specialists, BH Providers
REMINDER - 2023 Global Quality P4P Program - CAIR2 Participation Requirement
06/13
All Global Quality P4P PCPs
Global Quality P4P PCP– 2023 Program Guide Update
06/13
All Global Quality P4P PCPs
Global Quality P4P IPA – 2023 Program Guide Update
06/13
All Medi-Cal IPAs
Dementia Care Aware Cognitive Health Assessment Training
06/12
All PCPs & IPAs
Juneteenth Holiday – Monday June 19th
06/12
All IEHP Providers and IPAs
URGENT! Recalls, Market Withdrawals & Safety Alerts, May 2023
06/09
All IEHP PCPs, All IEHP Pharmacy Providers
URGENT! First Deadline for Medi-Cal Renewal is June 30th
06/09
All PCPs, Specialists, BH and Vision Providers
May 2023 Pharmacy & Therapeutics Update
06/09
IEHP Provider Network
2023 Underutilization Reports Available - Comp Diabetes Care HbA1c Testing Measure Replaced
06/07
All IPAs
ACTION REQUIRED - 2023 HIV/AIDS Specialist Survey
06/07
All IEHP Direct PCPs & Specialists
Updates to AB 1184 - Confidential Communication of Medical Information Involving Sensitive Services
06/05
All Medi-cal Providers & IPAs
IPA Monthly Interim PM Changes
06/05
All IPAs
REMINDER: DHCS APL 23-010 -Behavioral Health Treatment Coverage for Members Under the Age of 21
06/05
All BHT Providers
sFTP Critical Vulnerability Detected!
06/02
All IPAs, Hospitals & SNFs
New DHCS Drug Use Review (DUR) Board Educational Articles
06/02
All PCPs & OB/GYNs
REMINDER - AB 1184 Confidential Communication Request (CCR), Effective June 2, 2023
06/01
Medi-Cal IPAs
Updated IEHP sFTP Retention Policy
06/01
EDI Trading Partners
May 2023
REMINDER – Review the Early Start Roster the Portal
05/30
All Medi-Cal IPAs and PCPs
ACTION REQUESTED: Empowering Members, Resolving Non-Compliance: Provider - Patient Collaboration
05/26
All PCPs, OBGYNs, & Pediatricians
NCQA Health Equity Race and Ethnicity Data Collection
05/26
All PCPs, Specialists, BH, BHT & Vision Providers
SAVE THE DATE - DHCS EVV Office Hours - June 6th, 12th & 30th
05/26
All EVV Impacted Providers & Individual Nurse Providers
UPDATE - PASRR Requirements for SNFs
05/25
Skilled Nursing Facilities
Reminder: Utilize Member Alternate Contact Information for AER Outreach!
05/25
All PCPs, Specialists & BH Providers
Weekly Sessions: Achieve IEHPs P4P MX Connectivity Measure - Deadline Approaching
05/24
All Medi-Cal PCPs
Month-End IEHP Outbound 834 File Update
05/24
IEHP 834 Trading Partners
REMINDER - DHCS Quarterly Timely Access Survey
05/23
All Medi-Cal PCPs, Specialists, BH & Ancillary
UPDATE - Independent Medical Review (IMR) Forms
05/23
All Medi-Cal IPAs
Memorial Day Holiday
05/22
All IEHP Providers and IPAs
UPDATE - PASRR Requirements for GACHs
05/19
All General Acute Care Hospitals
Provider Portal – Sub User Account Types and Access Levels
05/19
All IEHP Providers
UPDATE - PASRR Requirements for SNFs
05/19
All Skilled Nursing Facilities
APL 23-005 EPSDT
05/19
All Medi-Cal PCPs
APL 23-005 EPSDT
05/19
All Medi-Cal IPAs
Termination - SNF COVID-19 Per Diem Rate
05/17
All Skilled Nursing Facilities
2023 GQ P4P PCP - MX Deadline Reminder
05/17
All GQ P4P PCP Providers
Medicare P4P IEHP Direct Blood Pressure Control Billing Guidance
05/16
All Direct DualChoice PCPs
REMINDER - 2023 Global Quality P4P Program - CAIR2 Participation Requirement
05/15
All Medi-Cal PCPs
Notice – APL 23-004 (Supersedes APL 22-018) – Skilled Nursing Facilities – Long Term Care Benefit Standardization and Transition of Members to Managed Care
05/12
All Skilled Nursing Facilities
Behavioral Health Training Webinar – June 14, 2023
05/12
All BH Providers
Behavioral Health Treatment Training Webinar - June 7, 2023
05/12
All BHT Providers
Manifest MedEx Provider Listening Session
05/10
All PCPs, Specialists & IPAs
Pharmacy Recalls, Withdrawals & Safety Alerts for April 2023
05/10
All IEHP PCPs, All IEHP Pharmacy Providers
UPDATE-Treatment Authorization Process
05/10
All Skilled Nursing Facilities
IPA Monthly Interim PM Changes
05/08
All IPAs
NEW - Behavioral Health Transition of Care Tool Requirement
05/05
All PCPs & BH Providers
New COVID-19 Vaccine Status Alerts Added to the Provider Portal
05/05
All PCPs
SAVE THE DATE - DHCS EVV Office Hours - May 10th, 24th, 26th
05/05
EVV Impacted Providers & Individual Nurse Providers
NEW: Annual Medi-Cal Eligibility Renewal (AER) Roster Now Available to Download Under CSV!
05/04
All Medi-Cal PCPs & IPAs
REMINDER: Initial Health Appointment (IHA) Roster
05/04
Medi-Cal PCPs & IPAs
Notice - Release of APL 22-032 “Continuity of Care”
05/04
All IPAs
Retired/Revised - UM Authorization Guidelines
05/03
All IPA Administrators & Medical Directors
Global Quality P4P PCP – NEW 2023 Interim Reports
05/03
Medi-Cal PCPs & IPAs
ACTION REQUIRED - AB 1184 Delegate Response Due by May 9, 2023
05/02
Medi-Cal IPAs & Delegates
Phase III – Lift 3 - Medi-Cal Rx Transition Policy Change
05/02
Medi-Cal PCPs & Specialists
Care Management Monthly Medicare Log Templates & Attachments
05/01
Medicare IPAs
Care Management Monthly Medi-Cal Log Templates & Attachments
05/01
Medi-Cal IPAs
Maternal Wellness Event
05/01
OB/GYNs, BH, Hospitals, Medi-Cal PCPs & IPAs
IEHP Outbound Monthly 834 File Delay
05/01
834 Trading Partners
April 2023
REMINDER - IEHP Interpreter Service Benefit for Members!
04/28
All Providers & IPAs
Month-End IEHP Outbound 834 File Update
04/26
834 Trading Partners
Weekly Sessions - Achieve IEHPs P4P MX Connectivity Measure
04/25
All Medi-Cal PCPs
New! 2023 IEHP Direct Stars Incentive Program – Reports and Rosters
04/25
All Direct DualChoice PCPs
UPDATES - Global Quality P4P - IPA 2023 Program Guide
04/25
All Medi-Cal IPAs
UPDATES - Global Quality P4P - PCP 2023 Program Guide
04/25
All Medi-Cal PCPs
EVV CODE Changes Effective April 20
04/18
EVV Impacted Providers, Home Infusion Providers & Individual Nurse Providers
SAVE THE DATE - DHCS EVV Office Hours - April 24th & 27th
04/18
EVV Impacted Providers and Individual Nurse Providers
Now Live! Annual Medi-Cal Eligibility Renewal (AER) Alerts and Roster!
04/17
All Medi-Cal PCPs & IPAs
UPDATE - 2023 IEHP Direct Stars Incentive Program Guide
04/17
All Direct DualChoice PCPs
Care Plans and Health Risk Assessments (HRAs) Reminder
04/14
All PCPs, Specialists, SNFs and CBAs
REMINDER: 2023 Global Quality P4P Program - CAIR2 Participation Requirement
04/12
Medi-Cal PCPs
Weekly Sessions - Achieve IEHPs P4P MX Connectivity Measure
04/12
Medi-Cal PCPs
Choice90Rx Optimization Program
04/11
All DualChoice PCPs
UPDATE to eAuth (eReferral) Form - Referral Determination Date Goes Live!
04/11
Direct PCPs
Pharmacy Recalls - Withdrawals - Safety Alerts - January to March 2023
04/10
All IEHP PCPs & Pharmacy Providers
Phase III – Lift 1 - Medi-Cal Rx Transition Policy Change
04/10
All Medi-Cal PCPs & Specialists
The ABCs of ACOs (Accountable Care Organizations)
04/07
Physicians & Practice Administrators
POSTPONED - Addition of Referral Determination Date to e-Auth Form
04/07
Direct PCPs
UPDATE to eAuth (eReferral) Form - Referral Determination Date
04/06
Direct PCPs
Phone Number CORRECTION: IEHP Eligibility Renewal Support Team First Round of Yellow Medi-Cal Renewal Packets Mailed to Members!
04/06
Medi-Cal PCPs & IPAs
IEHP Outbound Daily 834 Delta File Delay
04/06
834 Trading Partners
2023 IEHP Direct Stars Incentive Program Kick Off Meeting
04/04
All Direct DualChoice PCPs
2023 IEHP DualChoice (HMO D-SNP) Plan Benefits
04/03
Medicare PCPs, Specialists, Vision Providers & IPAs
March 2023
New DHCS Drug Use Review (DUR) Board Educational Articles
03/31
All Medi-Cal PCPs & Specialists
IEHP DualChoice (HMO D-SNP): Known Billing Issue
03/31
All IEHP Pharmacy Providers
Pharmacy Recalls - Withdrawals - Safety Alerts - March 1-15, 2023
03/31
All IEHP PCPs & Pharmacy Providers
Pharmacy Recalls - Withdrawals - Safety Alerts - Dec 2022 to Feb 2023
03/31
All IEHP PCPs & Pharmacy Providers
Access Standards - Appointment Availability - BH
03/29
All BH Providers
Achieve IEHPs P4P MX Connectivity Measure - Weekly Sessions
03/29
All Medi-Cal PCPs
CMS Signature Requirement Guidelines for Member Medical Records
03/28
All PCPs, Specialists, BH Providers & IPAs
The PHE is ending - How Will this Affect your IEHP Members?
03/27
All Medi-Cal PCPs & IPAs
Month-End IEHP Outbound 834 File Update
03/27
All IEHP 834 Trading Partners
REMINDER – Action Required by March 31st - Blood Lead Survey
03/23
All Pediatricians, Family Practice & Community Clinics
REMINDER - IEHP Contracts with Call the Car for Transportation
03/23
All Hospital Administrators, SNFs & Dialysis Center
REVISED – UM Authorization Guidelines
03/22
All IPA Administrators, Medical Directors & BH Providers
Reminder Coordination of Care Reports and Rosters
03/21
All IPAs
2023 IEHP Direct Stars Incentive Program Guide Release
03/17
All Direct DualChoice PCPs
PHA - Increased Enteric Disease Activity - Shigella
03/17
All PCPs
Manifest MedEx Seminar - Achieve IEHP's MX Connectivity Quality Process Measure
03/17
All Medi-Cal PCPs
Phase III – Lift 1 - Medi-Cal Rx Transition Policy Change
03/16
All Medi-Cal PCPs & Specialists
RESPONSE REQUIRED – Provider Newsletter and Communication Survey
03/15
All PCPs, Specialists, Vision, BH & BHT Providers
REMINDER - 2023 Global Quality P4P Program - CAIR2 Participation Requirement
03/15
All Medi-Cal PCPs
Comprehensive Practice Optimization Workshop
03/15
All Riverside County PCPs
Medical Assistants: Enhancing Patient Safety & Reducing Liability Risks
03/15
All Riverside County PCPs
IEHP Coordination of Benefits Agreement (COBA) Implementation – Update
03/13
All PCPs, Specialists, Ancillary, & Hospitals
ACTION REQUIRED - Blood Lead Survey
03/13
All Pediatricians, Family Practice & Community Clinics
Opioid Attestation for Coverage Determinations and Removal of X-Waiver
03/10
All DualChoice Providers
Social Determinants of Health - Community Supports Services Referral Process
03/10
All PCPs, Behavioral Health Providers & IPAs
Complex Case Management (CCM) Program – Severe Chronic Conditions
03/08
All Medi-Cal IPAs, PCPs, Specialists, & Behavioral Health Providers
UPDATE - IEHP Coordination of Benefits Agreement (COBA) Implementation
03/07
All FQHCs, IHCs, & RHCs
REMINDER - Clean Claim Tool Guide Available
03/07
All Skilled Nursing Facilities
GQ P4P PCP – 2023 Program Guide Update - Social Determinates of Health Measure
03/03
All Medi-Cal PCPs
GQ P4P IPA – 2023 Program Guide Update - Social Determinates of Health Measure
03/03
All Medi-Cal IPAs
Encouraging Sexual History Taking for Patient Care and Partner Services
03/03
All PCPs
Encounter Data Submission Enhancements – Live Now!
03/02
All Direct PCPs
IEHP Global Quality P4P Manifest MedEx (MX) FAQs
03/02
All Medi-Cal PCPs & IPAs
Riverside County Medical Association - Physician Burnout Webinar
03/02
All Riverside and San Bernardino County PCPs
Riverside County Medical Association's 19th Annual Cruisin' Thru CME
03/02
All Riverside County PCPs
February 2023
CMS Alert - Fraudulent Activities and Monitoring Recommendations
02/28
All Medicare IPAs
Update to D-SNP Letter Template
02/24
All Medicare IPAs
Alternate Contact Information for Members Now Available!
02/23
All PCPs
Alzheimer's and Dementia Seminar (ECHO) - Beginning March 29th
02/23
All PCPs
Month-End IEHP Outbound 834 File Update
02/23
834 Trading Partners
RESPONSE REQUESTED – Provider Newsletter and Communication Survey
02/21
All PCPs, Specialists, Vision, BH and BHT Providers
UPDATE - Referral Timeline Standards for IEHP DualChoice (HMO D-SNP) Members
02/21
All Medicare IPAs
Skinny Gene Project - Diabetes Prevention Program (DPP)
02/21
All PCPs
Protocols for Emergency and Post-Stabilization Care for IEHP Members
02/17
All Hospitals
REMINDER - 2023 Global Quality P4P Program - CAIR2 Participation Requirement- PCPs
02/16
All Medi-Cal PCPs
Last Phase - Medi-Cal Rx Reinstatement of PAs for 46 Drug Classes, Including Medical Supplies - Eff. February 24th
02/14
All Medi-Cal PCPs & Specialists
Presidents' Day Holiday
02/13
All IEHP Providers & IPAs
RESPONSE REQUIRED – Provider Newsletter and Communication Survey
02/13
All PCPs, Specialists, Vision, BH and BHT Providers
New Provider Portal Alert - Inpatient Discharges
02/09
All PCPs
Quality Bonus Services RA’s Now Available!
02/09
All Medi-Cal PCPs
Ask DHCS – Open Office Hours for EVV Home Health Care Services – February 17, 2023
02/03
All EVV Impacted Providers & Individual Nurse Practitioners
UPDATE – Initial Health Appointment and Retirement of IHEBA/SHA
02/02
All Medi-Cal PCPs & IPAs
Transition to 30-day Coverage Determination Backdating
02/02
All LTC & SNF Providers
Redlands Community Hospital – Behavioral Health Unit Closed
02/01
All PCPs & BH Providers
UPDATE - Independent Medical Review Form
02/01
All Medicare IPAs
January 2023
KidsVaxGrant 3.0 Deadline to Apply is February 17, 2023
01/31
All Pediatricians and Family Practice PCPs
Effective February 1, 2023 - Call The Car Will Replace American Logistics Company (ACL) for ALL Member Transportation
01/31
All PCPs, Specialists, BH & IPAs
Provider Manual Acknowledgement of Receipt (AOR) Winners
01/27
All Providers
Crisis Recovery Resource Guide and Toolkit Available
01/27
All Community Support Services
REMINDER - BHT Providers Must Submit Exit Reports and Exit Letters!
01/27
All BHT (QASP) Providers
D-SNP Model of Care Incentive Program - 2023 Program Guide Release
01/26
All Medicare IPAs
Help Protect Members - Flu Vaccine Reminder
01/25
All PCPs
2023 Global Quality P4P PCP Kick Off Meeting
01/25
All Medi-Cal PCPs
2023 Global Quality P4P IPA Kick Off Meeting
01/25
All IPAs
An ECHO Learning Opportunity - Alzheimer's And Dementia Care - Weekly Sessions Begin Feb 16th
01/24
All PCPs
REMINDER - 2023 Global Quality P4P Program - CAIR2 Participation Requirement- PCPs
01/23
All Medi-Cal PCPs
REMINDER - 2023 Global Quality P4P Program - CAIR2 Participation Requirement- IPAs
01/23
All Medi-Cal IPAs
Response Requested by Thursday, January 26! - CBAS Emergency Remote Services (ERS)
01/23
All CBAS Providers
Global Quality P4P PCP Program - 2023 Program Guide Release
01/19
All Medi-Cal PCPs
UPDATE! Medi-Cal Letter Templates
01/17
All Medi-Cal IPAs
Emergency Resource Guide and Services – Flooding Services Available!
01/17
All Community Support Services Providers
Medicare P4P IEHP Direct – Blood Pressure Control Billing Guidance
01/13
All DualChoice PCPs
NEW! Regulatory Submission Response Files – MAO-004 XWalk
01/13
All Medicare IPAs
ALERT! 837 SBR04 Encounter Data Requirement Changes
01/13
All Medicare IPAs
IEHP DualChoice (D-SNP) Model of Care Training Requirement
01/12
All DualChoice Hospitals
IEHP DualChoice (D-SNP) Model of Care Training Requirement
01/10
All Medicare IPAs
IEHP DualChoice (D-SNP) Model of Care Training Requirement
01/10
All DualChoice Providers
IEHP Outbound 834 File Update
01/10
All 834 Trading Partners
IEHP HOLIDAY - Martin Luther King Jr. Day
01/09
All IEHP Providers
CORRECTION to Changes to Quarterly Workplan Requirements
01/05
All Medicare IPAs
LAST CHANCE to Win a $50 Gift Card - Submit 2023 Provider Policy and Provider Manual Acknowledgement of Receipt (AOR)
01/04
All IEHP Providers
2023 Population Health Management Academy
01/04
All Riverside County PCPs
CORRECTION - 2022 GQ P4P PCP - Quality Bonus Services Code Update
01/03
All Medi-Cal PCPs
December 2022
Outbound Eligibility File Delay on January 1, 2023
12/29
All IPAs and Ancillary Providers
REMINDER - CoverMyMeds - Prior Authorization Submission Method for Dual Choice Members– Effective January 1, 2023
12/29
All Dual Choice PCPs & Specialists
REMINDER - Pharmacy Benefits Manager (PBM) Change for DualChoice (HMO D-SNP) - Member Outreach in Process
12/29
All Dual Choice PCPS and Medicare IPAs
Access Standards – Appointment Availability - BH Providers
12/28
All Behavioral Health Providers
Mandatory Managed Care Enrollment (MMCE) Phase II - January 1, 2023
12/27
All Medi-Cal PCPs & Specialists
Access Standards – Appointment Availability - PCPs & OB/GYNs
12/27
All PCPs & OB/GYNs
Access Standards – Appointment Availability - Specialists
12/27
All Specialists
NEW! State Fair Hearing and Independent Medical Review Forms added to D-SNP Letter Templates (Effective January 2, 2023)
12/27
All Medicare IPAs
REMINDER - Help Your Members Update Their Contact Information!
12/22
All PCPs
2022 GQ P4P PCP - Quality Bonus Services Code Update
12/22
All Medi-Cal PCPs & IPAs
UPDATED! D-SNP Letter Templates (Effective January 2, 2023)
12/21
All Medicare IPAs
Phase II Wave I– Prior Authorization Submission – January 20, 2023
12/21
Medi-Cal PCPs & Specialists
Crossing the Line - Examining Professional, Personal, & Ethical Boundaries
12/21
Riverside County PCPs & Specialists
IEHP Outbound Daily 834 Delta File Delay
12/20
All 834 Trading Partners
Revised UM Authorization Guidelines
12/19
All IPA Administrators & Medical Directors
REMINDER - IEHP DualChoice (HMO D-SNP) begins Jan 2023
12/19
All Medicare PCPs, Specialists & BH Providers
OB P4P Program - Early Postpartum Visit Update
12/19
All Medi-Cal OB/GYNs
My Life. My Choice. - An Online Advanced Care Planning Program
12/16
All Dual Choice PCPs
REMINDER - CoverMyMeds - Prior Authorization Submission Method for Dual Choice Members– Effective January 1, 2023
12/16
All Dual Choice PCPs & Specialists
IEHP 2022-2023 Holiday Hours
12/15
All Providers & IPAs
2022 Global Quality P4P Program – Data Submission Deadlines for PCPs!
12/15
All Medi-Cal PCPs
2022 Global Quality P4P Program – Data Submission Deadlines for IPAs!
12/15
All Medi-Cal IPAs
CORRECTION– New Fax Number for Physician Certification Statements for Non-Emergency Medical Transportation
12/09
All Hospitals and SNFs
Medicare Formulary Changes for 2023 IEHP DualChoice (HMO D-SNP)
12/08
All Medicare PCPs, Specialists & IPAs
Pharmacy Recalls, Withdrawals & Safety Alerts - November 2022
12/07
All PCPs
REMINDER - Physician Certification Statement (PCS) Requirement
12/06
All PCPs, Specialists, BH & IPAs
EVV Home Health Care Services Open Office Hours – December 16th
12/06
EVV Impacted Providers & Individual Nurse Practitioners
Mpox (formerly Monkeypox) Vaccine Available through Local Health Departments
12/05
All Medi-Cal PCPs & IPAs
IMPORTANT! DHCS Error – Members Will NOT be Disenrolled From IEHP
12/05
All Medicare PCPs & IPAs
Global Quality P4P PCP – 2022 Program Guide Update (Quality Bonus Services)
12/05
All Medi-Cal PCPs
The Alzheimer's Association Event - Resources for Improving Dementia Care in the Clinical Practice
12/02
All PCPs
CoverMyMeds - Prior Authorization Submission Method for Dual Choice Members– Effective January 1, 2023
12/02
All Dual Choice PCPs
REMINDER - IEHP Dual Choice (HMO D-SNP) begins Jan 2023
12/02
All Medicare PCPs, Specialists & BH Providers
Response Requested by December 6, 2022! - CBAS Emergency Remote Services - Reporting
12/02
All CBAS Providers
IEHP Formulary Changes - November P&T Update
12/02
All PCPs
November 2022 Pharmacy and Therapeutics Subcommittee Update
12/02
All PCPs
NEW! D-SNP Letter Templates - Claims (Effective January 2, 2023)
12/02
All Medicare IPAs
Effective Today! - IEHP Contracts with Call The Car For Transportation
12/01
All Hospitals & SNFs
COVID-19 Isolation in SNF
12/01
All SNFs
Living the Mission Awards Nomination Form
12/01
All IEHP Providers
November 2022
Inland Empire Community Health Assessment
11/30
All PCPs, IPAs, Specialists, & Behavioral Health Providers
Pharmacy Benefits Manager (PBM) Change for DualChoice (HMO D-SNP) - Member Outreach in Process
11/29
All DualChoice PCPs & Medicare IPAs
ID Cards with Errors Reissued to Dual Choice Members
11/23
Select Dual Choice PCPs
Inland Caregiver Resource Center Informational Webinar - ECHO
11/23
All PCPs
IEHP’s Quarterly Behavioral Health Provider Training
11/18
All Behavioral Health (BH) Providers
Thanksgiving Holiday
11/18
All IEHP Providers
IEHP Outbound Daily 834 Delta File Delay
11/18
All 834 Trading Partners
CoverMyMeds - Prior Authorization Submission Method for Dual Choice Members– Effective January 1, 2023
11/17
All IEHP DualChoice PCPs
IEHP DualChoice (HMO D-SNP) 2023 Vision Benefits
11/17
All Vision Providers
Riverside County Medical Association's Physician Holiday Social
11/17
All Riverside County PCPs & Specialists
RUHS - PHA - Early Respiratory Syncytial Virus (RSV) and Seasonal Influenza Activity
11/17
All Riverside County PCPs
Global Quality P4P PCP Meeting - 2023 Program Preview
11/16
All Medi-Cal PCPs
BHT (QASP) Provider Training
11/15
All BHT (QASP) Providers
Reminder - BH Emergency Instruction Standards
11/15
All BH Providers
Reminder - PCP and Specialist Emergency Instruction Standards
11/15
All PCPs & Specialists
UPDATE! D-SNP Letter Templates (Effective January 2, 2023)
11/15
All Medicare IPAs
UPDATE - Revised UM Authorization Guidelines to November 3, 2022 - UM-BH 08
11/14
All Medi-Cal IPAs & BHT Providers
Pharmacy Recalls, Withdrawals & Safety Alerts - October 2022
11/14
All PCPs
REMINDER: IEHP DualChoice (HMO D-SNP) begins Jan 2023
11/10
All Medicare PCPs, Specialists & BH Providers
REMINDER: Help Your Members Update Their Contact Information!
11/10
All IEHP PCPs
Maternal Wellness Event Flyer
11/09
All Medi-Cal PCPs, OB/GYNs, Peds, BH Providers & IPAs
Essure System - No Longer a Covered Benefit
11/09
All OB/GYNs
ACTION REQUIRED -Submit 2023 Provider Policy and Provider Manual Acknowledgement of Receipt (AOR) - Win a $50 Gift Card
11/08
All IEHP Providers
Veterans Day
11/04
All IEHP Providers & IPAs
Revised UM Authorization Guidelines
11/03
All BH Providers & IPAs
Pharmacy Recalls, Withdrawals & Safety Alerts - September 2022
11/02
All PCPs
October 2022
Medicare - Nondiscrimination Notice and Taglines Templates
10/31
All Medicare IPAs
REMINDER: IEHP Interpreter Services – A Covered Benefit!
10/31
All PCPs & IPAs
Continuous Glucose Monitors
10/28
All Medicare PCPs, Endocrinologists & IPAs
Health Education Classes Available in Riverside Area
10/27
All Riverside Area PCPs, Specialists & OBs
PHA - Outbreak of Ebola Virus Disease Due to Sudan Virus in Central Uganda
10/25
All Riverside County PCPs
834 Eligibility File Format Changes
10/25
All IHEP 834 Trading Partners
Global Quality P4P IPA Meeting – 2023 Program Preview
10/21
All Medi-Cal IPAs
REMINDER DHCS Hospice Rates – Prospective Calculation Based on Medicaid Rates
10/21
All Hospice Providers
NEW! D-SNP Letter Templates (Effective January 2, 2023)
10/21
All Medicare IPAs
Help Protect Your Members Against the Flu
10/20
All PCPs & IPAs
Public Health Emergency (PHE) Ending Soon – Help Your Members Reenroll!
10/19
All IEHP PCPs
REMINDER - Balance Billing of IEHP Members Not Permitted!
10/14
All IEHP Providers
ACTION REQUIRED - Correct Prioritization of Authorization Requests
10/14
All PCPs, Specialists & IPAs
Global Quality P4P PCP Meeting – 2023 Program Preview
10/13
All Medi-Cal PCPs
Flu Vaccine Notice -Access to Pharmacy Vaccine Network
10/13
All PCPs
Cal MediConnect Sunsets and IEHP Dual Choice (D-SNP) Begins
10/12
All PCPs
Academic Detailing Services Now Offered
10/11
All IEHP Providers & Pharmacies
REMINDER - ACTION REQUIRED - Electronic Visit Verification (EVV) Implementation Requirements – Self Registration Required by October 19, 2022
10/10
All Home Health Care Services (HHCS) Providers & Personal Care Services (PCS)
UPDATE - Independent Medical Review (IMR) Forms
10/10
All Medicare IPAs
UPDATE to September 8, 2022 Communication Authorization Timeframes
10/6
All Medi-Cal IPAs
Special Fraud Alert - Exercise Caution with Purported Telemedicine Companies
10/6
All IEHP Providers & IPAs
FAQs For Delegate Monitoring of Utilization Measures
10/5
All IPAs
September 2022
Global Quality P4P Programs – NEW 2022 Quality Bonus Services!
09/30
All Medi-Cal PCPs
Diversity Awareness Month - October 2022 - Please Join Us!
09/30
All IEHP Providers & IPAs
REMINDER - IEHP Coordination of Benefits Agreement (COBA) Implementation – Action Required!
09/30
All PCPs, Specialists, ANC & Hospitals
ICD-10-CM Risk Adjustment Code Changes for CMS HCC Code Capture
09/26
All Direct Dual Choice PCPs
UPDATE! – Continuous Glucose Monitoring (CGM) Systems (IPA)
09/23
All Medi-Cal IPAs
UPDATE! – Continuous Glucose Monitoring (CGM) Systems
09/22
All Medi-Cal PCPs & Endocrinologists
ACTION REQUIRED - Electronic Visit Verification (EVV) Implementation Requirements – Self Registration Required by October 19, 2022
09/22
All Home Health Care Services (HHCS) Providers & Personal Care Services (PCS)
UPDATED Medi-Cal Letter Templates
09/22
All Medi-Cal IPAs
URGENT ATTENTION: Phishing Email Alert
09/21
All IEHP Providers
Pharmacy Times - Medication Reconciliation
09/21
All Dual Choice PCPs
Grievance Process Updates - Grievance Summary Form - Due Date
09/15
All IPAs
Continuity of Care (COC) Rosters Now Available on SFTP
09/15
All IPAs
REMINDER - Enhanced Care Management Available for Members
09/15
All Medi-Cal ANC and Vision Providers
Coordination of Benefits Agreement (COBA) Implementation - Action Required
09/12
All PCPs, Specialists, ANC & Hospitals
REMINDER - Dilated Retinal Exam (DRE) for Diabetic Members
09/09
All PCPs & Vision Providers
Revised UM Authorization Guidelines
09/09
All IPA Administrators & Medical Directors
Annual BH&CM Medi-Cal IPA Training Survey
09/08
All Medi-Cal IPA Care Management Staff
IEHP Provider Portal Updates – Reports now Viewable by TIN
09/08
All Medi-Cal PCPs
NEW - Collecting Social Determinants of Health Data (SDOH)
09/08
All Medi-Cal PCPs, Specialists & BH Providers
Authorization Timeframes Notice of Action (NOA) Translation & Attachment
09/08
All Medi-Cal IPAs
Please Notify IEHP if Your Availability has Changed due to Area Fires
09/08
All Hemet and Big Bear Area Providers
Recalls, Withdrawals & Safety
09/08
All IEHP Providers & Pharmacies
IEHP Formulary Changes (P&T)
09/07
All IEHP PCPs
Access Standards - Appointment Availability - Specialists
09/02
All Specialists
Access Standards - Appointment Availability - PCP, Ob
09/02
All PCPs & Obs
Access Standards - Appointment Availability - BH
09/02
All Behavioral Health Providers
Vaccination Clinic and Resource Fair - September 10
09/02
All Direct PCPs
IEHP Medi-Cal Medical Benefit Formulary
09/02
All Medi-Cal PCPs, Specialists & Psychiatrists
August 2022 P&T Update
09/02
All IEHP Providers & Pharmacies
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.
IEHP DualChoice - 2023 計畫福利
ou will pay:
Benefits
Doctor Visit: $0
Vision Care: a combined limit of $350 each year for contact lenses and/or eyeglasses (frames).
Inpatient Hospital Care: $0
Home Health Agency Care: $0
Ambulance Services: $0
Transportation: $0. Including bus pass. Call the Car (CTC) at 1-855-673-3195, 24 hours a day, 7 days a week. For TTY users, call your relay service or California Relay Service at 711. For reservations call Monday-Friday, 7am-6pm (PST). Call at least 5 days before your appointment.
Diagnostic Tests, X-Rays & Lab Services: $0
Durable Medical Equipment: $0
Home and Community Based Services (HCBS): $0
Community Based Adult Services (CBAS): $0
Long Term Care that includes custodial care and facility: $0
Utilities allowance of $65 for covered utilities. You must qualify for this benefit.
Over the Counter (OTC) items allowance of $40 per quarter (every 3 months) towards the purchase of certain Over the Counter (OTC) items.
You pay nothing for a one-month or long term-supply of drugs
With IEHP DualChoice, you pay nothing for covered drugs as long as you follow the plan’s rules.
Tier 1 drugs are: generic, brand and biosimilar drugs. They have a copay of $0.
After your coverage begins with IEHP DualChoice, you must receive medical services and prescription drug services in the IEHP DualChoice network.
To learn more about the plan’s benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook.
2024 Summary of Benefits (PDF)(Coming soon)
2024 Annual Notice of Changes (PDF)
2024 IEHP DualChoice Member Handbook (PDF) (Coming soon)
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here. By clicking on this link, you will be leaving the IEHP DualChoice website.
Plan Premium
There is a monthly premium of $0-$41.00 for IEHP DualChoice. You may qualify for “Extra Help” which can help reduce your monthly premium.
Plan Deductible
There is no deductible for IEHP DualChoice.
Because you are eligible for Medi-Cal, you qualify for and are getting “Extra Help” from Medicare to pay for your prescription drug plan costs. You do not need to do anything further to get this Extra Help.
You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, you can contact:
1-800-MEDICARE (1-800-633-4227). , TTY users should call (877) 486-2048, 24 hours a day/7days a week
The Social Security Office at (800) 772-1213 between 7 a.m. and 7 p.m., Monday through Friday, TTY users should call (800) 325-0778; or
Your State Medicaid Office
How to get care coordination
Do you need help getting the care you need? A care team can help you. A care team may include your doctor, a care coordinator, or other health person that you choose. A care coordinator is a person who is trained to help you manage the care you need. You will get a care coordinator when you enroll in IEHP DualChoice. This person will also refer you to community resources, if IEHP DualChoice does not provide the services that you need.
To speak with a care coordinator, please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347.
Prior Authorization and Out of Network Coverage
What kinds of medical care and other services can you get without getting approval in advance from your Primary Care Provider (PCP) in IEHP DualChoice (HMO D-SNP)? You can get services such as those listed below without getting approval in advance from your Primary Care Provider (PCP).
Routine women’s health care, which includes breast exams, screening mammograms (X-rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider.
Flu shots as long as you get them from a network provider.
Emergency services from network providers or from out-of-network providers.
Urgently needed care from in-network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible, e.g., when you are temporarily outside of the plan’s service area.
Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area. (If possible, please call IEHP DualChoice Member Services before you leave the service area so we can help arrange for you to have maintenance dialysis while you are away.)
How to get care from specialists and other network providers
A specialist is a doctor who provides health care services for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples:
Oncologists care for patients with cancer.
Cardiologists care for patients with heart conditions.
Orthopedists care for patients with certain bone, joint, or muscle conditions.
You will usually see your PCP first for most of your routine healthcare needs such as physical checkups, immunization, etc. When your PCP thinks that you need specialized treatment or supplies, your PCP will need to get prior authorization (i.e., prior approval) from your Plan and/or medical group. This is called a referral. Your PCP will send a referral to your plan or medical group. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. If you don’t have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself. PCPs are usually linked to certain hospitals and specialists. When you choose a PCP, it also determines what hospital and specialist you can use.
What if a specialist or another network provider leaves our plan?
Sometimes a specialist, clinic, hospital or other network provider you are using might leave the plan. When a provider leaves a network, we will mail you a letter informing you about your new provider. If you prefer a different one, please call IEHP DualChoice Member Services and we can assist you in finding and selecting another provider.
How to get care from out-of-network providers
When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. In order to receive out-of-network services, your Primary Care Provider (PCP) or Specialist must submit a referral request to your plan or medical group. All requests for out-of-network services must be approved by your medical group prior to receiving services.
IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. This is not a complete list.
Information on this page is current as of October 01, 2023.
H8894_DSNP_24_4164896_M Pending Accepted
IEHP DualChoice - 2023 Plan Benefits
ou will pay:
Benefits
Doctor Visit: $0
Vision Care: $350 limit every year for contact lenses and eyeglasses (frames and lenses) -->
Vision care: Up to $350 limit every twelve months for eyeglasses (frames). Lenses are separately reimbursable based on prior approval and medical necessity.
Contact Lenses are covered up to $350 every twelve months in lieu of eyeglasses (Lenses and Frames).
Inpatient Hospital Care: $0
Home Health Agency Care: $0
Ambulance Services: $0
Transportation: $0. Including bus pass. Call our transportation vendor Call the Car (CTC) at (866) 880-3654, for TTY users, call your relay service or California Relay Service at 711. For reservations call Monday-Friday, 7am-6pm (PST). Call at least 5 days before your appointment.
Diagnostic Tests, X-Rays & Lab Services: $0
Durable Medical Equipment: $0
Home and Community Based Services (HCBS): $0
Community Based Adult Services (CBAS): $0
Long Term Care that includes custodial care and facility: $0
Utilities allowance of $40 for covered utilities. You must qualify for this benefit.
You pay nothing for a one-month or long term-supply of drugs
With IEHP DualChoice, you pay nothing for covered drugs as long as you follow the plan’s rules.
Tier 1 drugs are: generic, brand and biosimilar drugs. They have a copay of $0.
After your coverage begins with IEHP DualChoice, you must receive medical services and prescription drug services in the IEHP DualChoice network.
To learn more about the plan’s benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook.
2023 Summary of Benefits (PDF)
2023 Annual Notice of Changes (PDF)
2023 IEHP DualChoice Member Handbook (PDF)
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy of Adobe Acrobat Reader.By clicking on this link, you will be leaving the IEHP DualChoice website.
Plan Premium
With "Extra Help," there is no plan premium for IEHP DualChoice.
Plan Deductible
There is no deductible for IEHP DualChoice.
Because you are eligible for Medi-Cal, you qualify for and are getting “Extra Help” from Medicare to pay for your prescription drug plan costs. You do not need to do anything further to get this Extra Help.
You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, you can contact:
1-800-MEDICARE (1-800-633-4227). , TTY users should call (877) 486-2048, 24 hours a day/7days a week
The Social Security Office at (800) 772-1213 between 7 a.m. and 7 p.m., Monday through Friday, TTY users should call (800) 325-0778; or
Your State Medicaid Office
How to get care coordination
Do you need help getting the care you need? A care team can help you. A care team may include your doctor, a care coordinator, or other health person that you choose. A care coordinator is a person who is trained to help you manage the care you need. You will get a care coordinator when you enroll in IEHP DualChoice. This person will also refer you to community resources, if IEHP DualChoice does not provide the services that you need.
To speak with a care coordinator, please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. TTY users should call 1-800-718-4347.
Prior Authorization and Out of Network Coverage
What kinds of medical care and other services can you get without getting approval in advance from your Primary Care Provider (PCP) in IEHP DualChoice (HMO D-SNP)? You can get services such as those listed below without getting approval in advance from your Primary Care Provider (PCP).
Routine women’s health care, which includes breast exams, screening mammograms (X-rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider.
Flu shots as long as you get them from a network provider.
Emergency services from network providers or from out-of-network providers.
Urgently needed care from in-network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible, e.g., when you are temporarily outside of the plan’s service area.
Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area. (If possible, please call IEHP DualChoice Member Services before you leave the service area so we can help arrange for you to have maintenance dialysis while you are away.)
How to get care from specialists and other network providers
A specialist is a doctor who provides health care services for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples:
Oncologists care for patients with cancer.
Cardiologists care for patients with heart conditions.
Orthopedists care for patients with certain bone, joint, or muscle conditions.
You will usually see your PCP first for most of your routine healthcare needs such as physical checkups, immunization, etc. When your PCP thinks that you need specialized treatment or supplies, your PCP will need to get prior authorization (i.e., prior approval) from your Plan and/or medical group. This is called a referral. Your PCP will send a referral to your plan or medical group. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. If you don’t have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself. PCPs are usually linked to certain hospitals and specialists. When you choose a PCP, it also determines what hospital and specialist you can use.
What if a specialist or another network provider leaves our plan?
Sometimes a specialist, clinic, hospital or other network provider you are using might leave the plan. When a provider leaves a network, we will mail you a letter informing you about your new provider. If you prefer a different one, please call IEHP DualChoice Member Services and we can assist you in finding and selecting another provider.
How to get care from out-of-network providers
When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. In order to receive out-of-network services, your Primary Care Provider (PCP) or Specialist must submit a referral request to your plan or medical group. All requests for out-of-network services must be approved by your medical group prior to receiving services.
IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. This is not a complete list.
Information on this page is current as of October 1, 2022.
H8894_DSNP_23_3241532_M
IEHP DualChoice - 提出申訴
得的資訊 語言協助 我方通信 關於給付決定或上訴相關措施的時效性 如何向 IEHP DualChoice (HMO D-SNP) 提出申訴 1.請立即與我們聯繫 ─ 請致電 (877) 273-IEHP (4347) 與 IEHP DualChoice 聯繫,服務時間為每天上午 8 點至晚上 8 點,假日亦提供服務,TTY/TDD 使用者請撥 1-800-718-4347。您可以隨時提出申訴,除非係與 D 部分藥品有關。若申訴內容係與 D 部分藥品有關,您必須在申訴問題發生後 60 個曆日內提出。 如果您不想透過電話提出 (或者您致電過,但未獲得滿意答覆),您可以將要申訴的問題寫下來,然後郵寄給我們。如果您是透過書面形式提出申訴,我們也會透過書面形式回覆您的申訴。 您可以使用我們的「會員上訴與申訴申請表」。我們的所有醫師診間與服務提供者皆備有該表單,或者我們也可郵寄表單給您。您可以線上提出申訴。您可將填妥的表單提供給我們的計畫提供者,或寄送至下列地址,也可將填妥的表單傳真至下列號碼。此表單適用 IEHP DualChoice 及其他 IEHP 計畫。 IEHP DualChoice P.O. Box 1800 Rancho Cucamonga, CA 91729-1800 傳真:(909) 890-5877 無論是致電或致函,您都應立即聯繫 IEHP DualChoice 會員服務中心。 2.我們會審核您的申訴,然後給您答覆 我們會盡可能立即回覆您。當您透過電話提出申訴,我們會儘量在當次通話中答覆您。若您的健康狀況需要我們盡快答覆,我們會按照您的要求辦理。 大部分申訴可在 30 個曆日內得到答覆。如果我們需要更多資訊,且認定延遲是基於您的最大利益 (或者您自己要求更多時間),則我們可將申訴的答覆時間最多延長 14 天 (共 44 天)。 如果我們否決您的部分或全部申訴,或是我們不負責您所申訴的問題,則我們會告知您。我們會在回應時說明拒絕的理由。我們必須回覆是否同意您的申訴。 快速申訴 若您係因我們拒絕您的「快速給付裁決」或「快速上訴」申請而提出申訴,則我們會自動視同「快速」申訴處理。當您提出「快速」申訴時,則表示我們會在 24 小時內給您答覆。 哪些人可以提出申訴? 您或您指定之人可以提出申訴。您所指定之人即為您的「代表」。 您可以指定親戚、朋友、律師、倡權者、醫師或任何其他人作為您的代表。其他人可能已經獲得法院許可或依據州法可代表您提出申訴。如果您要指定擔任您代表的人士尚未獲得法院許可或不符合州法規定,則您與該人士必須簽署一份聲明並標註日期,以茲授予該人士擔任您代表的權利。如欲進一步瞭解如何指定代表,您可以致電 IEHP DualChoice 會員服務中心。 外部申訴 您可以向 Medicare 提出申訴 您可以將申訴發送給 Medicare。Medicare 申訴表可透過下列網址下載: https://www.medicare.gov/MedicareComplaintForm/home.aspx。 Medicare 會仔細審理您的申訴,並且會運用這項資訊改善 Medicare 計畫的品質。 若您有任何其他意見或疑慮,或者您認為本計畫未解決您的問題,請致電 (800) MEDICARE (800) 633-4227)。TTY/TDD 使用者請撥 (877) 486-2048。此為免付費電話。 您也可以向 Medi-Cal 提出申訴 監察專員辦公室也可從中立角度協助解決問題,以確保我們的會員獲得我們須提供的所有給付服務。監察專員辦公室與我方無關,也與任何保險公司或健康計畫無關。 監察專員辦公室的電話為 1-888-452-8609。這些服務是免費的。 您可以向加州管理式醫療保健部提出您的申訴 加州管理式醫療保健部 (DMHC) 負責管理各項健康計畫。您可以致電 DMHC 協助中心,取得有關 Medi-Cal 服務申訴方面的協助。若您在申訴緊急問題、涉及對您的健康造成立即嚴重危害之問題、您不同意我方計畫對您申訴的裁決,或我方計畫並未於 30 個曆日內解決您的申訴等方面需要協助,您可以聯繫 DMHC。 您可以透過下列兩種方式取得協助中心的協助: 致電 (888) 466-2219,TTY 使用者請撥 (877) 688-9891。此為免付費電話。 造訪管理式醫療保健部網站: http://www.dmhc.ca.gov/ 您可以向民權局提出申訴 如果您認為遭受到不公平對待,您可以向衛生與公眾服務部 (Department of Health and Human Services) 民權局提出申訴。例如,您可以提出無障礙設施或語言協助等相關申訴。民權局的電話為 (800) 368-1019。TTY 使用者請撥 (800) 537-7697。您也可以造訪 https://www.hhs.gov/ocr/index.html 瞭解詳細資訊。 您也可以聯絡當地的民權辦事處,地址是: U.S. Department of Health and Human Services 90 7th Street, Suite 4-100 San Francisco, CA 94103 電話:(800) 368-1019 TDD:(800) 537-7697 傳真:(415) 437-8329 您也受《美國殘障人士法案》(Americans with Disabilities Act) 之保護。您可以聯繫監察專員辦公室取得協助。電話號碼為 (888) 452-8609。 若您的申訴是與照護品質有關 您還有下列兩個選擇: 您可以向品質改善組織 (Quality Improvement Organization) 提出申訴。如果您願意,可以直接向該組織提出與您所獲得照護品質有關的申訴 (而非向我方計畫提出申訴)。如欲搜尋您所在州的品質改善組織名稱、地址與電話號碼,請參閱 IEHP DualChoice 會員手冊第 2 章。若您向該組織提出申訴,我們將與其共同解決您的申訴。 或者,您可以同時向雙方提出申訴。您可以視需求,同時向我們和品質改善組織提出與照護品質相關的申訴。 詳細資訊請參閱 IEHP DualChoice 會員手冊第 9 章。 處理您的 Medi-Cal 福利問題 若您向 IEHP 投保 Medi-Cal,並希望瞭解就 Medi-Cal 給付服務提出上訴與申訴的相關資訊,請致電 IEHP DualChoice 會員服務部,電話為 (877) 273-IEHP (4347),TTY 使用者請撥 (800) 718-4347。服務時間為太平洋標準時間每天上午 8 點至晚上 8 點,假日亦提供服務。 IEHP DualChoice (HMO D-SNP) 是與 Medicare 簽約的 HMO 計畫。投保 IEHP DualChoice (HMO D-SNP) 取決於合約續訂。 此頁面資訊為截至 2022 年 10 月 1 日的最新資訊。 H8894_DSNP_23_3241532_M Pending Accepted
Pharmacy Communications - Pharmacy Communications
to view the PDF files. You can download a free copy by clicking here. By clicking on this link, you will be leaving the IEHP website.
TITLE
DATE
RECIPIENTS
September 2023
New DHCS Drug Use Review (DUR) Board Educational Articles
09/29
All IEHP PCPs, All IEHP Pharmacy Providers
August 2023 Pharmacy and Therapeutics Update
09/06
All IEHP PCPs, All IEHP Pharmacy Providers
URGENT: Recalls, Market Withdrawals & Safety Alerts, August 2023
09/01
All IEHP PCPs, All IEHP Pharmacy Providers
August 2023
New DHCS Drug Use Review (DUR) Board Educational Articles
08/29
All PCPs, OBs & BH Providers
Claims Processing during State of Emergency
08/20
All IEHP Pharmacy Providers
URGENT: Recalls, Market Withdrawals & Safety Alerts, July 2023
08/01
All IEHP PCPs, All IEHP Pharmacy Providers
July 2023
New DHCS Drug Use Review (DUR) Board Educational Articles
07/27
All Medi-Cal PCPs & Specialists
RESOLVED - Dual Choice Member Billing Issue
07/07
All IEHP Pharmacy Providers
DualChoice (HMO D-SNP): Known Billing Issue
07/06
All IEHP Pharmacy Providers
June 2023
URGENT: Recalls, Market Withdrawals & Safety Alerts, June 2023
06/30
All IEHP PCPs, All IEHP Pharmacy Providers
URGENT! Recalls, Market Withdrawals & Safety Alerts, May 2023
06/09
All IEHP PCPs, All IEHP Pharmacy Providers
May 2023 Pharmacy & Therapeutics Update
06/09
IEHP Provider Network
New DHCS Drug Use Review (DUR) Board Educational Articles
06/02
All Medi-Cal PCPs & Specialists
May 2023
Pharmacy Recalls, Market Withdrawals Safety Alerts - April 2023
05/10
All IEHP PCP's, All IEHP Pharmacy Providers
April 2023
Pharmacy Recalls Withdrawals Safety Alerts - January to March 2023
04/10
All IEHP PCP's & Pharmacy Providers
March 2023
IEHP DualChoice (HMO D-SNP): Known Billing Issue
03/31
All IEHP Pharmacy Providers
Pharmacy Recalls - Withdrawals - Safety Alerts - March 1-15, 2023
03/31
All IEHP PCPs & Pharmacy Providers
Pharmacy Recalls - Withdrawals - Safety Alerts - Dec 2022 to Feb 2023
03/31
All IEHP PCPs & Pharmacy Providers
DualChoice Medicare Billing for Non-FDA Approved Medications
03/21
All IEHP Pharmacy Providers
Claim Processing during State of Emergency due to Snowstorm
03/03
All IEHP Pharmacy Providers
February 2023
Transition to 30-day Coverage Determination Backdating
02/02
All LTC & SNF Providers
January 2023
IEHP DualChoice (HMO D-SNP): Over-the-Counter Drugs
01/09-01/30
All IEHP Pharmacy Providers
IEHP DualChoice (HMO D-SNP): Medicare Part B Coinsurance Billing
01/05-01/13
All IEHP Pharmacy Providers
IEHP DualChoice (HMO D-SNP): PBM Update and Medicare Part B Coinsurance
01/02-01/20
All IEHP Pharmacy Providers
IEHP DualChoice (HMO D-SNP) Members - Medication Overrides
01/02
All IEHP Pharmacy Providers
December 2022
Cal MediConnect (CMC) to Medi-Cal Rx/HMO D-SNP Transition
12/22
All IEHP Pharmacy Providers
Claims Rejected in Error
12/19
All IEHP Pharmacy Providers
PBM Change & Prior Authorization Submission Method - for DualChoice (HMO D-SNP) Members (Effective January 1, 2023)
12/13-12/29
All IEHP Pharmacy Providers
Pharmacy Recalls, Withdrawals & Safety Alerts - November 2022
12/07
All IEHP Pharmacy Providers
CoverMyMeds - Prior Authorization Submission Method for DualChoice Members (Effective January 1, 2023)
12/01-12/12
All IEHP Pharmacy Providers
November 2022
Recalls, Withdrawals & Safety Alerts - October 2022
11/14
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts - September 2022
11/02
All IEHP Pharmacy Providers
COVID-19: Test to Treat Monoclonal Antibodies
11/01
All IEHP Pharmacy Providers
October 2022
Cal MediConnect to Medi-Cal Rx Transition (D-SNP)
10/28
All IEHP Pharmacy Providers
September 2022
Recalls, Withdrawals & Safety Alerts
09/08
All IEHP Pharmacy Providers
August 2022
2022-2023 Flu Vaccination for IEHP Members
08/31
All IEHP Pharmacy Providers
Reminder: Medi-Cal Rx Gradual Reinstatement of PAs - Phase 1
08/31
All IEHP Pharmacy Providers
30-Day Countdown: Reinstatement of PA Requirements for 11 Drug Classes
08/18
All IEHP Pharmacy Providers
30-Day Countdown: Reinstatement of PA Requirements for 11 Drug Classes
08/17
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts
08/10
All IEHP Pharmacy Providers
July 2022
Academic Detailing Services Now Offered
07/15
All IEHP Pharmacy Providers
DHCS Medi-Cal Rx Update: Postponement of Implementation of NCPDP Reject Code 80
07/13
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts
07/07
All IEHP Pharmacy Providers
June 2022
New DHCS DUR Board Educational Article
06/22
All IEHP Pharmacy Providers
MTM Medicare Pharmacy Mailing Campaign
06/08
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts
06/05
All IEHP Pharmacy Providers
Academic Detailing Services Now Offered
06/04
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: Blood Pressure Monitors and Cuffs
06/03
All IEHP Pharmacy Providers
Important Notice: COVID-19 Oral Antivirals Billing
06/01
All IEHP Pharmacy Providers
May 2022
Recalls, Withdrawals & Safety Alerts
05/05
All IEHP Pharmacy Providers
April 2022
Rejected Claims Due To Prescriber Error Codes
04/06
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts
04/05
All IEHP Pharmacy Providers
MTM COVID-19: Test to Treat
04/04
All IEHP Pharmacy Providers
March 2022
MTM Medicare Pharmacy Mailing Campaign
03/29
All IEHP Pharmacy Providers
New DHCS DUR Board Educational Article
03/16
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: How To Assist IEHP Members
03/28-03/31
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: How To Assist IEHP Members
03/21-03/25
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: How To Assist IEHP Members
03/14-03/18
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: How To Assist IEHP Members
03/07-03/11
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts
03/07
All IEHP Pharmacy Providers
IEHP Contracted DME Pharmacies: CGM, BP Monitor, Nebulizer
03/02
All IEHP Pharmacy Providers
February 2022
Medi-Cal Rx Transition: How To Assist IEHP Members
02/28-03/04
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: How To Assist IEHP Members
02/22-02/25
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: How To Assist IEHP Members
02/14-02/18
All IEHP Pharmacy Providers
Medi-Cal Rx Transition: How To Assist IEHP Members
02/10-02/11
All IEHP Pharmacy Providers
Pharmacy Empowerment Program
02/08
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts
02/07
All IEHP Pharmacy Providers
New DHCS DUR Board Educational Article
02/02
All IEHP Pharmacy Providers
January 2022
Free OTC COVID-19 Antigen Test Kits Available
01/31
All IEHP Pharmacy Providers
Medi-Cal Rx Transition Implementation
01/17-01/21
All IEHP Pharmacy Providers
Medi-Cal Rx Transition Implementation
01/10-01/14
All IEHP Pharmacy Providers
Medi-Cal Rx Transition Implementation
01/07
All IEHP Pharmacy Providers
Recalls, Withdrawals & Safety Alerts
01/05
All IEHP Pharmacy Providers
Pharmacy Services - Formulary
most appropriate, high quality and cost-effective drug therapies.
The Inland Empire Health Plan Pharmacy and Therapeutics (P & T) Subcommittee develops and monitors the Formulary. The P & T is composed of the IEHP Chief Medical Officer, Medical Directors, Director of Pharmaceutical Services, physicians from various medical specialties, local communities, and clinical pharmacists. This panel reviews the medications in all therapeutic categories based on safety, clinical efficacy, and cost-effectiveness and selects the most appropriate drugs in each class.
Formulary development and maintenance is a dynamic process. The IEHP P & T Subcommittee is responsible for developing, managing, updating and administering the Formulary. The Subcommittee also ensures that the IEHP Formulary remains responsive to the needs of our members and providers.
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Click here to download a free copy by clicking Adobe Acrobat Reader. By clicking on this link, you will be leaving the IEHP website.
IEHP Medi-Cal Formulary Items:
DHCS Noncapitated Physician Administered Drugs (PADs)
Medi-Cal Medical Benefit PA (PDF)
Medi-Cal Medical Benefit Formulary (PDF)
Referral Form for Medi-Cal Benefit (PDF)
Exceptions to criteria or requests for coverage of drugs not on the Medi-Cal Drug Benefit Formulary may be submitted by prescribers on the Referral Form for Medi-Cal Benefit.
Starting January 1, 2022, all IEHP Medi-Cal pharmacy services will be transitioned from managed care (MC) to fee for service (FFS). The Medi-Cal pharmacy benefits and services administered by the Department of Health Care Services (DHCS) will be identified collectively as "Medi-Cal Rx."
Magellan Medicaid Administration, Inc. (MMA) will assume operations for Medi-Cal Rx on behalf of DHCS.
For further information on Medi-Cal Rx, please visit: https://www.iehp.org/en/providers/pharmacy-services?target=medi-cal-rx
For more information on the Medi-Cal Rx Covered Drug List (CDL), please visit: https://medi-calrx.dhcs.ca.gov/home/cdl
IEHP DualChoice (HMO D-SNP) - Medicare-Medicaid Plan Items:
IEHP DualChoice (HMO D-SNP) Formulary Book (PDF)
Grievance Coverage Determination and Appeals Process
IEHP DualChoice (HMO D-SNP) Formulary Search Tool
E-prescribing Tips (PDF)
Information on this page is current as of October 2, 2023
Provider Resources - Forms
liance
Delegation Oversight Audit (DOA)
Grievance
Growth Chart
Health and Wellness
Historical Data Form
Inland Regional Center
Medi-Cal Letter Templates
Medicare-Medicaid Plan Letter Templates
D-SNP Letter Templates
Medicare
Non-Contracted Providers
Perinatal
Pharmacy
Provider Preventable Conditions (PPC)
UM/CM
Vision
Other
Behavioral Health
ABA 6 Month and Exit Progress Report Template (Word)
ABA Exit Letter Template (Word)
ABA Service Hour Log (Word)
ABA School BHT Services Request Form (Word)
Authorization Release of Information Form - English (PDF)
Authorization Release of Information Form - Spanish (PDF)
Behavioral Health Authorization Request Form (PDF)
BHT Social Skills Template (Word)
Coordination of Care Treatment Plan Form (PDF)
No Further Treatment Request Form (PDF)
Psych Testing Battery Plan (for Psychologist use only) (PDF)
(For BH Providers Only) Transition of Care Tool (PDF)
Claims
For Integrated Denial Notices please click here.
Please select on the links below to obtain the revised CMS 1500 form (version 02/12) and the CMS 1500 Reference Instruction Manual.
Acknowledgement Letter (Word)
Capitation Data File Format (Word)
Capitation Payment Deduction (Word)
Cease and Desist Letter (Word)
Claims Project Spreadsheet (Excel)
Clean Claim Tool Guide - UB04 Inpatient Form (PDF)
Clean Claim Tool Guide - UB04 Outpatient Form (PDF)
CMS 1500 Reference Instruction Manual (PDF)
Demand For Payment Letter (Word)
Determination Letter (Word)
Encounter Data CAP Request Letter (Word)
Encounter Data Penalty Letter (Word)
Hospital Directed Payment Dispute Form (Word)
ICE - Claim Denial Reason Guide - IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid) (Word)
Irrevocable Letter of Credit (Word)
Manifest Report (Word)
Medi-Cal Universe Layout Instructions (Word)
Notice of CAP Deductions (Word)
Notice of Denial of Payment - English (Word)
Notice of Denial of Payment - Spanish (Word)
Notice of Dismissal of Appeal Request (PDF)
Part C Organization Determinations, Appeals, and Grievances (ODAG) (PDF)
Payment Attestation (Word)
Provider Identified Overpayment Form (PDF)
Provider Identified Overpayment Form (Multiple) (PDF)
Provider Dispute Resolution (PDR) (PDF)
Remittance Advice - Medicare DualChoice Annual Visit (PDF)
Revised CMS 1500 Health Insurance Claim Form (PDF)
Sample Capitation Report (PDF)
Waiver of Liability Statement - IEHP Dual Choice (HMO D-SNP) - effective January 2023 (PDF)
Table 3 Payment Organization Determinations and Reconsiderations (PYMT_C) (PDF)
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Compliance
DHCS Privacy Incident Report (PDF)
Notice of Privacy Practices (Word)
IEHP Code of Business Conduct and Ethics (PDF)
Member Incentive Forms
Focus Group Incentive Program (FGI) - Request for Approval Form (Word)
Focus Group Incentive (FGI) Program - Evaluation Form (Word)
Member Incentive (MI) Program - Request for Approval (Word)
Member Incentive (MI) Program - Evaluation Form (Word)
Survey Incentive (SI) - Request for Approval Form (Word)
Survey Incentive (SI) - Evaluation Form (Word)
Nondiscrimination Language
Nondiscrimination Language Access Notice:
Medi-Cal (PDF)
Medicare (PDF)
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Delegation Oversight Audit (DOA)
Biographical Information Sheet
Credentialing DOA Audit Tool
HIPAA Security - Medi-Cal DOA
HIPAA Security - Medicare
Medi-Cal DOA Tool UM/CM/QI
Medicare DOA Tool UM/CM/QI
Medi-Cal UM Referral Template
Sub-Contracted Facility/Agency Services and Delegated Functions
Approved Referral Audit Tool (Excel)
California Specific - Reporting Requirements (PDF)
Care Coordinator to Member Ratio Template 5.1 (Excel)
Care Coordinator Training for Supporting Self-Direction (Excel)
Care Management California Children's Services Review Tool (PDF)
Care Transition Cases Log (Excel)
Credentialing and Recredentialing Report for Delegated Networks (Excel)
Credentialing and Recredentialing Report (Excel)
Delegation Oversight Audit Preparation Instructions - IEHP DualChoice (Word)
Delegation Oversight Audit Preparation Instructions - Medi-Cal (NCQA) (Word)
Delegation Oversight Audit Preparation Instructions - Medi-Cal (Word)
Denial Log Review Tool - IEHP DualChoice (Excel)
Denial Log Review Tool - IEHP Medi-Cal (Excel)
DOA CAP Response Form (Excel)
Enrollee Protections Reporting Template, CA2.1 (Excel)
IEHP ASM File Template (Excel)
IEHP Universe Expedited Auth MESAR Data Dictionary (PDF)
IEHP Universe Expedited Auth MESAR Template (Excel)
IEHP Universe M_Claims Data Dictionary (PDF)
IEHP Universe M_Claims Template (Excel)
IEHP Universe M_SAR Table 1 Standard and Expedited Service Authorization Requests (Excel)
IEHP Universe PYMT_C Table 3 Payment Organization Determinations and Reconsiderations (Excel)
IEHP Universe Standard Auth MSSAR Data Dictionary (PDF)
IEHP Universe Standard Auth MSSAR Template (Excel)
IPA Care Management Review Tool - IEHP DualChoice (PDF)
IPA Delegation Agreement - IEHP DualChoice (Word)
IPA Delegation Agreement - Medi-Cal (Word)
IPA Performance Evaluation Tool (Excel)
Medi-Cal Care Coordination Review Tool (PDF)
Medi-Cal Monthly Care Management Log (PDF)
Medi-Cal SPD Review Tool Data Dictionary (PDF)
MM Capitated Financial Alignment Model Reporting Requirements (PDF)
Monthly CCS Referral Log 2.0 (PDF)
Monthly Medicare Care Management Log 2.3 (PDF)
Monthly Medicare Plan Outreach Log 1.1 (PDF)
Practitioner Profile Template (Excel)
Precontractual Audit Preparation Instructions - IEHP DualChoice (Word)
Precontractual Audit Preparation Instruction - Medi-Cal (Word)
Program Description - Denial letter Sanction - IEHP DualChoice (PDF)
Referral Universe (Excel)
Request for UM Criteria Log (Word)
Response to Request for UM Criteria Letter (Word)
Second Opinion Tracking Log (Word)
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Grievance
The Grievance Forms below are for your Member's use when filing a complaint, or has an appeal regarding any aspect of care or service provided by you. Please select the Appeal and Grievance form appropriate for their use:
Medi-Cal Form
English (PDF)
Spanish (PDF)
Chinese (PDF)
Vietnamese (PDF)
Medicare Form
English (PDF)
Spanish (PDF)
Chinese (PDF)
Vietnamese (PDF)
The following IEHP DualChoice (HMO D-SNP) Letters will be effective January 1, 2023:
English (PDF)
Spanish (PDF)
Chinese (PDF)
Vietnamese (PDF)
Appeal Resolution Process - Medi-Cal - [English] (Word)
Appeal Resolution Process - Medi-Cal - [Spanish] (Word)
Grievance Resolution Process - Medi-Cal - [English] (Word)
Grievance Resolution Process - Medi-Cal - [Spanish] (Word)
Provider Fair Hearing Process (Word)
Provider Grievance Acknowledgement Letter (Word)
Provider Grievance Resolution Letter (Word)
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Growth Chart
Inland Empire Health Plan (IEHP) offers you easy access to useful reference materials and forms you may need. It's just one click away. Select the growth chart form that you need by clicking on the link below:
(0-36 months): Head Circumference-For-Age And Weight- For-Length Percentiles
Boys (PDF) Girls (PDF)
(0-36 months): Length and Weight-For-Age Percentiles
Boys (PDF) Girls (PDF)
(2-20 years): Stature and Weight-For-Age-Percentiles
Boys (PDF) Girls (PDF)
(2-20 years): Body Mass Index For-Age Percentiles
Boys (PDF) Girls (PDF)
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Health and Wellness
DPP Rx Pad (PDF)
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Historical Data Form
Historical Data Form (PDF)
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Inland Regional Center
Early Start (0-36 months) Referral (PDF)
Early Start Online Application
Eligibility and Intake
IRC Referrals (3-99+ years):
San Bernardino County: For Providers - (909) 890-4711 // Intake - (909) 890-3148
Riverside County: For Providers - (909) 890-4763 // Intake - (951) 826-2648
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Medi-Cal Letter Templates
A complete template includes all documents listed under each template in the order specified listed. Changes can only be made to highlighted areas, any changes made outside of the highlighted areas are strictly prohibited by DHCS.
Click on the title to expand the menu and download desired document.
Member Authorization Letter
English
Last Updated: 09/20/2022
Spanish
Last Updated: 09/20/2022
Chinese
Last Updated: 09/20/2022
Vietnamese
Last Updated: 09/20/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Continuity of Care Authorization Letter
English
Last Updated: 09/20/2022
Spanish
Last Updated: 09/20/2022
Chinese
Last Updated: 09/20/2022
Vietnamese
Last Updated: 09/20/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Notice of Action – Carve Out
English
Last Updated: 12/29/2022
Spanish
Last Updated: 12/29/2022
Chinese
Last Updated: 12/29/2022
Vietnamese
Last Updated: 12/29/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated May 22, 2023
Notice of Action - Delay
English
Last Updated: 12/27/2022
Spanish
Last Updated: 12/27/2022
Chinese
Last Updated: 12/27/2022
Vietnamese
Last Updated: 12/27/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated May 22, 2023
Notice of Action - Deny
English
Last Updated: 12/27/2022
Spanish
Last Updated: 12/27/2022
Chinese
Last Updated: 12/27/2022
Vietnamese
Last Updated: 12/27/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated May 22, 2023
Notice of Action - Modify
English
Last Updated: 12/28/2022
Spanish
Last Updated: 12/28/2022
Chinese
Last Updated: 12/28/2022
Vietnamese
Last Updated: 12/28/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated May 22, 2023
Notice of Action - Terminate
English
Last Updated: 01/06/2023
Spanish
Last Updated: 01/06/2023
Chinese
Last Updated: 01/06/2023
Vietnamese
Last Updated: 01/06/2023
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated May 22, 2023
Other Health Care Coverage Requesting Provider Letter
English
Last Updated: 03/17/2021
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Continuity of Care Terminate Letter
English
Last Updated: 09/20/2022
Spanish
Last Updated: 09/20/2022
Chinese
Last Updated: 09/20/2022
Vietnamese
Last Updated: 09/20/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Specialist Termination Letter
English
Last Updated: 09/20/2022
Spanish
Last Updated:09/20/2022
Chinese
Last Updated:09/20/2022
Vietnamese
Last Updated:09/20/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023
Prior Authorization Not Required
English
Last Updated: 09/20/2022
Spanish
Last Updated:09/20/2022
Chinese
Last Updated:09/20/2022
Vietnamese
Last Updated:09/20/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated August 14, 2023
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Medicare-Medicaid Plan Letter Templates
A complete template includes all documents listed under each template in the order specified listed. Changes can only be made to highlighted areas, any changes made outside of the highlighted areas are strictly prohibited by CMS.
Click on the title to expand the menu and download desired document.
Carve-Out Information Letter
English
Last Updated: 11/12/2017
Spanish
Last Updated: 10/31/2017
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Denial Reason Matrix
English
Last Updated: 07/03/2018
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Detailed Explanation of Non-Coverage
English
Last Updated: 12/17/2021
Spanish
Last Updated: 12/17/2021
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Detailed Notice of Discharge
English
Last Updated: 12/17/2021
Spanish
Last Updated: 12/17/2021
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Expedited Criteria Not Met
English
Last Updated: 10/31/2017
Spanish
Last Updated: 10/31/2017
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Extension Needed for Additional Information
English
Last Updated: 10/31/2017
Spanish
Last Updated: 10/31/2017
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Integrated Denial Notice - Part B Drugs - 7 day appeal - IPA
English
Last Updated: 02/14/2022
Spanish
Last Updated: 02/14/2022
Chinese
Last Updated: 02/14/2022
Vietnamese
Last Updated: 02/14/2022
Independent Medical Review - [English] [Spanish] [Chinese] [Vietnamese] Updated October 7, 2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Integrated Denial Notice - Part C - 30 day appeal - IPA
English
Last Updated: 03/08/2022
Spanish
Last Updated: 02/14/2022
Chinese
Last Updated: 02/14/2022
Vietnamese
Last Updated: 02/14/2022
Independent Medical Review - [English] [Spanish] [Chinese] [Vietnamese] Updated October 7, 2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Integrated Denial of Payment Notice - 7 day appeal - IPA
English
Last Updated: 03/17/2021
Spanish
Last Updated: 10/18/2021
Independent Medical Review - [English] [Spanish] [Chinese] [Vietnamese] Updated October 7, 2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Integrated Denial of Payment Notice - 30 day appeal - IPA
English
Last Updated: 03/17/2021
Spanish
Last Updated: 04/12/2017
Independent Medical Review - [English] [Spanish] [Chinese] [Vietnamese] Updated October 7, 2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Notice of Authorization of Services
English
Last Updated: 10/31/2017
Spanish
Last Updated: 10/31/17
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Notice of Dismissal of Coverage
English
Last Updated:03/10/2022
Spanish
Last Updated:03/10/2022
Chinese
Last Updated:03/10/2022
Vietnamese
Last Updated:03/10/2022
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Notice of Medicare Non-Coverage
English
Last Updated: 10/31/2017
Spanish
Last Updated: 10/31/2017
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
Notice of Reinstatement of Coverage
English
Last Updated: 10/31/2017
Spanish
Last Updated: 10/31/2017
Nondiscrimination Notice & Taglines - [English] [Spanish] [Chinese] [Vietnamese] Updated October 27, 2022
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NEW D-SNP Letter Templates
These templates should not be used until the effective date of January 2, 2023. Please continue using the current Medicare DualChoice letter templates currently seen on this webpage for the remainder of 2022.
A complete template includes all documents listed under each template in the order specified listed. Changes can only be made to highlighted areas, any changes made outside of the highlighted areas are strictly prohibited by CMS.
Click on the title to expand the menu and download desired document.
AOR Dismissal Letter
English
Last Updated: 09/26/2022
Spanish
Last Updated:09/26/2022
Chinese
Last Updated:09/26/2022
Vietnamese
Last Updated:09/26/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
AOR Request Letter
English
Last Updated: 09/26/2022
Spanish
Last Updated:09/26/2022
Chinese
Last Updated:09/26/2022
Vietnamese
Last Updated:09/26/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Continuity of Care - Notice of Authorization
English
Last Updated:08/24/2023
Spanish
Last Updated:08/24/2023
Chinese
Last Updated:08/24/2023
Vietnamese
Last Updated:08/24/2023
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Continuity of Care – Notice of Termination
English
Last Updated: 09/26/2022
Spanish
Last Updated:09/26/2022
Chinese
Last Updated:09/26/2022
Vietnamese
Last Updated:09/26/2022
Nondiscrimination Notice, Tagline, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Detailed Explanation of Non-Coverage
English
Last Updated: 09/26/2022
Spanish
Last Updated:09/26/2022
Chinese
Last Updated:09/26/2022
Vietnamese
Last Updated:09/26/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Detailed Notice of Discharge
English
Last Updated: 12/20/2022
Spanish
Last Updated:12/20/2022
Chinese
Last Updated:12/20/2022
Vietnamese
Last Updated:12/20/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Expedited Criteria Not Met
English
Last Updated: 09/26/2022
Spanish
Last Updated: 09/26/2022
Chinese
Last Updated: 09/26/2022
Vietnamese
Last Updated: 09/26/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Extension Needed for Additional Information
English
Last Updated: 09/26/2022
Spanish
Last Updated: 09/26/2022
Chinese
Last Updated: 09/26/2022
Vietnamese
Last Updated: 09/26/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Informational Letter to Beneficiary and PCP
English
Last Updated: 09/26/2022
Spanish
Last Updated: 09/26/2022
Chinese
Last Updated: 09/26/2022
Vietnamese
Last Updated: 09/26/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Notice of Authorization of Services
English
Last Updated: 09/27/2022
Spanish
Last Updated: 09/27/2022
Chinese
Last Updated: 09/27/2022
Vietnamese
Last Updated: 09/27/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Notice of Dismissal of Coverage Request
English
Last Updated: 09/26/2022
Spanish
Last Updated: 09/26/2022
Chinese
Last Updated: 09/26/2022
Vietnamese
Last Updated: 09/26/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Notice of Medicare Non-Coverage
English
Last Updated:09/27/2022
Spanish
Last Updated:09/27/2022
Chinese
Last Updated:09/27/2022
Vietnamese
Last Updated:09/27/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Cancelled Relocation Letter
English
Last Updated: 09/22/2022
Spanish
Last Updated:09/22/2022
Chinese
Last Updated:09/22/2022
Vietnamese
Last Updated:09/22/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Long-Term Care IPA and PCP Change Letter
English
Last Updated: 09/26/2022
Spanish
Last Updated:09/26/2022
Chinese
Last Updated:09/26/2022
Vietnamese
Last Updated:09/26/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Coverage Decision Letter Part B - 7 Day Appeal
English
Last Updated: 10/03/2022
Spanish
Last Updated:10/03/2022
Chinese
Last Updated:10/03/2022
Vietnamese
Last Updated:10/03/2022
*Additional Information for IPAs: Please include the integrated Coverage Decision Letter, the most recent IMR form, application instructions, DMHC’s toll-free telephone number, and an envelope addressed to DMHC.
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated January 01, 2023
State Fair Hearing Form - [English] [Spanish] [Chinese] [Vietnamese] Updated September 01, 2021
Coverage Decision Letter Medical – 30 Day Appeal
English
Last Updated: 10/03/2022
Spanish
Last Updated:10/03/2022
Chinese
Last Updated:10/03/2022
Vietnamese
Last Updated:10/03/2022
*Additional Information for IPAs: Please include the integrated Coverage Decision Letter, the most recent IMR form, application instructions, DMHC’s toll-free telephone number, and an envelope addressed to DMHC.
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
Independent Medical Review (IMR) Form - [English] [Spanish] [Chinese] [Vietnamese] Updated January 01, 2023
State Fair Hearing Form - [English] [Spanish] [Chinese] [Vietnamese] Updated September 01, 2021
Coverage Decision Letter - Claims
English
Last Updated: 11/22/2022
Spanish
Last Updated:11/22/2022
Chinese
Last Updated:11/22/2022
Vietnamese
Last Updated:11/22/2022
Nondiscrimination Notice, Taglines, Language Insert - [English] [Spanish] [Chinese] [Vietnamese] Updated July 14, 2023
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Medicare
Certificates of Medical Necessity (CMN) & DME Information Forms (DIF)
Positive Airway Pressure Devices for Obstructive Sleep Apnea (PDF)
Enteral and Parenteral Nutrition (PDF)
External Infusion Pump (PDF)
Osteogenesis Stimulators (PDF)
Oxygen (PDF)
Seat Lift Mechanisms (PDF)
Continuation Form (PDF)
Transcutaneous Electrical Nerve Stimulator (TENS) (PDF)
Pneumatic Compression Device (PDF)
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Non-Contracted Providers
To submit a referral to IEHP, please fill out the referral form below, include all clinical notes and fax it to IEHP. If you are referring back to yourself, please indicate such. If you need IEHP to direct the referral, please indicate that on the form.
Referral Authorization Request Form - Non-Contracted Providers (PDF)
If you are interested in becoming a network Provider, please click here.
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Perinatal
IEHP provides standard risk assessment forms that can be used by all Providers of obstetrical (OB) services. Please refer to IEHP Provider Policy 10D1, "Obstetrical Services, Guidelines for Obstetrical Services" for further detail. To obtain copies, simply click on the links below.
Edinburgh Postnatal Depression Screening Tool - English (PDF)
Edinburgh Postnatal Depression Screening Tool - Spanish (PDF)
ACOG Antepartum Record (PDF)
California Prenatal Screening Program (PDF)
Contraceptive Informed Choice Form - English (Word)
Contraceptive Informed Choice Form - Spanish (Word)
Initial Perinatal Risk Assessment Form - English (Word)
Initial Perinatal Risk Assessment Form - Spanish (Word)
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Pharmacy
Click here for Pharmacy forms.
Part D Excluded Provider Letter - English (Word)
Part D Excluded Provider Letter - Spanish (Word)
Prescription Transition Notice - English (PDF)
Prescription Transition Notice - Spanish (PDF)
Request for Addition or Deletion of a Drug to the Formulary (PDF)
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Provider Preventable Conditions (PPC)
By clicking on these links, you will be leaving the IEHP website.
On May 23,2017, the Department of Healthcare Services (DHCS) released All Plan Letter (APL) 17-009, reporting requirements related to Provider Preventable Conditions. In conjunction, DHCS released Dual Plan Letter (DPL) 17-002. As part of these instructions, the Health Plan, Network Providers, Delegates, Contracted Hospitals, and ambulatory surgical centers must report using PPC Form on DHCS secure online portal for both Medicare and Medi-Cal lines of business.
Further information is available on the following pages:
Instructions for Completing Online Reporting of PPCs
Medi-Cal Guidance on Reporting Provider-Preventable Conditions
Frequently Asked Questions
All Plan Letter (APL) 17-009
Duals Plan Letter (DPL) 17-002
PPC Form
Medicare and Medi-Cal lines of business must follow the instructions below:
Providers are REQUIRED to send a copy of the completed PPC submission from the DHCS secure online portal to IEHP by fax at (909) 890-5545 within five (5) business days of reporting to DHCS;
IEHP does not pay Provider claims nor reimburse a Provider for a PPC, in accordance with 42 CFR Section 438.3(g) and IEHP's three-way Cal MediConnect contract. Per IEHP policy and the Coordinated Care Initiative 3-Way Contract, IEHP reserves the right to recover or recoup any claim related to a PPC;
As outlined in both the APL/DPL - Reporting Requirements related to Provider Preventable Conditions, the following classify as PPCs and must be reported:
Category 1 - HCACs (For Any Inpatient Hospital Setting in Medicaid)
Any unintended foreign object retained after surgery
A clinically significant air embolism
An incidence of blood incompatibility
A stage III or stage IV pressure ulcer that developed during the patient's stay in the hospital
A significant fall or trauma that resulted in fracture, dislocation, intracranial injury, crushing injury, burn, or electric shock
A catheter-associated urinary tract infection
Vascular catheter-associated infection
Any of the following manifestations of poor glycemic control: diabetic ketoacidosis; nonketotic hyperosmolar coma; hypoglycemic coma; secondary diabetes with ketoacidosis; or secondary diabetes with hyperosmolarity
A surgical site infection following:
Coronary artery bypass graft (CABG) - mediastinitis
Bariatric surgery; including laparoscopic gastric bypass, gastroenterostomy, laparoscopic gastric restrictive surgery
Orthopedic procedures; including spine, neck, shoulder, elbow
Cardiac implantable electronic device procedures
Deep vein thrombosis/pulmonary embolism following total knee replacement or hip replacement with pediatric and obstetric exceptions
Latrogenic pneumothorax with venous catheterization
A vascular catheter-associated infection
Category 2 - Other Provider Preventable Conditions (For Any Health Care Setting)
Wrong surgical or other invasive procedure performed on a patient
Surgical or other invasive procedure performed on the wrong body part
Surgical or other invasive procedure performed on the wrong patient
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UM/CM
Acute Hospital Discharge Needs Request Form (PDF)
Acute Inpatient Data Sheet (Word)
Advance Health Care Directive - [English] (PDF)
Advance Health Care Directive - [Spanish] (PDF)
Advance Health Care Directive FAQs - [English] (Word)
Advance Health Care Directive FAQs - [Spanish] (Word)
Authorization or Refusal to Release Medical Record - Out of Network Family Planning - [English] (PDF)
Authorization or Refusal to Release Medical Record - Out of Network Family Planning - [Spanish] (PDF)
Authorization for Use and/or Disclosure of Patient Health Information - English (PDF)
Authorization for Use and/or Disclosure of Patient Health Information - Spanish (PDF)
Behavioral Health Hospital Survey - Corrective Action Plan Tool (PDF)
Behavioral Health Hospital Survey Tool (PDF)
California Minor Consent and Confidentiality Laws (PDF)
Care Management Referral Form (PDF)
CCS-GHPP Client Service Auth Request - Established Case (PDF)
CCS-GHPP Client Service Auth Request - New Case (PDF)
Consent for HIV Test - English (PDF)
Consent for HIV Test - Spanish (PDF)
Consent for Special Procedure - English (Word)
Consent for Special Procedure - Spanish (PDF)
Corrective Action Plan Notification Tool (PDF)
Desert AIDS Project Enrollment Form (PDF)
DMHC Provider Appointment Availability Survey Methodology (PDF)
DMHC Provider Appointment Availability Survey Tools (PDF)
GHPP Application to Determine Eligibility (PDF)
Health Plan Referral Form for Out-of-Network and Special Services (Word)
Health Risk Assessment (HRA) - IEHP DualChoice (HMO D-SNP) - English (PDF) - effective 1/1/2023
Health Risk Assessment (HRA) - IEHP DualChoice (HMO D-SNP) - Spanish (PDF) - effective 1/1/2023
Health Risk Assessment (HRA) - IEHP DualChoice (HMO D-SNP) - Chinese (PDF) - effective 1/1/2023
Health Risk Assessment (HRA) - IEHP DualChoice (HMO D-SNP) - Vietnamese (PDF) - effective 1/1/2023
HIV Testing Sites - Riverside and San Bernardino (PDF)
Home Health Check Off List (PDF)
Home Modification Consent Form - English (PDF) - effective 04/01/2023
Home Modification Consent Form - Spanish (PDF) - effective 04/01/2023
Home Modification Consent Form - Chinese (PDF) - effective 04/01/2023
Home Modification Consent Form - Vietnamese (PDF) - effective 04/01/2023
IEHP Medical Record Review Survey Addendum (PDF)
Interim Facility Site Review (Assessment) Tool (PDF)
Interim Facility Site Review (On-Site) Tool (PDF)
Long Term Care Initial Review Form (Word)
Long Term Care (LTC) Follow-Up Review Form (Word)
Long Term Care (LTC) Data Sheet (PDF)
MC 171 Form and Instruction 05-07 (PDF)
Medi-Cal FFS-Approved Transplant Centers of Excellence (PDF)
Medicare Non-Covered Benefits (Word)
My Path Palliative Care Program CAP Form (PDF)
Non-Emergency Medical Transportation (NEMT) Physician Certification Statement (PCS) (PDF)
PCP Referral Tracking Log (Word)
Periodicity Schedule - Dental (PDF)
Provider Appointment Availability Survey Manual (PDF)
Referral Audit CAP Notification Letter (Word)
Referral Audit Corrective Action Plan Tool (Word)
Referral Form (PDF)
Reportable Diseases and Conditions - Riverside (PDF)
Reportable Diseases and Conditions - San Bernardino (PDF)
Service Request Form for Skilled Nursing Facilities (PDF)
Service Request for Skilled Nursing Facilities (PDF)
SNF Initial Review (PDF)
SNF Follow-up Review (PDF)
Specialty Office Service Authorization Sets Grid (Word)
Standing Referral and Extended Access Referral to Specialty Care (PDF)
Sterilization Consent Form PM-330
PM-330 Form - Tips and Example (PDF)
PM-330 Form - English (PDF)
PM-330 Form - Spanish (PDF)
Transplant Team Referral Form (Word)
Transportation Requests Form (SNF & LTC) (PDF)
Transportation Requests Form (Hospital) (PDF)
UM Timeliness Standards - IEHP DualChoice (Word)
UM Timeliness Standards - Medi-Cal (Word)
Urgent Care CAP Complete Tool and Notification Letter (PDF)
Wound Assessment - Admission (PDF)
Wound Assessment - Follow - Up (PDF)
Wound Assessment - Addendum (PDF)
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Vision
Ophthalmologist Referral Form (PDF)
Vision Exception Request (VER) Form (PDF)
PCP Vision Report Form (PDF)
IEHP Lab Form (PDF)
Medi-Cal Non-Covered Services/Materials Waiver Form-English (PDF)
Medi-Cal Non-Covered Services/Materials Waiver Form-Spanish (PDF)
Medi-Cal Non-Covered Services/Materials Waiver Form-Chinese (PDF)
Medi-Cal Non-Covered Services/Materials Waiver Form-Vietnamese (PDF)
The following IEHP DualChoice (HMO D-SNP) Letters will be effective January 1, 2023:
IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-English (PDF)
IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-Spanish (PDF)
IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-Chinese (PDF)
IEHP DualChoice (HMO D-SNP) Non-Covered Services/Materials Waiver Form-Vietnamese (PDF)
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Other
AEVS Alpha Codes (PDF)
Attachment I - Statement of Agreement by Supervising Provider (PDF)
Authorization of Release - Use & Disclosure of PHI - English (PDF)
Authorization of Release - Use & Disclosure of PHI - Spanish (PDF)
Bariatric Surgeon Case Volume Attestation (PDF)
BIC Card (Word)
Change in Hospital Affiliation Letter (Word)
Change in IPA Affiliation Letter (Word)
Chronic Care Improvement Program (CCIP) Planning & Reporting Document (Word)
Corrective Action Plan Notification Tool (Word)
CMS 1696 Appointment of Representative - English (PDF)
CMS 1696 Appointment of Representative - Spanish (PDF)
Compliant Termination Letter (Word)
Contract Maintenance Request Form (PDF)
Coverage Determination Form - Provider and Member - [Chinese] (Word)
Coverage Determination Form - Provider and Member - [Spanish] (Word)
Credentialing Subcommittee Termination Letter (PDF)
Death Master File Identity Attestation (PDF)
Delegation of Services Agreement and Supervising Physician Form (PDF)
DHCS MMCD Facility Site Review (FSR) Standards (PDF)
DHCS MMCD Facility Site Review (FSR) Tool (PDF)
DHCS MMCD FSR Attachment 0C - Physical Accessibility Review Survey (Word)
DHCS MMCD FSR Attachment 0D - Ancillary Physical Accessibility Review Survey (PDF)
DHCS MMCD FSR Attachment 0E - CBAS Physical Accessibility Review Survey (PDF)
DHCS MMCD Medical Record Review (MRR) Standards (PDF)
DHCS MMCD Medical Record Review (MRR) Tool (PDF)
Frozen Enrollment Change Status (Word)
Hospital Admitting Arrangement Attestation - Admitter (PDF)
Hospital Admitting Arrangement Attestation - Admitting Physician (PDF)
Hospital Admitting Arrangement Attestation - Hospitalist (PDF)
Hospital Admitting Privileges Reference by Specialty (PDF)
Hospital Geographic Service Areas (Word)
IEHP Addendum E (PDF)
IEHP ID Card - Medi-Cal (Word)
IEHP ID Card - DualChoice (PDF)
IEHP Interim Facility Site Review Tool (Word)
IEHP Medical Record Review Survey Addendum (PDF)
IEHP Urgent Care Center Evaluation Tool (PDF)
IEHP PCP Leave of Absence Coverage Form (Word)
IEHP Peer Review Level I and Credentialing Appeal (PDF)
IEHP Peer Review Process and Level II Appeal (PDF)
IPA Hospital Link Responsibility Grid - IEHP DualChoice (Excel)
IPA Hospital Link Responsibility Grid - Medi-Cal (PDF)
Licensed Midwife Attestation (PDF)
Limited Enrollment Change Status (Word)
Member PCP Termination Notification Letter - [English] (Word)
Member PCP Termination Notification Letter - [Spanish] (Word)
Non-Compliant Termination Letter (Word)
Over Enrollment Change Status (Word)
Patient Transfer Agreement (PDF)
Peer Review Termination Letter (PDF)
Persons with Disabilities Workgroup Application (Word)
Plan Choice Form - Riverside - English - Medi-Cal (PDF)
Plan Choice Form - Riverside - Spanish - Medi-Cal (PDF)
Plan Choice Form - SB - English - Medi-Cal (PDF)
Plan Choice Form - SB - Spanish - Medi-Cal (PDF)
Prescribing Arrangements for DEA and CDS Eligible Practitioners (PDF)
Provider Preventable Conditions (Word)
Provider Privilege Adjustment Request Form (PDF)
Specialty Network Review (PDF)
Specialty Network Review - IEHP Initial Findings Template (Excel)
Specialty Network Review - IPA Response Template (Excel)
The Code of Conduct of the Persons with Disabilities Workgroup (Word)
Transgender Questionnaire (PDF)
Urgent Care CAP Complete Tool and Notification Letter (Word)
Verification of Qualifications for HIV/AIDS Physician Specialists (PDF)
Work History Form Past Five (5) Years' Request (PDF)
2017 Model Output Report (MOR) Data File Layout (PDF)
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