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If you have a fast complaint, it means we will give you an answer within 24 hours. You can still get a State Hearing. 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)? 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. Patients must maintain a stable medication regimen for at least four weeks before device implantation. 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. Most complaints are answered in 30 calendar days. You can switch yourDoctor (and hospital) for any reason (once per month). Receive information about clinical programs, including staff qualifications, request a change of treatment choices, participate in decisions about your health care, and be informed of health care issues that require self-management. Including bus pass. This is called a referral. 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, We take another careful look at all of the information about your coverage request. To make this request, or if you have any concerns about your continuity of care, please call IEHP DualChoice Member Services at 1-877-273-IEHP (4347). If we are using the standard deadlines, we must give you our answer within 7 calendar days after we get your appeal, or sooner if your health requires it. 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. 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. Click here to learn more about IEHP DualChoice. (Effective: April 3, 2017) IEHP DualChoice CMS has added a new section, Section 220.2, to Chapter 1, Part 4 of the Medicare National Coverage Determinations Manual entitled Magnetic Resonance Imaging (MRI). My problem is about a Medi-Cal service or item. We will use the standard deadlines unless we have agreed to use the fast deadlines., You can get a fast coverage decision only if you are asking for a drug you have not yet received. If we do not give you an answer within 30 calendar days or by the end of the extra days (if we took them), we will automatically send your case to Level 2 of the appeals process if your problem is about a Medicare service or item. To get a temporary supply of a drug, you must meet the two rules below: When you get a temporary supply of a drug, you should talk with your provider to decide what to do when your supply runs out. A new generic drug becomes available. This section is about asking for coverage decisions and making appeals with problems related to your benefits and coverage. You may also ask for an appeal by calling IEHP DualChoice Member Services at 1-877-273-IEHP (4347), 8am 8pm (PST), 7 days a week, including holidays. 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. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. You can always contact your State Health Insurance Assistance Program (SHIP). (Effective: April 7, 2022) Remember, you can request to change your PCP at any time. If your problem is about a Medi-Cal service or item, you can file a Level 2 Appeal yourself. Will not cover an experimental or investigational Medi-Cal treatment for a serious medical condition. (Effective: February 15, 2018) The Help Center cannot return any documents. (Implementation Date: February 19, 2019) This page provides you information on what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug. Call IEHP DualChoice Member Services if you need help in choosing a PCP or changing your PCP. 2. If possible, we will answer you right away. It also includes problems with payment. Here are three general rules about drugs that Medicare drug plans will not cover under Part D: For more information refer to Chapter 6 of yourIEHP DualChoice Member Handbook. Sacramento, CA 95899-7413. If your doctor or other provider asks for a service or item that we will not approve, or we will not continue to pay for a service or item you already have and we said no to your Level 1 appeal, you have the right to ask for a State Hearing. Calls to this number are free. The call is free. Transportation: $0. (Effective: January 18, 2017) Limited benefit from amplification is defined by test scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of open-set sentence recognition. Beneficiaries not meeting all the criteria for cochlear implants are deemed not eligible for Medicare coverage except for FDA-approved clinical trials as described in the NCD. Program Services There are five services eligible for a financial incentive. The leadless pacemaker eliminates the need for a device pocket and insertion of a pacing lead which are integral elements of traditional pacing systems. But if you do pay the bill, you can get a refund if you followed the rules for getting services and items. i. PO2 measurements can be obtained via the ear or by pulse oximetry. Unless you change plans, IEHP DualChoice (HMO D-SNP) will provide your Medicare benefits. For some types of problems, you need to use the process for coverage decisions and making appeals. Click here for more information on chimeric antigen receptor (CAR) T-cell therapy coverage. Medicare beneficiaries who are diagnosed with Symptomatic Peripheral Artery Disease who would benefit from this therapy. We also review our records on a regular basis. Or you can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. If you need to change your PCP for any reason, your hospital and specialist may also change. Complex Care Management; Medi-Cal Demographic Updates . These forms are also available on the CMS website: Medicare Prescription Drug Determination Request Form (for use by enrollees and providers), Deadlines for a standard coverage decision about a drug you have not yet received, If our answer is Yes to part or all of what you asked for, we must approve or give the coverage within 72 hours after we get your request or, if you are asking for an exception, your doctors or prescribers supporting statement. When you are following these instructions, please note: If we answer no to your appeal and the service or item is usually covered by Medicare, we will automatically send your case to the Independent Review Entity. What Prescription Drugs Does IEHP DualChoice Cover? 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. The letter will tell you how to make a complaint about our decision to give you a standard decision. Ask us for a copy by calling Member Services at (877) 273-IEHP (4347). Treatment for patients with existing co-morbidities that would preclude the benefit from the procedure. Covering a Part D drug that is not on our List of Covered Drugs (Formulary). The following information explains who qualifies for IEHP DualChoice (HMO D-SNP). If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan. Note: You can only make this request for services of Durable Medical Equipment (DME), transportation, or other ancillary services not included in our plan. If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. When that happens, we may remove the current drug, but your cost for the new drug will stay the same or will be lower. The Office of Ombudsman is not connected with us or with any insurance company or health plan. 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. There is no deductible for IEHP DualChoice. These changes might happen if: When these changes happen, we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill. Refer to Chapter 3 of your Member Handbook for more information on getting care. If the State Hearing decision is Yes to part or all of what you asked for, we must comply with the decision. The procedure must be performed by an interventional cardiologist or cardiac surgeon.<. If we dont give you our decision within 14 calendar days, you can appeal. If your doctor says that you need a fast coverage decision, we will automatically give you one. We will answer your request for an exception within 72 hours after we get your request (or your prescribers supporting statement). This is called a referral. Information on this page is current as of October 01, 2022. (800) 718-4347 (TTY), IEHP DualChoice Member Services A reasonable salary expectation is between $153,670.40 and $195,936.00, based upon experience and internal equity. You will be automatically disenrolled from IEHPDualChoice, when your new plans coverage begins. If there are no network pharmacies in that area, IEHP DualChoice Member Services may be able to make arrangements for you to get your prescriptions from an out-of-network pharmacy. All Medicare covered services, doctors, hospitals, labs, and x-rays, You will have access to a Provider network that includes many of the same Providers as your current plan, Coordination of the services you get now or that you might need, Personal history of sustained VT or cardiac arrest due to Ventricular Fibrillation (VF), Prior Myocardial Infarction (MI) and measured Left Ventricular Ejection Fraction (LVEF) less than or equal to .03, Severe, ischemic, dilated cardiomyopathy without history of sustained VT or cardiac arrest due to VF, and have New York Heart Association (NYHA) Class II or III heart failure with a LVEF less than or equal to 35%, Severe, non-ischemic, dilated cardiomyopathy without history of cardiac arrest or sustained VT, NYHA Class II or II heart failure, LVEF less than or equal for 35%, and utilization of optimal medical therapy for at a minimum of three (3) months, Documented, familial or genetic disorders with a high risk of life-threating tachyarrhythmias, but not limited to long QT syndrome or hypertrophic cardiomyopathy, Existing ICD requiring replacement due to battery life, Elective Replacement Indicator (ERI), or malfunction, The procedure is performed in a Clinical Laboratory Improvement Act (CLIA)-certified laboratory. Yes. Governing Board. Usually, your prescription drugs are only covered if they are filled at a network pharmacy including through our mail-order pharmacy services. Click here for more information onICD Coverage. You cannot make this request for providers of DME, transportation or other ancillary providers. You can then ask us to make an exception and cover the drug in the way you would like it to be covered for next year. All have different pros and cons. effort to participate in the health care programs IEHP DualChoice offers you. (Implementation Date: July 27, 2021) If our answer is Yes to part or all of what you asked for, we must give the coverage within 72 hours after we get your appeal. You have been in the plan for more than 90 days and live in a long-term care facility and need a supply right away. Members \. If you do not qualify by the end of the two-month period, youll de disenrolled by IEHP DualChoice. The treatment is based upon efficacy from a change in surrogate endpoint such as amyloid reduction. (Implementation Date: October 4, 2021). For example: We may make other changes that affect the drugs you take. You can also visit https://www.hhs.gov/ocr/index.html for more information. If we say no to part or all of your Level 1 Appeal, we will send you a letter. You can make a complaint to the Department of Health and Human Services Office for Civil Rights if you think you have not been treated fairly. You must ask for an appeal within 60 calendar days from the date on the letter we sent to tell you our decision. Information on this page is current as of October 01, 2022 We do a review each time you fill a prescription. If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No. app today. They all work together to provide the care you need. This service will be covered when the TAVR is used, for the treatment of symptomatic aortic valve stenosis. Then you can: 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. You should receive the IMR decision within 7 calendar days of the submission of the completed application. In most cases, you must file an appeal with us before requesting an IMR. IEHP DualChoice will give notice to IEHPDualChoice Members prior to removing Part D drug from the Part D formulary. Complain about IEHP DualChoice, its Providers, or your care. TTY users should call 1-877-486-2048. When we say existing relationship, it means that you saw an out-of-network provider at least once for a non-emergency visit during the 12 months before the date of your initial enrollment in our plan. Prescriptions written for drugs that have ingredients you are allergic to. Most of these drugs are Part D drugs. There are a few drugs that Medicare Part D does not cover but that Medi-Cal may cover. Who is covered: The PTA is covered under the following conditions: You ask us if a drug is covered for you (for example, when your drug is on the plans Formulary but we require you to get approval from us before we will cover it for you). If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No. i. We are also one of the largest employers in the region, designated as "Great Place to Work.". according to the FDA-approved indications and the following conditions are met: The procedure and implantation system received FDA premarket approval (PMA) for that system's FDA approved indication. Medi-Cal is public-supported health care coverage. Who is covered: Members must meet all of the following eligibility criteria: Click here for more information on LDCT coverage. Please call or write to IEHP DualChoice Member Services. H8894_DSNP_23_3241532_M. The benefit information is a brief summary, not a complete description of benefits. Get the My Life. At Level 2, an Independent Review Entity will review your appeal. (Effective: January 19, 2021) The following link will take you to the Centers for Medicaid and Medicare Services website, where you can look through the CMS Best Available Evidence Policy using the following link: CMS Best Available Evidence Policy. You may be able to get extra help to pay for your prescription drug premiums and costs. More . They are considered to be at high-risk for infection; or. The Medicare Complaint Form is available at:https://www.medicare.gov/MedicareComplaintForm/home.aspx. Our plans PCPs are affiliated with medical groups or Independent Physicians Associations (IPA). The call is free. This can speed up the IMR process. Ask within 60 days of the decision you are appealing. Our service area includes all of Riverside and San Bernardino counties. ICDs will be covered for the following patient indications: Please refer to section 20.4 of the NCD Manual for additional coverage criteria. 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. You can send your complaint to Medicare. Deadlines for standard appeal at Level 2 If your change request is received byIEHP by the 25th of the month, the change will be effective the first of the following month; if your change request is received byIEHP after the 25th of the month, the change will be effective the first day of the subsequent month (for some providers, you may need a referral from your PCP). A network provider is a provider who works with the health plan. What is a Level 1 Appeal for Part C services? Your PCP, along with the medical group or IPA, provides your medical care. (Effective: August 7, 2019) Effective January 19, 2021, CMS has determined that blood-based biomarker tests are an appropriate colorectal cancer screening test, once every 3 years for Medicare beneficiaries when certain requirements are met. IEHP offers a competitive salary and stellar benefit package . Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. The clinical research study must meet the standards of scientific integrity and relevance to the Medicare population described in this determination. The counselors at this program can help you understand which process you should use to handle a problem you are having. You can get a fast coverage decision coverage decision only if you are asking for coverage for care or an item you have not yet received. We will notify you by letter if this happens. 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. Please be sure to contact IEHP DualChoice Member Services if you have any questions. Unleashing our creativity and courage to improve health & well-being. 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. When you make an appeal to the Independent Review Entity, we will send them your case file. Beneficiaries who exhibit hypoxemia (low oxygen in your blood) when ALL (A, B, and C) of the following are met: A. Hypoxemia is based on results of a clinical test ordered and evaluated by a patients treating practitioner meeting either of the following: (Implementation Date: February 14, 2022) If the IRE says No to your appeal, it means they agree with our decision not to approve your request. are similar in many respects. Beneficiaries with Alzheimers Disease (AD) may be covered for treatment when the following conditions (A or B) are met: Click here for more information on Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimers Disease (AD). What if you are outside the plans service area when you have an urgent need for care? If you need help during the appeals process, you can call the Office of the Ombudsman at 1-888-452-8609. You can also have a lawyer act on your behalf. Effective June 21, 2019, CMS will cover TAVR under CED when the procedure is related to the treatment of symptomatic aortic stenosis and according to the Food and Drug Administration (FDA) approved indication for use with an approved device, or in clinical studies when criteria are met, in addition to the coverage criteria outlined in the NCD Manual. i. The phone number for the Office of the Ombudsman is 1-888-452-8609. To see if you qualify for getting extra help, you can contact: Do you need help getting the care you need? An IMR is a review of your case by doctors who are not part of our plan. VNS is non-covered for the treatment of TRD when furnished outside of a CMS-approved CED study. Can I ask for a coverage determination or make an appeal about Part D prescription drugs? IEHP DualChoice (HMO D-SNP) has contracts with pharmacies that equals or exceeds CMS requirements for pharmacy access in your area. Never wavering in our commitment to our Members, Providers, Partners, and each other. This is not a complete list. H8894_DSNP_23_3241532_M. Network providers are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with us to accept our paymentas payment in full. We will give you our decision sooner if your health condition requires us to. Get Help from an Independent Government Organization. (Implementation Date: July 22, 2020). Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). Heart failure cardiologist with experience treating patients with advanced heart failure. Information on this page is current as of October 01, 2022. You ask us to pay for a prescription drug you already bought. Effective for dates of service on or after December 1, 2020, CMS has updated section 20.9.1 of the National Coverage Determination Manual to cover ventricular assist devices (VADs) when received at facilities credentialed by a CMS approved organization and when specific requirements are met. This includes: The device is used following post-cardiotomy (period following open heart surgery) to support blood circulation. We will see if the service or item you paid for is a covered service or item, and we will check to see if you followed all the rules for using your coverage. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. This is true even if we pay the provider less than the provider charges for a covered service or item. 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. CMS has updated Chapter 1, Part 1, Section 20.7 of the Medicare National Coverage Determinations Manual providing additional information regarding PTA. (If possible, please call IEHP DualChoice Member Services before you leave the service area so we can help arrange for you to have maintenance dialysis while you are away.). For example, good reasons for missing the deadline would be if you have a serious illness that kept you from contacting us or if we gave you incorrect or incomplete information about the deadline for requesting an appeal. Click here for information on Next Generation Sequencing coverage. What is covered: 2. Hazelnuts are the round brown hard-shelled nuts of the trees of genus Corylus while walnuts are the wrinkled edible nuts of the trees of genus Juglans. All of our Doctors offices and service providers have the form or we can mail one to you. Arterial oxygen saturation at or above 89% when awake;or greater than normal decrease in oxygen level while sleeping represented by a decrease in arterial PO2 more than 10 mmHg or a decrease in arterial oxygen saturation more than 5%. (Implementation Date: January 17, 2022). CMS has updated Chapter 1, section 20.32 of the Medicare National Coverage Determinations Manual. IEHP Direct contracted PCPs who provide service to IEHP Direct DualChoice Members. Call IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. You can file a grievance. Treatment for patients with untreated severe aortic stenosis. Learn about your health needs and leading a healthy lifestyle. CMS has updated Chapter 1, section 20.19 of the Medicare National Coverage Determinations Manual. The intended effective date of the action. Your doctor or other provider can make the appeal for you. You can call the DMHC Help Center for help with complaints about Medi-Cal services. This gives you time to talk with your provider about getting a different drug or to ask us to cover the drug. You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage decision. (Effective: April 13, 2021) Beneficiaries receiving treatment for implanting a ventricular assist device (VAD), when the following requirements are met and: All other indications for the use of VADs not otherwise listed remain non-covered, except in the context of Category B investigational device exemption clinical trials (42 CFR 405) or as a routine cost in clinical trials defined under section 310.1 of the National Coverage Determinations (NCD) Manual. Who is covered: You can download a free copy here. There are two ways to make a Level 2 appeal for Medi-Cal services and items: 1) Independent Medical Review or 2) State Hearing. Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. Livanta BFCC-QIO Program If you want to change plans, call IEHP DualChoice Member Services. The plan's block transfer filing indicated that the termination was the result of conduct by Vantage that resulted in the inappropriate delay, denial or modification of authorizations for services and care provide to IEHP's Medi-Cal managed care enrollees. During these events, oxygen during sleep is the only type of unit that will be covered. We take a careful look at all of the information about your request for coverage of medical care. There are extra rules or restrictions that apply to certain drugs on our Formulary. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. Click here for more information on acupuncture for chronic low back pain coverage. If we do not give you an answer within 72 hours or by the end of the extra days (if we took them), we will automatically send your case to Level 2 of the appeals process if your problem is about a Medicare service or item. Effective for claims with dates of service on or after 01/18/17, Medicare will cover leadless pacemakers under CED when procedures are performed in CMS-approved studies. ii. Coverage for future years is two hours for patients diagnosed with renal disease or diabetes. The time of need is indicated when the presumption of oxygen therapy within the home setting will improve the patients condition. More. We call this the supporting statement.. This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision. You may use the following form to submit an appeal: Can someone else make the appeal for me? IEHP DualChoice (HMO D-SNP) has a list of Covered Drugs called a Formulary. This is called upholding the decision. It is also called turning down your appeal. If we do not agree with some or all of your complaint or dont take responsibility for the problem you are complaining about, we will let you know. If we answer no to your appeal and the service or item is usually covered by Medi-Cal, you can file a Level 2 Appeal yourself (see above).