1. A Provider can submit an appeal request via phone, online portal, fax, mail or redirected from Utilization Management (UM).
1. By phone toll free at (800) 440-IEHP (4347) or (800) 718-4347 (TTY);
2. By mail at P.O. Box 1800, Rancho Cucamonga, CA 91729-1800;
3. In person at 10801 Sixth St., Suite 120, Rancho Cucamonga, CA 91730-5987;
4. Via facsimile at (909) 890-5748; or
5. Online through the IEHP website at www.iehp.org;
2. Provider appeal requires written consent from the Member. Providers should submit to the Plan proof of written consent for appeals filed on behalf of the Member at the time of appeal filing. If not received, IEHP will reach out to the Member to request written consent.
3. The Member, a Provider acting on behalf of and with written consent from the Member, or the Member’s authorized representative may request a State Hearing in any of these situations:
a. Member received a Notice of Appeal Resolution stating that the initial adverse benefit determination has been upheld, and the request is made within one hundred twenty (120) calendar days from the date on the Notice of Appeal Resolution; or
b. Member has exhausted IEHP’s appeal process due to the health plan’s failure to adhere to the appeal notice and timing requirements; including failure to provide a fully translated notice; or
c. Member has exhausted IEHP’s appeal process due to the health plan’s failure to provide adequate notice in a selected alternative format to the Member, their family member, friend, associate, or authorized representative, if required by the ADA.
4. IEHP notifies its Members that the State must reach its decision within ninety (90) calendar days of the date of the request for standard State Hearing or within three (3) business days of the date of the request for expedited State Hearing.
5. IEHP ensures appeals are resolved as quickly as the Member’s health condition requires and do not exceed these regulatory timeframes:
a. Standard appeals are resolved within thirty (30) calendar days of receiving the appeal.
b. Expedited appeals are resolved no later than seventy-two (72) hours of receiving the appeal.
c. These timeframes may be extended by fourteen (14) calendar days if either of the two conditions apply:
i. The Member requests the extension; or
ii. IEHP Demonstrates, to the satisfaction of DHCS upon request, that there is a need for additional information and how the delay is in the Member’s best interest.
6. An acknowledgment letter to the Member within five (5) calendar days of receipt of the appeal.
7. Expedited appeals do not require Acknowledgement Letters, as these are resolved within seventy-two (72) hours. Oral notice of resolution of an expedited appeal is provided within seventy-two (72) hours.