If you want to change plans, call IEHP DualChoice Member Services. This additional time will allow you to correct your eligibility information if you believe that you are still eligible. If you are not satisfied with the result of the IMR, you can still ask for a State Hearing. We will give you our answer sooner if your health requires us to do so. Complex Care Management; Medi-Cal Demographic Updates . Autologous Platelet-Rich Plasma (PRP) treatment of acute surgical wounds when applied directly to the close incision, or for splitting or open wounds. 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. During these reviews, we look for potential problems such as: If we see a possible problem in your use of medications, we will work with your Doctor to correct the problem. Here are examples of coverage determination you can ask us to make about your Part D drugs. (Implementation date: June 27, 2017). https://www.medicare.gov/MedicareComplaintForm/home.aspx. Unless you change plans, IEHP DualChoice (HMO D-SNP) will provide your Medicare benefits. Then you can: Again, if a drug is suddenly recalled because its been found to be unsafe or for other reasons, the plan will immediately remove the drug from the Formulary. Information on this page is current as of October 01, 2022. This is called prior authorization. Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. (Effective: September 26, 2022) English vs. Black Walnuts: What's the Difference? - Serious Eats IEHP DualChoice Formulary consists of medications that are considered as first line therapies (drugs that should be used first for the indicated conditions). IEHP offers a competitive salary and stellar benefit package . If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. The screen test must have all the following: Food and Drug Administration (FDA) market authorization with an indication for colorectal cancer screening; and. 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. Black walnut trees are not really cultivated on the same scale of English walnuts. You will be able to get the service or item within 14 calendar days (for a standard coverage decision) or 72 hours (for a fast coverage decision) of when you asked. Interventional echocardiographer meeting the requirements listed in the determination. PCPs are usually linked to certain hospitals and specialists. 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. Your IEHP DualChoice Doctor cannot charge you for covered health care services, except for required co-payments. CMS reviews studies to determine if they meet the criteria listed in Section 160.18 of the National Coverage Determination Manual. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug. You and your provider can ask us to make an exception. It stores all your advance care planning documents in one place online. Program Services There are five services eligible for a financial incentive. We check to see if we were following all the rules when we said No to your request. of the appeals process. Fill out the Authorized Assistant Form if someone is helping you with your IMR. If you get a bill that is more than your copay for covered services and items, send the bill to us. The patient is under the care of a heart team, which consists of a cardiac surgeon, interventional cardiologist, and various Providers, nurses, and research personnel, The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the related aspects of TAVR, The hospital where the TAVR is complete must have various qualifications and implemented programs. If you would like to switch from our plan to another Medicare Advantage plan simply enroll in the new Medicare Advantage plan. Reviewers at the Independent Review Entity will take a careful look at all of the information related to your appeal. The letter will also explain how you can appeal our decision. Getting plan approval before we will agree to cover the drug for you. What if the Independent Review Entity says No to your Level 2 Appeal? National Coverage determinations (NCDs) are made through an evidence-based process. 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. Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States. 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. We will send you a letter within 5 calendar days of receiving your appeal letting you know that we received it. How do I ask the plan to pay me back for the plans share of medical services or items I paid for? You have the right to ask us for a copy of the information about your appeal. You can always contact your State Health Insurance Assistance Program (SHIP). . This is asking for a coverage determination about payment. Who is covered: (Implementation Date: February 27, 2023). You can then ask us to make an exception and cover the drug in the way you would like it to be covered for next year. Some changes to the Drug List will happen immediately. Rancho Cucamonga, CA 91729-1800 A clinical test providing the measurement of arterial blood gas. Also, its possible that your PCP might leave our plans network of providers and you would have to find a new PCP. If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will use the standard deadlines instead. The following medical conditions are not covered for oxygen therapy and oxygen equipment in the home setting: Other: (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. Who is covered: The PTA is covered under the following conditions: 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.. After your application and supporting documents are received from your plan, the IMR decision will be made within 30 calendar days. Can I ask for a coverage determination or make an appeal about Part D prescription drugs? 4. The organization will send you a letter explaining its decision. See plan Providers, get covered services, and get your prescription filled timely. 2020) 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. Click here for more information on ambulatory blood pressure monitoring coverage. The phone number for the Office of the Ombudsman is 1-888-452-8609. Oncologists care for patients with cancer. The letter will tell you how to make a complaint about our decision to give you a standard decision. IEHP DualChoice 2) State Hearing If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. You can tell Medi-Cal about your complaint. My Choice. If there are no network pharmacies in that area, IEHP DualChoice Member Services may be able to make arrangements for you to get your prescriptions from an out-of-network pharmacy. A network provider is a provider who works with the health plan. This government program has trained counselors in every state. Are a United States citizen or are lawfully present in the United States. 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. You, your doctor or other prescriber, or your representative can request the Level 2 Appeal. You have a right to give the Independent Review Entity other information to support your appeal. For more information, call IEHP DualChoice Member Services or read the IEHP DualChoice Member Handbook. H8894_DSNP_23_3241532_M. Medicare beneficiaries who meet either of the following criteria: Click here for more information on HBV Screenings. If we say No to your request for an exception, you can ask for a review of our decision by making an appeal. To learn more about asking for exceptions, see Chapter 9 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]). Study data for CMS-approved prospective comparative studies may be collected in a registry. To start your appeal, you, your doctor or other prescriber, or your representative must contact us. IEHP DualChoice will help you with the process. If your doctor says that you need a fast coverage decision, we will automatically give you one. 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 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. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Click here for more information on acupuncture for chronic low back pain coverage. 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%. (Implementation Date: October 8, 2021) If we agree to make an exception and waive a restriction for you, you can still ask for an exception to the co-pay amount we require you to pay for the drug. TDD users should call (800) 952-8349. 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 will need Adobe Acrobat Reader 6.0 or later to view the PDF files. For example, we might decide that a service, item, or drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. Here are two ways to get help from the Help Center: You can file a complaint with the Office for Civil Rights. The removal of these elements eliminates an important source of complications associated with traditional pacing systems while providing similar benefits. Box 1800 We take another careful look at all of the information about your coverage request. As an IEHP DualChoice (HMO D-SNP) Member, you have the right to: As an IEHP DualChoice Member, you have the responsibility to: For more information on Member Rights and Responsibilities refer to Chapter 8 of your IEHP DualChoice Member Handbook. You must qualify for this benefit. 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 miss this deadline and have a good reason for missing it, we may give you more time to make you appeal. This is not a complete list. You can also have your doctor or your representative call us. TTY users should call 1-800-718-4347. Click here for more information on Cochlear Implantation. If the IMR is decided in your favor, we must give you the service or item you requested. If we tell you after our review that the service or item is not covered, your case can go to a Level 2 Appeal. You can still get a State Hearing. Deadlines for a standard coverage decision about payment for a drug you have already bought, If our answer is Yes to part or all of what you asked for, we will make payment to you within 14 calendar days. "Coordinating" your services includes checking or consulting with other Plan providers about your care and how it is going. You, your representative, or your provider asks us to let you keep using your current provider. You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. We will see if the service or item you paid for is a covered service or item, and we will check to see if you followed all the rules for using your coverage. You are not responsible for Medicare costs except for Part D copays. You will not have a gap in your coverage. Remember, if you get a bill that is more than your copay for covered services and items, you should not pay the bill yourself. Who is covered? (SeeChapter 10 ofthe. IEHP DualChoice Medicare Team at (800) 741-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY users should call (800) 718-4347. 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. Click here to learn more about IEHP DualChoice. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). You can also have a lawyer act on your behalf. The MAC may determine necessary coverage for in home oxygen therapy for patients that do not meet the criteria described above. What is the Difference Between Hazelnut and Walnut The benefit information is a brief summary, not a complete description of benefits. Effective January 19, 2021, CMS has determined that blood-based biomarker tests are an appropriate colorectal cancer screening test, once every 3 years for Medicare beneficiaries when certain requirements are met. 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. What is covered? IEHP Welcome to Inland Empire Health Plan You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function. The form gives the other person permission to act for you. 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. (Effective: February 10, 2022) Be informed regarding Advance Directives, Living Wills, and Power of Attorney, and to receive information regarding changes related to existing laws. Have grievances heard and resolved in accordance with Medicare guidelines; Request quality of care grievances data from IEHP DualChoice. How to obtain an aggregate number of grievances, appeals, and exceptions filed with IEHP DualChoice (HMO D-SNP)? TTY users should call 1-800-718-4347. P.O. What kinds of medical care and other services can you get without getting approval in advance from your Primary Care Provider (PCP) in IEHP DualChoice (HMO D-SNP)? If you don't have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself. Decide in advance how you want to be cared for in case you have a life-threatening illness or injury. Effective June 21, 2019, CMS will cover TAVR under CED when the procedure is related to the treatment of symptomatic aortic stenosis and according to the Food and Drug Administration (FDA) approved indication for use with an approved device, or in clinical studies when criteria are met, in addition to the coverage criteria outlined in the NCD Manual. Remember, you can request to change your PCP at any time. The clinical study must address whether VNS treatment improves health outcomes for treatment resistant depression compared to a control group, by answering all research questions listed in 160.18 of the National Coverage Determination Manual. You dont have to do anything if you want to join this plan. 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. We will use the standard deadlines unless we have agreed to use the fast deadlines., You can get a fast coverage decision only if you are asking for a drug you have not yet received. If the State Hearing decision is Yes to part or all of what you asked for, we must comply with the decision. Beneficiaries that are at least 45 years of age or older can be screened for the following tests when all Medicare criteria found in this national coverage determination is met: Non-Covered Use: Get the My Life. For example, you can ask us to cover a drug even though it is not on the Drug List. What is covered? If you are taking the drug, we will let you know. The time of need is indicated when the presumption of oxygen therapy within the home setting will improve the patients condition. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. ACP and the advance health care directive can bridge the gap between the care someone wants and the care they receive if they lose the capacity to make their own decisions. Live in our service area (incarcerated individuals are not considered living in the geographic service area even if they are physically located in it. Arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88%, tested during functional performance of the patient or a formal exercise, You can ask us to reimburse you for IEHP DualChoice's share of the cost. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. Appeal any decision IEHP DualChoice makes regarding, but not limited to, a denial, termination, payment, or reduction of services. 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. 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. Usually, your prescription drugs are only covered if they are filled at a network pharmacy including through our mail-order pharmacy services. You can work with us for all of your health care needs. If your problem is urgent and involves an immediate and serious threat to your health, you may bring it immediately to the DMHCs attention. We will give you our answer sooner if your health requires us to. This is called upholding the decision. It is also called turning down your appeal. Its a good idea to make a copy of your bill and receipts for your records. 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. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. 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. 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). 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. If your Level 2 Appeal was an Independent Medical Review, you can request a State Hearing. In most cases, you must start your appeal at Level 1. Or, if you havent paid for the service or item yet, we will send the payment directly to the provider. Your care team and care coordinator work with you to make a care plan designed to meet your health needs. If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. (Effective: June 21, 2019) This is a person who works with you, with our plan, and with your care team to help make a care plan. (800) 440-4347 P.O. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition. Ask for an exception from these changes. According to the FDA labeling in an MRI environment, MRI coverage will be provided for beneficiaries under certain conditions. Your doctor or other provider can make the appeal for you. If you have been receiving care from a health care provider, you may have a right to keep your provider for a designated time period. 2. Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. You will be notified when this happens. If we decide to take extra days to make the decision, we will tell you by letter. 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. Never wavering in our commitment to our Members, Providers, Partners, and each other. 1. Information on this page is current as of October 01, 2022 Unleashing our creativity and courage to improve health & well-being. 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. (Implementation Date: November 13, 2020). are similar in many respects. IEHP DualChoice For more information see Chapter 9 of your IEHP DualChoice Member Handbook. The procedure must be performed in a hospital with infrastructure and experience meeting the requirements in this determination. 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. The reviewer will be someone who did not make the original coverage decision. Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities; or. The Office of Ombudsman is not connected with us or with any insurance company or health plan. 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. For inpatient hospital patients, the time of need is within 2 days of discharge. 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. Choose a PCP that is within 10 miles or 15 minutes of your home. Yes, you and your doctor may give us more information to support your appeal. The USPTF has found that screening for HBV allows for early intervention which can help decrease disease acquisition, transmission and, through treatment, improve intermediate outcomes for those infected. You are eligible for our plan as long as you: Only people who live in our service area can join IEHP DualChoice. H8894_DSNP_23_3879734_M Pending Accepted. (This is sometimes called prior authorization.), Being required to try a different drug first before we will agree to cover the drug you are asking for. 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. You can download a free copy here. If you are asking to be paid back, you are asking for a coverage decision.