2024 Manuals and Regulatory Trainings

00 - Table of Contents and Introduction (PDF) - [APPROVED] [REDLINE]

 

01 - Organizational Structure (PDF) - [APPROVED] [REDLINE]

 

02 - Committee Overview (PDF) - [APPROVED] [REDLINE]

 

03 - Enrollment and Assignment (PDF) - [APPROVED] [REDLINE]

 

04 - Eligibility and Verification (PDF) - [APPROVED] [REDLINE]

 

05 - Credentialing and Recredentialing (PDF) - [APPROVED] [REDLINE]

 

06 - Facility Site Review (PDF) - [APPROVED] [REDLINE]

 

07 - Medical Records Requirements (PDF) - [APPROVED] [REDLINE]

 

08 - Infection Control (PDF) - [APPROVED] [REDLINE]

 

09 - Access Standards (PDF) - [APPROVED] [REDLINE]

 

10 - Medical Care Standards (PDF) - [APPROVED] [REDLINE]

 

11 - Pharmacy (PDF) - [APPROVED] [REDLINE]

 

12 - Coordination of Care (PDF) - [APPROVED] [REDLINE]

 

13 - Quality Management (PDF) - [APPROVED] [REDLINE]

 

14 - Utilization Management (PDF) - [APPROVED] [REDLINE]

 

15 - Health Education (PDF) - [APPROVED] [REDLINE]

 

16 - Grievance and Appeals Resolution System (PDF) - [APPROVED] [REDLINE]

 

17 - Member Transfers and Disenrollment (PDF) - [APPROVED] [REDLINE]

 

18 - Provider Network (PDF) - [APPROVED] [REDLINE]

 

19 - Finance and Reimbursement (PDF) - [APPROVED] [REDLINE]

 

20 - Claims Processing (PDF) - [APPROVED] [REDLINE]

 

21 - Encounter Data Reporting (PDF) - [APPROVED] [REDLINE]

 

22 - Rights and Responsibilities (PDF) - [APPROVED] [REDLINE]

 

23 - Compliance (PDF) - [APPROVED] [REDLINE]

 

24 - Program Descriptions (PDF) - [APPROVED] [REDLINE]

 

25 - Delegation and Oversight (PDF) - [APPROVED] [REDLINE]

 

26 - Quick Reference (PDF) - [APPROVED] [REDLINE]

 

 

IPA Delegation Agreement – Medi-Cal (PDF) – Effective January 1, 2024

 

Summary of Effected Changes (PDF) - Published: September 30, 2023

 

00 - Table of Contents and Introduction (PDF) - [APPROVED] [REDLINE]

 

01 - Organizational Structure (PDF) - [APPROVED] [REDLINE]

 

02 - Committee Overview (PDF) - [APPROVED] [REDLINE]

 

03 - Enrollment and Assignment (PDF) - [APPROVED] [REDLINE]

 

04 - Eligibility and Verification (PDF) - [APPROVED] [REDLINE]

 

05 - Credentialing and Recredentialing (PDF) - [APPROVED] [REDLINE] 

 

06 - Facility Site Review (PDF) - [APPROVED] [REDLINE]

 

07 - Medical Records Requirements (PDF) - [APPROVED] [REDLINE]

 

08 - Infection Control (PDF) - [APPROVED] [REDLINE]

 

09 - Access Standards (PDF) - [APPROVED] [REDLINE] 

 

10 - Medical Care Standards (PDF) - [APPROVED] [REDLINE]

 

11 - Pharmacy (PDF) - [APPROVED] [REDLINE]

 

12 - Coordination of Care (PDF) - [APPROVED] [REDLINE] 

 

13 - Quality Management (PDF) - [APPROVED] [REDLINE]

 

14 - Utilization Management (PDF) - [APPROVED] [REDLINE]

 

15 - Health Education (PDF) - [APPROVED] [REDLINE]

 

16 - Grievance and Appeals Resolution System (PDF) - [APPROVED] [REDLINE]

 

17 - Member Transfers and Disenrollment (PDF) - [APPROVED] [REDLINE]

 

18 - Provider Network (PDF) - [APPROVED] [REDLINE]

 

19 - Finance and Reimbursement (PDF) - [APPROVED] [REDLINE]

 

20 - Claims Processing (PDF) - [APPROVED] [REDLINE]

 

21 - Encounter Data Reporting (PDF) - [APPROVED] [REDLINE]

 

22 - Rights and Responsibilities (PDF) - [APPROVED] [REDLINE]

 

23 - Compliance (PDF) - [APPROVED] [REDLINE]

 

24 - Program Descriptions (PDF) - [APPROVED] [REDLINE]

 

25 - Delegation and Oversight (PDF) - [APPROVED] [REDLINE]

 

26 - Quick Reference (PDF) - [APPROVED] [REDLINE]

 

IPA Delegation Agreement – (HMO D-SNP) (PDF) – Effective January 1, 2024 

 

Summary of Effected Changes (PDF) - Published: September 30, 2023

00 - Table of Contents (PDF) - [APPROVED] 

 

01 - Eligibility Verification (PDF) - [APPROVED] 

 

02 - Credentialing and Recredentialing (PDF) - [APPROVED] 

 

03 - Medical Record Requirements (PDF) - [APPROVED] [REDLINE]

 

04 - Access Standards (PDF) - [APPROVED]

 

05 - Medical Care Standards (PDF) - [APPROVED]

 

06 - Pharmacy (PDF) - [APPROVED] 

 

07 - Coordination of Care (PDF) - [APPROVED] 

 

08 - Quality Management (PDF) - [APPROVED] 

 

09 - Utilization Management (PDF) - [APPROVED]

10 - Dispute and Appeal Resolution (PDF) - [APPROVED] [REDLINE]

 

11 - Member Transfers and Disenrollment (PDF) - [APPROVED] 

 

12 - Provider Network (PDF) - [APPROVED]

 

13 - Claims Processing (PDF) - [APPROVED] 

 

14 - Encounter Data Reporting (PDF) - [APPROVED] 

 

15 - Rights and Responsibilities (PDF) - [APPROVED]

 

16 - Compliance (PDF) - [APPROVED] 

 

17 - Program Descriptions (PDF) - [APPROVED] 

 

18 - Delegation and Oversight (PDF) - [APPROVED] 

 

19 - Quick Reference (PDF) - [APPROVED] 

 

 

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, bed-day 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.

EDI Manual - Medi-Cal & IEHP DualChoice (HMO D-SNP)

00 - Table of Contents (PDF) - [APPROVED] [REDLINE]

 

01 - General Information (PDF) - [APPROVED] [REDLINE]

 

02 - Getting Started (PDF) - [APPROVED] [REDLINE]

 

03 - Eligibility Processing Procedures (PDF) - [APPROVED] [REDLINE]

 

04 - Encounter Data Processing Procedures (PDF) - [APPROVED] [REDLINE]

 

05 - Capitation Processing Procedures (PDF) - [APPROVED] [REDLINE]

 

06 - Claims EDI Processing Procedures (PDF) - [APPROVED] [REDLINE]

 

07 - Timeframe and Schedules (PDF) - [APPROVED] [REDLINE]

 

08 - IEHP 5010 837I Institutional IEHP DualChoice Encounter Companion Guide (PDF) - [APPROVED] [REDLINE]

 

09 - IEHP 5010 837I Institutional Medi-Cal Encounter Companion Guide (PDF) - [APPROVED] [REDLINE]

 

 

10 - IEHP 5010 837P Professional IEHP DualChoice Encounter Companion Guide (PDF) - [APPROVED] [REDLINE]

 

11 - IEHP 5010 837P Professional Medi-Cal Encounter Companion Guide (PDF) - [APPROVED] [REDLINE]

 

12 - IEHP 5010 837I Institutional Claims Companion Guide (PDF) - [APPROVED] [REDLINE]

 

13 - IEHP 5010 837P Professional Claims Companion Guide (PDF) - [APPROVED] [REDLINE]

 

14 - Authorization Data Exchange (PDF) - [APPROVED] [REDLINE]

 

15 - IEHP 5010 834 Standard Companion Guide (PDF) - [APPROVED] [REDLINE]

 

16 - IEHP 835 Standard Companion Guide (PDF) - [APPROVED] [REDLINE]

 

17 - IEHP Misdirected Outbound Professional Claims Companion Guide (PDF) - [APPROVED] [REDLINE]

 

18 - IEHP Misdirected Outbound Institutional Claims Companion Guide (PDF) - [APPROVED] [REDLINE]

 

EDI Manual - IEHP Covered (CCA)

00 - Table of Contents (PDF) - [APPROVED] 

 

01 - IEHP 5010 837P Professional Covered California Claims Companion (PDF) - [APPROVED] 

 

02 - IEHP 5010 Professional 837P Covered California Encounter Companion Guide  (PDF) - [APPROVED] [REDLINE]

 

03 - IEHP 5010 837I Instutional Covered California Claims Companion Guide (PDF) - [APPROVED] 

 

04 - IEHP 5010 Institutional 837I Covered California Encounter Companion Guide (PDF) - [APPROVED] [REDLINE]

 

05 -  IEHP 5010 Dental 837D Covered California Encounter Companion Guide (PDF) - [APPROVED] 

 

06 - 5010 834 Standard Covered California Companion Guide (PDF) - [APPROVED]

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.

You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.