Possible errors in the amount (dosage) or duration of a drug you are taking. There are many kinds of specialists. Transportation: $0. Concurrent with Carotid Stent Placement in Patients at High Risk for Carotid Endarterectomy (CEA) What if the Independent Review Entity says No to your Level 2 Appeal? 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 can download a free copy here. IEHP DualChoice (HMO D-SNP) has contracts with pharmacies that equals or exceeds CMS requirements for pharmacy access in your area. TTY users should call 1-800-718-4347. Rancho Cucamonga, CA 91729-1800 We are also one of the largest employers in the region, designated as "Great Place to Work.". Our service area includes all of Riverside and San Bernardino counties. Please select one of the following: Primary Care Doctor Specialist Behavioral Health Hospitals Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. If you are unable to get a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service. If you lose your zero share-of-cost, full scope Medi-Cal, you will be disenrolled from our plan (for your Medicare benefits) the first day of the following month andwill be covered by the Original Medicare. You can ask for a copy of the information in your appeal and add more information. P.O. To learn more about the plans benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook. If your Level 2 Appeal was a State Hearing, the California Department of Social Services will send you a letter explaining its decision. If we do not give you a decision within 7 calendar days, or 14 days if you asked us to pay you back for a drug you already bought, we will send your request to Level 2 of the appeals process. 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. (Effective: June 21, 2019) Send us your request for payment, along with your bill and documentation of any payment you have made. 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. (Implementation Date: December 10, 2018). If your doctor says that you need a fast coverage decision, we will automatically give you one. If your provider says you have a good medical reason for an exception, he or she can help you ask for one. You can file a grievance. This is called upholding the decision. It is also called turning down your appeal.. It usually takes up to 14 calendar days after you asked. (Implementation Date: January 17, 2022). All of our Doctors offices and service providers have the form or we can mail one to you. A new generic drug becomes available. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. 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 on September 26, 2022, CMS has updated section 50.3 of the National Coverage Determination (NCD) Manual that expands coverage on cochlear implants for the treatment of bilateral pre- or post- linguistic, sensorineural, moderate-to-profound hearing loss when the individual demonstrates limited benefit from amplification under Medicare Part B. 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. The DMHC may waive the requirement that you first follow our appeal process in extraordinary and compelling cases. Beneficiaries who meet the coverage criteria, if determined eligible. My Choice. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. Calls to this number are free. Please see below for more information. (Implementation Date: June 16, 2020). When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. 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. Deadlines for standard appeal at Level 2. IEHP DualChoice recognizes your dignity and right to privacy. Click here for more information on Topical Applications of Oxygen. They receive a left ventricular device (LVADs) if the device is FDA approved for short- or long-term use for mechanical circulatory support for beneficiaries with heart failure who meet the following requirements: Have New York Heart Association (NYHA) Class IV heart failure; and, Have a left ventricular ejection fraction (LVEF) 25%; and. 2. We will also use the standard 14 calendar day deadline instead. 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. 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 your health condition requires us to answer quickly, we will do that. These different possibilities are called alternative drugs. The procedure must be performed by an interventional cardiologist or cardiac surgeon.<. How will you find out if your drugs coverage has been changed? Including bus pass. If we do not give you an answer within 72 hours, we will send your request to Level 2. to part or all of what you asked for, we must give the coverage within 72 hours after we get your appeal. If you are having a problem with your care, you can call the Office of Ombudsman at 1-888-452-8609for help. Patient must be evaluated for suitability for repair and must documented and made available to the Heart team members meeting the requirements of this determination. 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. Prior to January 18, 2017, there was no national coverage determination (NCD) in effect. The Level 3 Appeal is handled by an administrative law judge. 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. CMS has updated section 240.2 of the National Coverage Determination Manual to amend the period of initial coverage for patients in section D of NCD 240.2 from 120 days to 90 days, to align with the 90-day statutory time period. Click here for information on Next Generation Sequencing coverage. The Centers for Medicare and Medical Services (CMS) has determined the following services to be necessary for the treatment of an illness or injury. The call is free. It attacks the liver, causing inflammation. Learn about your health needs and leading a healthy lifestyle. ii. Limitations, copays, and restrictions may apply. There are two ways to make a Level 2 appeal for Medi-Cal services and items: 1) Independent Medical Review or 2) State Hearing. A care team can help you. Drugs that may not be safe or appropriate because of your age or gender. 2020) If you have any other feedback or concerns, or if you feel the plan is not addressing your problem, please call (800) MEDICARE (800) 633-4227). You have the right to ask us for a copy of the information about your appeal. During these reviews, we look for potential problems such as: If we see a possible problem in your use of medications, we will work with your Doctor to correct the problem. Never wavering in our commitment to our Members, Providers, Partners, and each other. Or, if you are asking for an exception, 24 hours after we get your doctors or prescribers statement supporting your request. You can fax the completed form to (909) 890-5877. What is a Level 2 Appeal? Your membership will usually end on the first day of the month after we receive your request to change plans. IEHP DualChoice Formulary consists of medications that are considered as first line therapies (drugs that should be used first for the indicated conditions). CMS has updated Chapter 1, Part 1, Section 20.7 of the Medicare National Coverage Determinations Manual providing additional information regarding PTA. CMS has updated Chapter 1, Part 2, Section 90.2 of the Medicare National Coverage Determinations Manual to include NGS testing for Germline (inherited) cancer when specific requirements are met and updated criteria for coverage of Somatic (acquired) cancer. The DMHC may accept your application after 6 months if it determines that circumstances kept you from submitting your application in time. Prescriptions written for drugs that have ingredients you are allergic to. This includes: Primary Care Providers (PCPs) are usually linked to certain hospitals. An interventional echocardiographer must perform transesophageal echocardiography during the procedure. How can I make a Level 2 Appeal? (Implementation date: August 29, 2017 for MAC local edits; January 2, 2018 for MCS shared edits) When we complete the review, we will give you our decision in writing. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. For some types of problems, you need to use the process for coverage decisions and making appeals. Beneficiaries participating in a CMS approved clinical study undergoing Vagus Nerve Stimulation (VNS) for treatment resistant depression and the following requirements are met: Click here for more information on Vagus Nerve Stimulation. Ask for an exception from these changes. (Effective: April 3, 2017) Medicare has approved the IEHP DualChoice Formulary. You will not have a gap in your coverage. When you file a fast complaint, we will give you an answer to your appeal within 24 hours. 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). TTY should call (800) 718-4347. We are also one of the largest employers in the region, designated as "Great Place to Work.". Can someone else make the appeal for me for Part C services? IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. 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. The form gives the other person permission to act for you. IEHP DualChoice Member Services can assist you in finding and selecting another provider. Submit the required study information to CMS for approval. For problems and concerns regarding eligibility determinations, assessments, and care delivered by our contracted Community Based Adult Services (CBAS) centers, or Nursing Facilities/Sub-Acute Care Facilities, you should follow the process outlined below. No-cost or low-cost health care coverage for low-income adults, families with children, seniors, and people with disabilities. To be a Member of IEHP DualChoice, you must keep your eligibility with Medi-Cal and Medicare. Previously, PILD for LSS was covered for beneficiaries enrolled only in a CMS-approved prospective, randomized, controlled clinical trial (RCT) under the Coverage with Evidence Development (CED) paradigm. 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. Are a United States citizen or are lawfully present in the United States. to part or all of what you asked for, we must give you the coverage within 24 hours after we get your request or your doctors or prescribers statement supporting your request. You can also call if you want to give us more information about a request for payment you have already sent to us. Beneficiaries receiving treatment for Transcatheter Edge-to-Edge Repair (TEER) when either of the following are met: This determination will expire ten years after the effective date if a reconsideration is not made during this time. 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. The USPTF has found that screening for HBV allows for early intervention which can help decrease disease acquisition, transmission and, through treatment, improve intermediate outcomes for those infected. A clinical test providing a measurement of the partial pressure of oxygen (PO2) in arterial blood. Fill out the Independent Medical Review/Complaint Form available at: If you have them, attach copies of letters or other documents about the service or item that we denied. Have grievances heard and resolved in accordance with Medicare guidelines; Request quality of care grievances data from IEHP DualChoice. (Effective: September 26, 2022) This service will be covered when the TAVR is used, for the treatment of symptomatic aortic valve stenosis. Oxygen therapy can be renewed by the MAC if deemed medically necessary. CMS has updated Section 110.24 of the Medicare National Coverage Determinations Manual to include coverage of chimeric antigen receptor (CAR) T-cell therapy when specific requirements are met. If you have an urgent need for care, you probably will not be able to find or get to one of the providers in our plans network. What is covered: Medicare will cover both MNT and Diabetes Outpatient Self-Management Training (DSMT) during initial and subsequent years, if the physician determines treatment is medically necessary and as long as DSMT and MNT are not provided on the same date. 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. Our plan includes doctors, hospitals, pharmacies, providers of long-term services and supports, behavioral health providers, and other providers. An interventional echocardiographer must perform transesophageal echocardiography during the procedure.>. Click here to learn more about IEHP DualChoice. How to Enroll with IEHP DualChoice (HMO D-SNP), IEHP Texting Program Terms and Conditions. The clinical test must be performed at the time of need: Click here for more information on Leadless Pacemakers. 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. 1501 Capitol Ave., If your problem is about a Medicare service or item, the letter will tell you that we sent your case to the Independent Review Entity for a Level 2 Appeal. The extra rules and restrictions on coverage for certain drugs include: Being required to use the generic version of a drug instead of the brand name drug. Will my benefits continue during Level 1 appeals? Which Pharmacies Does IEHP DualChoice Contract With? IEHP DualChoice (HMO D-SNP) helps make your Medicare and Medi-Cal benefits work better together and work better for you. The clinical study must adhere to all the standards of scientific integrity and relevance to the Medicare population. Ask for the type of coverage decision you want. ii. Fill out the Authorized Assistant Form if someone is helping you with your IMR. You can tell the California Department of Managed Health Care about your complaint. Medicare beneficiaries who meet either of the following criteria: Click here for more information on HBV Screenings. A clinical test providing the measurement of arterial blood gas. Some changes to the Drug List will happen immediately. If your problem is about a Medicare service or item, we will automatically send your case to Level 2 of the appeals process as soon as the Level 1 Appeal is complete. IEHP offers a competitive salary and stellar benefit package . The Centers of Medicare and Medicaid Services (CMS) will cover Vagus Nerve Stimulation (VNS) for treatment-resistant depression when specific requirements are met. They also have thinner, easier-to-crack shells. You will keep all of your Medicare and Medi-Cal benefits. Information on procedures for obtaining prior authorization of services, Quality Assurance, disenrollment, and other procedures affecting IEHP DualChoice Members. P.O. NOTE: If you ask for a State Hearing because we told you that a service you currently get will be changed or stopped, you have fewer days to submit your request if you want to keep getting that service while your State Hearing is pending. a. You can ask us to make a faster decision, and we must respond in 15 days. (Implementation Date: February 19, 2019) (Implementation Date: December 12, 2022) Request a second opinion about a medical condition. To speak with a care coordinator, please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. 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 call Member Services to ask for a list of covered drugs that treat the same medical condition. (Implementation Date: March 24, 2023) We determine an existing relationship by reviewing your available health information available or information you give us. Or your doctor or other prescriber can tell us on the phone, and then fax or mail a statement. We are always available to help you. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. If you are traveling within the US, but outside of the Plans service area, and you become ill, lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy if you follow all other coverage rules identified within this document and a network pharmacy is not available. 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. The diagnostic laboratory test using NGS must have: Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic and; FDA-approved or cleared indication for use in that patients cancer and; results provided to the treating physician for management of the patient using a report template to specify treatment options. You do not need to give your doctor or other prescriber written permission to ask us for a coverage determination on your behalf. These different possibilities are called alternative drugs. Because you get assistance from Medi-Cal, you can end your membership in IEHPDualChoice at any time. CMS has issued a National Coverage Determination (NCD) which expands coverage to include leadless pacemakers when procedures are performed in CMS-approved Coverage with Evidence Development (CED) studies. You must qualify for this benefit. If you decide to make an appeal, it means you are going on to Level 1 of the appeals process. We will send you a letter within 5 calendar days of receiving your appeal letting you know that we received it. Will not cover an experimental or investigational Medi-Cal treatment for a serious medical condition. At Level 2, an Independent Review Entity will review our decision. The Independent Review Entity is an independent organization that is hired by Medicare. Call: (877) 273-IEHP (4347). If you dont have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself. Asking us to cover a Part D drug that is not on the plans List of Covered Drugs (Formulary), Asking us to waive a restriction on the plans coverage for a drug (such as limits on the amount of the drug you can get). For more information on Medical Nutrition Therapy (MNT) coverage click here. Upon expiration, coverage will be determined by the local Medicare Administrative Contractors (MACs). H8894_DSNP_23_3241532_M. Copays for prescription drugs may vary based on the level of Extra Help you receive. 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. The following criteria must also be met as described in the NCD: Non-Covered Use: It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. You do not need to do anything further to get this Extra Help. 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. The Heart team must participate in the national registry and track outcomes according to the requirements in this determination.>. If you have questions, you can contact IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. (Implementation Date: July 27, 2021) We also review our records on a regular basis. Medi-Cal is public-supported health care coverage. The letter you get from the Independent Review Entity will tell you the dollar amount needed to continue with the appeals process. TTY/TDD (877) 486-2048. 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. H5355_CMC_22_2746205Accepted, (Effective: September 27, 2021) IEHP DualChoice will give notice to IEHPDualChoice Members prior to removing Part D drug from the Part D formulary. You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY (800) 718-4347. You, your representative, or your doctor (or other prescriber) can do this. 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. There are over 700 pharmacies in the IEHP DualChoice network. The letter will tell you how to make a complaint about our decision to give you a standard decision. 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. They all work together to provide the care you need. To start your appeal, you, your doctor or other provider, or your representative must contact us. At Level 2, an Independent Review Entity will review your appeal. TDD users should call (800) 952-8349. Coverage for future years is two hours for patients diagnosed with renal disease or diabetes. We will give you our answer sooner if your health requires us to do so. Use of other PET radiopharmaceutical tracers for cancer may be covered at the discretion of local Medicare Administrative Contractors (MACs), when used in accordance to their Food and Drug Administration (FDA) approval indications. . View Plan Details. Who is covered: For some drugs, the plan limits the amount of the drug you can have. After your coverage begins with IEHP DualChoice, you must receive medical services and prescription drug services in the IEHP DualChoice network. For example, this means that your care team makes sure: Your doctors know about all the medicines you take so they can make sure youre taking the right medicines and can reduce any side effects you may have from the medicines. See plan Providers, get covered services, and get your prescription filled timely. (Implementation date: June 27, 2017). Consist of 30-60 minute sessions comprising of therapeutic exercise-training program for PAD; Be conducted in a hospital outpatient setting or physicians office; Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD; and. It has been concluded that high-quality research illustrates the effectiveness of SET over more invasive treatment options and beneficiaries who are suffering from Intermittent Claudication (a common symptom of PAD) are now entitled to an initial treatment. You must submit your claim to us within 1 year of the date you received the service, item, or drug. When possible, take along all the medication you will need. They are considered to be at high-risk for infection; or. TTY/TDD users should call 1-800-718-4347. The reviewer will be someone who did not make the original decision. Generally, you must receive all routine care from plan providers and network pharmacies to access their prescription drug benefits, except in non-routine circumstances, quantity limitations and restrictions may apply. 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. Treatment of Atherosclerotic Obstructive Lesions 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. The procedure removes a portion of the lamina in order to debulk the ligamentum flavum, essentially widening the spinal canal in the affected area. For additional details on how to reach us for appeals, see Chapter 9 of the IEHP DualChoice Member Handbook. Rancho Cucamonga, CA 91729-1800. Unless you change plans, IEHP DualChoice (HMO D-SNP) will provide your Medicare benefits.

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