Choice of Physicians and Providers
When you enroll in an IEHP Covered plan, you must select a Network Primary Care Physician (“PCP”). Your PCP will manage your medical care and will provide or obtain authorization for covered medical service except for:
- Emergency services.
- Out-of-network urgent care while out of the service area.
- Preventive health services (including immunizations) in-network.
- Obstetrician and gynecological services in-network.
- Sexual and reproductive health care services in-network.
- Certain behavioral health and substance use disorder services in-network.
Call your PCP directly to set up a visit. To find a listing of the Network Primary Care Physicians in the IEHP Service Area, visit the IEHP website at iehp.org and click on “Find a Doctor.” You can also call IEHP Member Services 1-855-433-IEHP (4347) (TTY 711).
IEHP’s Covered California Network
Benefits for physician and hospital services are only available when you live or work in the
IEHP Service Area and use a Network Provider. You must also get covered services and
supplies from Network ancillary, Pharmacy, and Behavioral Health Providers.
The benefits of this plan are only available for covered services received from Network
Provider, except for:
a) Urgent Care while outside of the IEHP Service Area.
b) All Emergency Care.
c) Covered Services provided by a non-contracted provider when authorized by IEHP.
Note: Not all Physician and Hospitals that contract with IEHP are Network Providers for this
plan. Only those Physicians and Hospitals identified as participating in the Covered California
Network may provide services under this plan. The continued participation of any one
physician, hospital, or other provider cannot be guaranteed. Please call IEHP Member Services
for help identifying Network Providers in the Covered California network.
If you have a doctor you want to keep, or you want to find a new PCP, you can look in the IEHP
Provider Directory. To find a listing of the Network Primary Care Physicians in the IEHP Service Area, visit the IEHP website at iehp.org and click on “Find a Doctor.” You can also call IEHP Member Services 1-855-433-IEHP (4347) (TTY 711).
Selecting a Primary Care Physician
Each member of your household that is enrolled with IEHP may select a different PCP. Contact
IEHP Member Services to select a PCP. If you and your enrolled dependent(s) did not select a
PCP after enrolling, IEHP will assign a PCP based on:
- The language you speak.
- The distance to a PCP office from Your house. We try to assign you a PCP within 10 miles.
- The PCP’s specialty most appropriate for the member’s age. For children, a pediatrician may be assigned as the PCP. Until you make your PCP choice, IEHP assigns one for you.
Changing Your PCP
If You would like to change your or your dependent’s PCP, please call IEHP Member Services
at 1-855-433-IEHP (4347) (TTY 711). You may also make this change by visiting the IEHP
website at iehp.org. The requested changes will be effective the following day.
Non-Contracted Provider Services Obtained at a Network Facility
While getting Covered Services at a Network health facility, if you receive Covered Services
from a non-contracted provider, you will pay the Network cost sharing amount for these
services. Non-contracted Providers at Network facilities cannot bill you for their services when
the services are approved by IEHP.
Selecting a Network Mental Health Professional
Mental Health and Substance Use Disorder benefits are covered under your IEHP Covered plan. If you need help finding a Network Mental Health Professional, call IEHP Member Services at 1-855-433-IEHP (4347) (TTY 711). IEHP will help you identify a Network Mental Health Professional or a Network physician close to where you live or work, with whom you can set up a visit. IEHP has a Maternal Mental Health Program which includes treatment for pre- and post-partum maternal mental health conditions. Your PCP or you can call IEHP Member Services at 1-855-433-IEHP (4347) (TTY 711) to set up a visit.
Certain services and supplies for Mental Health and Substance Use Disorders may require prior
authorization by IEHP to be covered. Please refer to "Mental Health and Substance Use
Disorders" in the "Plan Benefits" section of the EOC for a complete description of Mental Health and Substance Use Disorder services and supplies.
Specialist, Referral Care, and Authorizations
Sometimes you may need care that the PCP cannot provide. At such times, your PCP will submit
a referral for you to see to a Specialist or other health care provider for that care.
Your PCP or another Specialist will provide you a referral to visit a Specialist within the time
frame listed in the “Access to Care Guidelines” section of this EOC. A Specialist is a doctor who
has extra education in one area of medicine. Your PCP will work with you to choose a Network
Specialist. Other services that might need a referral include in-office procedures:
- X-rays
- Lab work
- Physical therapy
- EKG
- EEG
- Medical social services
- Home health care
Your PCP may give you a form to take to the Specialist. The Specialist will fill out the form and
send it back to your PCP. The Specialist will treat you for as long as they think you need
treatment. If you have a health problem that needs special medical care for a long time, you may
need a standing referral. Refer to the “Standing Referral to Specialty Care for Medical and
Surgical Services” section of the EOC for more information.
You are completely financially responsible for medical care that the PCP does not provide or
IEHP does not authorize except for medically necessary care provided in a legitimate
emergency.
Timeframes by type of referral request:
- Routine or regular referral – 5 business days
- Urgent referral – 24 to 48 hours
Please call IEHP if You do not get a response within the above time frames.
Prior Authorizations
Some health care services require review and approval/denial by IEHP according to medical necessity. This is called Prior Authorization. IEHP will work with your provider to receive and review all necessary information in order to analyze the request for authorization. If the request is denied, you will be informed and told how to appeal the denial. Refer to the “Prior Authorization” section of the EOC for more information. If Mental Health or Substance Use Disorder service is not available in network within geographic and timely access standards, IEHP will arrange out-of-network and follow-up services.