Provider

Forms

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.

Delegation Oversight Audit (DOA)

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:

 

 

 

The following IEHP DualChoice (HMO D-SNP) Letters will be effective January 1, 2023:

English (PDF)         Spanish (PDF)         Chinese (PDF)         Vietnamese (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)
 
 
 

 

Historical Data Form

Inland Regional Center

  • 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

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.

   
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

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

English
Last Updated: 02/20/2024
Spanish
Last Updated: 02/20/2024
Chinese
Last Updated: 02/20/2024
Vietnamese
Last Updated: 02/20/2024

*The complete NOA letter template includes the following documents posted under each template in the order listed: Notice of Action Letter Template, Your Rights, State Fair Hearing, Nondiscrimination Notice & Taglines, and Independent Medical Review.

 

Your Rights- [English] [Spanish] [Chinese] [Vietnamese] Updated February 20, 2024

 

State Fair Hearing - [English] [Spanish] [Chinese] [Vietnamese] Updated February 20, 2024

 

Nondiscrimination Notice & Taglines- [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023

 

Independent Medical Review (IMR) Form - [ English] [ Spanish] [ Chinese] [ Vietnamese] Updated May 22, 2023

English
Last Updated: 02/20/2024
Spanish
Last Updated: 02/20/2024
Chinese
Last Updated: 02/20/2024
Vietnamese
Last Updated: 02/20/2024

*The complete NOA letter template includes the following documents posted under each template in the order listed: Notice of Action Letter Template, Your Rights, State Fair Hearing, Nondiscrimination Notice & Taglines, and Independent Medical Review.

 

Your Rights- [English] [Spanish] [Chinese] [Vietnamese] Updated February 20, 2024

 

State Fair Hearing - [English] [Spanish] [Chinese] [Vietnamese] Updated February 20, 2024

 

Nondiscrimination Notice & Taglines- [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023

 

Independent Medical Review (IMR) Form - [ English] [ Spanish] [ Chinese] [ Vietnamese] Updated May 22, 2023

English
Last Updated: 02/20/2024
Spanish
Last Updated: 02/20/2024
Chinese
Last Updated: 02/20/2024
Vietnamese
Last Updated: 02/20/2024

*The complete NOA letter template includes the following documents posted under each template in the order listed: Notice of Action Letter Template, Your Rights, State Fair Hearing, Nondiscrimination Notice & Taglines, and Independent Medical Review.

 

Your Rights- [English] [Spanish] [Chinese] [Vietnamese] Updated February 20, 2024

 

State Fair Hearing - [English] [Spanish] [Chinese] [Vietnamese] Updated February 20, 2024

 

Nondiscrimination Notice & Taglines- [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023

 

Independent Medical Review (IMR) Form - [ English] [ Spanish] [ Chinese] [ Vietnamese] Updated May 22, 2023

English
Last Updated: 02/20/2024
Spanish
Last Updated: 02/20/2024
Chinese
Last Updated: 02/20/2024
Vietnamese
Last Updated: 02/20/2024

*The complete NOA letter template includes the following documents posted under each template in the order listed: Notice of Action Letter Template, Your Rights, State Fair Hearing, Nondiscrimination Notice & Taglines, and Independent Medical Review.

 

Your Rights- [English] [Spanish] [Chinese] [Vietnamese] Updated February 20, 2024

 

State Fair Hearing - [English] [Spanish] [Chinese] [Vietnamese] Updated February 20, 2024

 

Nondiscrimination Notice & Taglines- [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023

 

Independent Medical Review (IMR) Form - [ English] [ Spanish] [ Chinese] [ Vietnamese] Updated May 22, 2023

English
Last Updated: 02/20/2024
Spanish
Last Updated: 02/20/2024
Chinese
Last Updated: 02/20/2024
Vietnamese
Last Updated: 02/20/2024

*The complete NOA letter template includes the following documents posted under each template in the order listed: Notice of Action Letter Template, Your Rights, State Fair Hearing, Nondiscrimination Notice & Taglines, and Independent Medical Review.

 

Your Rights- [English] [Spanish] [Chinese] [Vietnamese] Updated February 20, 2024

 

State Fair Hearing- [English] [Spanish] [Chinese] [Vietnamese] Updated February 20, 2024

 

Nondiscrimination Notice & Taglines- [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023

 

Independent Medical Review (IMR) Form - [ English] [ Spanish] [ Chinese] [ Vietnamese] Updated May 22, 2023

English
Last Updated: 03/17/2021

 

Nondiscrimination Notice & Taglines- [English] [Spanish] [Chinese] [Vietnamese] Updated August 01, 2023

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

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

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

New D-SNP 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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

English
Last Updated: 02/06/2024
Spanish
Last Updated: 02/06/2024
Chinese
Last Updated: 02/06/2024
Vietnamese
Last Updated: 02/06/2024

*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

English
Last Updated: 02/06/2024
Spanish
Last Updated: 02/06/2024
Chinese
Last Updated: 02/06/2024
Vietnamese
Last Updated: 02/06/2024

*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

English
Last Updated: 01/17/2024
Spanish
Last Updated: 01/17/2024
Chinese
Last Updated: 01/17/2024
Vietnamese
Last Updated: 01/17/2024

Nondiscrimination Notice, Taglines, Language Insert - [ English] [ Spanish] [ Chinese] [ Vietnamese] Updated July 14, 2023

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 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.

 

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:

 

Medicare and Medi-Cal lines of business must follow the instructions below:

  1. 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;
  2. 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;
  3. 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

UM/CM

Other

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