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. It also includes problems with payment. This number requires special telephone equipment. If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. 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. Providers from other groups including patient practitioners, nurses, research personnel, and administrators. 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. Call: (877) 273-IEHP (4347). English Walnuts. Sprint from Voice Telephone: (800) 877-5379, Visit: 10801 Sixth Street, Suite 120, Rancho Cucamonga, CA 91730. If you dont have the IEHP DualChoice Provider and Pharmacy Directory, you can get a copy from IEHP DualChoice Member Services. 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. Have grievances heard and resolved in accordance with Medicare guidelines; Request quality of care grievances data from IEHP DualChoice. If we do not give you a decision within 7 calendar days, or 14 days if you asked us to pay you back for a drug you already bought, we will send your request to Level 2 of the appeals process. Medicare beneficiaries with LSS who are participating in an approved clinical study. If we uphold the denial after Redetermination, you have the right to request a Reconsideration. 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. You must qualify for this benefit. But in some situations, you may also want help or guidance from someone who is not connected with us. (Implementation Date: February 14, 2022) Then you may submit your request one of these ways: To the county welfare department at the address shown on the notice. You can fax the completed form to (909) 890-5877. 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. Interventional Cardiologist meeting the requirements listed in the determination. You might leave our plan because you have decided that you want to leave. These different possibilities are called alternative drugs. Box 1800 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. To get a temporary supply of a drug, you must meet the two rules below: When you get a temporary supply of a drug, you should talk with your provider to decide what to do when your supply runs out. Medi-Cal through Kaiser Permanente in California If we say no, you have the right to ask us to change this decision by making an appeal. The formal name for making a complaint is filing a grievance. A grievance is the kinds of problems related to: How to file a Grievance with IEHP DualChoice (HMO D-SNP). Sometimes a specialist, clinic, hospital or other network provider you are using might leave the plan. You should provide all requested information such as your full name, address, telephone number, the name of the plan or county that took the action against you, the aid program(s) involved, and a detailed reason why you want a hearing. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.). When we send the payment, its the same as saying Yes to your request for a coverage decision. Effective on or after April 10, 2018, MRI coverage will be provided when used in accordance to the FDA labeling in an MRI environment. IEHP DualChoice Beneficiaries with Alzheimers Disease (AD) may be covered for treatment when the following conditions (A or B) are met: Click here for more information on Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimers Disease (AD). Their shells are thick, tough to crack, and will likely stain your hands. Prior to filling your prescription at an out-of-network pharmacy, call IEHP DualChoice Member Services to find out if there is a network pharmacy in the area where you are traveling. IEHP completes termination of Vantage contract; three plans extend It usually takes up to 14 calendar days after you asked. You wont pay a premium, or pay for doctor visits or other medical care if you go to a provider that works with our health plan. 711 (TTY), To Enroll with IEHP IEHP DualChoice. If your health requires it, ask the Independent Review Entity for a fast appeal.. You must choose your PCP from your Provider and Pharmacy Directory. Effective for claims with dates of service on or after 12/07/16, Medicare will cover PILD under CED for beneficiaries with LSS when provided in an approved clinical study. 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. 2020) 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. Getting plan approval before we will agree to cover the drug for you. The FDA provides new guidance or there are new clinical guidelines about a drug. For inpatient hospital patients, the time of need is within 2 days of discharge. 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. Its a good idea to make a copy of your bill and receipts for your records. Can my doctor give you more information about my appeal for Part C services? (Implementation Date: December 10, 2018). Who is covered: 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. Submit the required study information to CMS for approval. If the Independent Medical Review decision is Yes to part or all of what you asked for, we must provide the service or treatment. This will give you time to talk to your doctor or other prescriber. TTY users should call 1-800-718-4347. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. This is known as Exclusively Aligned Enrollment, and. A fast coverage decision means we will give you an answer within 24 hours after we get your doctors statement. The procedure must be performed in a hospital with infrastructure and experience meeting the requirements in this determination. Ask us for a copy by calling Member Services at (877) 273-IEHP (4347). You can download a free copy here. 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. The therapy is used for a medically accepted indication, which is defined as used for either and FDA approved indication according to the label of that product, or the use is supported in one or more CMS approved compendia. 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. 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). Information on this page is current as of October 01, 2022. 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. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. You can give the completed form to any IEHP Provider or mail it to: Call: 1-888-452-8609(TTY 711) Monday through Friday, 9 a.m. to 5 p.m. The letter will explain why more time is needed. Beneficiaries receiving treatment for implanting a ventricular assist device (VAD), when the following requirements are met and: All other indications for the use of VADs not otherwise listed remain non-covered, except in the context of Category B investigational device exemption clinical trials (42 CFR 405) or as a routine cost in clinical trials defined under section 310.1 of the National Coverage Determinations (NCD) Manual. IEHP DualChoice (HMO D-SNP) helps make your Medicare and Medi-Cal benefits work better together and work better for you. You can ask for a copy of the information in your appeal and add more information. The clinical study must adhere to all the standards of scientific integrity and relevance to the Medicare population. 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. A Level 1 Appeal is the first appeal to our plan. It attacks the liver, causing inflammation. The clinical research study must meet the standards of scientific integrity and relevance to the Medicare population described in this determination. 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. If you get a bill that is more than your copay for covered services and items, send the bill to us. Beneficiaries that are at least 45 years of age or older can be screened for the following tests when all Medicare criteria found in this national coverage determination is met: Non-Covered Use: A specialist is a doctor who provides health care services for a specific disease or part of the body. 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. 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. 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. The reviewer will be someone who did not make the original decision. Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We may not tell you before we make this change, but we will send you information about the specific change or changes we made. What is covered: If you are having a problem with your care, you can call the Office of Ombudsman at 1-888-452-8609for help. Effective for claims with dates of service on or after February 10, 2022, CMS will cover, under Medicare Part B, a lung cancer screening counseling and shared decision-making visit. If you are not satisfied with the result of the IMR, you can still ask for a State Hearing. The NCR serves as a liaison for matters involving the contract between IEHP and both Network and Non-Network Providers. The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. If we decide to take extra days to make the decision, we will tell you by letter. H8894_DSNP_23_3241532_M. 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. (Effective: December 15, 2017) There are over 700 pharmacies in the IEHP DualChoice network. This section is about asking for coverage decisions and making appeals with problems related to your benefits and coverage. We will review our coverage decision to see if it is correct. of the appeals process. Click here for more information on Positron Emission Tomography NaF-18 (NaF-18 PET) to Identify Bone Metastasis of Cancer coverage. You will be automatically disenrolled from IEHPDualChoice, when your new plans coverage begins. A new generic drug becomes available. Will not pay for emergency or urgent Medi-Cal services that you already received. The reviewer will be someone who did not make the original coverage decision. Effective June 21, 2019, CMS will cover TAVR under CED when the procedure is related to the treatment of symptomatic aortic stenosis and according to the Food and Drug Administration (FDA) approved indication for use with an approved device, or in clinical studies when criteria are met, in addition to the coverage criteria outlined in the NCD Manual. If the IMR is decided in your favor, we must give you the service or item you requested. Try to choose a PCP that can admit you to the hospital you want within 30 miles or 45 minutes of your home. 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. This is a group of doctors and other health care professionals who help improve the quality of care for people with Medicare. 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. Are a United States citizen or are lawfully present in the United States. 2023 Plan Benefits. As an IEHP DualChoice (HMO D-SNP) Member, you have the right to: As an IEHP DualChoice Member, you have the responsibility to: For more information on Member Rights and Responsibilities refer to Chapter 8 of your IEHP DualChoice Member Handbook. You can call SHIP at 1-800-434-0222. In some cases, we can give you a temporary supply of a drug when the drug is not on the Drug List or when it is limited in some way. The letter you get from the IRE will explain additional appeal rights you may have. An annual screening for lung cancer with LDCT will be available if specific eligibility criteria are met. Here are a few examples: You will usually see your PCP first for most of your routine healthcare needs such as physical checkups, immunization, etc. Or, if you are asking for an exception, 24 hours after we get your doctors or prescribers statement supporting your request. 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. If your doctor or other prescriber tells us that your health requires a fast coverage decision, we will automatically agree to give you a fast coverage decision, and the letter will tell you that. (Effective: February 10, 2022) Information on this page is current as of October 01, 2022. We will send you a letter telling you that. If your Level 2 Appeal was a State Hearing, the California Department of Social Services will send you a letter explaining its decision. It stores all your advance care planning documents in one place online. Click here for more information onICD Coverage. If you wish, you and your doctor or other prescriber may give us additional information to support your appeal. The following criteria must also be met as described in the NCD: Non-Covered Use: In some cases, IEHP is your medical group or IPA. An interventional echocardiographer must perform transesophageal echocardiography during the procedure.>. IEHP DualChoice network providers are required to comply with minimum standards for pharmacy practices as established by the State of California. H8894_DSNP_23_3241532_M. Hepatitis B Virus (HBV) is transmitted by exposure to bodily fluids. You must apply for an IMR within 6 months after we send you a written decision about your appeal. Please see below for more information. app today. Vision Care: $350 limit every year for contact lenses and eyeglasses (frames and lenses). For more information on Grievances see Chapter 9 of your IEHP DualChoice Member Handbook. Beneficiaries must be managed by a team of medical professionals meeting the minimum requirements in the National Coverage Determination Manual. Advance care planning (ACP) involves shared decision making to write down-in an advance care directive-a persons wishes about their future medical care. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug. We must respond whether we agree with the complaint or not. Your PCP, along with the medical group or IPA, provides your medical care. 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. Information on procedures for obtaining prior authorization of services, Quality Assurance, disenrollment, and other procedures affecting IEHP DualChoice Members. 1. Usually, your prescription drugs are only covered if they are filled at a network pharmacy including through our mail-order pharmacy services. This additional time will allow you to correct your eligibility information if you believe that you are still eligible. Learn about your health needs and leading a healthy lifestyle. Concurrent with Carotid Stent Placement in FDA-Approved Post-Approvals Studies The time of need is indicated when the presumption of oxygen therapy within the home setting will improve the patients condition. We must give you our answer within 30 calendar days after we get your appeal. 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. Box 1800 TTY users should call (800) 718-4347. 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. (Implementation Date: October 8, 2021) (800) 440-4347 Get a 31-day supply of the drug before the change to the Drug List is made, or. If the dollar value of the drug coverage you want meets a certain minimum amount, you can make another appeal at Level 3. P.O. If you have a fast complaint, it means we will give you an answer within 24 hours. 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. Here are two ways to get information directly from Medicare: By clicking on this link, you will be leaving the IEHP DualChoice website. When your PCP thinks that you need specialized treatment or supplies, your PCP will need to get prior authorization (i.e., prior approval) from your Plan and/or medical group. (Effective: April 7, 2022) We check to see if we were following all the rules when we said No to your request. (SeeChapter 10 ofthe. From time to time (during the benefit year), IEHP DualChoice revises (adding or removing drugs) the Formulary based on new clinical evidence and availability of products in the market.

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