General Information
The Inland Empire Health Plan (IEHP) Provider Manual is designed to help IEHP's contracted Providers understand how IEHP functions 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), the Centers for Medicare and Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA).
The Delegate or Provider has the responsibility to ensure review, understanding, and attestation of the information contained in the Manual.
Acknowledgement of Receipt (AOR)
2023
- Providers:
- 2023 Provider eAOR
Providers are encouraged to attest electronically using the following recommended browsers: Google Chrome, Microsoft Edge, Mozilla Firefox
- 2023 Provider eAOR
- 2023 Hospital & IPA AORs
- For more information regarding 2023 Manuals, click here.
2023 Manuals
Effective 01/01/2023
Click on the following links to access that specific section:
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.
Provider Manual - 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)
Summary of Effected Changes (PDF) - Published: September 30, 2022
Provider Manual - IEHP DualChoice (HMO D-SNP)
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) 
Summary of Effected Changes (PDF) - Published: September 30, 2022
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.
- 2023 Medi-Cal
- 2023 IEHP DualChoice (HMO D-SNP) and Plan Benefits and Cost Sharing
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
01 - General Information (PDF)
03 - Eligibility Processing Procedures (PDF)
04 - Encounter Data Processing Procedures (PDF)
05 - Capitation Processing Procedures (PDF)
06 - Claims EDI Processing Procedures (PDF)
07 - Timeframe and Schedules (PDF)
08 - IEHP 5010 837I Institutional IEHP DualChoice Encounter Companion Guide (PDF)
09 - 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)
16 - IEHP 835 Standard Companion Guide (PDF)
17 - IEHP Misdirected Outbound Professional Claims Companion Guide (PDF)
18 - IEHP Misdirected Outbound Institutional Claims 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.Regulatory Trainings
- Code of Business Conduct and Ethics (PDF)
- Compliance Training (FWA, HIPAA Privacy and Security) (PDF)
- Cultural and Linguistics (C & L) Training (PDF)
- IEHP DualChoice (HMO D-SNP) Model of Care Training (PDF)
- IEHP DualChoice (HMO D-SNP) Model of Care Training (HTML)
2023 Acknowledgement of Receipt
- Provider eAOR
Providers are encouraged to attest electronically using the following recommended browsers: Google Chrome, Microsoft Edge, Mozilla Firefox - Provider AOR (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.