A provider dispute is a written notice from the provider to Inland Empire Health Plan (IEHP) that:
IEHP accepts disputes from providers if they are submitted within 365 days of receipt of IEHPs decision (for example, IEHPs Remittance Advice (RA) indicating a claim was denied or adjusted).
When submitting a provider dispute, a provider should use a Provider Dispute Resolution Request form. If the dispute is for multiple, substantially similar claims, complete the spreadsheet on page 2 of the Provider Dispute Resolution Request Form
The Provider Dispute Resolution Reqest form for Medi-Cal, IEHP DualChoice (HMO D-SNP), and IEHP Covered lines of business can be downloaded from the Claims section of the following IEHP web page.
If you disagree with your payment determination or a have received a written request to refund an overpayment issued by IEHP that you do not agree with, you may file a Provider Dispute. The Provider Dispute can be submitted:
Online
Log into IEHP's Secure Provider Portal
Select Provider Login
Select Claim Status
IEHP Claims Appeal Resolution Unit - Medi-Cal
PO BOX 4319
Rancho Cucamonga, CA 91729-4319
IEHP Claims Appeal Resolution Unit - IEHP DualChoice (HMO D-SNP)
PO BOX 40
Rancho Cucamonga, CA 91729-4319
IEHP Claims Appeal Resolution and Recovery Unit - IEHP Covered
PO BOX 4469
Rancho Cucamonga, CA 91729-4349
Fax
IEHP does not accept Provider Disputes that have been "faxed" to the organization.
IEHP acknowledges receipt of each provider dispute, regardless of whether the dispute is complete, within 15 business days of receipt.
IEHP resolves each provider dispute within 45 business days following receipt of the dispute, and provides the provider with a written determination stating the reasons for determination.
If IEHP determines to pay additional monies based on information originally provided and/or available at the time the claim was first presented to IEHP for adjudication, or a result of a processing error IEHP will automatically include the appropriate interest amount if payment is not issued within required regulatory timeframes.
A non-contracted provider, on his or her own behalf, is permitted to file a standard appeal for a denied claim only if the non-contracted provider completes a waiver of liability statement, which provides that the non-contracted provider will not bill IEHP DualChoice (HMO D-SNP) Plan Members.
Providers may call the IEHP Provider Call Center at (909) 890-2054 or (866) 223-4347 Monday-Friday, 8:00 am to 5pm PST.
IEHP provides Members triage, screening, and advice services by telephone 24 hours a day, 7 days a week through its Nurse Advice Line (NAL). By calling the NAL, Members receive assistance with access to urgent or emergency services from an on-call physician, or licensed triage personnel. IEHP Members can reach this 24/7 Nurse Advice Line at (888)-244-IEHP (4347) or 711 (TTY).
IEHP requires contracted and non-contracted hospitals to obtain prior authorization for post-stabilization care for Members (patients). IEHP requests the patient’s diagnosis as indicated by the treating physician or surgeon and any other information reasonably necessary for the Plan to decide on whether to authorize post-stabilization care or to assume management of the patient’s care by prompt transfer to another facility. The hospital should request prior authorization from IEHP’s Utilization Management (UM) Department by:
IEHP makes every effort to respond to requests for necessary post-stabilization care within thirty (30) minutes of receipt. The services are considered approved if IEHP does not respond within this timeframe. All subsequent hospital day are subject to review for medical necessity.
IEHP will inform the provider of the Plan’s decision and will coordinate the transfer of the Member if IEHP denies the request for authorization of post-stabilization care and elects to transfer the Member to another health care provider.
IEHP requires contracted and non-contracted providers of behavioral health crisis services (including, but not limited to, 988 centers and mobile crisis teams) to obtain prior authorization for post-stabilization care for Members (patients). The provider should request prior authorization from IEHP’s Utilization Management (UM) Department by:
IEHP makes every effort to respond to requests for necessary post-stabilization care within thirty (30) minutes of receipt. The services are considered approved if IEHP does not respond within this timeframe.
IEHP will inform the provider of the Plan’s decision and will coordinate the transfer of the Member if IEHP denies the request for authorization of post-stabilization care and elects to transfer the Member to another health care provider.
If a Member presents at the emergency department for non-emergency services, please refer the Member to their IEHP Member Handbook, section 3 (How to Get Care), which outlines the process for obtaining a referral.
The IEHP Member Handbooks for Medi-Cal and IEHP DualChoice (HMO D-SNP) lines of business can be downloaded from the Member Materials web page on the IEHP website.
Complete facility claims for authorized health care services must be sent to:
Inland Empire Health Plan
Attn: Claims Department – IEHP Direct
PO BOX 4349
Rancho Cucamonga, CA 91729-4349
Complete professional claims for authorized health care services must be sent to:
Providers under the Medi-Cal program must not submit claims to, demand or otherwise collect reimbursement from a Medi-Cal beneficiary, or from other persons on behalf of the beneficiary, for any service included in the Medi-Cal program’s scope of benefits in addition to a claim submitted to the Medi-Cal program for that service.
The Centers for Medicare & Medicaid Services (CMS), the Department of Health Care Services (DHCS), and National Committee for Quality Assurance (NCQA) requirement that out-of-network providers routinely seen by IEHP DualChoice (HMO D-SNP) Members, receive training on IEHP's Model of Care Training for our D-SNP Members.
The training module, additional resources and the Acknowledgement of Receipt forms are available to access from the following IEHP web pages:
Pursuant to Assembly Bill (AB) 2843, effective July 1, 2025, all in-network and out-of-network Providers are to provide coverage for "emergency room medical care" and "follow-up health care treatment" for a Member who is treated following a rape or sexual assault, without imposing cost sharing for the first nine months after the Member initiates treatment.
Please note that “follow-up health care treatment” includes medical or surgical services for the diagnosis, prevention or treatment of medical conditions arising from an instance of rape or sexual assault.
Please refer to the Penal Code Sections 261, 261.6,263, 263.1 & 286, 287, 288.7 for definitions of “rape” and “sexual assault”.
For any additional questions contact the IEHP Provider Call Center at (909) 890-2054, (866) 223-4347 or email ProviderServices@iehp.org.
Per the federal CURES Act, if a provider (enrolled, contracted or subcontracted) renders Medi-Cal services that are subject to EVV, that provider is now required to be registered and trained on using either the CalEVV system or an Alternate EVV solution. In addition, the provider will now also be required to submit EVV visit data.
As a result of the CURES Act, the Department of Health Care Services (DHCS), and its partners may take disciplinary action(s) to address non-compliant providers, per Welfare and Institutions Code 14043.51.
Please note that for providers submitting claims for services subject to the California Electronic Visit Verification (CalEVV) mandate, but have yet to comply with applicable federal and state requirements regarding the CalEVV system or an Alternate EVV system registration this non-compliance may result in payment denial.
For providers who will use the CAlEVV System option to remain in compliance of this regulatroy mandate the following steps can be taken to successfully meet the CalEVV registration and submission of EVV visit data requirements.
Review the DHCS EVV website and register for the CalEVV System.
You will receive an email with information on how to set up your CalEVV account called a "Welcome Kit". Save all the information sent to you in your "Welcome Kit" email.
When you have completed the setup, instruct your caregivers how to capture CURES compliant visits.
Direct care staff collect EVV visit data when providing services and the office staff use the portal to check that visits are CURES compliant or ‘verified’.
Sandata will contact your Alternate EVV vendor to ensure that your vendors are able to transmit CURES compliant EVV visit data to the state.
Once your vendor has been credentialed, you must partner with your vendor on how to capture CURES compliant EVV visit data through your Alternate EVV system.
The CalEVV program team and its partners can help answer questions that providers may have.
In cases where an out-of-network provider that has been approved to provide service(s) to an IEHP Member and needs to refer said IEHP Member to another out-of-network provider, the approved out-of-network provider must first contact the Member’s IPA to request the referral. The Member’s IPA will review the request for referral and provide a decision within regulatory timeframes. The Member’s IPA will approve the request if it is deemed medically necessary and if IEHP or the IPA does not have an appropriate alternative provider available within its network.
If you have any questions or if you would like to request a referral, please reach out to the Member’s IPA.
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