TTY users should call (800) 718-4347. ICDs will be covered for the following patient indications: Please refer to section 20.4 of the NCD Manual for additional coverage criteria. Who is covered: This will give you time to talk to your doctor or other prescriber. The call is free. 2) State Hearing If your Level 2 Appeal was an Independent Medical Review, you can request a State Hearing. The organization will send you a letter explaining its decision. Or your doctor or other prescriber can tell us on the phone, and then fax or mail a statement. 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 removal of these elements eliminates an important source of complications associated with traditional pacing systems while providing similar benefits. Receive services without regard to race, ethnicity, national origin, religion, sex, age, mental or physical disability or medical condition, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), disability, genetic information, or source of payment. IEHP offers a competitive salary and stellar benefit package . 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. If you want the Independent Review Organization to review your case, your appeal request must be in writing. Information on the page is current as of March 2, 2023 There are extra rules or restrictions that apply to certain drugs on our Formulary. The patient is under the care of a heart team, which consists of a cardiac surgeon, interventional cardiologist, and various Providers, nurses, and research personnel, The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the related aspects of TAVR, The hospital where the TAVR is complete must have various qualifications and implemented programs. This service will be covered when the TAVR is used, for the treatment of symptomatic aortic valve stenosis. Your PCP should speak your language. You have the right to ask us for a copy of the information about your appeal. However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan. This service will be covered only for beneficiaries diagnosed with chronic Lower Back Pain (cLBP) when the following conditions are met: All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare. You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. What to do if you have a problem or concern with IEHP DualChoice (HMO D-SNP): You can call IEHP Member Services at (877) 273-IEHP (4347) and ask for a Member Complaint Form. Yes. Make necessary appointments for routine and sick care, and inform your Doctor when you are unable to make a scheduled appointment. When we complete the review, we will give you our decision in writing. Routine womens health care, which includes breast exams, screening mammograms (X-rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider. Click here for information on Next Generation Sequencing coverage. They can also answer your questions, give you more information, and offer guidance on what to do. You can give the completed form to any IEHP Provider or mail it to: Call: 1-888-452-8609(TTY 711) Monday through Friday, 9 a.m. to 5 p.m. You can call IEHP DualChoice at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. If your PCP leaves our Plan, we will let you know and help you choose another PCP so that you can keep getting covered services. (Implementation Date: June 16, 2020). At Level 2, an Independent Review Entity will review the decision. If you put your complaint in writing, we will respond to your complaint in writing. You will be automatically disenrolled from IEHPDualChoice, when your new plans coverage begins. Prescriptions written for drugs that have ingredients you are allergic to. Advance care planning (ACP) involves shared decision making to write down-in an advance care directive-a persons wishes about their future medical care. Generally, IEHP DualChoice (HMO D-SNP) will cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. When possible, take along all the medication you will need. This is asking for a coverage determination about payment. Your care team and care coordinator work with you to make a care plan designed to meet your health needs. Try to choose a PCP that can admit you to the hospital you want within 30 miles or 45 minutes of your home. IEHP DualChoice Member Services can assist you in finding and selecting another provider. Click here to learn more about IEHP DualChoice. The PCP you choose can only admit you to certain hospitals. For the benefit year of 2023 here is what youll get and what you will pay: With IEHP DualChoice, you pay nothing for covered drugs as long as you follow the plans rules. We will review our coverage decision to see if it is correct. This is called prior authorization. Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. This means within 24 hours after we get your request. Effective for claims with dates of service on or after 12/07/16, Medicare will cover PILD under CED for beneficiaries with LSS when provided in an approved clinical study. Again, if a drug is suddenly recalled because its been found to be unsafe or for other reasons, the plan will immediately remove the drug from the Formulary. TTY/TDD (877) 486-2048. Information on this page is current as of October 01, 2022, Centers for Medicare and Medicaid Services. 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. If we do not meet this deadline, we will send your request to Level 2 of the appeals process. To stay a member of IEHP DualChoice, you must qualify again by the last day of the two-month period. Then, we check to see if we were following all the rules when we said No to your request. i. Are a United States citizen or are lawfully present in the United States. (Effective: August 7, 2019) 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. Effective for dates of service on or after January 27, 2020, CMS has determined that NGS, as a diagnostic laboratory test, is reasonable and necessary and covered nationally for patients with germline (inherited) cancer when performed in a CLIA-certified laboratory, when ordered by a treating physician and when specific requirements are met. There are over 700 pharmacies in the IEHP DualChoice network. You might leave our plan because you have decided that you want to leave. After your application and supporting documents are received from your plan, the IMR decision will be made within 3 calendar days. You can also call if you want to give us more information about a request for payment you have already sent to us. 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)? Yes. This means that your PCP will be referring you to specialists and services that are affiliated with their medical group. CMS has updated Chapter 1, section 30.3.3 of the Medicare National Coverage Determinations Manual. What is covered: Infected individuals may develop symptoms such as nausea, anorexia, fatigue, fever, and abdominal pain, or may be asymptomatic. Welcome to Inland Empire Health Plan \. We will send you a letter within 5 calendar days of receiving your appeal letting you know that we received it. c. The Medicare Administrative Contractors (MACs) will review the arterial PO2 levels above and also take into consideration various oxygen measurements that can results from factors such as patients age, patients skin pigmentation, altitude level and the patients decreased oxygen carrying capacity. When your complaint is about quality of care. If an alternative drug would be just as effective as the drug you are asking for, and would not cause more side effects or other health problems, we will generally not approve your request for an exception. You, your doctor or other prescriber, or your representative can request the Level 2 Appeal. It has been updated that coverage determinations for providing Topical Application of Oxygen for the treatment of chronic wounds can be made by the local Contractors. Effective for claims with dates of service on or after 09/28/2016, CMS covers screening for HBV infection. The Heart team must participate in the national registry and track outcomes according to the requirements in this determination.>. Have advanced heart failure for at least 14 days and are dependent on an intraaortic balloon pump (IABP) or similar temporary mechanical circulatory support for at least 7 days. This is called upholding the decision. It is also called turning down your appeal. The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. The benefit information is a brief summary, not a complete description of benefits. With "Extra Help," there is no plan premium for IEHP DualChoice. Your doctor or other provider can make the appeal for you. Your doctor or other prescriber can fax or mail the statement to us. Treatments must be discontinued if the patient is not improving or is regressing. In most cases you have 120 days to ask for a State Hearing after the Your Hearing Rights notice is mailed to you. 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. Note, the Member must be active with IEHP Direct on the date the services are performed. (SeeChapter 10 ofthe. If your problem is urgent and involves an immediate and serious threat to your health, you may bring it immediately to the DMHCs attention. All the changes are reviewed and approved by a selected group of Providers and Pharmacists that are currently in practice. If you request a fast coverage decision coverage decision, start by calling or faxing our plan to ask us to cover the care you want. Department of Health Care Services It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. (800) 718-4347 (TTY), IEHP DualChoice Member Services Click here to download a free copy by clicking Adobe Acrobat Reader. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which IEHP DualChoice (HMO D-SNP) authorizes use of out-of-network providers. Here are your choices: There may be a different drug covered by our plan that works for you. The list can help your provider find a covered drug that might work for you. If you are having a problem with your care, you can call the Office of Ombudsman at 1-888-452-8609for help. You may also contact the local Office for Civil Rights office at: U.S. Department of Health and Human Services. We will contact the provider directly and take care of the problem. This additional time will allow you to correct your eligibility information if you believe that you are still eligible. If you lie about or withhold information about other insurance you have that provides prescription drug coverage. If you dont have the IEHP DualChoice Provider and Pharmacy Directory, you can get a copy from IEHP DualChoice Member Services. Or you can make your complaint to both at the same time. The screen test must have all the following: Food and Drug Administration (FDA) market authorization with an indication for colorectal cancer screening; and. An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. (Implementation Date: October 8, 2021) The care team helps coordinate the services you need. 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. For some drugs, the plan limits the amount of the drug you can have. The letter will explain why more time is needed. iv. 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. 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. Including bus pass. You can ask us to make a faster decision, and we must respond in 15 days. Yes. Prior to the beneficiarys first lung cancer LDCT screening, the beneficiary must receive a counseling and shared decision-making visit that meets specific criteria. https://www.medicare.gov/MedicareComplaintForm/home.aspx. LSS is a narrowing of the spinal canal in the lower back. For example, we might decide that a service, item, or drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. 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. Interventional Cardiologist meeting the requirements listed in the determination. Explore Opportunities. IEHP DualChoice 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. Your IEHP DualChoice Doctor cannot charge you for covered health care services, except for required co-payments. How to Enroll with IEHP DualChoice (HMO D-SNP) Here are two ways to get help from the Help Center: You can file a complaint with the Office for Civil Rights. You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function. If the appeal comes from someone besides you or your doctor or other provider, we must receive the completed Appointment of Representative form before we can review the appeal. Most recently, as of May 1, 2016, Medi-Cal now covers all low income children under the age of 19, regardless of immigration status. Patients demonstrating arterial PO2 between 56-59 mm Hg, or whos arterial blood oxygen saturation is 89%, with any of the following condition: If your treatment was denied because it was experimental or investigational, you do not have to take part in our appeal process before you apply for an IMR. 2. Providers from other groups including patient practitioners, nurses, research personnel, and administrators. The letter will also explain how you can appeal our decision. Who is covered? If you would like to switch from our plan to another Medicare Advantage plan simply enroll in the new Medicare Advantage plan. 2. We will say Yes or No to your request for an exception. Effective for dates of service on or after January 19, 2021, CMS has updated section 20.33 of the National Coverage Determination Manual to cover Transcatheter Edge-to-Edge Repair (TEER) for Mitral Valve Regurgitation when specific requirements are met. We will give you our answer sooner if your health requires it. (800) 718-4347 (TTY), IEHP 24-Hour Nurse Advice Line (for IEHP Members only) (Effective: January 19, 2021) You should receive the IMR decision within 45 calendar days of the submission of the completed application. 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. This is called upholding the decision. It is also called turning down your appeal.. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. Effective February 15, 2020, CMS will cover FDA approved Vagus Nerve Stimulation (VNS) devices for treatment-resistant depression through Coverage with Evidence Development (CED) in a CMS approved clinical trial in addition to the coverage criteria outlined in the National Coverage Determination Manual. For more information on Member Rights and Responsibilities refer to Chapter 8 of your. You can always contact your State Health Insurance Assistance Program (SHIP). If your doctor says that you need a fast coverage decision, we will automatically give you one. Unleashing our creativity and courage to improve health & well-being. Appointment of Representatives Form (PDF), 2023 Drugs Requiring Prior Authorization (PDF). Who is covered: Beneficiaries receiving treatment for chronic non-healing diabetic wounds for a duration of 20 weeks, when prepared by a device cleared by the Food and Drug Administration (FDA) for the management of exuding (bleeding, oozing, seeping, etc.) Click here for more information on MRI Coverage. Sign up for the free app through our secure Member portal. IEHP DualChoice network providers are required to comply with minimum standards for pharmacy practices as established by the State of California. 10820 Guilford Road, Suite 202 All requests for out-of-network services must be approved by your medical group prior to receiving services. If the coverage decision is No, how will I find out? (Effective: January 19, 2021) All screenings DNA tests, effective April 28, 2008, through October 8, 2014. A medical group or IPA is a group of physicians, specialists, and other providers of health services that see IEHP Members. H8894_DSNP_23_3241532_M. If you ask for a fast coverage decision, without your doctors support, we will decide if you get a fast coverage decision. The form gives the other person permission to act for you. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. New to IEHP DualChoice. 2020) 1. How much time do I have to make an appeal for Part C services? How can I make a Level 2 Appeal? If you are asking for a standard appeal, you can make your appeal by sending a request in writing. You do not need to do anything further to get this Extra Help. a. Noncoverage specifically includes the following: Click here for more information on Ambulatory Electroencephalographic Monitoring and Colorectal Cancer Screening Tests. CAR, when all the following requirements are met: Autologous treatment is for cancer with T-cells expressing at least one chimeric antigen receptor (CAR); and, Treatment is administered at a healthcare facility enrolled in the FDAs REMS; and. We will answer your request for an exception within 72 hours after we get your request (or your prescribers supporting statement). Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. TTY/TDD users should call 1-800-718-4347. We do the right thing by: Placing our Members at the center of our universe. 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. Patients depressive illness meets a minimum criterion of four prior failed treatments of adequate dose and duration as measured by a tool designed for this purpose. They mostly grow wild across central and eastern parts of the country. 1. Your membership will usually end on the first day of the month after we receive your request to change plans. Autologous Platelet-Rich Plasma (PRP) treatment of acute surgical wounds when applied directly to the close incision, or for splitting or open wounds. If you do not agree with our decision, you can make an appeal. Receive information about IEHP DualChoice, its programs and services, its Doctors, Providers, health care facilities, and your drug coverage and costs, which you can understand. Vision Care: $350 limit every year for contact lenses and eyeglasses (frames and lenses). It also has care coordinators and care teams to help you manage all your providers and services. How to ask for coverage decision coverage decision to get medical, behavioral health, or certain long-term services and supports (CBAS, or NF services). If you need help during the appeals process, you can call the Office of the Ombudsman at 1-888-452-8609. This government program has trained counselors in every state. (Effective: April 3, 2017) Effective July 2, 2019, CMS will cover Ambulatory Blood Pressure Monitoring (ABPM) when beneficiaries are suspected of having white coat hypertension or masked hypertension in addition to the coverage criteria outlined in the NCD Manual. If an alternative drug would be just as effective as the drug you are asking for, and would not cause more side effects or other health problems, we will generally not approve your request for an exception. VNS is non-covered for the treatment of TRD when furnished outside of a CMS-approved CED study. (Implementation Date: December 12, 2022) You can ask us to reimburse you for our share of the cost by submitting a claim form. We are the largest health plan in the Inland Empire, and one of the fastest-growing health plans in the nation. Here are two ways to get information directly from Medicare: By clicking on this link, you will be leaving the IEHP DualChoice website. By clicking on this link, you will be leaving the IEHP DualChoice website. 2023 IEHP DualChoice Member Handbook (PDF), Click here to download a free copy of Adobe Acrobat Reader.
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