(800) 718-4347 (TTY), IEHP 24-Hour Nurse Advice Line (for IEHP Members only) For inpatient hospital patients, the time of need is within 2 days of discharge. 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. If our answer is Yes 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. All physicians participating in the procedure must have device-specific training by the manufacturer of the device. You will usually see your PCP first for most of your routine health care needs. 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. The List of Covered Drugs and pharmacy and provider networks may change throughout the year. 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. P.O. The benefit information is a brief summary, not a complete description of benefits. Visit the Department of Managed Health Care's website: 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. In the instance where there is not FDA labeling specific to use in an MRI environment, coverage is only provided under specific conditions including the following: Medicare beneficiaries with an Implanted pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy defibrillator (CRT-D). If you have a standard appeal at Level 2, the Independent Review Entity must give you an answer to your Level 2 Appeal within 7 calendar days after it gets your appeal. The problem with using black walnuts in cooking is the fact that the black walnuts have a very tough shell and the nuts are difficult to extract. How to Enroll with IEHP DualChoice (HMO D-SNP), IEHP Texting Program Terms and Conditions. Concurrent with Carotid Stent Placement in Food and Drug Administration (FDA) Approved Category B Investigational Device Exemption (IDE) Clinical Trials You can send your complaint to Medicare. Make necessary appointments for routine and sick care, and inform your Doctor when you are unable to make a scheduled appointment. To learn more about asking for exceptions, see Chapter 9 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]). Infected individuals may develop symptoms such as nausea, anorexia, fatigue, fever, and abdominal pain, or may be asymptomatic. During these events, oxygen during sleep is the only type of unit that will be covered. 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? 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. 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: "Coordinating" your services includes checking or consulting with other Plan providers about your care and how it is going. Ask us for a copy by calling Member Services at (877) 273-IEHP (4347). 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. If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to our plan). 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 you are asking us to pay you back for medical care you have already received and paid for yourself, you are not allowed to ask for a fast appeal. However, sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 more calendar days. Thus, this is the main difference between hazelnut and walnut. Changing your Primary Care Provider (PCP). We establish that you had an existing relationship with a primary or specialty care provider, with some exceptions. (800) 718-4347 (TTY), IEHP DualChoice Member Services If you would like to switch from our plan to Original Medicare but you have not selected a separate Medicare prescription drug plan. However, your PCP can always use Language Line Services to get help from an interpreter, if needed. This is not a complete list. (Implementation date: June 27, 2017). If you are appealing a decision our plan made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a fast appeal., The requirements for getting a fast appeal are the same as those for getting a fast coverage decision.. 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. If you decide to go on to a Level 2 Appeal, the Independent Review Entity (IRE) will review our decision. 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. 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. (Implementation Date: December 10, 2018). Program Services There are five services eligible for a financial incentive. Ask for an exception from these changes. Effective on or after April 10, 2018, MRI coverage will be provided when used in accordance to the FDA labeling in an MRI environment. 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. Remember, if you get a bill that is more than your copay for covered services and items, you should not pay the bill yourself. In some cases, IEHP is your medical group or IPA. TTY users should call 1-800-718-4347. By clicking on this link, you will be leaving the IEHP DualChoice website. Call, write, or fax us to make your request. (Effective: April 10, 2017) 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. 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). H8894_DSNP_23_3241532_M. wounds affecting the skin. Medicare beneficiaries in need of a pacemaker who are participating in an approved clinical study. 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. If you think your health requires it, you should ask for a fast appeal. If you are asking us to pay you back for a drug you already bought, we must give you our answer within 14 calendar days after we get your appeal. These different possibilities are called alternative drugs. 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. The care team helps coordinate the services you need. If you have questions, you can contact IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Mail or fax your forms and any attachments to: You may complete the "Request for State Hearing" on the back of the notice of action. Treatment of Atherosclerotic Obstructive Lesions 2023 Inland Empire Health Plan All Rights Reserved. What is a Level 2 Appeal? At Level 2, an Independent Review Entity will review the decision. You can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. The clinical study must adhere to all the standards of scientific integrity and relevance to the Medicare population. Please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. CMS has updated Chapter 1, section 20.19 of the Medicare National Coverage Determinations Manual. Noncoverage specifically includes the following: Click here for more information on Ambulatory Electroencephalographic Monitoring and Colorectal Cancer Screening Tests. Information on this page is current as of October 01, 2022, Centers for Medicare and Medicaid Services. 10820 Guilford Road, Suite 202 If your health requires it, ask us to give you a fast coverage decision 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. Yes, you and your doctor may give us more information to support your appeal. You can get the form at. How to Enroll with IEHP DualChoice (HMO D-SNP) You will get a letter from us about the change in your eligibility with instructions to correct your eligibility information. Change the coverage rules or limits for the brand name drug. Notify IEHP if your language needs are not met. Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. When that happens, we may remove the current drug, but your cost for the new drug will stay the same or will be lower. It also has care coordinators and care teams to help you manage all your providers and services. 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. Join our Team and make a difference with us! This letter will tell you if the service or item is usually covered by Medicare or Medi-Cal. The registry shall collect necessary data and have a written analysis plan to address various questions. The leadless pacemaker eliminates the need for a device pocket and insertion of a pacing lead which are integral elements of traditional pacing systems. 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). If you get a bill that is more than your copay for covered services and items, send the bill to us. This service will be covered when the TAVR is used for the treatment of symptomatic aortic valve stenosis according to the FDA-approved indications and the following conditions are met: This service will be covered when the TAVR is not expressly listed as an FDA-approved indication, but when performed within a clinical study and the following conditions are met: Click here for more information on NGS coverage. Drugs that may not be necessary because you are taking another drug to treat the same medical condition. 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. This includes denial of payment for a service after the service has been rendered (post-service) or denial of service prior to the service being rendered (pre-service). CMS-approved studies of a monoclonal antibody directed against amyloid approved by the FDA for the treatment of AD based upon evidence of efficacy from a direct measure of clinical benefit must address all of the questions included in section B.4 of this National Coverage Determination. A reasonable salary expectation is between $153,670.40 and $195,936.00, based upon experience and internal equity. National Coverage determinations (NCDs) are made through an evidence-based process. There is no deductible for IEHP DualChoice. IEHP DualChoice The Centers of Medicare and Medicaid Services (CMS) will cover acupuncture for chronic low back pain (cLBP) when specific requirements are met. your medical care and prescription drugs through our plan. The Level 3 Appeal is handled by an administrative law judge. If we decide to change or stop coverage for a service or item that was previously approved, we will send you a notice before taking the action. If your case is urgent and you qualify for an IMR, the DMHC will review your case and send you a letter within 2 calendar days telling you that you qualify for an IMR. There are two ways to ask for a State Hearing: If you meet this deadline, you can keep getting the disputed service or item until the hearing decision is made. If you are having a problem with your care, you can call the Office of Ombudsman at 1-888-452-8609for help. app today. If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize the medical care coverage within 72 hours or give you the service or item within 14 calendar days from the date we receive the IREs decision. 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. Oxygen therapy can be renewed by the MAC if deemed medically necessary. when beneficiaries are suspected of having white coat hypertension or masked hypertension in addition to the coverage criteria outlined in the, Ambulatory Blood Pressure Monitoring (ABPM), for the diagnosis of hypertension when either there is suspected white coat or masked hypertension. 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. You have a right to appeal or ask for Formulary exception if you disagree with the information provided by the pharmacist. When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. For example, you can ask us to cover a drug even though it is not on the Drug List. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. A clinical test providing the measurement of arterial blood gas. Flu shots as long as you get them from a network provider. H8894_DSNP_23_3241532_M. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer and; has not been previously tested with the same test using NGS for the same cancer genetic content and; has decided to seek further cancer treatment (e.g., therapeutic chemotherapy). 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. This includes: Primary Care Providers (PCPs) are usually linked to certain hospitals. What is covered: (This is sometimes called step therapy.). All other indications for colorectal cancer screening not otherwise specific in the regulations or the National Coverage Determination above. If you believe we should not take extra days, you can file a fast complaint about our decision to take extra days. 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. of the appeals process. If the Independent Medical Review decision is Yes to part or all of what you asked for, we must provide the service or treatment. 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. It tells which Part D prescription drugs are covered by IEHP DualChoice. For example: We may make other changes that affect the drugs you take. 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.) Who is covered: Members must meet all of the following eligibility criteria: Click here for more information on LDCT coverage. 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. You, your representative, or your provider asks us to let you keep using your current provider. You should receive the IMR decision within 7 calendar days of the submission of the completed application. You can call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. If you decide to make an appeal, it means you are going on to Level 1 of the appeals process. Our plans Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B. 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. You will be notified when this happens. If you prefer a different one, please call IEHP DualChoice Member Services and we can assist you in finding and selecting another provider. Request and receive appeal data from IEHP DualChoice; Receive notice when an appeal is forwarded to the Independent Review Entity (IRE); Automatic reconsideration by the IRE when IEHP DualChoice upholds its original adverse determination in whole or in part; Administrative Law Judge (ALJ) hearing if the independent review entity upholds the original adverse determination in whole or in part and the remaining amount in controversy is $100 or more; Request Departmental Appeals Board (DAB) review if the ALJ hearing is unfavorable to the Member in whole or in part; Judicial review of the hearing decision if the ALJ hearing and/or DAB review is unfavorable to the Member in whole or in part and the amount remaining in controversy is $1,000 or more; Make a quality of care complaint under the QIO process; Request QIO review of a determination of noncoverage of inpatient hospital care; Request QIO review of a determination of noncoverage in skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities; Request a timely copy of your case file, subject to federal and state law regarding confidentiality of patient information; Challenge local and national Medicare coverage determination. Initial coverage for patients experiencing conditions not described above can be limited to a prescription shorter than 90 days, or less than the numbers of days indicated on the practitioners prescription. Related Resources. You do not need to give your doctor or other prescriber written permission to ask us for a coverage determination on your behalf. 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. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. Livanta is not connect with our plan. If your doctor or other prescriber tells us that your health requires a fast coverage decision, we will automatically agree to give you a fast coverage decision, and the letter will tell you that. An interventional echocardiographer must perform transesophageal echocardiography during the procedure.>. For CMS-approved studies, the protocol, including the analysis plan, must meet requirements listed in this NCD. Who is covered: C. Beneficiarys diagnosis meets one of the following defined groups below: 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. 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). TTY/TDD users should call 1-800-430-7077. Call IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Other persons may already be authorized by the Court or in accordance with State law to act for you. (888) 244-4347 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. 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. Has not resolved your Level 1 Appeal on a Medi-Cal service within 30 calendar days for a standard appeal or 72 hours for a fast appeal. Get Help from an Independent Government Organization. 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). Orthopedists care for patients with certain bone, joint, or muscle conditions. (Implementation Date: July 5, 2022). For some types of problems, you need to use the process for coverage decisions and making appeals. For reservations call Monday-Friday, 7am-6pm (PST). i. When you choose your PCP, remember the following: You will usually see your Primary Care Provider (PCP) first for most of your routine healthcare needs such as physical check-ups, immunization, etc. Capable of producing standardized plots of BP measurements for 24 hours with daytime and nighttime windows and normal BP bands demarcated; Provided to patients with oral and written instructions, and a test run in the physicians office must be performed; and. 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. Whether you call or write, you should contact IEHP DualChoice Member Services right away. Heart failure cardiologist with experience treating patients with advanced heart failure. Typically, our Formulary includes more than one drug for treating a particular condition. If you ask for a fast coverage decision, without your doctors support, we will decide if you get a fast coverage decision. At Level 2, an Independent Review Entity will review our decision. Patient must also present hypoxemia signs and symptoms such as nocturnal restlessness, insomnia, or impairment of cognitive process. Interventional Cardiologist meeting the requirements listed in the determination. Also, its possible that your PCP might leave our plans network of providers and you would have to find a new PCP. 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. Rights and Responsibilities Upon Disenrollment, Ending your membership in IEHP DualChoice (HMO D-SNP) may be voluntary (your own choice) or involuntary (not your own choice). 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. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. Be under the direct supervision of a physician. This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Who is covered: If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. Making an appeal means asking us to review our decision to deny coverage. For more information, call IEHP DualChoice Member Services or read the IEHP DualChoice Member Handbook. All other indications for colorectal cancer screening not otherwise specified in the Social Security Act, regulations, or the above remain nationally non-covered. You dont have to do anything if you want to join this plan. If we need more information, we may ask you or your doctor for it. If your provider says you have a good medical reason for an exception, he or she can help you ask for one. Drugs that may not be safe or appropriate because of your age or gender. If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will use the standard deadlines instead. 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. A fast coverage decision means we will give you an answer within 24 hours after we get your doctors statement. Request a second opinion about a medical condition. 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. View Plan Details. Sprint from Voice Telephone: (800) 877-5379, Visit: 10801 Sixth Street, Suite 120, Rancho Cucamonga, CA 91730. We are the largest health plan in the Inland Empire, and one of the fastest-growing health plans in the nation. If the Independent Review Entity approves a request to pay you back for a drug you already bought, we will send payment to you within 30 calendar days after we get the decision. Note, the Member must be active with IEHP Direct on the date the services are performed. Box 997413 The person you name would be your representative. You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. If your Level 2 Appeal went to the Medicare Independent Review Entity, it will send you a letter explaining its decision. 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. We will cover your prescription at an out-of-network pharmacy if at least one of the following applies: If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than paying your normal share of the cost) when you fill your prescription. My Choice. 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. This is a person who works with you, with our plan, and with your care team to help make a care plan. The reviewer will be someone who did not make the original coverage decision. 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. IEHP (Inland Empire Health Plan) is a provider that contains a network of doctors, dentists, pyschs, therapists, and specialists. The Office of the Ombudsmanis not connected with us or with any insurance company or health plan. 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. 2. 2023 IEHP DualChoice Member Handbook (PDF), Click here to download a free copy of Adobe Acrobat Reader. What is covered: We serve 1.5 million residents of Riverside and San Bernardino counties through government-sponsored programs including Medi-Cal (families, adults, seniors and people with disabilities) and Cal MediConnect. You can ask us to reimburse you for IEHP DualChoice's share of the cost. 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. Have a Primary Care Provider who is responsible for coordination of your care. You can call SHIP at 1-800-434-0222. You may use the following form to submit an appeal: Can someone else make the appeal for me?
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