This additional time will allow you to correct your eligibility information if you believe that you are still eligible. 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. Copays for prescription drugs may vary based on the level of Extra Help you receive. The letter will tell you how to do this. We will send you a notice before we make a change that affects you. 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 that happens, we may remove the current drug, but your cost for the new drug will stay the same or will be lower. You can call the California Department of Social Services at (800) 952-5253. Your IEHP DualChoice Doctor cannot charge you for covered health care services, except for required co-payments. 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. The Centers of Medicare and Medicaid Services (CMS) will cover Vagus Nerve Stimulation (VNS) for treatment-resistant depression when specific requirements are met. (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. a. See form below: Deadlines for a fast appeal at Level 2 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. This can speed up the IMR process. All physicians participating in the procedure must have device-specific training by the manufacturer of the device. Because you get assistance from Medi-Cal, you can end your membership in IEHPDualChoice at any time. This is not a complete list. 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. 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. What is covered: Your benefits as a member of our plan include coverage for many prescription drugs. (Effective: January 27, 20) 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. Unleashing our creativity and courage to improve health & well-being. Breathlessness without cor pulmonale or evidence of hypoxemia; or. 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. If you do not qualify by the end of the two-month period, youll de disenrolled by IEHP DualChoice. The patient is experiencing a major depressive episode, as measured by a guideline recommended depression scale assessment tool on two visits, within a 45-day span prior to implantation of the VNS device. If you are not satisfied with the result of the IMR, you can still ask for a State Hearing. 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. You can contact the Office of the Ombudsman for assistance. The counselors at this program can help you understand which process you should use to handle a problem you are having. The letter will also explain how you can appeal our decision. Prior to January 18, 2017, there was no national coverage determination (NCD) in effect. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. If you are making a complaint because we denied your request for a fast coverage determination or fast appeal, we will automatically give you a fast complaint. Who is covered: The PTA is covered under the following conditions: Get Help from an Independent Government Organization. You can file a grievance. (Implementation Date: March 24, 2023) To learn more about your prescription drug costs, call IEHP DualChoice Member Services. Our IEHP DualChoice (HMO D-SNP) Provider and Pharmacy Directory gives you a complete list of our network pharmacies that means all of the pharmacies that have agreed to fill covered prescriptions for our plan members. TTY users should call (800) 718-4347 or fax us at (909) 890-5877. (Implementation date: October 2, 2017 for design and coding; January 1, 2018 for testing and implementation) This includes: The device is used following post-cardiotomy (period following open heart surgery) to support blood circulation. Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plans service area. You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY (800) 718-4347. Or you can make your complaint to both at the same time. (Effective: April 3, 2017) Complain about IEHP DualChoice, its Providers, or your care. 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. How much time do I have to make an appeal for Part C services? The call is free. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. Until your membership ends, you are still a member of our plan. If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. Who is covered: You can tell Medi-Cal about your complaint. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Level 2 Appeal for Part D drugs. Sign up for the free app through our secure Member portal. 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 your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. If your Level 2 Appeal was a State Hearing, the California Department of Social Services will send you a letter explaining its decision. Most complaints are answered in 30 calendar days. The list must meet requirements set by Medicare. This letter will tell you if the service or item is usually covered by Medicare or Medi-Cal. The phone number is (888) 452-8609. Request a second opinion about a medical condition. 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. The Centers of Medicare and Medicaid Services (CMS) will cover transcatheter aortic valve replacement (TAVR) under Coverage with Evidence Development (CED) when specific requirements are met. The clinical research study must critically evaluate each patient's quality of life pre- and post-TAVR for a minimum of 1 year, but must also address other various questions. We will send you a notice with the steps you can take to ask for an exception. At IEHP, you will find opportunities to take initiative, expand your knowledge and advance your career while working a position that's both challenging and rewarding. IEHP DualChoice (HMO D-SNP) helps make your Medicare and Medi-Cal benefits work better together and work better for you. The Help Center cannot return any documents. Hepatitis B Virus (HBV) is transmitted by exposure to bodily fluids. 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. What if you are outside the plans service area when you have an urgent need for care? We also review our records on a regular basis. Complex Care Management; Medi-Cal Demographic Updates . Read your Medicare Member Drug Coverage Rights. What is covered: 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. We will also give notice if there are any changes regarding prior authorizations, quantity limits, step therapy or moving a drug to a higher cost-sharing tier. Now, the NCD will cover PILD for LSS under both RCT and longitudinal studies. Box 4259 Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. Our plan cannot cover a drug purchased outside the United States and its territories. 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. Upon expiration, coverage will be determined by the local Medicare Administrative Contractors (MACs). We must give you our answer within 14 calendar days after we get your request. All of our plan participating providers also contract us to provide covered Medi-Cal benefits. IEHP DualChoice. Black walnut trees are not really cultivated on the same scale of English walnuts. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. If the Independent Medical Review decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. Choose a PCP that is within 10 miles or 15 minutes of your home. Livanta BFCC-QIO Program Enrollment in IEHP DualChoice (HMO D-SNP) depends on contact renewal. 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). Our plans Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B. To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for an coverage decision. Can my doctor give you more information about my appeal for Part C services? IEHP DualChoice will cover many of the Medicare and Medi-Cal benefits you get now, including: You will have access to a Provider network that includes many of the same Providers as your current plan. If you need help to fill out the form, IEHP Member Services can assist you. IEHP offers a competitive salary and stellar benefit package . The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. If you prefer a different one, please call IEHP DualChoice Member Services and we can assist you in finding and selecting another provider. This is called prior authorization. Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. Use the IEHP Medicare Prescription Drug Coverage Determination Form for a prior authorization. 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. 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: Information is also below. 2023 Inland Empire Health Plan All Rights Reserved. We will say Yes or No to your request for an exception. Who is covered? Our plans PCPs are affiliated with medical groups or Independent Physicians Associations (IPA). Click here for more information on chimeric antigen receptor (CAR) T-cell therapy coverage. Use of autologous Platelet-Derived Growth Factor (PDGF) for treatment of chronic, non-healing, cutaneous (affecting the skin) wounds, and. We do a review each time you fill a prescription. A medical group or IPA is a group of physicians, specialists, and other providers of health services that see IEHP Members. Prior to the beneficiarys first lung cancer LDCT screening, the beneficiary must receive a counseling and shared decision-making visit that meets specific criteria. If you ask for a fast coverage decision on your own (without your doctors or other prescribers support), we will decide whether you get a fast coverage decision. TTY users should call 1-800-718-4347. TTY should call (800) 718-4347. Ask for an exception from these changes. 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. IEHP DualChoice. Who is covered: IEHP DualChoice (HMO D-SNP) has a list of Covered Drugs called a Formulary. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. 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. See Chapters 7 and 9 of the IEHP DualChoice Member Handbookto learn how to ask the plan to pay you back. You can always contact your State Health Insurance Assistance Program (SHIP). You can also visit, You can make your complaint to the Quality Improvement Organization. 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. All of our Doctors offices and service providers have the form or we can mail one to you. They also have thinner, easier-to-crack shells. Change the coverage rules or limits for the brand name drug. The PCP you choose can only admit you to certain hospitals. Within 10 days of the mailing date of our notice of action; or. (Effective: January 1, 2022) You can ask for an IMR if you have also asked for a State Hearing, but not if you have already had a State Hearing, on the same issue. 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.) Treatment of Atherosclerotic Obstructive Lesions This is called a referral. If the Independent Medical Review decision is Yes to part or all of what you asked for, we must provide the service or treatment. 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). 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. (Effective: May 25, 2017) You will get a letter from us about the change in your eligibility with instructions to correct your eligibility information. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. Here are two ways to get help from the Help Center: You can file a complaint with the Office for Civil Rights. They can also answer your questions, give you more information, and offer guidance on what to do. (Effective: February 15. For more information on Home Use of Oxygen coverage click here. If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. You can call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. A clinical test providing a measurement of the partial pressure of oxygen (PO2) in arterial blood. IEHP: "Inland Empire Health Plan (IEHP) is a not-for-profit Medi-Cal and Medicare health plan headquartered in Rancho Cucamonga, California. View Plan Details. If you have questions, you can contact IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. No means the Independent Review Entity agrees with our decision not to approve your request. Your enrollment in your new plan will also begin on this day. What is covered: Effective for dates of service on or after April 13, 2021, CMS has updated section 270.3 of the National Coverage Determination Manual to cover Autologous (obtained from the same person) Platelet-Rich Plasma (PRP) when specific requirements are met. If you move out of our service area for more than six months. If we say Yes to your request for an exception, the exception usually lasts until the end of the calendar year. For patients whose initial prescription for oxygen did not originate during an inpatient hospital stay, the time of need occurs when the treating practitioner identifies signs and symptoms of hypoxemia that can be relieved with at home oxygen therapy. This service will be covered when the Ambulatory Blood Pressure Monitoring (ABPM) is used for the diagnosis of hypertension when either there is suspected white coat or masked hypertension and the following conditions are met: Coverage of other indications for ABPM is at the discretion of the Medicare Administrative Contractors. CMS has updated Chapter 1, Part 1, Section 20.7 of the Medicare National Coverage Determinations Manual providing additional information regarding PTA. 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). Important things to know about asking for exceptions. Direct and oversee the process of handling difficult Providers and/or escalated cases. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. 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. If you want the Independent Review Organization to review your case, your appeal request must be in writing. TTY/TDD (800) 718-4347. Receive information about your rights and responsibilities as an IEHP DualChoice Member. You must choose your PCP from your Provider and Pharmacy Directory. The services of SHIP counselors are free. At Level 2, an Independent Review Entity will review our decision. You will be automatically enrolled in IEHP DualChoice and do not need to do anything to keep these services. H8894_DSNP_23_3241532_M. 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. Make recommendations about IEHP DualChoice Members rights and responsibilities policies. With a network of more than 6,000 Providers and 2,000 Team Members, we provide . 8am - 8pm (PST), 7 days a week, including holidays, TTY: (800) 718-4347. to part or all of what you asked for, we will make payment to you within 14 calendar days. CMS has added a new section, Section 20.35, to Chapter 1 entitled Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). If IEHP DualChoice removes a covered Part D drug or makes any changes in the IEHP DualChoice Formulary, IEHP DualChoice will post the formulary changes on the IEHP DualChoice website and notify the affected Members at least thirty (30) days prior to effective date of the change made on the IEHP DualChoice Formulary. You will be notified when this happens. Our service area includes all of Riverside and San Bernardino counties. Your PCP, along with the medical group or IPA, provides your medical care. Making an appeal means asking us to review our decision to deny coverage. The list can help your provider find a covered drug that might work for you. You can file a grievance online. Your benefits as a member of our plan include coverage for many prescription drugs. Ask us for a copy by calling Member Services at (877) 273-IEHP (4347). (Effective: September 26, 2022) Call: (877) 273-IEHP (4347). This is not a complete list. The List of Covered Drugs and pharmacy and provider networks may change throughout the year. Oncologists care for patients with cancer. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision. 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 clinical test must be performed at the time of need: You can contact Medicare. During this time, you must continue to get your medical care and prescription drugs through our plan. Effective September 27, 2021, CMS has updated section 240.2 of the National Coverage Determination Manual to cover oxygen therapy and oxygen equipment for in home use of both acute and chronic conditions, short- or long- term, when a patient exhibits hypoxemia. It also has care coordinators and care teams to help you manage all your providers and services. The DMHC may waive the requirement that you first follow our appeal process in extraordinary and compelling cases. If we tell you after our review that the service or item is not covered, your case can go to a Level 2 Appeal. Click here for more information on Positron Emission Tomography NaF-18 (NaF-18 PET) to Identify Bone Metastasis of Cancer coverage. 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. Explore Opportunities. Annapolis Junction, Maryland 20701. This means that your PCP will be referring you to specialists and services that are affiliated with their medical group. We will look into your complaint and give you our answer. 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. Call at least 5 days before your appointment. Beneficiaries with either a renal disease or diabetes diagnosis as defined in 42 CFR 410.130. (Effective: February 10, 2022) Getting plan approval before we will agree to cover the drug for you. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. It also has care coordinators and care teams to help you manage all your providers and services. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. In most cases you have 120 days to ask for a State Hearing after the Your Hearing Rights notice is mailed to you. A drug is taken off the market. You can get a fast coverage decision only if the standard 14 calendar day deadline could cause serious harm to your health or hurt your ability to function. All other indications of VNS for the treatment of depression are nationally non-covered. The person you name would be your representative. You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Will my benefits continue during Level 1 appeals? (Implementation Date: October 8, 2021) With this app, you or a designated person with Power of Attorney can access your advance health care directives at any time from a home computer or smartphone. P.O. You can send your complaint to Medicare. In order to receive out-of-network services, your Primary Care Provider (PCP) or Specialist must submit a referral request to your plan or medical group. You can ask for a State Hearing for Medi-Cal covered services and items. It attacks the liver, causing inflammation. IEHP DualChoice must end your membership in the plan if any of the following happen: The IEHPDualChoice Privacy Notice describes how medical information about you may be used and disclosed, and how you can get access to this information. With "Extra Help," there is no plan premium for IEHP DualChoice. What is a Level 1 Appeal for Part C services? When you make an appeal to the Independent Review Entity, we will send them your case file. You can ask us to reimburse you for IEHP DualChoice's share of the cost. Will not cover an experimental or investigational Medi-Cal treatment for a serious medical condition. If you are under a Doctors care for an acute condition, serious chronic condition, pregnancy, terminal illness, newborn care, or a scheduled surgery, you may ask to continue seeing your current Doctor. It stores all your advance care planning documents in one place online. 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. Mitral valve TEERs are covered for other uses not listed as an FDA-approved indication when performed in a clinical study and the following requirements are met: The procedure must be performed by an interventional cardiologist or cardiac surgeon. Related Resources. 3. 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. 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 NCD Manual. 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. You cannot make this request for providers of DME, transportation or other ancillary providers. If your doctor says that you need a fast coverage decision, we will automatically give you one. Beneficiaries receiving autologous treatment for cancer with T-cell expressing at least one least one chimeric antigen receptor CAR, when all the following requirements are met: The use of non-FDA-approved autologous T-cell expressing at least one CAR is non-covered or when the coverage requirements are not met. The clinical research must evaluate the required twelve questions in this determination. We are always available to help you. If you wish, you can make your complaint about quality of care to our plan and also to the Quality Improvement Organization. To start your appeal, you, your doctor or other provider, or your representative must contact us. It tells which Part D prescription drugs are covered by IEHP DualChoice. This is true even if we pay the provider less than the provider charges for a covered service or item. Eligible Members The population for this P4P program includes IEHP Direct DualChoice Members. What is covered: We will let you know of this change right away. 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 can call Member Services to ask for a list of covered drugs that treat the same medical condition. The Independent Review Entity is an independent organization that is hired by Medicare. You must apply for an IMR within 6 months after we send you a written decision about your appeal. You, your representative, or your provider asks us to let you keep using your current provider. Effective for claims with dates of service on or after 09/28/2016, CMS covers screening for HBV infection. Yes. 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. If you dont have the IEHP DualChoice Provider and Pharmacy Directory, you can get a copy from IEHP DualChoice Member Services. The formal name for making a complaint is filing a grievance. A grievance is the kinds of problems related to: How to file a Grievance with IEHP DualChoice (HMO D-SNP).
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