What to do if you have a problem or concern with IEHP DualChoice (HMO D-SNP): You can call IEHP Member Services at (877) 273-IEHP (4347) and ask for a Member Complaint Form. Most recently, as of May 1, 2016, Medi-Cal now covers all low income children under the age of 19, regardless of immigration status. Copays for prescription drugs may vary based on the level of Extra Help you receive. There are many kinds of specialists. IEHP DualChoice will give notice to IEHPDualChoice Members prior to removing Part D drug from the Part D formulary. 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. If you have questions, you can contact IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States. Click here to download a free copy of Adobe Acrobat Reader.By clicking on this link, you will be leaving the IEHP DualChoice website. If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. Your PCP will send a referral to your plan or medical group. Appeal any decision IEHP DualChoice makes regarding, but not limited to, a denial, termination, payment, or reduction of services. Who is covered: The PTA is covered under the following conditions: 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. You have the right to ask us for a copy of the information about your appeal. 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). P.O. 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. Screening computed tomographic colonography (CTC), effective May 12, 2009. See form below: Deadlines for a fast appeal at Level 2 You will need Adobe Acrobat Reader6.0 or later to view the PDF files. 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. a. . Patients depressive illness meets a minimum criterion of four prior failed treatments of adequate dose and duration as measured by a tool designed for this purpose. They all work together to provide the care you need. You can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. 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). 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. What is a Level 2 Appeal? A specialist is a doctor who provides health care services for a specific disease or part of the body. A reasonable salary expectation is between $153,670.40 and $195,936.00, based upon experience and internal equity. This is called upholding the decision. It is also called turning down your appeal.. Whether you call or write, you should contact IEHP DualChoice Member Services right away. Click here to learn more about IEHP DualChoice. The Office of Ombudsman is not connected with us or with any insurance company or health plan. Please call or write to IEHP DualChoice Member Services. Tier 1 drugs are: generic, brand and biosimilar drugs. Information on this page is current as of October 01, 2022. 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. 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. Calls to this number are free. If you are asking to be paid back, you are asking for a coverage decision. 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. IEHP DualChoice (HMO D-SNP) has a process in place to identify and reduce medication errors. Medi-Cal is public-supported health care coverage. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Medicare beneficiaries in need of a pacemaker who are participating in an approved clinical study. This is not a complete list. See plan Providers, get covered services, and get your prescription filled timely. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. 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. You can contact Medicare. (Implementation Date: January 17, 2022). 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. Beneficiaries with Somatic (acquired) cancer or Germline (inherited) cancer when performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all the following requirements are met: Medicare Administrative Contractors (MACs) may determine coverage of NGS as a diagnostic test when additional specific criteria are met. The program is not connected with us or with any insurance company or health plan. Cardiologists care for patients with heart conditions. What if the Independent Review Entity says No to your Level 2 Appeal? All other indications for colorectal cancer screening not otherwise specified in the Social Security Act, regulations, or the above remain nationally non-covered. Sacramento, CA 95899-7413. Inform your Doctor about your medical condition, and concerns. What is covered? It has been updated that coverage determinations for providing Topical Application of Oxygen for the treatment of chronic wounds can be made by the local Contractors. A care team may include your doctor, a care coordinator, or other health person that you choose. When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. 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. CMS has updated Chapter 1, section 20.19 of the Medicare National Coverage Determinations Manual. What is covered: Be treated with respect and courtesy. The treatment is based upon efficacy from a direct measure of clinical benefit in CMS-approved prospective comparative studies. For the treatment of symptomatic moderate to severe mitral regurgitation (MR) when the patient still has symptoms, despite stable doses of maximally tolerated guideline directed medical therapy (GDMT) and cardiac resynchronization therapy, when appropriate and the following are met: Treatment is a Food and Drug Administration (FDA) approved indication. Also, its possible that your PCP might leave our plans network of providers and you would have to find a new PCP. 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. After your application and supporting documents are received from your plan, the IMR decision will be made within 3 calendar days. We will send you a letter telling you that. 3. By clicking on this link, you will be leaving the IEHP DualChoice website. Your benefits as a member of our plan include coverage for many prescription drugs. 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. The clinical research must evaluate the patients quality of life pre and post for a minimum of one year and answer at least one of the questions in this determination section. Be under the direct supervision of a physician. If IEHP DualChoice removes a Covered Part D drug or makes any changes in the IEHP DualChoice Formulary, we will post the formulary changes on IEHPDualChoice website and notify the affected Members at least thirty (30) days prior to effective date of the change made on the IEHP DualChoice Formulary. Click here for more information on PILD for LSS Screenings. We add a generic drug that is not new to the market and: Replace a brand name drug currently on the Drug List or. The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. H8894_DSNP_23_3241532_M. You may be able to get extra help to pay for your prescription drug premiums and costs. If the coverage decision is No, how will I find out? Related Resources. 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. i. Who is covered? 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. 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. Patient must also present hypoxemia signs and symptoms such as nocturnal restlessness, insomnia, or impairment of cognitive process. We will send you a letter within 5 calendar days of receiving your appeal letting you know that we received it. Click here for more information on Cochlear Implantation. It also has care coordinators and care teams to help you manage all your providers and services. 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. You must make the request on or before the later of the following in order to continue your benefits: If you meet this deadline, you can keep getting the disputed service or item while your appeal is processing. If we tell you after our review that the service or item is not covered, your case can go to a Level 2 Appeal. 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. Have grievances heard and resolved in accordance with Medicare guidelines; Request quality of care grievances data from IEHP DualChoice. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. Medicare beneficiaries who are diagnosed with Symptomatic Peripheral Artery Disease who would benefit from this therapy. Please see below for more information. Concurrent with Intracranial Stent Placement in FDA-Approved Category B IDE Clinical Trials (800) 718-4347 (TTY), IEHP DualChoice Member Services a. Program Services There are five services eligible for a financial incentive. 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. 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. If you would like to switch from our plan to Original Medicare but you have not selected a separate Medicare prescription drug plan. The letter you get from the Independent Review Entity will tell you the dollar amount needed to continue with the appeals process. Choose a PCP that is within 10 miles or 15 minutes of your home. You, your representative, or your doctor (or other prescriber) can do this. If you do not get this approval, your drug might not be covered by the plan. Your enrollment in your new plan will also begin on this day. Prescriptions written for drugs that have ingredients you are allergic to. View Plan Details. 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. When you choose your PCP, you are also choosing the affiliated medical group. Be informed regarding Advance Directives, Living Wills, and Power of Attorney, and to receive information regarding changes related to existing laws. When will I hear about a standard appeal decision for Part C services? We have arranged for these providers to deliver covered services to members in our plan. Covering a Part D drug that is not on our List of Covered Drugs (Formulary). 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. PILD is a posterior decompression of the lumbar spine performed under indirect image guidance without any direct visualization of the surgical area. Read your Medicare Member Drug Coverage Rights. We do a review each time you fill a prescription. To learn how to submit a paper claim, please refer to the paper claims process described below. Who is covered: Medicare beneficiaries will have their blood-based colorectal cancer screening test covered once every 3 years when ordered by a treating physician and the following conditions are met: (Effective: December 1, 2020) TTY/TDD users should call 1-800-430-7077. The procedure must be performed in a hospital with infrastructure and experience meeting the requirements in this determination. Click here to download a free copy by clicking Adobe Acrobat Reader. Box 1800 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. TTY users should call 1-800-718-4347. Review, request changes to, and receive a copy of your medical records in a timely fashion. 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). In some cases, IEHP is your medical group or IPA. Eligible Members The population for this P4P program includes IEHP Direct DualChoice Members. Your PCP will also help you arrange or coordinate the rest of the covered services you get as a member of our Plan. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. 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. CMS has updated Chapter 1, Part 1, Section 20.4 of the Medicare National Coverage Determinations Manual providing additional coverage criteria for Implantable Cardiac Defibrillators (ICD) for Ventricular Tachyarrhythmias (VTs). 1501 Capitol Ave., Your PCP should speak your language. Call IEHP DualChoice Member Services if you need help in choosing a PCP or changing your PCP. When can you end your membership in our plan? You will be automatically enrolled in IEHP DualChoice and do not need to do anything to keep these services. H8894_DSNP_23_3241532_M. You dont have to do anything if you want to join this plan. 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. You should receive the IMR decision within 7 calendar days of the submission of the completed application. 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). In this situation (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. For the purpose of this decision, cLBP is defined as: nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. (Implementation Date: December 10, 2018). By clicking on this link, you will be leaving the IEHP DualChoice website. The Office of the Ombudsman also helps solve problems from a neutral standpoint to make sure that our members get all the covered services that we must provide. We will give you our answer sooner if your health requires us to. If you do not qualify by the end of the two-month period, youll de disenrolled by IEHP DualChoice. New to IEHP DualChoice. effort to participate in the health care programs IEHP DualChoice offers you. The registry shall collect necessary data and have a written analysis plan to address various questions. If you are admitted to one of these hospitals, a hospitalist may serve as your caregiver as long as you remain in the hospital. This is called a referral. H5355_CMC_22_2746205Accepted, (Effective: September 27, 2021) Effective on or after April 10, 2018, MRI coverage will be provided when used in accordance to the FDA labeling in an MRI environment. With a network of more than 6,000 Providers and 2,000 Team Members, we provide . Call our transportation vendor Call the Car (CTC) at (866) 880-3654, for TTY users, call your relay service or California Relay Service at 711. You may change your PCP for any reason, at any time. 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. If you are taking the drug, we will let you know. You can contact the Office of the Ombudsman for assistance. All screenings DNA tests, effective April 28, 2008, through October 8, 2014. Will not cover an experimental or investigational Medi-Cal treatment for a serious medical condition. If we say Yes to your request for an exception, the exception usually lasts until the end of the calendar year. If we say No to your request for an exception, you can ask for a review of our decision by making an appeal. 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? You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. 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. Which Pharmacies Does IEHP DualChoice Contract With? PO2 may be performed by the treating practitioner or by a qualified provider or supplier of laboratory services. 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. Advance care planning (ACP) involves shared decision making to write down-in an advance care directive-a persons wishes about their future medical care. Concurrent with Carotid Stent Placement in Food and Drug Administration (FDA) Approved Category B Investigational Device Exemption (IDE) Clinical Trials How to Enroll with IEHP DualChoice (HMO D-SNP), IEHP Texting Program Terms and Conditions. a clinical indication for germline (inherited) testing for hereditary breast or ovarian cancer and; a risk factor for germline (inherited) breast or ovarian cancer and; not been previously tested with the same germline test using NGS for the same germline genetic content. (Implementation Date: February 27, 2023). 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%. MRI field strength of 1.5 Tesla using Normal Operating Mode, The Implanted pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy defibrillator (CRT-D) system has no fractured, epicardial, or abandoned leads, The facility has implemented a specific checklist. D-SNP Transition. It attacks the liver, causing inflammation. Making an appeal means asking us to review our decision to deny coverage. The device must be approved by the Food and Drug Administration (FDA) for this purpose; OR. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. The list must meet requirements set by Medicare. Then, we check to see if we were following all the rules when we said No to your request. We will say Yes or No to your request for an exception. If the decision is No for all or part of what I asked for, can I make another appeal? There may be qualifications or restrictions on the procedures below. Can someone else make the appeal for me for Part C services? This is true even if we pay the provider less than the provider charges for a covered service or item. There are extra rules or restrictions that apply to certain drugs on our Formulary. If we are using the fast deadlines, we will give you our answer within 72 hours after we get your appeal, or sooner if your health requires it. 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. 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. Learn about your health needs and leading a healthy lifestyle. If you get a bill that is more than your copay for covered services and items, send the bill to us. We may not tell you before we make this change, but we will send you information about the specific change or changes we made. You can call SHIP at 1-800-434-0222. It usually takes up to 14 calendar days after you asked. For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. 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.
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