Direct and oversee the process of handling difficult Providers and/or escalated cases. We also review our records on a regular basis. They all work together to provide the care you need. asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test), and, average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohns Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer). You can ask for a copy of the information in your appeal and add more information. This is not a complete list. Beneficiaries receiving autologous treatment for cancer with T-cell expressing at least one. Bringing focus and accountability to our work. For problems and concerns regarding eligibility determinations, assessments, and care delivered by our contracted Community Based Adult Services (CBAS) centers, or Nursing Facilities/Sub-Acute Care Facilities, you should follow the process outlined below. Patients implanted with a VNS device for TRD may receive a VNS device replacement if it is required due to the end of battery life, or any other device-related malfunction. To speak with a care coordinator, please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. The device must be approved by the Food and Drug Administration (FDA) for this purpose; OR. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. 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. 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. The list must meet requirements set by Medicare. However, your PCP can always use Language Line Services to get help from an interpreter, if needed. The problem with using black walnuts in cooking is the fact that the black walnuts have a very tough shell and the nuts are difficult to extract. When we add the new generic drug, we may also decide to keep the current drug on the list but change its coverage rules or limits. We must respond whether we agree with the complaint or not. Have advanced heart failure for at least 14 days and are dependent on an intraaortic balloon pump (IABP) or similar temporary mechanical circulatory support for at least 7 days. Information on this page is current as of October 01, 2022. If our answer is No to part or all of what you asked for, we will send you a letter. Limited benefit from amplification is defined by test scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of open-set sentence recognition. IEHP: "Inland Empire Health Plan (IEHP) is a not-for-profit Medi-Cal and Medicare health plan headquartered in Rancho Cucamonga, California. It stores all your advance care planning documents in one place online. Can I ask for a coverage determination or make an appeal about Part D prescription drugs? IEHP DualChoice Cal MediConnect (Medicare-Medicaid Plan) is changing to IEHP DualChoice (HMO D-SNP) on January 1, 2023. 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. You have been in the plan for more than 90 days and live in a long-term care facility and need a supply right away. 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. To learn more about asking for exceptions, see Chapter 9 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]). For other types of problems you need to use the process for making complaints. 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. You, your representative, or your doctor (or other prescriber) can do this. Organized as a Joint Powers Agency, Inland Empire Health Plan (IEHP) is a local, not-for-profit, public health plan. Non-Covered Use: We will give you our answer sooner if your health requires it. Live in our service area (incarcerated individuals are not considered living in the geographic service area even if they are physically located in it. You can also call if you want to give us more information about a request for payment you have already sent to us. 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.. We are also one of the largest employers in the region, designated as "Great Place to Work.". P.O. For example, this means that your care team makes sure: Your doctors know about all the medicines you take so they can make sure youre taking the right medicines and can reduce any side effects you may have from the medicines. We serve 1.5 million residents of Riverside and San Bernardino counties through government-sponsored programs including Medi-Cal (families, adults, seniors and people with disabilities) and Cal MediConnect. 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. Related Resources. We will send you a notice with the steps you can take to ask for an exception. If you are admitted to one of these hospitals, a hospitalist may serve as your caregiver as long as you remain in the hospital. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. If you are not satisfied with the result of the IMR, you can still ask for a State Hearing. Typically, our Formulary includes more than one drug for treating a particular condition. 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. This is called prior authorization. Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. If we are using the standard deadlines, we must give you our answer within 72 hours after we get your request or, if you are asking for an exception, after we get your doctors or prescribers supporting statement. Additional hours of treatment are considered medically necessary if a physician determines there has been a shift in the patients medical condition, diagnosis or treatment regimen that requires an adjustment in MNT order or additional hours of care. Here are two ways to get help from the Help Center: You can file a complaint with the Office for Civil Rights. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. Effective for dates of service on or after October 9, 2014, all other screening sDNA tests not otherwise specified above remain nationally non-covered. You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. Who is covered: Beneficiaries receiving treatment for chronic non-healing diabetic wounds for a duration of 20 weeks, when prepared by a device cleared by the Food and Drug Administration (FDA) for the management of exuding (bleeding, oozing, seeping, etc.) If you qualify for an IMR, the DMHC will review your case and send you a letter within 7 calendar days telling you that you qualify for an IMR. a. to part or all of what you asked for, we must approve or give the coverage within 72 hours after we get your request or, if you are asking for an exception, your doctors or prescribers supporting statement. It also has care coordinators and care teams to help you manage all your providers and services. The letter will also explain how you can appeal our decision. 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)? Click here for information on Next Generation Sequencing coverage. 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. 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. Black Walnuts on the other hand have a bolder, earthier flavor. A fast coverage decision means we will give you an answer within 24 hours after we get your doctors statement. The screen test must have all the following: Food and Drug Administration (FDA) market authorization with an indication for colorectal cancer screening; and. Have grievances heard and resolved in accordance with Medicare guidelines; Request quality of care grievances data from IEHP DualChoice. "Coordinating" your services includes checking or consulting with other Plan providers about your care and how it is going. Your doctor or other provider can make the appeal for you. To learn how to submit a paper claim, please refer to the paper claims process described below. Effective for dates of service on or after January 27, 2020, CMS has determined that NGS, as a diagnostic laboratory test, is reasonable and necessary and covered nationally for patients with germline (inherited) cancer when performed in a CLIA-certified laboratory, when ordered by a treating physician and when specific requirements are met. For example, you can make a complaint about disability access or language assistance. To learn more about the plans benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook. We will generally cover a drug on the plans Formulary as long as you follow the other coverage rules explained in Chapter 6 of the IEHP DualChoice Member Handbookand the drug is medically necessary, meaning reasonable and necessary for treatment of your injury or illness. You will get a care coordinator when you enroll in IEHP DualChoice. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision. TTY users should call (800) 537-7697. The State or Medicare may disenroll you if you are determined no longer eligible to the program. You ask us if a drug is covered for you (for example, when your drug is on the plans Formulary but we require you to get approval from us before we will cover it for you). If you request a fast coverage decision coverage decision, start by calling or faxing our plan to ask us to cover the care you want. b. What if you are outside the plans service area when you have an urgent need for care? 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? Here are your choices: There may be a different drug covered by our plan that works for you. The following medical conditions are not covered for oxygen therapy and oxygen equipment in the home setting: Other: (Implementation Date: February 14, 2022) To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for an coverage decision. Concurrent with Intracranial Stent Placement in FDA-Approved Category B IDE Clinical Trials Effective January 21, 2020, CMS will cover acupuncture for chronic low back pain (cLBP) for up to 12 visits in 90 days and an additional 8 sessions for those beneficiaries that demonstrate improvement, in addition to the coverage criteria outlined in the NCD Manual. (Effective: January 1, 2023) Rancho Cucamonga, CA 91729-4259. You will be automatically disenrolled from IEHPDualChoice, when your new plans coverage begins. Medicare beneficiaries who are diagnosed with Symptomatic Peripheral Artery Disease who would benefit from this therapy. The procedure must be performed by an interventional cardiologist or cardiac surgeon.<. If PO2 and arterial blood gas results are conflicting, the arterial blood gas results are preferred source to determine medical need. Click here for more information on chimeric antigen receptor (CAR) T-cell therapy coverage. Yes, you and your doctor may give us more information to support your appeal. You can get a fast coverage decision coverage decision only if you are asking for coverage for care or an item you have not yet received. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. Who is covered: Members must meet all of the following eligibility criteria: Click here for more information on LDCT coverage. We will tell you about any change in the coverage for your drug for next year. 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. They have a copay of $0. An acute HBV infection could progress and lead to life-threatening complications. Rancho Cucamonga, CA 91729-1800 You are never required to pay the balance of any bill. If we say No to your appeal, you then choose whether to accept this decision or continue by making another appeal. Because you get assistance from Medi-Cal, you can end your membership in IEHPDualChoice at any time. We take a careful look at all of the information about your request for coverage of medical care. Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative Form. your medical care and prescription drugs through our plan. 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, A reasonable salary expectation is between $153,670.40 and $195,936.00, based upon experience and internal equity. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Call (888) 466-2219, TTY (877) 688-9891. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy: We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgently needed care. But in some situations, you may also want help or guidance from someone who is not connected with us. The clinical test must be performed at the time of need: You will not have a gap in your coverage. What is covered? It attacks the liver, causing inflammation. An interventional echocardiographer must perform transesophageal echocardiography during the procedure. Most of the walnuts we eat in the United States are commonly known as English walnuts, but black walnuts are also prized and delicious. For example, you can make a complaint about disability access or language assistance. D-SNP Transition. This is called upholding the decision. It is also called turning down your appeal.. Which Pharmacies Does IEHP DualChoice Contract With? 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. 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. 3. Can my doctor give you more information about my appeal for Part C services? The Office of the Ombudsmanis not connected with us or with any insurance company or health plan. 5. 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. If you are having a problem with your care, you can call the Office of Ombudsman at 1-888-452-8609for help. 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). The clinical research must evaluate the required twelve questions in this determination. How long does it take to get a coverage decision coverage decision for Part C services? We will send you a letter telling you that. TTY users should call (800) 537-7697. How to obtain an aggregate number of grievances, appeals, and exceptions filed with IEHP DualChoice (HMO D-SNP)? You can contact Medicare. 2) State Hearing Hazelnuts have more carbohydrates and dietary fibres than walnuts while walnuts have more calories, proteins, and fats than hazelnuts. How to Enroll with IEHP DualChoice (HMO D-SNP), IEHP Texting Program Terms and Conditions. Medicare will cover both MNT and Diabetes Outpatient Self-Management Training (DSMT) during initial and subsequent years, if the physician determines treatment is medically necessary and as long as DSMT and MNT are not provided on the same date. This is asking for a coverage determination about payment. Sprint from Voice Telephone: (800) 877-5379, Visit: 10801 Sixth Street, Suite 120, Rancho Cucamonga, CA 91730. 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. The Centers of Medicare and Medicaid Services (CMS) will cover claims for effective dates of service on or after February 15, 2018. Heart failure cardiologist with experience treating patients with advanced heart failure. If you call us with a complaint, we may be able to give you an answer on the same phone call. 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 you do not agree with our decision, you can make an appeal. Both of these processes have been approved by Medicare. Initial coverage for patients experiencing conditions not described above can be limited to a prescription shorter than 90 days, or less than the numbers of days indicated on the practitioners prescription. However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. 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. How can I make a Level 2 Appeal? Are a United States citizen or are lawfully present in the United States. (800) 718-4347 (TTY), IEHP DualChoice Member Services You will keep all of your Medicare and Medi-Cal benefits. Information on this page is current as of October 01, 2022. 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. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. 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). There are many kinds of specialists. If you dont have the IEHP DualChoice Provider and Pharmacy Directory, you can get a copy from IEHP DualChoice Member Services. Deadlines for standard appeal at Level 2. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. Treatment for patients with existing co-morbidities that would preclude the benefit from the procedure. If you are asking for a standard appeal, you can make your appeal by sending a request in writing. Unleashing our creativity and courage to improve health & well-being. But if you do pay the bill, you can get a refund if you followed the rules for getting services and items. Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States. What is covered: Percutaneous Transluminal Angioplasty (PTA) is covered in the below instances in order to improve blood flow through the diseased segment of a vessel in order to dilate lesions of peripheral, renal and coronary arteries. We will let you know of this change right away. If we decide to take extra days to make the decision, we will tell you by letter. (Implementation Date: June 12, 2020). Medicare Prescription Drug Coverage and Your Rights Notice- Posting of Member Drug Coverage Rights: Medicare requires pharmacies to provide notice to enrollees each time a member is denied coverage or disagrees with cost-sharing information. 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. of the appeals process. 2. Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. If IEHP DualChoice removes a covered Part D drug or makes any changes in the IEHP DualChoice Formulary, IEHP DualChoice will post the formulary changes on the IEHP DualChoice website and notify the affected Members at least thirty (30) days prior to effective date of the change made on the IEHP DualChoice Formulary. IEHP (Inland Empire Health Plan) is a provider that contains a network of doctors, dentists, pyschs, therapists, and specialists. We establish that you had an existing relationship with a primary or specialty care provider, with some exceptions. A new generic drug becomes available. 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. For additional information on step therapy and quantity limits, refer to Chapter5 of theIEHP DualChoice Member Handbook. You can call (800) MEDICARE (800) 633-4227, 24 hours a day, 7 days a week, TTY (877) 486-2048. If the IRE says No to your appeal, it means they agree with our decision not to approve your request. (Effective: July 2, 2019) The Heart team must participate in the national registry and track outcomes according to the requirements in this determination.>. (800) 440-4347 This is not a complete list. For more information on network providers refer to Chapter 1 of the IEHP DualChoice Member Handbook. We do the right thing by: Placing our Members at the center of our universe. Most recently, as of May 1, 2016, Medi-Cal now covers all low income children under the age of 19, regardless of immigration status. If we do not give you an answer within 72 hours 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. This person will also refer you to community resources, if IEHP DualChoice does not provide the services that you need. A clinical test providing the measurement of arterial blood gas. If your health requires it, ask us to give you a fast coverage decision Medicare beneficiaries in need of a pacemaker who are participating in an approved clinical study. https://www.medicare.gov/MedicareComplaintForm/home.aspx. 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. Mail your request for payment together with any bills or receipts to us at this address: IEHPDualChoice If you have a fast complaint, it means we will give you an answer within 24 hours. You can send your complaint to Medicare. You have the right to choose someone to represent you during your appeal or grievance process and for your grievancesand appeals to be reviewed as quickly as possible and be told how long it will take. TTY users should call 1-800-718-4347. Review, request changes to, and receive a copy of your medical records in a timely fashion. 3. Please see Chapter 9 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]) of the Member Handbook for more information on exceptions. (Implementation Date: July 5, 2022). IEHP DualChoice will help you with the process. If you do not stay continuously enrolled in Medicare Part A and Part B. (Effective: February 19, 2019) Click here to download a free copy of Adobe Acrobat Reader.By clicking on this link, you will be leaving the IEHP DualChoice website. VNS is non-covered for the treatment of TRD when furnished outside of a CMS-approved CED study. By clicking on this link, you will be leaving the IEHP DualChoice website. You must ask to be disenrolled from IEHP DualChoice. Getting plan approval before we will agree to cover the drug for you. 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. For patients whose initial prescription for oxygen did not originate during an inpatient hospital stay, the time of need occurs when the treating practitioner identifies signs and symptoms of hypoxemia that can be relieved with at home oxygen therapy. 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. Be prepared for important health decisions Change the coverage rules or limits for the brand name drug. IEHP DualChoice will give notice to IEHPDualChoice Members prior to removing Part D drug from the Part D formulary. Learn about your health needs and leading a healthy lifestyle. If the State Hearing decision is Yes to part or all of what you asked for, we must comply with the decision.