An ICD is an electronic device to diagnose and treat life threating Ventricular Tachyarrhythmias (VTs) that has demonstrated improvement in survival rates and reduced cardiac death for certain patients. Beneficiaries receiving autologous treatment for cancer with T-cell expressing at least one. 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. To learn how to submit a paper claim, please refer to the paper claims process described below. H8894_DSNP_23_3241532_M. TTY users should call 1-877-486-2048. Remember, you can request to change your PCP at any time. Deadlines for standard appeal at Level 2. You can ask for an Independent Medical Review (IMR) from the Help Center at the California Department of Managed Health Care (DMHC). 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. If we say no to part or all of your Level 1 Appeal, we will send you a letter. Appointment of Representatives Form (PDF), 2023 Drugs Requiring Prior Authorization (PDF). You may be able to order your prescription drugs ahead of time through our network mail order pharmacy service or through a retail network pharmacy that offers an extended supply. (800) 718-4347 (TTY), IEHP 24-Hour Nurse Advice Line (for IEHP Members only) He or she can work with you to find another drug for your condition. Your PCP, along with the medical group or IPA, provides your medical care. (Implementation Date: January 17, 2022). If we are using the standard deadlines, we must give you our answer within 7 calendar days after we get your appeal, or sooner if your health requires it. No means the Independent Review Entity agrees with our decision not to approve your request. English Walnuts. Ask for an exception from these changes. 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. According to the FDA labeling in an MRI environment, MRI coverage will be provided for beneficiaries under certain conditions. What is covered: wounds affecting the skin. (Implementation Date: June 12, 2020). The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. The person you name would be your representative. You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. We will answer your request for an exception within 72 hours after we get your request (or your prescribers supporting statement). How to Enroll with IEHP DualChoice (HMO D-SNP) (This is sometimes called step therapy.). At Level 2, an Independent Review Entity will review our decision. You can call the DMHC Help Center for help with complaints about Medi-Cal services. What is covered? The Medicare Complaint Form is available at: 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. You can call SHIP at 1-800-434-0222. 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? (888) 244-4347 Removing a restriction on our coverage. 2. We may contact you or your doctor or other prescriber to get more information. In these situations, please check first with IEHP DualChoice Member Services to see if there is a network pharmacy nearby. Click here for more information on Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). A reasonable salary expectation is between $153,670.40 and $195,936.00, based upon experience and internal equity. 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. This is not a complete list. We will send you a notice before we make a change that affects you. If our answer is No to part or all of what you asked for, we will send you a letter. IEP Defined The Individualized Educational Plan (IEP) is a plan or program developed to ensure that a child who has a disability identified under the law and is attending an elementary or secondary educational institution receives specialized instruction and related services. When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. Ask us for a copy by calling Member Services at (877) 273-IEHP (4347). By clicking on this link, you will be leaving the IEHP DualChoice website. Pulmonary hypertension or cor pulmonale (high blood pressure in pulmonary arteries), determined by the measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVFL; or, Have a Primary Care Provider who is responsible for coordination of your care. Because you are eligible for Medi-Cal, you qualify for and are getting Extra Help from Medicare to pay for your prescription drug plan costs. Please see below for more information. An annual screening for lung cancer with LDCT will be available if specific eligibility criteria are met. The screen test must have all the following: Food and Drug Administration (FDA) market authorization with an indication for colorectal cancer screening; and. The counselors at this program can help you understand which process you should use to handle a problem you are having. Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative Form. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. Tier 1 drugs are: generic, brand and biosimilar drugs. Get Help from an Independent Government Organization. If you want to change plans, call IEHP DualChoice Member Services. Follow the plan of treatment your Doctor feels is necessary. The reviewer will be someone who did not make the original coverage decision. Infected individuals may develop symptoms such as nausea, anorexia, fatigue, fever, and abdominal pain, or may be asymptomatic. Walnut trees (Juglans spp.) TTY users should call (800) 537-7697. What is covered? This government program has trained counselors in every state. But in some situations, you may also want help or guidance from someone who is not connected with us. Our plans PCPs are affiliated with medical groups or Independent Physicians Associations (IPA). For example: We may make other changes that affect the drugs you take. A Cal MediConnect Plan is an organization made up of Doctors, Hospitals, Pharmacies, Providers of long-term services and supports, Behavioral Health Providers, and other Providers. If our answer is Yes to part or all of what you asked for, we must approve or give the coverage within 30 calendar days after we get your appeal. Ask within 60 days of the decision you are appealing. 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. It tells which Part D prescription drugs are covered by IEHP DualChoice. Yes. ICDs will be covered for the following patient indications: Please refer to section 20.4 of the NCD Manual for additional coverage criteria. TTY/TDD (877) 486-2048. We do the right thing by: Placing our Members at the center of our universe. What is covered? You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. (Effective: January 27, 20) (Implementation Date: March 26, 2019). IEHP DualChoice will give notice to IEHPDualChoice Members prior to removing Part D drug from the Part D formulary. The letter will tell you how to do this. P.O. Thus, this is the main difference between hazelnut and walnut. If you disagree with a coverage decision we have made, you can appeal our decision. Per the recommendation of the United States Preventive Services Task Force (USPSTF), CMS has issued a National Coverage Determination (NCD) which expands coverage to include screening for HBV infection. 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. However, if the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drugs manufacturer removes the drug from the market we will immediately remove the drug from our formulary. You can send your complaint to Medicare. Be treated with respect and courtesy. You can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. 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. For CMS-approved studies, the protocol, including the analysis plan, must meet requirements listed in this NCD. Your membership will usually end on the first day of the month after we receive your request to change plans. You have the right to ask us for a copy of your case file. 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. Your IEHP DualChoice Doctor cannot charge you for covered health care services, except for required co-payments. Yes. To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for an coverage decision. If you ask for a fast coverage decision, without your doctors support, we will decide if you get a fast coverage decision. An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. This is called upholding the decision. It is also called turning down your appeal. We must give you our answer within 14 calendar days after we get your request. (Effective: February 19, 2019) If this happens, you will have to switch to another provider who is part of our Plan. A clinical test providing a measurement of the partial pressure of oxygen (PO2) in arterial blood. You should receive the IMR decision within 45 calendar days of the submission of the completed application. You must choose your PCP from your Provider and Pharmacy Directory. All other indications for colorectal cancer screening not otherwise specific in the regulations or the National Coverage Determination above. How will I find out about the decision? The phone number for the Office for Civil Rights is (800) 368-1019. There are also limited situations where you do not choose to leave, but we are required to end your membership. If you dont know what you should have paid, or you receive bills and you dont know what to do about those bills, we can help. If your case is urgent and you qualify for an IMR, the DMHC will review your case and send you a letter within 2 calendar days telling you that you qualify for an IMR. You dont have to do anything if you want to join this plan. We may not tell you before we make this change, but we will send you information about the specific change or changes we made. 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. Bringing focus and accountability to our work. Information on the page is current as of December 28, 2021 Erythrocythemia (increased red blood cells) with a hematocrit greater than 56%. 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 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. The treatment is based upon efficacy from a change in surrogate endpoint such as amyloid reduction. The State or Medicare may disenroll you if you are determined no longer eligible to the program. If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. CMS has revised Chapter 1, Section 20.29, Subsection C Topical Application of Oxygen to remove the exclusion of this treatment. 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. You can ask us to make a faster decision, and we must respond in 15 days. How can I make a Level 2 Appeal? TTY users should call 1-800-718-4347. 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. 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 more information on Home Use of Oxygen coverage click here. If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan. You can contact the Office of the Ombudsman for assistance. If we agree to make an exception and cover a drug that is not on the Formulary, you will need to pay the cost-sharing amount that applies to drug. The following criteria must also be met as described in the NCD: Non-Covered Use: You can call Member Services to ask for a list of covered drugs that treat the same medical condition. For more information, call IEHP DualChoice Member Services or read the IEHP DualChoice Member Handbook. Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. The following information explains who qualifies for IEHP DualChoice (HMO D-SNP). (Effective: February 10, 2022) In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. 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. (Implementation Date: January 3, 2023) (Effective: January 1, 2023) We will send you a notice with the steps you can take to ask for an exception. Be prepared for important health decisions 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. Our plan includes doctors, hospitals, pharmacies, providers of long-term services and supports, behavioral health providers, and other providers. Inland Empire Health Plan (IEHP) has over 1,234 Doctors, 3,676 Specialists, 724 Pharmacies, 74 Urgent Care, 243 OB/GYNs, 383 Behavioral Health Providers, 40 major Hospitals, and 313 Vision doctors in Riverside and San Bernardino counties. Read Will my benefits continue during Level 2 appeals in Chapter 9 of the Member Handbook for more information. ((Effective: December 7, 2016) Who is covered? A fast coverage decision means we will give you an answer within 24 hours after we get your doctors statement. The form gives the other person permission to act for you. Prior to January 18, 2017, there was no national coverage determination (NCD) in effect. If you have any other feedback or concerns, or if you feel the plan is not addressing your problem, please call (800) MEDICARE (800) 633-4227). 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.. You are not responsible for Medicare costs except for Part D copays. If you prefer a different one, please call IEHP DualChoice Member Services and we can assist you in finding and selecting another provider. Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States. 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. Medi-Cal provides free or low-cost health coverage to low-income individuals and their families.California has been expanding Medi-Cal to a larger and more diverse group of people. Use the IEHP Medicare Prescription Drug Coverage Determination Form for a prior authorization. ii. 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. C. Beneficiarys diagnosis meets one of the following defined groups below: You can file a grievance online. How to ask for coverage decision coverage decision to get medical, behavioral health, or certain long-term services and supports (CBAS, or NF services). If your problem is about a Medi-Cal service or item, you can file a Level 2 Appeal yourself. Effective for dates of service on or after August 7, 2019, CMS covers autologous treatment for cancer with T-cell expressing at least one chimeric antigen receptor (CAR) when administered at healthcare facilities enrolled in the Food and Drug Administrations (FDA) Risk Evaluation and Mitigation Strategies (REMS) and when specific requirements are met. Deadlines for standard appeal at Level 2 PO2 may be performed by the treating practitioner or by a qualified provider or supplier of laboratory services. Beneficiaries who meet the coverage criteria, if determined eligible. 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. If you miss the deadline for a good reason, you may still appeal. Use of other PET radiopharmaceutical tracers for cancer may be covered at the discretion of local Medicare Administrative Contractors (MACs), when used in accordance to their Food and Drug Administration (FDA) approval indications. 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). IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. The Office of the Ombudsman. IEHP (Inland Empire Health Plan) is a provider that contains a network of doctors, dentists, pyschs, therapists, and specialists. (Effective: January 1, 2022) Have grievances heard and resolved in accordance with Medicare guidelines; Request quality of care grievances data from IEHP DualChoice. Drugs that may not be safe or appropriate because of your age or gender. The list must meet requirements set by Medicare. 2) State Hearing Can I get a coverage decision faster for Part C services? 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. If your doctor says that you need a fast coverage decision, we will automatically give you one. 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. All other indications for colorectal cancer screening not otherwise specified in the Social Security Act, regulations, or the above remain nationally non-covered. A standard coverage decision means we will give you an answer within 72 hours after we get your doctors statement. Choose a PCP that is within 10 miles or 15 minutes of your home. Treatment of Atherosclerotic Obstructive Lesions Covering a Part D drug that is not on our List of Covered Drugs (Formulary). 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 recently, as of May 1, 2016, Medi-Cal now covers all low income children under the age of 19, regardless of immigration status. Medicare beneficiaries with LSS who are participating in an approved clinical study. During these events, oxygen during sleep is the only type of unit that will be covered. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. Information on the page is current as of March 2, 2023 Request and receive appeal data from IEHP DualChoice; Receive notice when an appeal is forwarded to the Independent Review Entity (IRE); Automatic reconsideration by the IRE when IEHP DualChoice upholds its original adverse determination in whole or in part; Administrative Law Judge (ALJ) hearing if the independent review entity upholds the original adverse determination in whole or in part and the remaining amount in controversy is $100 or more; Request Departmental Appeals Board (DAB) review if the ALJ hearing is unfavorable to the Member in whole or in part; Judicial review of the hearing decision if the ALJ hearing and/or DAB review is unfavorable to the Member in whole or in part and the amount remaining in controversy is $1,000 or more; Make a quality of care complaint under the QIO process; Request QIO review of a determination of noncoverage of inpatient hospital care; Request QIO review of a determination of noncoverage in skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities; Request a timely copy of your case file, subject to federal and state law regarding confidentiality of patient information; Challenge local and national Medicare coverage determination. 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. You have access to a care coordinator. The following criteria must be used to identify a beneficiary demonstrating treatment resistant depression: Beneficiary must be in a major depressive disorder episode for at least two years or have had at least four episodes, including the current episode. CMS-approved studies of a monoclonal antibody directed against amyloid approved by the FDA for the treatment of AD based upon evidence of efficacy from a direct measure of clinical benefit must address all of the questions included in section B.4 of this National Coverage Determination. IEHP DualChoice develops and maintains the Formulary continuously by reviewing the efficacy (how effective) and safety (how safe) of new drugs, compare new versus existing drugs, and develops clinical practice guidelines based on clinical evidence. You can change your Doctor by calling IEHP DualChoice Member Services. IEHP DualChoice network providers are required to comply with minimum standards for pharmacy practices as established by the State of California. Receive information about IEHP DualChoice, its programs and services, its Doctors, Providers, health care facilities, and your drug coverage and costs, which you can understand. Arterial PO2 at or below 55 mm Hg, or arterial oxygen saturation at or below 88% when tested during sleep for patients that demonstrate an arterial PO2 at or above 56 mmHg, or 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. 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)? You should receive the IMR decision within 7 calendar days of the submission of the completed application. CMS has updated Chapter 1, section 160.18 of the Medicare National Coverage Determinations Manual. The treatment is considered reasonably likely to predict a clinical benefit and is administrated in a randomized controlled trial under an investigational new drug application. Click here for more information on ambulatory blood pressure monitoring coverage. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. There are over 700 pharmacies in the IEHP DualChoice network. What is covered: 504 Plan Defined The 504 Plan is a plan developed to ensure that a child who has a disability CMS has added a new section, Section 220.2, to Chapter 1, Part 4 of the Medicare National Coverage Determinations Manual entitled Magnetic Resonance Imaging (MRI). If you disagree with our decision, you can ask the DMHC Help Center for an IMR. Information on this page is current as of October 01, 2022 These forms are also available on the CMS website: How will the plan make the appeal decision? IEHP DualChoice Formulary consists of medications that are considered as first line therapies (drugs that should be used first for the indicated conditions). If we are using the fast deadlines, we must give you our answer within 24 hours. 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. To learn how to name your representative, you may call IEHP DualChoice Member Services. 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. We will tell you about any change in the coverage for your drug for next year. (Effective: April 13, 2021) For additional details on how to reach us for appeals, see Chapter 9 of the IEHP DualChoice Member Handbook. An acute HBV infection could progress and lead to life-threatening complications. Click here for more information on Cochlear Implantation. 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. TDD users should call (800) 952-8349. For inpatient hospital patients, the time of need is within 2 days of discharge. If you have any authorizations pending approval, if you are in them idle of treatment, or if specialty care has been scheduled for you by your current Doctor, contact IEHP to help you coordinate your care during this transition time. 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.
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