IEHP POLICY AND PROCEDURE MANUAL
MEDICARE DUALCHOICE (HMO SNP) AND
IEHP DUALCHOICE CAL MEDICONNECT PLAN
(MEDICARE-MEDICAID PLAN)
TABLE OF CONTENTS
INTRODUCTION
A.
B.
C.
1.
ORGANIZATIONAL STRUCTURE
A.
B.
C.
2.
Manual Overview
IEHP Overview
Manual Updates
1. Policy and Procedure Manual
2. Benefit Manual
3. EDI Manual
4. Summary of Effected Changes
5. IEHP Code of Business Conduct and Ethics
6. Model of Care (MOC) Training
7. Distribution Letter
8. Acknowledgment of Receipt
General
Joint Powers Agency (JPA) Governing Board
IEHP Committees
Attachments
COMMITTEE OVERVIEW
A.
B.
C.
D.
E.
F.
G.
H.
I.
Public Policy Participation Committee (PPPC)
Provider Advisory Committee (PAC)
Quality Management (QM) Committee
Peer Review Subcommittee
Pharmacy and Therapeutic (P&T) Subcommittee
Credentialing Subcommittee
Utilization Management (UM) Subcommittee
Persons with Disabilities Workgroup (PDW)
Coordinated Care Initiative (CCI) Stakeholder Advisory Committee
Attachment
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3.
ENROLLMENT AND ASSIGNMENT
A.
B.
C.
D.
E.
F.
G.
4.
IEHP Service Area
(1) Medicare DualChoice (HMO SNP)
(2) IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan)
Primary Care Physician (PCP) Assignment
(1) Medicare DualChoice (HMO SNP)
(2) IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan)
Member Identification Cards
(1) Medicare DualChoice (HMO SNP)
(2) IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan)
Identifying IPA and Hospital Affiliation
(1) Medicare DualChoice (HMO SNP)
(2) IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan)
Post Enrollment Kit
(1) Medicare DualChoice (HMO SNP)
(2) IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan)
Enrollment and Eligibilty
(1) Medicare DualChoice (HMO SNP)
(2) IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan)
Eligible Members
(1) Medicare DualChoice (HMO SNP)
(2) IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan)
Attachments
ELIGIBILITY AND VERIFICATION
A.
B.
Eligibility Verification
(1) Medicare DualChoice (HMO SNP)
(2) IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan)
Eligibility Verification Methods
(1) Eligibility Files - Medicare DualChoice (HMO SNP)
(2) Eligibility Files- IEHP DualChoice Cal MediConnect Plan (Medicare-Medi-caid
Plan)
(3) Interactive Voice Response (IVR) - Medicare DualChoice (HMO SNP)
(4) Interactive Voice Response (IVR) - IEHP DualChoice Cal MediConnect Plan
(Medicare-Medicaid Plan)
(5) Online Eligibility Verification System (OEVS) - Medicare DualChoice (HMO
SNP)
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C.
5.
CREDENTIALING AND RECREDENTIALING
A.
B.
C.
D.
E.
F.
6.
Site Review and Medical Records Review Survey Requirements and Monitoring
Physical Accessibility Review Survey (PARS)
PCP Sites Denied Participation or Removed from the IEHP Network
Residency Teaching Clinics
Rural Clinics
Non-Physician Practitioner Requirements
Primary Care Physician (PCP) Referral Audits
Attachments
MEDICAL RECORDS REQUIREMENTS
A.
B.
C.
D.
8.
IEHP Practitioner Guidelines
Practitioner Credentialing Requirements
IEHP Quality Oversight of Participating Practitioners
Hospital Privileges
Subcontracted Organization Providers
Credentialing Appeals Process
Attachments
FACILITY SITE REVIEW
A.
B.
C.
D.
E.
F.
G.
7.
(6) Online Eligibility Verification System (OEVS) - IEHP DualChoice Cal
MediConnect Plan (Medicare-Medicaid Plan)
(7) Other - Medicare DualChoice (HMO SNP)
(8) Other - IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan)
Member Co-Payments
(1) Medicare DualChoice (HMO SNP)
(2) IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid Plan)
Attachments
PCP Medical Records Requirements
Information Disclosure and Confidentiality of Medical Records
Informed Consent
Durable Power of Attorney for Healthcare – Advance Directive
Attachments
INFECTION CONTROL
A.
Infection Control
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Attachments
9.
ACCESS STANDARDS
A.
B.
C.
D.
E.
F.
G.
H.
Access Standards
Missed Appointments
Access to Care for People with Disabilities
(1) Members who are Deaf or Hard-of-Hearing
Access to Sensitive Services
Open Access to Obstetrical or Gynecological Services
Cancer Screening and Treatment Services
Non-Emergency Transportation Services
IEHP Disability Program Description
Attachments
10. MEDICAL CARE STANDARDS
A.
B.
C.
Initial Preventive Physical Exam
Adult Preventive Services
Pediatric Preventive Services
(1) Well Child Visits
(2) Immunization Services
D. Obstetrical Services - PCP Role in Care of Pregnant Members
(1) Guidelines for Obstetrical Services
(2) Obstetric Care by Certified Nurse Midwives
(3) PCP Provision of Obstetric Care
(4) Multi-Disciplinary Perinatal services
E. Referrals to the Supplemental Food Program for Women, Infants, and Children (WIC)
F. Sterilization Services
G. Sexually Transmitted Disease (STD) Services
H. HIV Testing and Counseling
I.
Tuberculosis Services
J. Reporting Communicable Diseases to Public Health Authorities
K. Family Planning Services
L. Mandatory Elder or Dependent Adult Abuse and neglect Reporting
M. Mandatory Child Abuse and Neglect Reporting
N. Mandatory Domestic Violence Reporting
O. Vision Examination Level Standards
Attachments
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11. PHARMACY
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
P.
Q.
R.
S.
T.
U.
V.
W.
X.
Y.
Formulary Management
Prior Authorization For Non-Formulary Medications
Medication Handling Requirements at PCP Sites
Physician Profiling Program
Pharmacy Reports
Emergency Department and Hospital Inpatient Discharge Medication Requirement
Coverage Determination
Co-Payment Requirement
True Out-of-Pocket (TrOOP) Expenditures
Coordination of Benefits (COB)
Pharmacy Access Standards
Pharmacy Claims Processing
Medication Quality Assurance Program
Medication Therapy Management Program
Transition Process
Pharmacy Program to Control Fraud, Waste, and Abuse
Insulin Administration Devices and Diabetic Testing Supplies
Medicare DualChoice Vaccine Coverage
Best Available Evidence (BAE)
Pharmacy Provider Policies and Procedures Summary
Member Request for Pharmacy Reimbursement
Pharmacy Program Manual – Medicare
Long Term Care (LTC) Claims
Pharmacy Audit Program
Pharmacy Credentialing and Re-Credentialing
Attachments
12. COORDINATION OF CARE
A. Case Management Requirements
(1) IEHP Monitoring and Oversight
(2) IPA Responsibilities
(3) Reporting Requirements
(4) PCP Role
(5) Identifying and Reporting Potential Abuse of IEHP Members
(6) Model of Care – Member Identification, Stratification and Interventions
(7) Model of Care – Transition of Care
(8) Model of Care – Health Risk Assessment
(9) Model of Care – Training
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(10) Model of Care - Interdisciplinary Care Team
(11) Individual Care Plan
(12) Continuity of Care
B. California Children’s Services (CCS)
C. Organ Transplant
D. Behavioral Health
(1) Behavioral Health Services
(2) Alcohol and Drug Treatment Services
(3) Admission and Concurrent Review – Global and Shared Risk
E. Chiropractic Care
F. Developmental Disabilities
G. Vision Services
(1) Vision Exception Requests (VER)
(2) Vision Provider Referrals
H. Disease Management Program
I. Community Based Adult Services (CBAS)
(1) Unbundled Services
J. Care Plan Option Services
K. Multipurpose Senior Services Program (MSSP)
Attachments
13. QUALITY MANAGEMENT
A.
B.
C.
D.
E.
F.
IEHP Quality Management Program Description
Quality Studies Medical Records Access
Corrective Action Plan (CAP) Requirements
IPA Quality Management Program Structure Requirements
Quality Management (QM) Reporting Requirements
Quality Management (QM) Program Overview for Members, Providers and
Practitioners
G. Delegation Oversight Audit
H. Delegated Activities
I. Capitated Hospital Delegation Agreement – IEHP DualChoice
J. Chaperone Guidance
Attachments
14. UTILIZATION MANAGEMENT
A.
B.
Utilization Management Delegation and Monitoring
Review Procedures
(1) Primary Care Physician (PCP) Referrals
a. PCP Referral Tracking Log
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C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
(2) Standing Referral/Extended Access to Specialty Care
Second Opinions
Emergency Services
Pre-Service Referral Authorization Process
Wheelchair Purchase Referral Procedure
Inpatient Review/ Notice of Non-Coverage of Continued Inpatient Hospital, SNF,
Home Health Agency or Comprehensive Outpatient Rehabilitation Facility Services
Expedited Initial Organization Determination (EIOD)
Focused Referral and Denial Audits
Utilization Management Reporting Requirements
Long Term Care (LTC) – Custodial Level
Long Term Care (LTC) – Skilled Level
Hospice Services
Attachments
15. HEALTH EDUCATION
A.
B.
C.
Health Education
IEHP Child Safety Programs
Cultural and Linguistic Services
(1) Foreign Language Capabilities
(2) Spanish Language Competency Audits
(3) Non-Discrimination
D. IEHP Family Asthma Program
E. IEHP Diabetes Self-Management Program
F. IEHP Stop Smoking Program
G. IEHP Adult Weight Loss Program
H. IEHP “Healthy Babies” Pregnancy Program
I.
IEHP Healthy Heart Program
J. IEHP Pediatric Weight Loss Program
K. IEHP Blood Pressure Management Program
L. Cultural and Linguistic Services Program Description
M. IEHP Disease Management – BREATHE Program
N. IEHP Disease Management – JOURNEY Program
Attachments
16. GRIEVANCE RESOLUTION SYSTEM
A.
Appeal and Grievance Resolution Process for Members – (Standard and Expedited)
(1) Appeal (Reconsideration or Redetermination) Resolution Process for Part C and
Part D Members – Urgent (Expedited) Appeals
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(2) Appeal (Reconsideration or Redetermination) for Part C and Part D Members Standard, Fast (Immediate) and Fast-Track Appeals
B. Appeal and Grievance Resolution Process for Providers
(1) Initial
(2) Health Plan
(3) UM Decisions
(4) IPA, Hospital, and Practitioner
C. Member Rights and Options
Attachments
17. MEMBER TRANSFERS AND DISENROLLMENT
A.
B.
C.
D.
Primary Care Physician (PCP) Transfers
(1) Voluntary
(2) Involuntary
Disenrollment from IEHP
(1) Voluntary – Medicare DualChoice (HMO SNP)
(2) Voluntary – IEHP DualChoice Cal MediConnect (Medicare – Medicaid Plan)
(3) Involuntary Member Behavior
(4) Involuntary Member Status Changes – Medicare DualChoice (HMO SNP)
(5) Involuntary Member Status Changes – IEHP DualChoice Cal MediConnect
(Medicare – Medicaid Plan)
Continuity of Care
Episode of Care - Inpatient
18. PROVIDER NETWORK
A.
B.
C.
D.
E.
F.
G.
H.
I.
Primary Care Physician (PCP)
(1) Affiliation Numbers
(2) Enrollment Limits
Provider Directory
PCP, Vision and Behavior Health Provider Network Changes
IPA Reported PCP Changes
(1) PCP Termination
(2) Specialty Practitioner Termination
Management Services Organization (MSO) Changes
Specialty Panel
Provider Resources
Hospital Affiliations
Leave of Absence
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Table of Contents
J.
K.
L.
IEHP Terminations of PCPs, Specialists, and Vision Providers
Hospital Network Participation Standards
Provider Charging Members
Attachments
19. FINANCE AND REIMBURSEMENT
A.
B.
C.
D.
Financial Viability
(1) IPA
(2) Hospital
Medicare Capitation
(1) IPA
(2) IEHP Direct Providers
Pay For Performance (P4P)
IPA Financial Supervision
Attachments
20. CLAIMS PROCESSING
A.
B.
C.
D.
E.
F.
G.
Claims Processing
(1) Claims Appeals – Denied Claims
(2) Provider Payment Dispute Resolution
Billing of IEHP Members
14-Day Letter
Claims and Compliance Audits
Coordination of Benefits
Claims and Payment Appeal Reporting
Third Party Liability
Attachments
21. ENCOUNTER DATA REPORTING
A.
B.
C.
D.
E.
Encounter Data Submission Requirements
CMS Part C Report Requirements
Medicare Risk Adjustment and Hierarchical Condition Categories
Medicare DualChoice Data Sharing Program
Encounter Data Submission Requirements for Directly Contracted Capitated Providers
Attachments
22. MEMBER RIGHTS AND RESPONSIBILITIES
A.
Members’ Rights and Responsibilities
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B.
Practitioners’ Rights and Responsibilities
23. COMPLIANCE
A.
B.
C.
D.
E.
Fraud, Waste and Abuse Program
HIPAA Protected Health Information
Healthcare Professional Advice to Members
IPA Performance Evaluation
Monitoring of First Tier Downstream and Related Entities
Attachments
24. QUICK REFERENCE
A.
B.
C.
Quick Reference Guide
Glossary
Index
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INTRODUCTION
A.
Manual Overview
__________________________________________________________________
The Inland Empire Health Plan (IEHP) Provider Policy and Procedure Manual 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), and
the Centers for Medicare and Medicaid Services (CMS). The provisions of this Manual must be
adhered to by all of IEHP’s Providers.
This Manual is intended to incorporate the statutory, regulatory and contractual requirements
imposed by DHCS, DMHC, CMS and other agencies such as medical professional licensing
boards. It is not intended to replace or exclude any statutory, regulatory or contractual
requirement not stated herein.
The Managed Care Coordinator for each Provider has the responsibility of ensuring the
appropriate people in their organization review and understand the information contained in this
Manual. Additionally, periodic updates are sent to keep the Manual current and our Providers
informed of any policy changes.
IEHP holds training sessions for its Providers to assist in learning IEHP policies and procedures
as outlined in this Manual.
INLAND EMPIRE HEALTH PLAN
Chief Approval: Signature on file
Original Effective Date:
January 1, 2007
Chief Title: Chief Executive Officer
July 1, 2013
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Revision Date:
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INTRODUCTION
B.
IEHP Overview
Inland Empire Health Plan is a not for profit public entity that is a Health Maintenance
Organization (HMO) serving Medi-Cal, Medicare DualChoice (HMO SNP), IEHP DualChoice
Cal MediConnect Plan (Medicare – Medicaid Plan), and Healthy Kids beneficiaries residing in
Riverside and San Bernardino Counties.
IEHP is a Knox-Keene licensed Health Plan and is regulated by the California Department of
Managed Health Care (DMHC), the California Department of Health Services (DHCS), and as
well as the federal government’s Centers for Medicare and Medicaid Services (CMS).
IEHP was formed on July 26, 1994 as a Joint Powers Agency (JPA) created by the two counties
to administer the Two-Plan Model as the Local Initiative Medi-Cal Managed Health Care Plan.
IEHP commenced operations on September 1, 1996.
Mission Statement
To organize and improve the delivery of quality, accessible and wellness
based healthcare services for our community.
INLAND EMPIRE HEALTH PLAN
Chief Approval: Signature on file
Original Effective Date:
January 1, 2007
Chief Title: Chief Executive Officer
July 1, 2014
IEHP Provider Policy and Procedure Manual
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Revision Date:
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INTRODUCTION
C.
Manual Updates
__________________________________________________________________
The Inland Empire Health Plan (IEHP) Provider Policy and Procedure Manual (Provider Manual)
is reviewed and updated in its entirety at least once a year. IEHP maintains and issues manuals on
disk that are distributed externally to contracting entities in accordance with contractual and
regulatory requirements.
The Provider Manual annual update includes the following:
1. Policy and Procedure Manual
• Medi-Cal
• Healthy Kids
• Medicare DualChocie (HMO SNP) and IEHP DualChoice Cal MediConnect Plan
(Medicare – Medicaid Plan)
2. Benefit Manual
• Medi-Cal
• Healthy Kids
• Medicare DualChocie (HMO SNP) and IEHP DualChoice Cal MediConnect Plan
(Medicare – Medicaid Plan)
3. EDI Manual (IPA and Delegates only)
4. Summary of Effected Changes
5. IEHP Code of Business Conduct and Ethics
6. Model of Care (MOC) Training
7. Distribution Letter
8. Acknowledgment of Receipt
INLAND EMPIRE HEALTH PLAN
Chief Approval: Signature on file
Original Effective Date:
Chief Title: Chief Executive Officer
July 1, 2014
Revision Date:
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