The phone number for the Office for Civil Rights is (800) 368-1019. There are two ways you can asked to be disenrolled: To disenroll, please call Health Care Options (HCO) at 1-844-580-7272, 8am - 6pm (PST), Monday - Friday. You have the right to ask us for a copy of the information about your appeal. a. If you are unable to get a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service. Sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 calendar more days. To the California Department of Social Services: To the State Hearings Division at fax number 916-651-5210 or 916-651-2789. Have grievances heard and resolved in accordance with Medicare guidelines; Request quality of care grievances data from IEHP DualChoice. 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. For additional details on how to reach us for appeals, see Chapter 9 of the IEHP DualChoice Member Handbook. If your provider says you have a good medical reason for an exception, he or she can help you ask for one. When will I hear about a standard appeal decision for Part C services? If the decision is No for all or part of what I asked for, can I make another appeal? Click here for more information on Ventricular Assist Devices (VADs) coverage. Click here for more information on ambulatory blood pressure monitoring coverage. 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. They all work together to provide the care you need. If possible, we will answer you right away. Some of the advantages include: You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. 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). P.O. To learn more about your prescription drug costs, call IEHP DualChoice Member Services. i. Who is covered: Interventional Cardiologist meeting the requirements listed in the determination. Information on the page is current as of March 2, 2023 The device must be approved by the Food and Drug Administration (FDA) for this purpose; OR. 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. If you want the Independent Review Organization to review your case, your appeal request must be in writing. If you want to change plans, call IEHP DualChoice Member Services. Rancho Cucamonga, CA 91729-1800 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. Concurrent with Carotid Stent Placement in Patients at High Risk for Carotid Endarterectomy (CEA) The clinical research must evaluate the required twelve questions in this determination. For additional information on step therapy and quantity limits, refer to Chapter5 of theIEHP DualChoice Member Handbook. After your application and supporting documents are received from your plan, the IMR decision will be made within 30 calendar days. This can speed up the IMR process. Its a good idea to make a copy of your bill and receipts for your records. (Implementation Date: March 26, 2019). If the Independent Medical Review decision is Yes to part or all of what you asked for, we must provide the service or treatment. What is covered: Suppose that you are temporarily outside our plans service area, but still in the United States. Then you may submit your request one of these ways: To the county welfare department at the address shown on the notice. (866) 294-4347 When you file a fast complaint, we will give you an answer to your appeal within 24 hours. However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. The time of need is indicated when the presumption of oxygen therapy within the home setting will improve the patients condition. This means within 24 hours after we get your request. If we are using the fast deadlines, we must give you our answer within 24 hours. Fax: (909) 890-5877. 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. An interventional echocardiographer must perform transesophageal echocardiography during the procedure.>. Deadlines for standard appeal at Level 2. We take another careful look at all of the information about your coverage request. The clinical study must adhere to all the standards of scientific integrity and relevance to the Medicare population. IEHP DualChoice must end your membership in the plan if any of the following happen: The IEHPDualChoice Privacy Notice describes how medical information about you may be used and disclosed, and how you can get access to this information. If you lose your zero share-of-cost, full scope Medi-Cal, you will be disenrolled from our plan (for your Medicare benefits) the first day of the following month andwill be covered by the Original Medicare. We may not tell you before we make this change, but we will send you information about the specific change or changes we made. of the appeals process. 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. Prescriptions written for drugs that have ingredients you are allergic to. You might leave our plan because you have decided that you want to leave. Beneficiaries who exhibit hypoxemia (low oxygen in your blood) when ALL (A, B, and C) of the following are met: A. Hypoxemia is based on results of a clinical test ordered and evaluated by a patients treating practitioner meeting either of the following: If the service or item is not covered, or you did not follow all the rules, we will send you a letter telling you we will not pay for the service or item and explaining why. Make necessary appointments for routine and sick care, and inform your Doctor when you are unable to make a scheduled appointment. IEHP DualChoice Notify IEHP if your language needs are not met. You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY (800) 718-4347. Be treated with respect and courtesy. We are also one of the largest employers in the region, designated as "Great Place to Work.". 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. For more information on Grievances see Chapter 9 of your IEHP DualChoice Member Handbook. Typically, our Formulary includes more than one drug for treating a particular condition. This is called a referral. Click here for more information on Transcatheter Edge-to-Edge Repair [TEER] for Mitral Valve Regurgitation coverage . If you are having a problem with your care, you can call the Office of Ombudsman at 1-888-452-8609for help. For example, you can ask us to cover a drug even though it is not on the Drug List. An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. 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. You may be able to get extra help to pay for your prescription drug premiums and costs. 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. 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. Note, the Member must be active with IEHP Direct on the date the services are performed. You may change your PCP for any reason, at any time. A Level 1 Appeal is the first appeal to our plan. 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. If your health requires it, ask the Independent Review Entity for a fast appeal.. (Implementation Date: June 16, 2020). Group I: Some changes to the Drug List will happen immediately. P.O. For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. (Implementation date: August 29, 2017 for MAC local edits; January 2, 2018 for MCS shared edits) Remember, if you get a bill that is more than your copay for covered services and items, you should not pay the bill yourself. After the continuity of care period ends, you will need to use doctors and other providers in the IEHP DualChoice network that are affiliated with your primary care providers medical group, unless we make an agreement with your out-of-network doctor. Appointment of Representatives Form (PDF), 2023 Drugs Requiring Prior Authorization (PDF). How will the plan make the appeal decision? (Implementation Date: July 2, 2018). We do not allow our network providers to bill you for covered services and items. The letter will explain why more time is needed. (877) 273-4347 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. 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. 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. We will give you our decision sooner if your health condition requires us to. 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. 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. 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. This is known as Exclusively Aligned Enrollment, and. (Effective: July 2, 2019) (Effective: January 19, 2021) IEHP DualChoice will help you with the process. The Centers of Medicare and Medicaid Services (CMS) will cover claims for effective dates of service on or after February 15, 2018. You can contact Medicare. If you want a fast appeal, you may make your appeal in writing or you may call us. Read Will my benefits continue during Level 2 appeals in Chapter 9 of the Member Handbook for more information. Making an appeal means asking us to review our decision to deny coverage. Asking for a fast coverage decision coverage decision: Here are the rules for asking for a fast coverage decision coverage decision: You must meet the following two requirements to get a fast coverage decision coverage decision: If the coverage decision is Yes, when will I get the service or item? Deadlines for standard appeal at Level 2 For more information see Chapter 9 of your IEHP DualChoice Member Handbook. Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States. If PO2 and arterial blood gas results are conflicting, the arterial blood gas results are preferred source to determine medical need. Study data for CMS-approved prospective comparative studies may be collected in a registry. You, your representative, or your doctor (or other prescriber) can do this. What is covered: If you are asking to be paid back, you are asking for a coverage decision. You can ask for an Independent Medical Review (IMR) from the Help Center at the California Department of Managed Health Care (DMHC). You do not need to do anything further to get this Extra Help. We must respond whether we agree with the complaint or not. 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. Please select one of the following: Primary Care Doctor Specialist Behavioral Health Hospitals We will say Yes or No to your request for an exception. These different possibilities are called alternative drugs. If our answer is Yes to part or all of what you asked for, we must authorize or provide the coverage within 72 hours after we get your appeal. You may contact the DMHC if you need help with a complaint involving an urgent issue or one that involves an immediate and serious threat to your health, you disagree with our plans decision about your complaint, or our plan has not resolved your complaint after 30 calendar days. 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. If we say no, you have the right to ask us to change this decision by making an appeal. Covering a Part D drug that is not on our List of Covered Drugs (Formulary). Walnuts grow in U.S. Department of Agriculture plant hardiness zones 4 through 9, and hickories can be . Your PCP will also help you arrange or coordinate the rest of the covered services you get as a member of our Plan. 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. Then, we check to see if we were following all the rules when we said No to your request. The MAC may determine necessary coverage for in home oxygen therapy for patients that do not meet the criteria described above. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). (You cannot get a fast coverage decision coverage decision if your request is about payment for care or an item you have already received.). 2. (Implementation date: December 18, 2017) In most cases, you must start your appeal at Level 1. If you are traveling within the US, but outside of the Plans service area, and you become ill, lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy if you follow all other coverage rules identified within this document and a network pharmacy is not available. Remember, you can request to change your PCP at any time. The Centers of Medicare and Medicaid Services (CMS) will cover transcatheter aortic valve replacement (TAVR) under Coverage with Evidence Development (CED) when specific requirements are met. If you are not satisfied with the result of the IMR, you can still ask for a State Hearing. Screening computed tomographic colonography (CTC), effective May 12, 2009. Get the My Life. If you let someone else use your membership card to get medical care. It also needs to be an accepted treatment for your medical condition. Typically, our Formulary includes more than one drug for treating a particular condition. You will get a care coordinator when you enroll in IEHP DualChoice. 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. An interventional echocardiographer must perform transesophageal echocardiography during the procedure. The Centers of Medicare and Medicaid Services (CMS) will cover acupuncture for chronic low back pain (cLBP) when specific requirements are met. This additional time will allow you to correct your eligibility information if you believe that you are still eligible. If your Level 2 Appeal was an Independent Medical Review, the Department of Managed Health Care will send you a letter explaining its decision. 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. If the answer is No, we will send you a letter telling you our reasons for saying No. If your health requires it, ask for a fast appeal, Our plan will review your appeal and give you our decision. The intended effective date of the action. Medicare beneficiaries who are diagnosed with Symptomatic Peripheral Artery Disease who would benefit from this therapy. With "Extra Help," there is no plan premium for IEHP DualChoice. If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals). The call is free. Because you get assistance from Medi-Cal, you can end your membership in IEHPDualChoice at any time. 5. Calls to this number are free. This means that your PCP will be referring you to specialists and services that are affiliated with their medical group. 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. You must ask to be disenrolled from IEHP DualChoice. 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. IEHP: "Inland Empire Health Plan (IEHP) is a not-for-profit Medi-Cal and Medicare health plan headquartered in Rancho Cucamonga, California. 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. IEHP DualChoice will honor authorizations for services already approved for you. Black Walnuts on the other hand have a bolder, earthier flavor. Our plan cannot cover a drug purchased outside the United States and its territories. You must apply for an IMR within 6 months after we send you a written decision about your appeal. However, your PCP can always use Language Line Services to get help from an interpreter, if needed. 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. You may also ask for judicial review of a State Hearing denial by filing a petition in Superior Court (under Code of Civil Procedure Section 1094.5) within one year after you receive the decision. What is covered? We also review our records on a regular basis. If you do not qualify by the end of the two-month period, youll de disenrolled by IEHP DualChoice. Your benefits as a member of our plan include coverage for many prescription drugs. Beneficiaries receiving autologous treatment for cancer with T-cell expressing at least one least one chimeric antigen receptor CAR, when all the following requirements are met: The use of non-FDA-approved autologous T-cell expressing at least one CAR is non-covered or when the coverage requirements are not met. Medicare beneficiaries with LSS who are participating in an approved clinical study. 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. The diagnostic laboratory test using NGS must have: Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic and; FDA-approved or cleared indication for use in that patients cancer and; results provided to the treating physician for management of the patient using a report template to specify treatment options. The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. (This is sometimes called step therapy.). We have arranged for these providers to deliver covered services to members in our plan. 4. It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. a. The Medicare Complaint Form is available at:https://www.medicare.gov/MedicareComplaintForm/home.aspx. 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. The letter will tell you how to make a complaint about our decision to give you a standard decision. c. The Medicare Administrative Contractors (MACs) will review the arterial PO2 levels above and also take into consideration various oxygen measurements that can results from factors such as patients age, patients skin pigmentation, altitude level and the patients decreased oxygen carrying capacity. Information on this page is current as of October 01, 2022. Click here for more information on Transcatheter Edge-to-Edge Repair [TEER] for Mitral Valve Regurgitation coverage . If you ask for a fast coverage decision, without your doctors support, we will decide if you get a fast coverage decision. We will review our coverage decision to see if it is correct. Ask within 60 days of the decision you are appealing. H8894_DSNP_23_3879734_M Pending Accepted. wounds affecting the skin. Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. All physicians participating in the procedure must have device-specific training by the manufacturer of the device. Get Help from an Independent Government Organization. The call is free. 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. The Centers of Medicare and Medicaid Services (CMS) will cover Ambulatory Blood Pressure Monitoring (ABPM) when specific requirements are met. 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. This is called upholding the decision. It is also called turning down your appeal.. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. It attacks the liver, causing inflammation. 3. Asymptomatic (no signs or symptoms of lung cancer); Tobacco smoking history of at least 20 pack-years (one pack-year = smoking one pack per day for one year; 1 pack =20 cigarettes); Current smoker or one who has quit smoking within the last 15 years; Receive an order for lung cancer screening with LDCT. 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. ICDs will be covered for the following patient indications: Please refer to section 20.4 of the NCD Manual for additional coverage criteria. 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. The Centers for Medicare and Medical Services (CMS) has determined the following services to be necessary for the treatment of an illness or injury. and hickory trees (Carya spp.) Emergency services from network providers or from out-of-network providers. 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. Denies, changes, or delays a Medi-Cal service or treatment (not including IHSS) because our plan determines it is not medically necessary. (Implementation Date: July 5, 2022). The plan's block transfer filing indicated that the termination was the result of conduct by Vantage that resulted in the inappropriate delay, denial or modification of authorizations for services and care provide to IEHP's Medi-Cal managed care enrollees. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. The reviewer will be someone who did not make the original coverage decision. By clicking on this link, you will be leaving the IEHP DualChoice website. When you choose a PCP, it also determines what hospital and specialist you can use. The Heart team must participate in the national registry and track outcomes according to the requirements in this determination.>. How to voluntarily end your membership in our plan? We will also give notice if there are any changes regarding prior authorizations, quantity limits, step therapy or moving a drug to a higher cost-sharing tier. Within 10 days of the mailing date of our notice to you that the adverse benefit determination (Level 1 appeal decision) has been upheld; or. You may choose different health plans, or providers, under Medi-Cal, like IEHP or Molina Healthcare, Blue Shield, Health Net, etc. If your Level 2 Appeal was a State Hearing, the California Department of Social Services will send you a letter explaining its decision. 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. Click here for more information on Leadless Pacemakers. If you do not agree with our decision, you can make an appeal. 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.
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