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Receive emergency care whenever and wherever you need it. If your Level 2 Appeal went to the Medicare Independent Review Entity, you can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. Transportation: $0. wounds affecting the skin. The program is not connected with us or with any insurance company or health plan. The DMHC may accept your application after 6 months if it determines that circumstances kept you from submitting your application in time. CMS has updated Chapter 1, section 20.19 of the Medicare National Coverage Determinations Manual. Who is covered? For additional information on step therapy and quantity limits, refer to Chapter5 of theIEHP DualChoice Member Handbook. Urgently needed care from in-network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible, e.g., when you are temporarily outside of the plans service area. You will not have a gap in your coverage. Use the IEHP DualChoice Provider and Pharmacy Directory below to find a network provider: What is a Primary Care Provider (PCP) and their role in your Plan? If you have Medi-Cal with IEHP and would like information on how to pursue appeals and grievances related to Medi-Cal covered services, please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), TTY (800) 718-4347, 8am - 8pm (PST), 7 days a week, including holidays. The therapy is used for a medically accepted indication, which is defined as used for either and FDA approved indication according to the label of that product, or the use is supported in one or more CMS approved compendia. You will be automatically disenrolled from IEHPDualChoice, when your new plans coverage begins. They have a copay of $0. The patient is experiencing a major depressive episode, as measured by a guideline recommended depression scale assessment tool on two visits, within a 45-day span prior to implantation of the VNS device. IEHP DualChoice, a Medicare Medi-Cal Plan, allows you to get your covered Medicare and Medi-Cal benefits through our plan. We will contact the provider directly and take care of the problem. The Centers of Medicare and Medicaid Services (CMS) will cover Vagus Nerve Stimulation (VNS) for treatment-resistant depression when specific requirements are met. You might leave our plan because you have decided that you want to leave. At IEHP, you will find opportunities to take initiative, expand your knowledge and advance your career while working a position that's both challenging and rewarding. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. Asking for a fast coverage decision coverage decision: Here are the rules for asking for a fast coverage decision coverage decision: You must meet the following two requirements to get a fast coverage decision coverage decision: If the coverage decision is Yes, when will I get the service or item? Click here for more information on Ventricular Assist Devices (VADs) coverage. Click here for more information on PILD for LSS Screenings. How will the plan make the appeal decision? You should provide all requested information such as your full name, address, telephone number, the name of the plan or county that took the action against you, the aid program(s) involved, and a detailed reason why you want a hearing. If we tell you after our review that the service or item is not covered, your case can go to a Level 2 Appeal. With IEHP DualChoice, you will still have an IEHP DualChoice Member Service team to get help for your needs. If the service or item you paid for is covered and you followed all the rules, we will send you the payment for our share of the cost of the service or item within 60 calendar days after we get your request. P.O. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. What kinds of medical care and other services can you get without getting approval in advance from your Primary Care Provider (PCP) in IEHP DualChoice (HMO D-SNP)? The reviewer will be someone who did not make the original coverage decision. For more detailed information on each of the NCDs including restrictions and qualifications click on the link after each NCD or call IEHP DualChoice Member Services at (877) 273-IEHP (4347) 8am-8pm (PST), 7 days a week, including holidays, or. Have grievances heard and resolved in accordance with Medicare guidelines; Request quality of care grievances data from IEHP DualChoice. Flu shots as long as you get them from a network provider. This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision. In most cases, you must file an appeal with us before requesting an IMR. IEHP DualChoice (HMO D-SNP) has a list of Covered Drugs called a Formulary. Our plans Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B. When you are discharged from the hospital, you will return to your PCP for your health care needs. Hepatitis B Virus (HBV) is transmitted by exposure to bodily fluids. To see if you qualify for getting extra help, you can contact: Do you need help getting the care you need? https://www.medicare.gov/MedicareComplaintForm/home.aspx. IEHP DualChoice will honor authorizations for services already approved for you. (Implementation Date: October 4, 2021). disease); An additional 8 sessions will be covered for those patients demonstrating an improvement. If our answer is No to part or all of what you asked for, we will send you a letter. In this situation (when you are outside the service area and cannot get care from a network provider), our plan will cover urgently needed care that you get from any provider. Most of the walnuts we eat in the United States are commonly known as English walnuts, but black walnuts are also prized and delicious. You can change your Doctor by calling IEHP DualChoice Member Services. A Cal MediConnect Plan is an organization made up of Doctors, Hospitals, Pharmacies, Providers of long-term services and supports, Behavioral Health Providers, and other Providers. The treatment is based upon efficacy from a change in surrogate endpoint such as amyloid reduction. A network provider is a provider who works with the health plan. We will answer your request for an exception within 72 hours after we get your request (or your prescribers supporting statement). Oncologists care for patients with cancer. For the purpose of this decision, cLBP is defined as: nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. You will be automatically enrolled in IEHP DualChoice and do not need to do anything to keep these services. 2020) We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision. An ICD is an electronic device to diagnose and treat life threating Ventricular Tachyarrhythmias (VTs) that has demonstrated improvement in survival rates and reduced cardiac death for certain patients. You or your provider must show documentation of an existing relationship and agree to certain terms when you make the request. Effective January 21, 2020, CMS will cover acupuncture for chronic low back pain (cLBP), for up to 12 visits in 90 days and an additional 8 sessions for those beneficiaries that demonstrate improvement, in addition to the coverage criteria outlined in the. In order to receive out-of-network services, your Primary Care Provider (PCP) or Specialist must submit a referral request to your plan or medical group. H8894_DSNP_23_3241532_M. If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize or give you the drug coverage within 24 hours after we get the decision. You must qualify for this benefit. According to IEHP, 99.4 percent of enrollees retained the same primary care physicians. To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for an coverage decision. If you disagree with the action, you can file a Level 1 Appeal and ask that we continue your benefits for the service or item. The person you name would be your representative. You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. The phone number for the Office of the Ombudsman is 1-888-452-8609. If you don't have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself. You may be able to get extra help to pay for your prescription drug premiums and costs. i. Arterial PO2 at or below 55 mm Hg or arterial oxygen saturation at or below 88% when tested at rest in breathing room air, or; If you do not stay continuously enrolled in Medicare Part A and Part B. Emergency services from network providers or from out-of-network providers. The device must be approved by the Food and Drug Administration (FDA) for this purpose; OR. Interventional echocardiographer meeting the requirements listed in the determination. You have the right to choose someone to represent you during your appeal or grievance process and for your grievancesand appeals to be reviewed as quickly as possible and be told how long it will take. Disrespect, poor customer service, or other negative behaviors, Timeliness of our actions related to coverage decisions or appeals, You can use our "Member Appeal and Grievance Form." What is covered: If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals). Box 1800 If you have any authorizations pending approval, if you are in them idle of treatment, or if specialty care has been scheduled for you by your current Doctor, contact IEHP to help you coordinate your care during this transition time. The PCP you choose can only admit you to certain hospitals. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. When your PCP thinks that you need specialized treatment or supplies, your PCP will need to get prior authorization (i.e., prior approval) from your Plan and/or medical group. If the service or item is not covered, or you did not follow all the rules, we will send you a letter telling you we will not pay for the service or item and explaining why. (800) 440-4347 Your benefits as a member of our plan include coverage for many prescription drugs. The following medical conditions are not covered for oxygen therapy and oxygen equipment in the home setting: Other: If your Level 2 Appeal was an Independent Medical Review, you can request a State Hearing. We must give you our answer within 30 calendar days after we get your appeal. The letter will also explain how you can appeal our decision. Inland Empire Health Plan (IEHP) has over 1,234 Doctors, 3,676 Specialists, 724 Pharmacies, 74 Urgent Care, 243 OB/GYNs, 383 Behavioral Health Providers, 40 major Hospitals, and 313 Vision doctors in Riverside and San Bernardino counties. The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. Click here for more information onICD Coverage. But in some situations, you may also want help or guidance from someone who is not connected with us. Proven test performance characteristics for a blood-based screening test with both sensitivity greater than or equal to 74% and specificity greater than or equal to 90% in the detection of colorectal cancer compared to the recognized standard (accepted as colonoscopy at this time), based on the pivotal studies included in the FDA labeling. (This is called upholding the decision. It is also called turning down your appeal.) The letter you get will explain additional appeal rights you may have. What if you are outside the plans service area when you have an urgent need for care? Handling problems about your Medi-Cal benefits. Changing your Primary Care Provider (PCP). We will also give notice if there are any changes regarding prior authorizations, quantity limits, step therapy or moving a drug to a higher cost-sharing tier. (Effective: January 18, 2017) After your coverage begins with IEHP DualChoice, you must receive medical services and prescription drug services in the IEHP DualChoice network. Concurrent with Carotid Stent Placement in FDA-Approved Post-Approvals Studies TTY users should call 1-800-718-4347. Review, request changes to, and receive a copy of your medical records in a timely fashion. Diagnostic Tests, X-Rays & Lab Services: $0, Home and Community Based Services (HCBS): $0, Community Based Adult Services (CBAS): $0, Long Term Care that includes custodial care and facility: $0. Please see below for more information. CMS has updated Chapter 1, section 160.18 of the Medicare National Coverage Determinations Manual. Are inotrope dependent OR have a Cardiac Index (CI) < 2.2 L/min/m2, while not on inotropes, and meet one of the following: Are on optimal medical management, based on current heart failure practice guidelines for at least 45 out of the last 60 days and are failing to respond; or. Appointment of Representatives Form (PDF), 2023 Drugs Requiring Prior Authorization (PDF). (Implementation Date: January 3, 2023) The clinical study must adhere to all the standards of scientific integrity and relevance to the Medicare population. If possible, we will answer you right away. If you need a response faster because of your health, you should ask us to make a fast coverage decision. If we approve the request, we will notify you of our coverage decision coverage decision within 72 hours. Remember, you can request to change your PCP at any time. Effective on or after April 10, 2018, MRI coverage will be provided when used in accordance to the FDA labeling in an MRI environment. An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. Annapolis Junction, Maryland 20701. If you are requesting an exception, provide the supporting statement. Your doctor or other prescriber must give us the medical reasons for the drug exception. Our service area includes all of Riverside and San Bernardino counties. Reviewers at the Independent Review Entity will take a careful look at all of the information related to your appeal. (Effective: April 3, 2017) Call (888) 466-2219, TTY (877) 688-9891. CMS reviews studies to determine if they meet the criteria listed in Section 160.18 of the National Coverage Determination Manual. Beneficiaries receiving autologous treatment for cancer with T-cell expressing at least one. However, your PCP can always use Language Line Services to get help from an interpreter, if needed. A reasonable salary expectation is between $153,670.40 and $195,936.00, based upon experience and internal equity. See below for a brief description of each NCD. IEHP DualChoice Member Services can assist you in finding and selecting another provider. Possible errors in the amount (dosage) or duration of a drug you are taking. The Centers for Medicare and Medical Services (CMS) has determined the following services to be necessary for the treatment of an illness or injury. Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. View Plan Details. Beneficiaries must be managed by a team of medical professionals meeting the minimum requirements in the National Coverage Determination Manual. If we agree to make an exception and waive a restriction for you, you can still ask for an exception to the co-pay amount we require you to pay for the drug. Heart failure cardiologist with experience treating patients with advanced heart failure. (877) 273-4347 You may contact the DMHC if you need help with a complaint involving an urgent issue or one that involves an immediate and serious threat to your health, you disagree with our plans decision about your complaint, or our plan has not resolved your complaint after 30 calendar days. TTY users should call 1-800-718-4347. Note: You can only make this request for services of Durable Medical Equipment (DME), transportation, or other ancillary services not included in our plan. (Implementation Date: September 20, 2021). IEHP DualChoice develops and maintains the Formulary continuously by reviewing the efficacy (how effective) and safety (how safe) of new drugs, compare new versus existing drugs, and develops clinical practice guidelines based on clinical evidence. Beneficiaries that demonstrate limited benefit from amplification. Effective for dates of service on or after December 15, 2017, CMS has updated section 220.6.19 of the National Coverage Determination Manual clarifying there are no nationally covered indications for Positron Emission Tomography NaF-18 (NaF-18 PET). If the DMHC decides that your case is not eligible for IMR, the DMHC will review your case through its regular consumer complaint process. Effective for dates of service on or after October 9, 2014, all other screening sDNA tests not otherwise specified above remain nationally non-covered. The services of SHIP counselors are free. All of our Doctors offices and service providers have the form or we can mail one to you. If you wish, you can make your complaint about quality of care to our plan and also to the Quality Improvement Organization. Concurrent with Intracranial Stent Placement in FDA-Approved Category B IDE Clinical Trials Rancho Cucamonga, CA 91729-1800 Beneficiaries receiving autologous treatment for cancer with T-cell expressing at least one least one chimeric antigen receptor CAR, when all the following requirements are met: The use of non-FDA-approved autologous T-cell expressing at least one CAR is non-covered or when the coverage requirements are not met. Information on procedures for obtaining prior authorization of services, Quality Assurance, disenrollment, and other procedures affecting IEHP DualChoice Members. A care coordinator is a person who is trained to help you manage the care you need. Screening computed tomographic colonography (CTC), effective May 12, 2009. If the IRE says No to your appeal, it means they agree with our decision not to approve your request. The letter will also tell how you can file a fast appeal about our decision to give you a fast coverage decision instead of the fast coverage decision you requested. When you file a fast complaint, we will give you an answer to your appeal within 24 hours. IEHP DualChoice (HMO D-SNP) has a process in place to identify and reduce medication errors. Off-label use is any use of the drug other than those indicated on a drugs label as approved by the Food and Drug Administration. (Effective: May 25, 2017) It also has care coordinators and care teams to help you manage all your providers and services. The form gives the other person permission to act for you. For other types of problems you need to use the process for making complaints. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more days (44 days total) to answer your complaint. Sprint from Voice Telephone: (800) 877-5379, Visit: 10801 Sixth Street, Suite 120, Rancho Cucamonga, CA 91730. (Effective: April 13, 2021) How will you find out if your drugs coverage has been changed? If you are asking to be paid back, you are asking for a coverage decision. 2. Who is covered: Medicare beneficiaries will have their blood-based colorectal cancer screening test covered once every 3 years when ordered by a treating physician and the following conditions are met: (Effective: December 1, 2020) (Effective: August 7, 2019) Your test results are shared with all of your doctors and other providers, as appropriate. For additional details on how to reach us for appeals, see Chapter 9 of the IEHP DualChoice Member Handbook. We will say Yes or No to your request for an exception. Complex Care Management; Medi-Cal Demographic Updates . CMS has expanded the PILD for LSS National Coverage Determination (NCD) to now cover beneficiaries that are enrolled in a CMS-approved prospective longitudinal study. From time to time (during the benefit year), IEHP DualChoice revises (adding or removing drugs) the Formulary based on new clinical evidence and availability of products in the market. Your doctor or other provider can make the appeal for you. (Implementation Date: March 26, 2019). The procedure must be performed in a hospital with infrastructure and experience meeting the requirements in this determination. Arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88%, tested during functional performance of the patient or a formal exercise, After cracking, the nutmeat is easy to remove from the English walnut shell, while the nutmeat from the black walnut is much more difficult to remove after it has been cracked . If the IRE reverses our decision and says we should pay you, we must send the payment to you or to the provider within 30 calendar days. We determine an existing relationship by reviewing your available health information available or information you give us. What is covered: Who is covered? app today. Prior to the beneficiarys first lung cancer LDCT screening, the beneficiary must receive a counseling and shared decision-making visit that meets specific criteria. Non-Covered Use: The following uses are considered non-covered: Click here for more information on Blood-Derived Products for Chronic, Non-Healing Wounds coverage. Effective for dates of service on or after January 1, 2022, CMS has updated section 180.1 of the National Coverage Determination Manual to cover three hours of administration during one year of Medical Nutrition Therapy (MNT) in patients with a diagnosis of renal disease or diabetes, as defined in 42 CFR 410.130. There are extra rules or restrictions that apply to certain drugs on our Formulary. Your PCP, along with the medical group or IPA, provides your medical care. You wont pay a premium, or pay for doctor visits or other medical care if you go to a provider that works with our health plan. When will I hear about a standard appeal decision for Part C services? You can tell the California Department of Managed Health Care about your complaint. You can contact Medicare. If the coverage decision is No, how will I find out? If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition. 2. Call: (877) 273-IEHP (4347). If the answer is No, we will send you a letter telling you our reasons for saying No. Some hospitals have hospitalists who specialize in care for people during their hospital stay. It attacks the liver, causing inflammation. This is called upholding the decision. It is also called turning down your appeal.. IEHP DualChoice will help you with the process. Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities; or. Whether you call or write, you should contact IEHP DualChoice Member Services right away. TTY should call (800) 718-4347. You can fax the completed form to (909) 890-5877. However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. IEHP DualChoice is very similar to your current Cal MediConnect plan. You must ask for an appeal within 60 calendar days from the date on the letter we sent to tell you our decision. TTY users should call (800) 718-4347. If IEHP DualChoice removes a covered Part D drug or makes any changes in the IEHP DualChoice Formulary, IEHP DualChoice will post the formulary changes on the IEHP DualChoice website and notify the affected Members at least thirty (30) days prior to effective date of the change made on the IEHP DualChoice Formulary. If your doctor says that you need a fast coverage decision, we will automatically give you one. This is not a complete list. What is covered: Percutaneous Transluminal Angioplasty (PTA) is covered in the below instances in order to improve blood flow through the diseased segment of a vessel in order to dilate lesions of peripheral, renal and coronary arteries. If your health requires it, ask us to give you a fast coverage decision Including bus pass. After your application and supporting documents are received from your plan, the IMR decision will be made within 30 calendar days. Livanta is not connect with our plan. For some types of problems, you need to use the process for coverage decisions and making appeals. a. Call IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays.
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