CurrentMolina HealthcarePolicy N/A

Initial Health Appointment (IHA) requirements and medical record review

Defines Molina Healthcare's expectations for completing and documenting an Initial Health Appointment (IHA) for newly enrolled Medi‑Cal managed care members and describes the medical record review process; applies to primary care providers responsible for IHAs in California (Molina).

Policy Summary

PayerMolina Healthcare

PolicyInitial Health Appointment (IHA) requirements and medical record review

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionComplete and document a comprehensive Initial Health Appointment within 120 calendar days of enrollment, including history, exam, risk assessment, preventive needs, education, diagnoses/plan and follow-up.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

120max days to complete IHA

10-20charts selected for MRR

1min outreach attempts

CPT listbilling codes listed

3 to <21dental referral age

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Initial Health Appointment Coverage Criteria

IHA coverage criteria

Covered when ALL of the following are met

IHA applicability: Member is newly enrolled and has not been actively enrolled with the plan in the prior 12 months; IHA must be completed by a PCP or equivalent in a primary care medical setting

Timing: IHA completed within 120 calendar days of enrollment (or within applicable AAP periodicity timelines for ages two and younger if shorter). If the member's medical record already contains complete information updated within the prior 12 months, a full IHA may not be required.<=120 days

Content: IHA includes comprehensive history; comprehensive physical and mental exam; identification of risks and assessment of preventive screening needs; health education/anticipatory guidance; diagnoses and plan including follow-up; dental exam for all ages; dental referral for ages 3 to <21.

Documentation: All IHA components must be documented in the medical record, legible and signed/dated. Outreach attempts and documented exceptions (e.g., prior adequate exam within 12 months, documented refusals, missed appointments with outreach) must be present in the record.

IHA exceptions

Exceptions (IHA may not be required or may be satisfied when ANY of the following apply)

Prior exam within 12 months: Established patient with a complete and current exam in the medical record within the prior 12 months (documentation supporting the exception must exist).

Perinatal members: Initial prenatal visit may satisfy the IHA if performed within the required timeframe.

Missed/non-response: After documented scheduling/outreach attempts, missed appointments or non-response may be considered an exception if documentation of the attempts exists in the record.

Effective 1/1/2023, completion of the IHEBA/SHA is no longer a required component of the Initial Health Appointment (IHA). This change removes the prior requirement that the IHA include the IHEBA/SHA tool while preserving all other IHA expectations (timing, content, and documentation).

The removal of the IHEBA/SHA requirement means that use of that specific screening instrument is not mandatory to meet IHA compliance. Providers may use other validated tools or clinical assessment methods so long as the IHA still fulfills the policy’s required components (comprehensive history, physical and mental exam, risk identification, preventive needs assessment, health education, diagnoses/plan and follow up) and is documented in the medical record.

Billing and Coding for IHAs

Initial Health Appointment / related billing codesmixedCovered

99381
99382
99383
99384
99385
99386
99387
99391
99392
99393

1–10 of 74

1/8

Primary diagnosis ICD-10 codes suggested with 99215ICD-10

Z00.00
Z00.01
Z00.110
Z00.111
Z00.121
Z00.129
Z01.401
Z01.419
Z00.9
Z02.1

1–10 of 14

1/2

IHA completion timeframe — within 120 calendar days of enrollment

Completion timeframeIHA must be completed within 120 calendar days of enrollment

APL referenceCurrent guidance aligns with DHCS All Plan Letter (APL) 22-030 noting the 120-day benchmark

Prior-document noteOlder documents referenced 90 days or a 12-month updated record; current policy uses 120 days

Exception when prior exam existsIf the member's medical record already contains complete information updated within the prior 12 months, a full IHA may not be required

Provider Responsibilities and Operational Guidance

Billing Rule

Billing codes for IHA — provider guidance

For billing of services associated with completion of the Comprehensive Initial Health Assessment (IHA), use appropriate CPT/HCPCS codes for the visit type performed. For established patients within the 120-day IHA timeframe, bill using CPT 99215 plus an appropriate diagnosis code. Ensure documentation supports the level of service billed and that the IHA components are present in the medical record.

Covered CPT/HCPCS codes include (non-exhaustive list): 99381, 99382, 99383, 99384, 99385, 99386, 99387, 99391, 99392, 99393, 99394, 99395, 99396, 99397, 99204, 99205, 99214, 59400, 59425, 59426, 59510, 59610, 59618, 96160, 96161, 99211, 99212, 99213, 99241, 99242, 99243, 99244, 99245, 99354, 99355, 99401, 99402, 99403, 99404, 99411, 99412, 99429, 99444, 99446, 99447, 99448, 99449, 99450, 99455, 99456, 99222, 99223, 99341, 99421, 99422, 99423, 99441, 99442, 99443, 99460, 99463, 99201, G0465, G0402, G0438, G0439, G0463, T1015, G0468, Z1034, Z1038, Z1032, Z6500
For an established patient seen for the IHA within the 120-day window, bill CPT 99215 plus diagnosis code that justifies the visit and services provided.
Ensure modifiers or service-specific guidance are applied as appropriate (e.g., telehealth modifiers when applicable) and that any additional services (behavioral health, care coordination, screenings) are billed with the correct supporting CPT/HCPCS codes.

Policy Background

The Initial Health Appointment (IHA) is a comprehensive assessment performed for newly enrolled members to establish care, identify current or emerging health issues, and address preventive service needs. The IHA must be completed by a primary care provider (or equivalent) within 120 calendar days of enrollment (or earlier if required by AAP periodicity for children under two) and must document the required clinical components and follow-up plan in the medical record.

Key Definitions

Initial Health Appointment (IHA) — definition and scope of who performs it and the setting

DefinitionInitial Health Appointment (IHA): a comprehensive assessment of a newly enrolled Medi‑Cal managed care member to establish care, identify risks, and address preventive service needs

Who performs the IHAMust be completed by a primary care provider (PCP) or equivalent (e.g., physician, nurse practitioner, physician assistant)

SettingPerformed in a primary care medical setting (PCP office or equivalent)

Purpose and scopeMay be completed across one or more visits but must cover history, physical exam, risk identification, preventive needs, education, diagnoses, plan and follow-up

Policy Summary

PayerMolina Healthcare

PolicyInitial Health Appointment (IHA) requirements and medical record review

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2023

Next Review DateN/A

SourceLink

On This Page

Claims must be supported by complete medical record documentation of IHA components (history & physical, risk assessment, preventive screenings status, health education/anticipatory guidance, diagnoses/plan, follow-up instructions) and outreach/scheduling attempts when applicable.

Note

Operational workflow — best practices

Identify new members at the start of each month and perform outreach within 30 days. Schedule the IHA to occur within 120 days of assignment; encourage an in-person component when possible. Use checklists to ensure all IHA components are completed and document outreach, scheduling attempts, missed appointments, or refusals in the medical record.

Generate new-member lists (Availity or IPA Member List) monthly.
Contact members by phone and letter/mail within first 30 days of enrollment; document all attempts.
Schedule IHA within 120 days; if virtual care is provided, include at least one in-person component when clinically appropriate.
Track completion using practice dashboards and Molina reports; set internal targets for improvement.

Documentation Required

Required IHA documentation

All components of the Comprehensive IHA must be documented in the member's medical record. Documentation must be legible, dated and signed (electronic signatures acceptable). If an exception applies (for example, a complete exam within the prior 12 months), include supporting documentation.

Required IHA components to document: history & physical exam, risk assessment, status of preventive screenings, health education/anticipatory guidance, diagnoses/plan, and follow-up instructions.
If relying on an exception (e.g., prior adequate exam within 12 months or initial prenatal visit for perinatal members), document the basis for the exception and reference dates/results.
Document outreach and scheduling attempts (phone, text, email, letter/mail) and any member refusals.

Denial Risk

Documentation deficiencies — consequences & examples

If required IHA components or outreach/scheduling documentation are missing, Molina may deny associated quality credit or request corrective action. Examples of deficiencies include absent history/physical, no documented risk assessment or preventive screening status, missing signatures/dates, or lack of documented scheduling attempts after enrollment.

Consequences: findings on review may trigger corrective action plans and follow-up meetings; incomplete documentation can affect quality measurement and potential payment implications.
Examples of documentation deficiencies: illegible notes, undated/unsigned records, missing preventive screening status, no evidence of outreach after member enrollment, or failure to document exceptions with supporting records.

Prior Authorization

MRR findings and corrective action

Molina will conduct Medical Record Reviews (MRR) to validate completion and documentation of IHAs. Reviews may be onsite, virtual, or desktop and typically include 10-20 selected member charts. Findings will be documented and may result in corrective action plans if missing components or insufficient outreach documentation are identified.

Molina will randomly select PCP sites and schedule the IHA MRR with the practice.
Types of review: Onsite (paper charts), Virtual (screen share), Desktop (EHR access).
MRR will assess inclusion of all IHA components and evidence of outreach/scheduling; trends and deficiencies will be reported.