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(Effective: January 1, 2023) To see if you qualify for getting extra help, you can contact: Do you need help getting the care you need? 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. You can contact Medicare. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. More . 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 National Coverage Determination Manual. The Centers for Medicare and Medical Services (CMS) has determined the following services to be necessary for the treatment of an illness or injury. You will not have a gap in your coverage. You, your representative, or your doctor (or other prescriber) can do this. An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. 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. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. (Effective: January 19, 2021) Medicare beneficiaries who are diagnosed with Symptomatic Peripheral Artery Disease who would benefit from this therapy. You can work with us for all of your health care needs. Call, write, or fax us to make your request. When we complete the review, we will give you our decision in writing. LSS is a narrowing of the spinal canal in the lower back. Beneficiaries must be managed by a team of medical professionals meeting the minimum requirements in the National Coverage Determination Manual. Our plan includes doctors, hospitals, pharmacies, providers of long-term services and supports, behavioral health providers, and other providers. We will give you our answer sooner if your health requires us to. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). (This is called upholding the decision. It is also called turning down your appeal.) The letter you get will explain additional appeal rights you may have. When we say existing relationship, it means that you saw an out-of-network provider at least once for a non-emergency visit during the 12 months before the date of your initial enrollment in our plan. Information on this page is current as of October 01, 2022. You will be automatically enrolled in a Medicare Medi-Cal Plan offered by IEHP DualChoice. If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. If we do not meet this deadline, we will send your request to Level 2 of the appeals process. 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. 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. 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. and hickory trees (Carya spp.) Click here for more information onICD Coverage. The phone number for the Office of the Ombudsman is 1-888-452-8609. Non-Covered Use: The following uses are considered non-covered: Click here for more information on Blood-Derived Products for Chronic, Non-Healing Wounds coverage. Can I ask for a coverage determination or make an appeal about Part D prescription drugs? 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. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drugs manufacturer takes a drug off the market, we will take it off the Drug List. If your PCP leaves our Plan, we will let you know and help you choose another PCP so that you can keep getting covered services. If our answer is No to part or all of what you asked for, we will send you a letter. The procedure removes a portion of the lamina in order to debulk the ligamentum flavum, essentially widening the spinal canal in the affected area. (Implementation Date: October 8, 2021) Box 4259 If your health requires it, ask the Independent Review Entity for a fast appeal.. 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. Who is covered? What if the Independent Review Entity says No to your Level 2 Appeal? CMS has updated Chapter 1, section 20.19 of the Medicare National Coverage Determinations Manual. 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. You may also have rights under the Americans with Disability Act. You can download a free copy here. Make necessary appointments for routine and sick care, and inform your Doctor when you are unable to make a scheduled appointment. If you disagree with a coverage decision we have made, you can appeal our decision. 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 we answer no to your appeal and the service or item is usually covered by Medi-Cal, you can file a Level 2 Appeal yourself (see above). Previous Next ===== TABBED SINGLE CONTENT GENERAL. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. 504 Plan Defined The 504 Plan is a plan developed to ensure that a child who has a disability Treatment of Atherosclerotic Obstructive Lesions Live in our service area (incarcerated individuals are not considered living in the geographic service area even if they are physically located in it. Rancho Cucamonga, CA 91729-1800. 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. 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. a. There may be qualifications or restrictions on the procedures below. Reviewers at the Independent Review Entity will take a careful look at all of the information related to your appeal. 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. 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. 1. 3. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). Group I: Generally, IEHP DualChoice (HMO D-SNP) will cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Please call or write to IEHP DualChoice Member Services. If you are taking the drug, we will let you know. Eligible beneficiaries are entitled to 36 sessions over a 12-week period after meeting with the physician responsible for PAD treatment and receiving a referral. This is asking for a coverage determination about payment. iii. 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. CMS has updated Chapter 1, section 160.18 of the Medicare National Coverage Determinations Manual. Treatment is furnished as part of a CMS approved trial through Coverage with Evidence Development (CED).Detailed clinical trial criteria can be found in section 160.18 of the National Coverage Determination Manual. IEHP DualChoice also provides information to the Centers for Medicare and Medicaid Services (CMS) regarding its quality assurance measures according to the guidelines specified by CMS. 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. 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. If patients with bipolar disorder are included, the condition must be carefully characterized. All of our Doctors offices and service providers have the form or we can mail one to you. 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. TTY/TDD (877) 486-2048. Hazelnuts are the round brown hard-shelled nuts of the trees of genus Corylus while walnuts are the wrinkled edible nuts of the trees of genus Juglans. Most complaints are answered in 30 calendar days. When you choose a PCP, it also determines what hospital and specialist you can use. app today. Information on procedures for obtaining prior authorization of services, Quality Assurance, disenrollment, and other procedures affecting IEHP DualChoice Members. Now, the NCD will cover PILD for LSS under both RCT and longitudinal studies. You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY (800) 718-4347. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Follow the appeals process. These changes might happen if: When these changes happen, we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill. 5. 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. Information on this page is current as of October 01, 2022. 4. IEHP DualChoice is very similar to your current Cal MediConnect plan. Join our Team and make a difference with us! We will say Yes or No to your request for an exception. 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. All screenings DNA tests, effective April 28, 2008, through October 8, 2014. What is a Level 1 Appeal for Part C services? What is covered? 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. Copays for prescription drugs may vary based on the level of Extra Help you receive. Then you may submit your request one of these ways: To the county welfare department at the address shown on the notice. The List of Covered Drugs and pharmacy and provider networks may change throughout the year. For additional details on how to reach us for appeals, see Chapter 9 of the IEHP DualChoice Member Handbook. 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. There is no deductible for IEHP DualChoice. Interventional Cardiologist meeting the requirements listed in the determination. A clinical test providing the measurement of arterial blood gas. If the DMHC decides that your case is not eligible for IMR, the DMHC will review your case through its regular consumer complaint process. Call: (877) 273-IEHP (4347). Members \. Some hospitals have hospitalists who specialize in care for people during their hospital stay. The letter you get from the IRE will explain additional appeal rights you may have. This includes getting authorization to see specialists or medical services such as lab tests, x-rays, and/or hospital admittance. During these events, supplemental oxygen is provided during exercise, if the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air. (Implementation date: October 2, 2017 for design and coding; January 1, 2018 for testing and implementation) National Coverage determinations (NCDs) are made through an evidence-based process. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. Infected individuals may develop symptoms such as nausea, anorexia, fatigue, fever, and abdominal pain, or may be asymptomatic. Who is covered: Be informed regarding Advance Directives, Living Wills, and Power of Attorney, and to receive information regarding changes related to existing laws. How to voluntarily end your membership in our plan? The removal of these elements eliminates an important source of complications associated with traditional pacing systems while providing similar benefits. If you do not agree with our decision, you can make an appeal. IEHP DualChoice is for people with both Medicare (Part A and B) and Medi-Cal. P.O. 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. IEHP DualChoice (HMO D-SNP) has a list of Covered Drugs called a Formulary. 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. We must give you our answer within 30 calendar days after we get your appeal. A care coordinator is a person who is trained to help you manage the care you need. If you are not satisfied with the result of the IMR, you can still ask for a State Hearing. If you get a bill that is more than your copay for covered services and items, send the bill to us. You may be able to get extra help to pay for your prescription drug premiums and costs. All physicians participating in the procedure must have device-specific training by the manufacturer of the device. To be a Member of IEHP DualChoice, you must keep your eligibility with Medi-Cal and Medicare. Hepatitis B Virus (HBV) is transmitted by exposure to bodily fluids. We do a review each time you fill a prescription. Concurrent with Carotid Stent Placement in FDA-Approved Post-Approvals Studies They also have thinner, easier-to-crack shells. If you are asking to be paid back, you are asking for a coverage decision. You can send your complaint to Medicare. For example: We may make other changes that affect the drugs you take. If we say no to part or all of your Level 1 Appeal, we will send you a letter. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.). We do not allow our network providers to bill you for covered services and items. 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. You can ask us for a standard appeal or a fast appeal.. 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. Are a United States citizen or are lawfully present in the United States. How much time do I have to make an appeal for Part C services? 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 may choose different health plans, or providers, under Medi-Cal, like IEHP or Molina Healthcare, Blue Shield, Health Net, etc. Click here for more information on Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). P.O. They all work together to provide the care you need. Quantity limits. Review your Member Handbook, and call IEHP DualChoice Member Services if you do not understand something about your coverage and benefits. When you make an appeal to the Independent Review Entity, we will send them your case file. They can also answer your questions, give you more information, and offer guidance on what to do. 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. If the Independent Review Entity says No to part or all of what you asked for, it means they agree with the Level 1 decision. Appeal any decision IEHP DualChoice makes regarding, but not limited to, a denial, termination, payment, or reduction of services. IEHP (Inland Empire Health Plan) is a provider that contains a network of doctors, dentists, pyschs, therapists, and specialists. Have grievances heard and resolved in accordance with Medicare guidelines; Request quality of care grievances data from IEHP DualChoice. If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we get your appeal. H8894_DSNP_23_3879734_M Pending Accepted. Or your doctor or other prescriber can tell us on the phone, and then fax or mail a statement. Bringing focus and accountability to our work. Network providers are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with us to accept our paymentas payment in full. You can download a free copy by clicking here. This means that your PCP will be referring you to specialists and services that are affiliated with their medical group. 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. 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 Office of Ombudsman is not connected with us or with any insurance company or health plan. ), and, Are age 21 and older at the time of enrollment, and, Have both Medicare Part A and Medicare Part B, and, Are a full-benefit dual eligible beneficiary and enroll in IEHP DualChoice for your Medicare benefits and Inland Empire Health Plan (IEHP) for your Medi-Cal benefits. 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 72 hours after we get the decision. 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. The Centers of Medicare and Medicaid Services (CMS) will cover acupuncture for chronic low back pain (cLBP) when specific requirements are met. Prior to filling your prescription at an out-of-network pharmacy, call IEHP DualChoice Member Services to find out if there is a network pharmacy in the area where you are traveling. TTY users should call 1-800-718-4347. You must ask to be disenrolled from IEHP DualChoice. (Effective: August 7, 2019) Your PCP will send a referral to your plan or medical group. (Implementation Date: March 26, 2019). The following information explains who qualifies for IEHP DualChoice (HMO D-SNP). This is not a complete list. 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. 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. Receive emergency care whenever and wherever you need it. Eligible Members The population for this P4P program includes IEHP Direct DualChoice Members. 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. If the coverage decision is No, how will I find out? These different possibilities are called alternative drugs. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. An interventional echocardiographer must perform transesophageal echocardiography during the procedure. All Medicare covered services, doctors, hospitals, labs, and x-rays, You will have access to a Provider network that includes many of the same Providers as your current plan, Coordination of the services you get now or that you might need, Personal history of sustained VT or cardiac arrest due to Ventricular Fibrillation (VF), Prior Myocardial Infarction (MI) and measured Left Ventricular Ejection Fraction (LVEF) less than or equal to .03, Severe, ischemic, dilated cardiomyopathy without history of sustained VT or cardiac arrest due to VF, and have New York Heart Association (NYHA) Class II or III heart failure with a LVEF less than or equal to 35%, Severe, non-ischemic, dilated cardiomyopathy without history of cardiac arrest or sustained VT, NYHA Class II or II heart failure, LVEF less than or equal for 35%, and utilization of optimal medical therapy for at a minimum of three (3) months, Documented, familial or genetic disorders with a high risk of life-threating tachyarrhythmias, but not limited to long QT syndrome or hypertrophic cardiomyopathy, Existing ICD requiring replacement due to battery life, Elective Replacement Indicator (ERI), or malfunction, The procedure is performed in a Clinical Laboratory Improvement Act (CLIA)-certified laboratory. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. You must choose your PCP from your Provider and Pharmacy Directory. TTY (800) 718-4347. CMS approved studies must also adhere to the standards of scientific integrity that have been identified in section 5 of this NCD by the Agency for Healthcare Research and Quality (AHRQ). IEHP DualChoice. 2. Opportunities to Grow. D-SNP Transition. Erythrocythemia (increased red blood cells) with a hematocrit greater than 56%. Decide in advance how you want to be cared for in case you have a life-threatening illness or injury. Information on this page is current as of October 01, 2022, Centers for Medicare and Medicaid Services. A clinical test providing a measurement of the partial pressure of oxygen (PO2) in arterial blood. If the appeal comes from someone besides you or your doctor or other provider, we must receive the completed Appointment of Representative form before we can review the appeal. You have access to a care coordinator. Who is covered: Screening computed tomographic colonography (CTC), effective May 12, 2009. Treatments must be discontinued if the patient is not improving or is regressing. Or you can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. 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. This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision. (888) 244-4347 disease); An additional 8 sessions will be covered for those patients demonstrating an improvement. When you file a fast complaint, we will give you an answer to your appeal within 24 hours. 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. Livanta is not connect with our plan. 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. 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. What is covered: 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). If you do not want to first appeal to the plan for a Medi-Cal service, in special cases you can ask for an Independent Medical Review. TTY/TDD users should call 1-800-430-7077. Medicare beneficiaries in need of a pacemaker who are participating in an approved clinical study. The PCP you choose can only admit you to certain hospitals. If you would like to switch from our plan to another Medicare Advantage plan simply enroll in the new Medicare Advantage plan. Try to choose a PCP that can admit you to the hospital you want within 30 miles or 45 minutes of your home. Be under the direct supervision of a physician. Beneficiaries receiving autologous treatment for cancer with T-cell expressing at least one. 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. CMS has updated Chapter 1, section 30.3.3 of the Medicare National Coverage Determinations Manual. If you are asking for a standard appeal, you can make your appeal by sending a request in writing. Topical Application of Oxygen for Chronic Wound Care. This number requires special telephone equipment. Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. The following criteria must also be met as described in the NCD: Non-Covered Use: i. When can you end your membership in our plan? For a patient demonstrating arterial PO2 at or above 56 mm Hg, or an arterial oxygen saturation at or above 89%, at rest and during the day. CMS reviews studies to determine if they meet the criteria listed in Section 160.18 of the National Coverage Determination Manual. 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. Treatment for patients with existing co-morbidities that would preclude the benefit from the procedure. Tier 1 drugs are: generic, brand and biosimilar drugs. IEHP DualChoice will help you with the process. But if you do pay the bill, you can get a refund if you followed the rules for getting services and items. To find the name, address, and phone number of the Quality Improvement Organization in your state, lookin Chapter 2 of your. iv. Or, if you havent paid for the service or item yet, we will send the payment directly to the provider. If the decision is No for all or part of what I asked for, can I make another appeal? Rancho Cucamonga, CA 91729-1800 Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. This person will also refer you to community resources, if IEHP DualChoice does not provide the services that you need. (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.). Suppose that you are temporarily outside our plans service area, but still in the United States. A standard coverage decision means we will give you an answer within 72 hours after we get your doctors statement. For CMS-approved studies, the protocol, including the analysis plan, must meet requirements listed in this NCD. You and your provider can ask us to make an exception. Rancho Cucamonga, CA 91729-4259. Sacramento, CA 95899-7413. 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.