Compliance
Compliance Program
Our Compliance Program is designed to:
- Ensure we comply with applicable laws, rules, and regulations
- Reduce or eliminate Fraud, Waste, and Abuse (FWA)
- Prevent, detect, and correct non-compliance
- Reinforce our commitment to culture of compliance for which we strive
- Establish and implement our shared commitment to honesty, integrity, transparency, and accountability
Code of Business Conduct and Ethics
Inland Empire Health Plan (IEHP) expects Team Members and business entities doing business with IEHP to conduct business activities in an ethical and professional manner that promotes public trust and confidence in the integrity of IEHP. The Code is meant to provide guidance about the compliance culture at IEHP and the role that each Team Member, including management, Chief Officers and the Governing Board, plays in building and preserving that culture.
Compliance, Fraud, Waste, and Abuse (FWA), and Privacy Program Training
The IEHP Compliance, FWA, and Privacy Training Program focuses on the elements of an effective Compliance Program, conduct & ethics, and the Fraud, Waste and Abuse and Privacy Programs.
IEHP requires delegated entities to provide Compliance Training to their employees, Providers, downstream entities, Board of Directors, and Contractors within 90 days of hire/start.
IEHP is committed to a culture of compliance, ethics, and integrity, the goal of Compliance Training is to provide all associated parties the ability to demonstrate awareness of IEHP’s requirements, including regulations and policies & procedures associated with Compliance as it relates to daily work.
If you have questions or additional suggestions, please e-mail The IEHP Compliance Department at compliance@iehp.org.
General Compliance Training (PDF)
Eligibility to Participate in Federal and State Health Program
Inland Empire Health Plan (IEHP) is prohibited from issuing payment for services provided, ordered, or prescribed by an individual or entity that is excluded, ineligible, or terminated from participation in State and Federal health care programs in accordance with regulatory and contractual requirements.
IEHP conducts regular reviews of the following Federal and State exclusionary lists:
- Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE list)
- GSA Excluded Parties List System (EPLS)
- DHCS Medi-Cal Suspended and Ineligible Provider List
Exclusion Screening
IEHP has a screening process to identify individuals and entities that appear on the DHHS OIG LEIE, the GSA EPLS, the Medicare Opt-Out List and the DHCS Medi-Cal Suspended and Ineligible Provider List prior to appointment, contracting, and/or employment and monthly thereafter to ensure that none of these individuals or entities are excluded, ineligible or terminated from participation in State and Federal programs.
Delegated entities must implement a screening program for employees, Board Members, contractors, and business partners to avoid relationships with individuals and/or entities that tend toward inappropriate conduct.
This program includes:
- Prior to contracts and monthly thereafter, review of the GSA System for Award Management (SAM), the Department of Health Care Services Medi-Cal Suspended and Ineligible list, and the Office of Inspector General’s (OIG) List of Excluded Individuals and Entities (LEIE) that are excluded from participation in government health care programs (42 CFR §10011901).
- A monthly review of the Department of Health Care Services Medi-Cal Suspended and Ineligible list.
- Criminal record checks when appropriate or as required by law.
- Review of the National Practitioner Databank (NPDB).
- Review of professional license status for sanctions and/or adverse actions.
- Reporting results to Compliance Committee, Governing Body, and IEHP as necessary.
Fraud, Waste, and Abuse (FWA)
IEHP has established a Fraud, Waste, and Abuse Program to detect, correct, and prevent fraud, waste, and abuse on part of Team Members, IEHP Members, Providers, Vendors, delegated entities and any other entity doing business with IEHP.
Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program, or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health care benefit program.
Examples include:
- Knowingly billing for services or prescriptions not furnished or supplies not provided
- Knowingly altering claim forms for a higher payment
- Selling medicine, medical equipment, or other things received through IEHP
Waste includes overuse of services, or other practices that, directly or indirectly, result in unnecessary costs. Waste is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources.
Examples include:
- Conducting excessive office visits
- Writing excessive prescriptions or ordering excessive tests
- Prescribing more medications than necessary for the treatment of a specific condition
Abuse includes actions that may, directly or indirectly, result in unnecessary costs and improper payment or services. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment.
Examples include:
- Billing for unnecessary medical services or medical equipment
- Billing for brand name drugs when generics are dispensed
- Misusing codes on a claim, such as upcoding and unbundling codes.
Report potential FWA Click Here (By clicking on this link, you will be leaving the IEHP website).
Privacy Incident/ Breach
IEHP has established a HIPAA Privacy Program to ensure that Member’s health information is properly protected while allowing the flow of health information needed to provide and promote high-quality health care.
A privacy breach is defined as unauthorized acquisition, access, use, or disclosure of protected health information (PHI) which compromises the security or privacy of such information.
PHI is health information that relates to a Member’s past, present or future physical or mental health or condition, including the provision of his/her health care, or payment for that care and contains personally identifiable information (PII) such as name, SSN, DOB, Member ID, address, or any other unique identifier related to the Member.
This generally means that a breach occurs when PHI is accessed, used, or disclosed to an individual or entity that does not have a business reason to know that information. The law does allow information to be accessed, used, or disclosed when it is related to treatment, payment, or healthcare operations directly associated with the work that we do at IEHP on behalf of our Members.
Report a Privacy Incident/Breach Click Here (By clicking on this link, you will be leaving the IEHP website).
Reporting Information
IEHP has the following resources available for reporting fraud, waste or abuse, Privacy issues, and other compliance issues:
Compliance Hotline: (866) 355-9038
Fax: (909) 477-8536
E-mail: compliance@iehp.org.
Mail:
IEHP Compliance Officer
P.O. Box 1800
Rancho Cucamonga, CA 91729-1800
Online: Report a Compliance Issue Click Here (By clicking on this link, you will be leaving the IEHP website).
Frequently Asked Questions (FAQs)
What are some common examples of fraud?
Providers
- Billing for services not rendered
- Paying a "kickback" in exchange for a referral for medical services or goods
- Unbundling
- Overcharging for services or goods
- Using false credentials
Members
- Allowing unauthorized individuals to use ID card to obtain benefits
- Altering prescriptions
- Falsifying residence information to obtain benefits
- Drug seeking or doctor shopping to obtain narcotics
What do I do if I suspect an IEHP Member is engaging in possible fraud, waste or abuse?
First, document your suspicions. Then, contact IEHP’s Compliance Department at (866) 355-9038 and explain the case to one of our Representatives. At times, IEHP may request additional information that is necessary to investigate the case. Thus, Provider documentation is strongly encouraged.
IEHP also has the following resources available for reporting fraud, waste or abuse, Privacy issues, and other compliance issues:
Compliance Hotline: (866) 355-9038
Fax: (909) 477-8536
E-mail: compliance@iehp.org
Mail:
IEHP Compliance Officer
P.O. Box 1800
Rancho Cucamonga, CA 91729-1800
Online: (By clicking on the following links, you will be leaving the IEHP website)
Report a Compliance Issue Click Here
Report a Privacy Incident/Breach Click Here
Report potential FWA Click Here
What do I do if my facility has made some billing errors?
If you suspect that errors in billing may have occurred, contact your IEHP Provider Services Representative at (909) 890-2054.
What are some other things I can do as a Provider?
- Periodically perform internal audits of billing practices and compare billing records with payments received.
- Do not leave prescription pads, which include a Provider's identification and license number, out in the open. For example, do not store prescription pads in exam room cabinets or leave on office counters.
Guidelines for Care Management Training
The Centers for Medicare & Medicaid Services (CMS) and the Department of Health Care Services (DHCS) require that IEHP staff and contracted Delegates, Practitioners, and Providers receive training on the Cal MediConnect program and IEHP’s model of care:
- Interdisciplinary Care Team (ICT) Fact Sheet (PDF)
- IEHP Guidelines for Care Management Training (Printable) (PDF)
- IEHP Guidelines for Care Management Training (HTML)
Member Incentive Forms
- Focus Group Incentive (FGI) - Request for Approval Form (PDF)
- Focus Group Incentive (FGI) - Evaluation Form (PDF)
- Member Incentive (MI) Program - Request for Approval (PDF)
- Member Incentive (MI) Program - Annual Update/End of Program Evaluation (PDF)
- Survey Incentive (SI) - Request for Approval Form (PDF)
- Survey Incentive (SI) - Evaluation Form (PDF)
Contact the OIG
The Office of the Inspector General (OIG) is there to assist you and maintains a hotline, which offers a confidential means for reporting vital information. For information on confidentiality, please contact the hotline and ask about their confidential source program. Each caller is encouraged to assist the OIG by providing information on how they can be contacted for additional information but the caller may remain anonymous.
Contacting the Office of the Inspector General
Phone: (800) HHS-TIPS (447-8477)
E-mail: Htips@oc.dhhs.gov
Additional Hotlines
DHCS MEDI-Cal Fraud Hotline
Phone: (800) 822-6222
E-mail: stopmedicalfraud@dhs.ca.gov
The recorded message may be heard in English and four other languages: Spanish, Vietnamese, Cambodian, and Russian. The call is free and the caller may remain anonymous.
Fraud Prevention
Fraud Prevention, it's a Team Effort
In an effort to prevent fraud and abuse, IEHP encourages Providers and their staff to report any suspicious circumstances when they arise. You may want to ask for another form of identification in addition to the IEHP Member identification card. Identification with both a picture and a signature, such a valid driver's license or State identification card, are suggested. We are informing Members of this concern and are requesting that they have additional identification available when they come to you.
To obtain more compliance guidelines, the Department of Health and Human Services (HHS) offers assistance (By clicking on this link, you will be leaving the IEHP website).
Nondiscrimination Language
Nondiscrimination Language Access Notice:
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.
Claims
Medi-Cal Learning Portal 
The Medi-Cal Learning Portal provides extensive resources and a broad range of topics for all types of Providers with questions regarding billing requirements and claims processing guidelines. Resources are not limited to webinars, computer based training, and webinars. Providers also have direct access to their Regional Representative and the Small Provider Billing Unit (SPBU) through this link (By clicking on this link, you will be leaving the IEHP website) https://learn.medi-cal.ca.gov/.
Medi-Cal Rates and Codes
By clicking on these links, you will be leaving the IEHP website.
Medi-Cal Rates
The file lists the maximum reimbursement rates payable by the Medi-Cal program for covered procedures described in the HCPCS and CPT-4 coding system.
Resource: website
CPT Codes
This website is aimed at providing information to Providers on Medicare's National CCI edits, but will not address specific CCI edits.
Resource: website
Alpha-Numeric HCPCS Files
These files contain the Level II alpha-numeric HCPCS procedure and modifier codes, their long and short descriptions, and applicable Medicare administrative, coverage, and pricing data.
Resource: website
ZIP code To Carrier Locality File
This file is primarily intended for use by ambulance suppliers to map ZIP Codes to CMS carriers and localities. This file will also map ZIP Codes to their State and can determine whether the ZIP Code has a rural designation as determined by CMS.
Resource: website
Medicare Physician Fee Schedule
Information on services covered by the Medicare Physician Fee Schedule (MPFS).
Resource: website
Educational Opportunities
Interdisciplinary Care Team (ICT) Fact Sheet (PDF)
Healthcare Provider Toolkit: Assisting Patients with Requests for Workplace Accommodations or Leaves of Absence (PDF)
Specialty Mental Health Care Coordination
The Centers for Medicare and Medicaid Services (CMS) is requiring IEHP and its IPAs to document and report the efforts made to coordinate the care of IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) Members receiving specialty mental health services through the County Mental Health Plans. As of June 1, 2018, IEHP has put policies and procedures in place to comply with these process and reporting requirements:
- On the first (1st) of each month, IEHP will provide IPAs and County MH Clinics a list of IEHP DualChoice Members known to be receiving specialty mental health services through the County MH Plans.
- IPAs are expected to outreach to these Members and their County MH Clinic Provider, as well as, document their outreach attempts and outcomes as outlined in Policy 12A2, “Care Management Requirements – IPA Responsibilities.”
- IPAs are required to provide data elements specific to this measure, as outlined in Policy 21F, “Medicare MMP Reporting Requirements – IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan) and Attachment, “Medicare Provider Reporting Requirements Schedule” in Section 21.
- IEHP, through its Delegation Oversight process, will monitor the IPAs’ compliance with documentation and reporting requirements, as outlined in Policy 13G, “Delegation Oversight Audit.”
To access the On-Site training material presented to IPAs and County Mental Health Clinics, click here (PDF).
Staying Healthy Assessment (SHA) Training
The Staying Healthy Assessment (SHA) forms consist of seven age-specific pediatric questionnaires and two adult questionnaires. The Primary Care Physician (PCP) is responsible for ensuring the SHA is administered to each Member within 120 days of enrollment and may be administered as part of the Member's initial health assessment. The training resources below provide information on completing the SHA for your patients.
- Staying Healthy Assessment (SHA) Training (PDF)
- SHA Pediatric Questions by Age Group (PDF)
- SHA Adult Questions by Age Group (PDF)
- Alternative IHEBA Review Form (PDF)
- Bright Futures Notification Form (PDF)
- SHA Format Notification Form (PDF)
Providers must complete the SHA Training. Please do not forget to fax in the Proof of Training Form to (909) 890-2968 when the training has been completed.
To access the SHA questionnaires under Forms, please click here.
Online Cultural Competency Training
AHRQ Health Literacy Modules Available for Continuing Education (CE) and Maintenance of Certification (MOC) Credit
Physicians and nurses can earn CE credits while learning about the challenges in caring for patients with low health literacy as well as strategies to improve overall patient communication and care. OptumHealth Education is issuing continuing education credit for taking the AHRQ-developed Health Literacy Knowledge Self-Assessment. No fees are charged for the two CE activities:
By clicking on these links, you will be leaving the IEHP website.
1. An Updated Overview of Health Literacy
Link (optumhealtheducation.com)
2. Improving Health Literacy by Improving Communication Skills
Link (optumhealtheducation.com)
Pediatricians and family physicians can earn credit for re-certification (MOC Part 2) as well as CE by taking the Health Literacy Knowledge Self-Assessment through the American Board of Pediatrics and the American Academy of Family Physicians, respectively.
To learn about AHRQ’s tools to address health literacy, visit Health Literacy Topics at https://www.ahrq.gov/health-care-information/topics/topic-health-literacy.html
To find out about other free AHRQ continuing education opportunities, go to www.ahrq.gov
Contact moreinfo@optumhealtheducation.com with questions.
The following courses are great resources for Health Professionals, Physicians, Physician Assistants and Nurse Practitioners.
Office of Minority Health - https://cccm.thinkculturalhealth.hhs.gov/
CDC - www.cdc.gov
U.S. Department of Health and Human Service, Health Resources and Services Administration - www.hrsa.gov
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.
Forms
Click on the following links to jump to that specific section:
Behavioral Health
- Psych Testing Battery Plan (for Psychologist use only) (PDF)
- Universal Authorization release of Information Form - English (PDF)
- Universal Authorization release of Information Form - Spanish (PDF)
- Behavioral Health Authorization Request Form (PDF)
- Coordination of Care Treatment Plan Form (PDF)
- No Further Treatment Request Form (PDF)
Claims
Please select on the links below to obtain the revised CMS 1500 form (version 02/12) and the CMS 1500 Reference Instruction Manual.
- Letter Template
Medicare-Medicaid Plan
- Refund Form (PDF)
- Provider Dispute Resolution (PDR) (PDF)
- Clean Claim Tool Guide - UB04 Inpatient Form (PDF)
- Clean Claim Tool Guide - UB04 Outpatient Form (PDF)
- Waiver of Liability Statement - Cal MediConnect Plan (PDF)
- Revised CMS 1500 Health Insurance Claim Form (PDF)
- CMS 1500 Reference Instruction Manual (PDF)
Compliance
- Click here for Compliance forms
Delegation Oversight Audit (DOA)
- Biographical Information Sheet (PDF)
- Compliance Program Effectiveness DOA Audit Tool - Medi-Cal
- Compliance Program Effectiveness DOA Audit Tool - Medicare
- Credentialing DOA Audit Tool
- Medi-Cal DOA Tool UM/CM/QI
- Medi-Cal UM Referral Template
- Medicare DOA Tool UM/CM/QI
- Sub-Contracted Facility/Agency Services and Delegated Functions (PDF)
EFT and ERA 835 Enrollment
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) - Medicare Form
English (PDF) Spanish (PDF)
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)
Historical Data Form
Medi-Cal Letter Templates
Medicare-Medicaid Plan Letter Templates
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)
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.
If you are interested in becoming a network Provider, please click here.
Perinatal
IEHP provides standard risk assessment forms that must 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)
- Initial and Trimester Assessment and Care Plan (PDF)
- Perinatal Protocols (PDF)
- Postpartum Assessment and Care Plan (PDF)
- Pregnancy Notification/Outcome Report (PDF)
Pharmacy
- Click here for Pharmacy forms.
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.
- 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
Staying Healthy Assessment
PCPs are responsible for assuring the Staying Healthy Assessment (SHA) Questionnaire is administered during the Initial Health Assessment to each IEHP Member within 120 days of the Member's enrollment.The SHA Questionnaire is available in over nine different languages and in nine separate age categories.
Printed English and Spanish versions are available through your IPA or you can get the forms you need by using the menu below.
7098 A 0-6 Months
Select Language: English, Spanish, Arabic, Armenian, Chinese,
Hmong, Korean, Russian, Tagalog, Vietnamese
7098 B 7-12 Months
Select Language: English, Spanish, Arabic, Armenian, Chinese,
Hmong, Korean, Russian, Tagalog, Vietnamese
7098 C 1-2 Years
Select Language: English, Spanish, Arabic, Armenian, Chinese,
Hmong, Korean, Russian, Tagalog, Vietnamese
7098 D 3-4 Years
Select Language: English, Spanish, Arabic, Armenian, Chinese,
Hmong, Korean, Russian, Tagalog, Vietnamese
7098 E 5-8 Years
Select Language: English, Spanish, Arabic, Armenian, Chinese,
Hmong, Korean, Russian, Tagalog, Vietnamese
7098 F 9-11 Years
Select Language: English, Spanish, Arabic, Armenian, Chinese,
Hmong, Korean, Russian, Tagalog, Vietnamese
7098 G 12-17 Years
Select Language: English, Spanish, Arabic, Armenian, Chinese,
Hmong, Korean, Russian, Tagalog, Vietnamese
7098 H Adult
Select Language: English, Spanish, Arabic, Armenian, Chinese,
Hmong, Korean, Russian, Tagalog, Vietnamese
7098 I Senior
Select Language: English, Spanish, Arabic, Armenian, Chinese,
Hmong, Korean, Russian, Tagalog, Vietnamese
UM/CM
- Authorization for Use and/or Disclosure of Patient Health Information - English (PDF)
- Authorization for Use and/or Disclosure of Patient Health Information - Spanish (PDF)
- Care Management Referral Form (PDF)
- Consent for HIV Test - English (PDF)
- Consent for HIV Test - Spanish (PDF)
- Contraceptive Informed Choice Form - English (PDF)
- Contraceptive Informed Choice Form - Spanish (PDF)
- Diabetic Prescription Referral Form -Preveon Health (PDF)
- Health Risk Assessment (HRA) - IEHP DualChoice - English (PDF)
- Health Risk Assessment (HRA) - IEHP DualChoice - Spanish (PDF)
- HIV Testing Sites - Riverside and San Bernardino (PDF)
- Long Term Care (LTC) Data Sheet (PDF)
- Non-Emergency Medical Transportation (NEMT) Physician Certification Statement (PCS) (PDF)
- Pain Assessment and Treatment Plan Form (PDF)
- Referral Form (PDF)
- Service Request for Skilled Nursing Facilities (PDF)
- SNF Initial Review (PDF)
- SNF Follow-up Review (PDF)
- Sterilization Consent Form PM-330
PM-330 Form - Tips and Example (PDF)
PM-330 Form - English (PDF)
PM-330 Form - Spanish (PDF) - Transportation Requests Form (SNF & LTC) (PDF)
- Transportation Requests Form (Hospital) (PDF)
- Wound Assessment - Admission (PDF)
- Wound Assessment - Follow - Up (PDF)
- Wound Assessment - Addendum (PDF)
Vision
- Opthalmologist Referral Form (PDF)
- Vision Exception Request (VER) Form (PDF)
- PCP Vision Report Form (PDF)
- IEHP Lab Form (PDF)
- Non Covered Services/Materials Waiver Form-English (PDF)
- Non Covered Services/Materials Waiver Form-Spanish (PDF)
Other
- Authorization of Release - Use & Disclosure of PHI - English (PDF)
- Authorization of Release - Use & Disclosure of PHI - Spanish (PDF)
- CMS 1696 Appointment of Representative - English (PDF)
- CMS 1696 Appointment of Representative - Spanish (PDF)
- Contracts Maintenance Request Form (PDF)
- Provider Services Materials Request Form (PDF)
- 2017 Model Output Report (MOR) Data File Layout (PDF)
Health & Wellness
IEHP partners with Providers to help educate Members about their health conditions and achieve health goals. IEHP’s Health & Wellness Programs help Members learn how to manage their health and make healthy lifestyle changes. You can refer your IEHP Members to these programs anytime by logging into the Secure Provider Website and completing the Health Education Program Request Form.
- Health Resources
- Kids and Teens
- Managing Your Illness
- Pregnancy and Postpartum
- Senior Health
- Weight Management
Health & Wellness Brochures
Brochures
Inland Empire Health Plan (IEHP) offers many Wellness Programs that focus on the health and well-being of our Members. Most of our programs are free, join us at our next session and learn ways to stay healthy. Get information on important health topics through our health education brochures:Educational Resources
2016 Group Needs Assessment (GNA) Report
The 2016 GNA Report describes Medi-Cal Members’ health risks and practices, chronic health condition incidence, utilization patterns, health education and cultural and linguistic needs. IEHP administers the GNA every five years; the findings of the GNA may help Providers better understand and serve our Members.
For questions please contact IEHP Health Education Department at (866) 224-4347.
Provider Education Resources
- Inland Empire EHR Resource Center California Technical Assistance Program to help with EHR implementation and meaningful use.
- "Tips From Former Smokers" campaign featuring Rebecca, a former smoker who struggled with depression for years. Below are links to the campaign materials:
By clicking on these links, you will be leaving the IEHP website.
- Rebecca's Videos: http://www.cdc.gov/tobacco/campaign/tips/resources/videos/rebecca-videos.html
- Podcast: http://www2c.cdc.gov/podcasts/player.asp?f=8639229
- Print Ad: http://www.cdc.gov/tobacco/campaign/tips/resources/ads/tips-5-rebecca-full.pdf
- Mental Health Care Professionals: Help Your Patients Quit Smoking: http://www.cdc.gov/tobacco/campaign/tips/partners/health/mental/index.html
- Web Button for Rebecca Campaign(under Mental Health Conditions: Depression and Anxiety): http://www.cdc.gov/tobacco/campaign/tips/resources/buttons/index.htm
- Baby's Optimal Nutrition with Ultimate Support (BONUS)
- Resource Guide (PDF)
- Breastfeeding Support "BONUS Helpline" News Release
Member Education Resources
The following websites are good sources of easy-to-read patient information that can be downloaded, printed or ordered.By clicking on these links, you will be leaving the IEHP website.
| RESOURCE | DESCRIPTION |
|---|---|
| Medline Plus |
A service of the US National Library of Medicine and the National Institutes of Health. Easy to read information and audio tutorials on many health topics in English and Spanish. Topics are available in multiple languages. |
| American College of Physicians Foundation |
Download free “Health Tips” in English and Spanish on a variety of health topics, or order easy-to-read diabetes booklets. |
| Food and Drug Administration - Office of Women's Health |
Easy-to-read handouts in English, Spanish and other languages on nutrition, diabetes, depression and other topics related to women’s health. |
| Learning About Diabetes, Inc. |
Easy to read “Handouts and Visual Aids” in color on diabetes care and nutrition to help patients eat the right foods to control blood sugar. |
| Weight Control Information Network |
An extensive list of health education materials about healthy weight and physical activity in English and Spanish. Materials can be printed or ordered. |
| Health Information Translations | Easy-to-read educational handouts on many health topics and in multiple languages. |
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.
Manuals
Benefits
These Benefit Manuals are offered as guidelines to determine benefit eligibility and are not intended to be construed as or to serve as a standard of medical care, or as a contractual agreement for payment. Standards of medical care are determined on the basis of all facts and circumstances for each individual case.
Benefit Manual Information
The subheadings “Examples of Covered Benefits” and “Examples of Non-Covered Benefits” are meant to give specific examples but are not intended to be an all-inclusive list of examples, unless specified in the text of the benefit.
If a benefit question is not addressed in the Benefit Manual, please contact IEHP at (909) 890-2000 for further information.
Electronic Data Interchange (EDI)
The manual documents the procedures, protocols and formats for electronic data exchange between IEHP and its contracted Providers related to Member eligibility, encounter data, bedday reporting, capitation reports and electronic claims submissions.
The following sections document the processing schedules, file formats, procedures and narrative information that is necessary for Providers to understand and conduct electronic data exchange that is HIPAA compliant which is required under the IEHP Agreement.
2019 EDI Manual
3 - Eligibility Processing Procedures (PDF)
4 - Encounter Data Processing Procedures (PDF)
5 - Capitation Processing Procedures (PDF)
6 - Claims EDI Processing Procedures (PDF)
7 - Timeframe and Schedules (PDF)
8 - IEHP 5010 837I Institutional IEHP DualChoice Encounter Companion Guide (PDF)
9 - IEHP 5010 837I Institutional Medi-Cal Encounter Companion Guide (PDF)
10 - IEHP 5010 837P Professional IEHP DualChoice Encounter Companion Guide (PDF)
11 - IEHP 5010 837P Professional Medi-Cal Encounter Companion Guide (PDF)
12 - IEHP 5010 837I Institutional Claims Companion Guide (PDF)
13 - IEHP 5010 837P Professional Claims Companion Guide (PDF)
14 - Authorization Data Exchange (PDF)
15 - IEHP 5010 834 Standard Companion Guide (PDF)
For comments, questions about this manual or technical support, contact the IEHP IT Help Desk at (909) 890-2025 or by email at: HELPDESK@iehp.org.
Provider Manuals
The Inland Empire Health Plan (IEHP) Provider Policy and Procedure is designed to help IEHP's Contracted Entities (Providers) understand how IEHP works 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), California Managed Risk Medical Insurance Board (MRMIB) and the Centers for Medicare and Medicaid Services (CMS). The provisions of these Provider Manuals must be adhered by all of IEHP's Providers.
Medi-Cal
00 - Table of Contents and Introduction (PDF)
01 - Organizational Structure (PDF)
03 - Enrollment and Assignment (PDF)
04 - Eligibility and Verification (PDF)
05 - Credentialing and Recredentialing (PDF)
06 - Facility Site Review (PDF)
07 - Medical Records Requirements (PDF)
10 - Medical Care Standards (PDF)
12 - Coordination of Care (PDF)
14 - Utilization Management (PDF)
16 - Grievance and Appeals Resolution System (PDF)
17 - Member Transfers and Disenrollment (PDF)
19 - Finance and Reimbursement (PDF)
21 - Encounter Data Reporting (PDF)
22 - Rights and Responsibilities (PDF)
24 - Program Descriptions (PDF)
25 - Delegation and Oversight (PDF)
DualChoice Cal MediConnect
00 - Table of Contents and Introduction (PDF)
01 - Organizational Structure (PDF)
03 - Enrollment and Assignment (PDF)
04 - Eligibility and Verification (PDF)
05 - Credentialing and Recredentialing (PDF)
06 - Facility Site Review (PDF)
07 - Medical Records Requirements (PDF)
10 - Medical Care Standards (PDF)
12 - Coordination of Care (PDF)
14 - Utilization Management (PDF)
16 - Grievance and Appeals Resolution System (PDF)
17 - Member Transfers and Disenrollment (PDF)
19 - Finance and Reimbursement (PDF)
21 - Encounter Data Reporting (PDF)
22 - Rights and Responsibilities (PDF)
24 - Program Descriptions (PDF)
25 - Delegation and Oversight (PDF)
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.POLST Registry
By clicking on these links, you will be leaving the IEHP website.
To login, visit https://www.capolstregistry.org/#/.
To sign up, simply go to https://www.capolstregistry.org/#/mdsignup.
For any questions, please contact Care Directives at (888) 621-4383 or email support@caredirectives.org.
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.Pharmacy Services
Here, you will find links to the Pharmacy Program Manual, Communications, DTM Program, Prior Authorization Criteria, Clinical Practice Guidelines, Forms, IEHP Formulary, and Safety Resources with drug recall information.
If you have any questions regarding services provided by the Pharmaceutical Services Department, please feel free to contact the IEHP Pharmacy Department at (909) 890-2049.
Quality & Clinical Resources and Tools
The tools provided on this page are meant to be used as resources to assist primary care providers in delivering care in accordance with IEHP standards. Resources are reviewed regularly and updated to reflect changes from a regulatory and clinical standpoint.
Clinical Practice Guidelines Library
The guidelines contained on this page are recommended by IEHP with the intent to enhance Member care. All content has been reviewed by IEHP to align with the standards practiced by leading health organizations.
Staying Healthy
The Department of Health and Human Services supports work completed by the USPSTF. For the complete, up to date list of recommendations, please visit (by clicking on this link, you will be leaving the IEHP website) https://www.uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/.
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.After Hours Care, After Hours Phone Numbers for Coverage Determination and Expedited Appeals,
LabCorp Locations, and Urgent Care Facilities
After Hours Care
IEHP Providers can direct Members to access care after hours. After hour care includes the 24-Hour Nurse Advice Line, DocOnline and Urgent Care Clinics.
24-Hour Nurse Advice Line
Your Members can call the IEHP 24-Hour Nurse Advice Line for medical advice anytime, day or night.
DocOnline, an extension to the Nurse Advice Line, allows Members to speak with a board-certified Physician for advice after hours using telephonic and/or video devices. DocOnline Physicians will triage, assess, and provide diagnoses for minor acute conditions. Physicians may also give treatment advice, refill select prescriptions and refer Members for in-person care.After Hours Phone Numbers for Coverage Determination and Expedited Appeals (IEHP Medicare DualChoice Cal MediConnect Members)
The following numbers are to be used for after hour requests:
- Coverage Determinations: Phone: (888) 860-1297
- Expedited Appeals: Phone: (866) 233-4347 and Fax: (909) 890-5748
LabCorp Locations
A listing of LabCorp Patient Service Centers around the Inland Empire can be found below:
Urgent Care Clinics
Any of your IEHP Members needing medical attention may visit an Urgent Care Clinic after regular business office hours and on weekends. A listing of all Urgent Care Clinics is found on the IEHP Doctor Search.
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.
Utilization Management Clinical Criteria
Welcome to the Utilization Management Clinical Criteria page. IEHP has created UM Subcommittee Approved Authorization Guidelines to serve as one of the sets of criteria for medical necessity decisions. Our goal in creating this page is to provide you with easily accessible electronic versions of IEHP’s UM guidelines. IEHP utilizes a variety of sources in developing our UM guidelines which include:
- Medicare and Medi-Cal’s coverage policy statements
- Evidence in the peer-reviewed published medical literature
- Technology assessments and structured evidence reviews
- Evidence-based consensus statements
- Expert opinions of healthcare Providers
- Evidence-based guidelines from nationally recognized professional healthcare organizations and public health agencies.
IEHP is also licensed to use InterQual and Apollo Medical Review Criteria to guide in utilization management decisions.
Since medical technology is constantly evolving, our clinical guidelines are subject to change without prior notification. Additional UM Subcommittee Guidelines may be developed as needed or may be withdrawn from use.
Please note that benefits may vary based on Member’s line of business; therefore, certain services discussed in the UM Subcommittee Guidelines may not be a covered benefit.
Providers may obtain information about criteria, either in general or relating to specific UM decisions, from IEHP upon request by contacting the IEHP UM Department. Please contact the IEHP Provider Relations Team at (909) 890-2054 to be connected to the UM Department.
Behavioral Health
Diagnostic Testing
- CT Screening for Lung Cancer (PDF)
- DEXA Scan (PDF)
- Elastography (PDF)
- Electroencephalogram (EEG) (PDF)
- Fetal Echocardiogram (Gynecology and Obstetrics) (PDF)
- Genetic Testing BRCA 1 and BRCA 2 Mutations for Assessing Breast and Ovarian Cancer Risk (PDF)
- Inflammatory Bowel Disease Serology (PDF)
- Magnetic Resonance Spectroscopy (PDF)
- MRI Utilization in the Diagnosis of ADHD or Autism (PDF)
- Myelography During Epidurals Under Fluoroscopic Guidance (PDF)
- Vestibular Autorotation Test (PDF)
- Video EEG (PDF)
DME and Medical Supplies
- Attain Performa Quadripolar Lead Study (PDF)
- Binaural (Analog or Digital) Hearing Aids (PDF)
- Cold Therapy (PDF)
- Compression Garments (PDF)
- Durable Medical Equipment (PDF)
- Electrical Stimulation Modalities (H-wave stimulation, interferential stimulation) (PDF)
- Home Use of Oxygen (PDF)
- Nebulizers (PDF)
- Power Wheelchairs and Power Operated Vehicles (PDF)
- Vagus Nerve Stimulator (PDF)
ENT
Gynecology and Obstetrics
- Antepartum Fetal Assessment (PDF)
- Fetal Echocardiogram (PDF)
- Full Integrated and Serum Integrated Screening (PDF)
Neurology
- Bone Marrow Transplant in Treatment of Multiple Sclerosis (PDF)
- Intravenous Immunoglobulin for Multiple Sclerosis (PDF)
Oncology
- Bevacizumab (Avastin) for Non-Small Cell Lung Cancer (PDF)
- Selective Internal Radiation Therapy (PDF)
Orthopedic
- Foot Orthotics (PDF)
- Lumbar Artificial Disc Replacement (PDF)
- Percutaneous Vertebroplasty and Kyphoplasty (PDF)
- Physical Therapy Guidelines for Chronic Conditions (PDF)
- PILD and MILD Procedures (PDF)
- Prolotherapy and Platelet Enriched Plasma Injection (PDF)
- Treatment of Osteochondral Defects (PDF)
Pain Management
- Genicular Nerve Neurotomy (PDF)
- Pain Management - Centers of Excellence (COE) (PDF)
- Pain Management - Interventional Treatment / Diagnostic Procedures (PDF)
- Referrals to Pain Management Specialist (PDF)
- Sacroiliac Joint Fusion (PDF)
Pediatric
Surgical Procedures
- Adolescent Bariatric Consultation and Surgery (PDF)
- Bronchial Thermoplasty (PDF)
- Gender Dysphoria (PDF)
- Liver Biopsy in Conjunction with Bariatric Surgery (PDF)
- Natural Orifice Transluminal Endoscopic Surgery (PDF)
- Provider Supervised Weight Loss Checklist (PDF)
- Robotically Assisted Surgery (PDF)
Other
- Acupuncture Services (PDF)
- Care Plan Option (PDF)
- Complementary and Alternative Medicine or Holistic Therapies (PDF)
- Congregate Living Health Facilities (PDF)
- Criteria for Custodial Care: Medi-Cal (PDF)
- Hair Removal (PDF)
- Health Homes Program (HHP) (PDF)
- Hepatitis C - Center of Excellence (COE) Admission Criteria (PDF)
- Inpatient Medical Detoxification (PDF)
- My Path (A Palliative Care Approach) (PDF)
- Recuperative Care Admission (PDF)
- Reference Product Pegfilgrastim and Biosimilar Products (PDF)
- Tertiary Care Center Referral Requests (PDF)
- Transitional Care Medicine (PDF)
- Transportation Criteria (PDF)