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. For example, you can make a complaint about disability access or language assistance. If your health requires it, ask us to give you a fast coverage decision If the IMR is decided in your favor, we must give you the service or item you requested. You can also have a lawyer act on your behalf. Most of the walnuts we eat in the United States are commonly known as English walnuts, but black walnuts are also prized and delicious. Click here to download a free copy of Adobe Acrobat Reader.By clicking on this link, you will be leaving the IEHP DualChoice website. Follow the appeals process. If your Level 2 Appeal was a State Hearing, the California Department of Social Services will send you a letter explaining its decision. 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. 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: For inpatient hospital patients, the time of need is within 2 days of discharge. CMS has updated Chapter 1, Part 1, Section 20.4 of the Medicare National Coverage Determinations Manual providing additional coverage criteria for Implantable Cardiac Defibrillators (ICD) for Ventricular Tachyarrhythmias (VTs). See plan Providers, get covered services, and get your prescription filled timely. Oncologists care for patients with cancer. Yes. You may also contact the local Office for Civil Rights office at: U.S. Department of Health and Human Services. You have a care team that you help put together. If our answer is Yes to part or all of what you asked for, we must give the coverage within 72 hours after we get your appeal. If the complaint is about a Part D drug, you must file it within 60 calendar days after you had the problem you want to complain about. Appointment of Representatives Form (PDF), 2023 Drugs Requiring Prior Authorization (PDF). All other indications for colorectal cancer screening not otherwise specified in the Social Security Act, regulations, or the above remain nationally non-covered. National Coverage determinations (NCDs) are made through an evidence-based process. The screen test must have all the following: Food and Drug Administration (FDA) market authorization with an indication for colorectal cancer screening; and. If the answer is No, we will send you a letter telling you our reasons for saying No. A medical group or IPA is a group of physicians, specialists, and other providers of health services that see IEHP Members. We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency. (800) 720-4347 (TTY). Changing your Primary Care Provider (PCP). Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). If the plan says No at Level 1, what happens next? Patients depressive illness meets a minimum criterion of four prior failed treatments of adequate dose and duration as measured by a tool designed for this purpose. For more information on Member Rights and Responsibilities refer to Chapter 8 of your. TTY users should call (800) 718-4347. 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. 3. We are also one of the largest employers in the region, designated as "Great Place to Work.". Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States. IEHP: "Inland Empire Health Plan (IEHP) is a not-for-profit Medi-Cal and Medicare health plan headquartered in Rancho Cucamonga, California. There are also limited situations where you do not choose to leave, but we are required to end your membership. The Office of the Ombudsman. Effective for dates of service on or after December 15, 2017, CMS has updated section 220.6.19 of the National Coverage Determination Manual clarifying there are no nationally covered indications for Positron Emission Tomography NaF-18 (NaF-18 PET). Our plan includes doctors, hospitals, pharmacies, providers of long-term services and supports, behavioral health providers, and other providers. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. CMS has added a new section, Section 20.35, to Chapter 1 entitled Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). 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. You can tell Medicare about your complaint. Most recently, as of May 1, 2016, Medi-Cal now covers all low income children under the age of 19, regardless of immigration status. It also needs to be an accepted treatment for your medical condition. (Effective: July 2, 2019) If you let someone else use your membership card to get medical care. The Social Security Office at (800) 772-1213 between 7 a.m. and 7 p.m., Monday through Friday, TTY users should call (800) 325-0778; or. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. Ask for the type of coverage decision you want. Effective July 2, 2019, CMS will cover Ambulatory Blood Pressure Monitoring (ABPM) when beneficiaries are suspected of having white coat hypertension or masked hypertension in addition to the coverage criteria outlined in the NCD Manual. CMS has expanded the PILD for LSS National Coverage Determination (NCD) to now cover beneficiaries that are enrolled in a CMS-approved prospective longitudinal study. Get Help from an Independent Government Organization. Receive emergency care whenever and wherever you need it. Your provider will also know about this change. We may not tell you before we make this change, but we will send you information about the specific change or changes we made. Typically, our Formulary includes more than one drug for treating a particular condition. Please see below for more information. IEHP DualChoice is very similar to your current Cal MediConnect plan. If your provider says you have a good medical reason for an exception, he or she can help you ask for one. To find the name, address, and phone number of the Quality Improvement Organization in your state, lookin Chapter 2 of your. All the changes are reviewed and approved by a selected group of Providers and Pharmacists that are currently in practice. Usually, your prescription drugs are only covered if they are filled at a network pharmacy including through our mail-order pharmacy services. If your Level 2 Appeal went to the Medicare Independent Review Entity, it will send you a letter explaining its decision. Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. How to voluntarily end your membership in our plan? For reservations call Monday-Friday, 7am-6pm (PST). Group II: IEHP DualChoice will honor authorizations for services already approved for you. If you are making a complaint because we denied your request for a fast coverage determination or fast appeal, we will automatically give you a fast complaint. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision. Who is covered? Treatment for patients with existing co-morbidities that would preclude the benefit from the procedure. How can I make a Level 2 Appeal? If your doctor or other provider asks for a service or item that we will not approve, or we will not continue to pay for a service or item you already have and we said no to your Level 1 appeal, you have the right to ask for a State Hearing. The letter you get from the IRE will explain additional appeal rights you may have. 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. If you are requesting an exception, provide the supporting statement. Your doctor or other prescriber must give us the medical reasons for the drug exception. There are extra rules or restrictions that apply to certain drugs on our Formulary. Who is covered? If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. If we uphold the denial after Redetermination, you have the right to request a Reconsideration. Click here to learn more about IEHP DualChoice. H8894_DSNP_23_3241532_M. 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. If we are using the fast deadlines, we must give you our answer within 24 hours. Click here for more information on Leadless Pacemakers. How to ask for coverage decision coverage decision to get medical, behavioral health, or certain long-term services and supports (CBAS, or NF services). This service will be covered when the TAVR is used, for the treatment of symptomatic aortic valve stenosis. Contact us promptly call IEHP DualChoice at (877) 273-IEHP (4347), 8am - 8pm, 7 days a week, including holidays.TTY users should call 1-800-718-4347. A care coordinator is a person who is trained to help you manage the care you need. You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. 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. If you decide to make an appeal, it means you are going on to Level 1 of the appeals process. (800) 440-4347 You should not pay the bill yourself. This will give you time to talk to your doctor or other prescriber. The registry shall collect necessary data and have a written analysis plan to address various questions. Tier 1 drugs are: generic, brand and biosimilar drugs. LSS is a narrowing of the spinal canal in the lower back. 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. IEHP DualChoice. 1. 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. 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. Our service area includes all of Riverside and San Bernardino counties. Deadlines for standard appeal at Level 2. 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. 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. You will be automatically enrolled in IEHP DualChoice and do not need to do anything to keep these services. (Effective: January 1, 2022) You can call the DMHC Help Center for help with complaints about Medi-Cal services. Information on this page is current as of October 01, 2022 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. A reasonable salary expectation is between $153,670.40 and $195,936.00, based upon experience and internal equity. Suppose that you are temporarily outside our plans service area, but still in the United States. The California Department of Managed Health Care (DMHC) is responsible for regulating health plans. 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. TTY/TDD users should call 1-800-430-7077. Fecal Occult Blood Tests (gFOBT) once every 12 months, The Cologuard Multi-target Stool DNA (sDNA) Test once every 3 years, Blood-based Biomarker Tests once every 3 years, Diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with limited benefit, Cognitive ability to use hearing clues and a willingness to undergo an extended program of rehabilitation, Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, and freedom from lesions in the hearing nerve and acoustic areas of the central nervous system, No indicated risks to surgery that are determined harmful or inadvisable, The device must be used in accordance with Food and Drug Administration (FDA) approved labeling, You can complete the Member Complaint Form. This additional time will allow you to correct your eligibility information if you believe that you are still eligible. 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. You can always contact your State Health Insurance Assistance Program (SHIP). Positron Emission Tomography NaF-18 (NaF-18 PET) services to identify bone metastases of cancer provided on or after December 15, 2017, are nationally non-covered. Eligible Members The population for this P4P program includes IEHP Direct DualChoice Members. This page provides you information on what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug. Who is covered: Here are examples of coverage determination you can ask us to make about your Part D drugs. 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. When will I hear about a standard appeal decision for Part C services? In some cases, IEHP is your medical group or IPA. At Level 2, an Independent Review Entity will review our decision. With this app, you or a designated person with Power of Attorney can access your advance health care directives at any time from a home computer or smartphone. All screenings DNA tests, effective April 28, 2008, through October 8, 2014. CMS has updated Chapter 1, Part 1, Section 20.7 of the Medicare National Coverage Determinations Manual providing additional information regarding PTA. We will look into your complaint and give you our answer. For some drugs, the plan limits the amount of the drug you can have. This is known as Exclusively Aligned Enrollment, and. disease); An additional 8 sessions will be covered for those patients demonstrating an improvement. But if you do pay the bill, you can get a refund if you followed the rules for getting services and items. If you call us with a complaint, we may be able to give you an answer on the same phone call. An IMR is a review of your case by doctors who are not part of our plan. (800) 718-4347 (TTY), IEHP 24-Hour Nurse Advice Line (for IEHP Members only) CMS has updated Chapter 1, section 30.3.3 of the Medicare National Coverage Determinations Manual. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. 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. If your Level 2 Appeal was an Independent Medical Review, you can request a State Hearing. Ask within 60 days of the decision you are appealing. Yes. 2. If this happens, you will have to switch to another provider who is part of our Plan. If you are having a problem with your care, you can call the Office of Ombudsman at 1-888-452-8609for help. P.O. You can file a fast complaint and get a response to your complaint within 24 hours. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. 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. TTY users should call 1-800-718-4347. IEHP DualChoice network providers are required to comply with minimum standards for pharmacy practices as established by the State of California. The letter you get from the Independent Review Entity will tell you the dollar amount needed to continue with the appeals process. With a network of more than 6,000 Providers and 2,000 Team Members, we provide . (Effective: February 15, 2018) 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. 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. CMS has updated Chapter 1, Part 2, Section 90.2 of the Medicare National Coverage Determinations Manual to include NGS testing for Germline (inherited) cancer when specific requirements are met and updated criteria for coverage of Somatic (acquired) cancer. Oxygen therapy can be renewed by the MAC if deemed medically necessary. The beneficiary is under pre- or post-operative care of a heart team meeting the following: Cardiac Surgeon meeting the requirements listed in the determination. Click here to download a free copy by clicking Adobe Acrobat Reader. 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. Click here for more information on study design and rationale requirements. We will tell you in advance about these other changes to the Drug List. Change the coverage rules or limits for the brand name drug. 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. Getting plan approval before we will agree to cover the drug for you. 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. We will also use the standard 14 calendar day deadline instead. You do not need to do anything further to get this Extra Help. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. Limitations, copays, and restrictions may apply. TTY should call (800) 718-4347. (Implementation Date: February 27, 2023). Call our transportation vendor Call the Car (CTC) at (866) 880-3654, for TTY users, call your relay service or California Relay Service at 711. This includes: The device is used following post-cardiotomy (period following open heart surgery) to support blood circulation. 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. Patients must maintain a stable medication regimen for at least four weeks before device implantation. If you want the Independent Review Organization to review your case, your appeal request must be in writing. 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. Advance care planning (ACP) involves shared decision making to write down-in an advance care directive-a persons wishes about their future medical care. Denies, changes, or delays a Medi-Cal service or treatment (not including IHSS) because our plan determines it is not medically necessary. What is a Level 1 Appeal for Part C services? If the appeal comes from someone besides you or your doctor or other provider, we must receive the completed Appointment of Representative form before we can review the appeal. (Effective: January 1, 2023) 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. To ask if your PCP or other providers are in our network in 2023, call IEHP DualChoice Member Services. (Implementation Date: October 8, 2021) You can also visit, You can make your complaint to the Quality Improvement Organization. You can tell the California Department of Managed Health Care about your complaint. My problem is about a Medi-Cal service or item. They also have thinner, easier-to-crack shells. We will notify you by letter if this happens. H8894_DSNP_23_3241532_M. Click here for more information on Topical Applications of Oxygen. 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. We will give you our answer sooner if your health requires us to do so. There is no deductible for IEHP DualChoice. Here are your choices: There may be a different drug covered by our plan that works for you. Or, if you havent paid for the service or item yet, we will send the payment directly to the provider. The form gives the other person permission to act for you. It stores all your advance care planning documents in one place online. Who is covered? If you would like to switch from our plan to another Medicare Advantage plan simply enroll in the new Medicare Advantage plan. Who is covered? IEHP DualChoice recognizes your dignity and right to privacy. How do I ask the plan to pay me back for the plans share of medical services or items I paid for? Will not cover an experimental or investigational Medi-Cal treatment for a serious medical condition. (800) 718-4347 (TTY), IEHP DualChoice Member Services 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. Beneficiaries receiving autologous treatment for cancer with T-cell expressing at least one. 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. All physicians participating in the procedure must have device-specific training by the manufacturer of the device. Group I: 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. 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. IEHP DualChoice (HMO D-SNP) has a process in place to identify and reduce medication errors. Click here for more information on Cochlear Implantation. We take a careful look at all of the information about your request for coverage of medical care. All other indications of VNS for the treatment of depression are nationally non-covered. a. H8894_DSNP_23_3879734_M Pending Accepted. We do the right thing by: Placing our Members at the center of our universe. We will send you a letter within 5 calendar days of receiving your appeal letting you know that we received it. 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. ), and, Are age 21 and older at the time of enrollment, and, Have both Medicare Part A and Medicare Part B, and, Are a full-benefit dual eligible beneficiary and enroll in IEHP DualChoice for your Medicare benefits and Inland Empire Health Plan (IEHP) for your Medi-Cal benefits. B. Routine womens health care, which includes breast exams, screening mammograms (X-rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider. 504 Plan Defined The 504 Plan is a plan developed to ensure that a child who has a disability If we decide to take extra days to make the decision, we will tell you by letter. You have a right to give the Independent Review Entity other information to support your appeal. IEHP (Inland Empire Health Plan) is a provider that contains a network of doctors, dentists, pyschs, therapists, and specialists. i. 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. Effective on April 7, 2022, CMS has updated section 200.3 of the National Coverage Determination (NCD) Manual to cover Food and Drug Administration (FDA) approved monoclonal antibodies directed against amyloid for treatment of Alzheimers Disease (AD) when the coverage criteria below is met. To see if you qualify for getting extra help, you can contact: Do you need help getting the care you need? Quantity limits. Urgently needed care from in-network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible, e.g., when you are temporarily outside of the plans service area. Who is covered: If the service or item you paid for is covered and you followed all the rules, we will send you the payment for our share of the cost of the service or item within 60 calendar days after we get your request. You can ask us to make a faster decision, and we must respond in 15 days. What is covered: TTY/TDD (800) 718-4347. Inform your Doctor about your medical condition, and concerns. You must apply for an IMR within 6 months after we send you a written decision about your appeal. English Walnuts. 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. (Implementation Date: November 13, 2020). (Implementation Date: July 22, 2020). You can call the California Department of Social Services at (800) 952-5253. The form gives the other person permission to act for you. 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. 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. Your PCP will send a referral to your plan or medical group. The procedure removes a portion of the lamina in order to debulk the ligamentum flavum, essentially widening the spinal canal in the affected area. If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan. Make recommendations about IEHP DualChoice Members rights and responsibilities policies. IEHP DualChoice will help you with the process. IEHP DualChoice Direct and oversee the process of handling difficult Providers and/or escalated cases. Read Will my benefits continue during Level 2 appeals in Chapter 9 of the Member Handbook for more information. 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. 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. Black walnut trees are not really cultivated on the same scale of English walnuts. If you would like to switch from our plan to Original Medicare but you have not selected a separate Medicare prescription drug plan. 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. Effective for dates of service on or after January 19, 2021, CMS has updated section 20.33 of the National Coverage Determination Manual to cover Transcatheter Edge-to-Edge Repair (TEER) for Mitral Valve Regurgitation when specific requirements are met. How to Enroll with IEHP DualChoice (HMO D-SNP), IEHP Texting Program Terms and Conditions. We establish that you had an existing relationship with a primary or specialty care provider, with some exceptions. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. 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. ICDs will be covered for the following patient indications: Please refer to section 20.4 of the NCD Manual for additional coverage criteria.