POLICIES, DOCUMENTS AND FORMS

Policies

• Utilization Management Policy & Procedures
• Standing Specialist Referral Policy
• Humboldt IPA Quality and Medical Managment Program

Documents

• Request to Restrict Use and Disclosure of Protected Health Information
• HIPAA Notification of Privacy Practices
• Member Rights and Responsibilities

Forms

• Provider Dispute Resolution
• Claim Status Request
• Electronic Funds Transfer (EFT) Enrollment Form
• Sample Acknowledgement of Financial Responsibility

Appeals and Grievances

• Anthem Blue Cross – Call the Anthem Blue Cross of California phone number listed on the back of the member’s ID card.
• Anthem Grievance Reference Guide
• Anthem Member Grievance
• Blue Shield Member Grievance
• Member Grievance and Appeal Form
• All Other Health Plans – Please contact The Humboldt IPA at 443-4563 or go to the contact us page of this web site.