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
Provider disputes and supporting information must be submitted to:
IEHP Claims Appeal Resolution Unit - Medi-Cal
PO BOX 4319
Rancho Cucamonga, CA 91729-4319
IEHP Claims Appeal Resolution Unit - IEHP DualChoice (HMO-DSNP)
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
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.
Contracted providers may visit our online Provider website for more information. Providers may also 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.
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 IEHPs Model of Care for our D-SNP Members:
To report any issues with this system or process or for any questions, please send an email to DGHospitalRelationsServiceTeam@iehp.org
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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