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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: Click here for more information on acupuncture for chronic low back pain coverage. Unless you change plans, IEHP DualChoice (HMO D-SNP) will provide your Medicare benefits. Call IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Noncoverage specifically includes the following: Click here for more information on Ambulatory Electroencephalographic Monitoring and Colorectal Cancer Screening Tests. IEHP DualChoice Fax: (909) 890-5877. (866) 294-4347 If you call us with a complaint, we may be able to give you an answer on the same phone call. Be under the direct supervision of a physician. With IEHP DualChoice, you will still have an IEHP DualChoice Member Service team to get help for your needs. Medicare beneficiaries who meet either of the following criteria: Click here for more information on HBV Screenings. Now, the NCD will cover PILD for LSS under both RCT and longitudinal studies. Yes. This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision. Topical Application of Oxygen for Chronic Wound Care. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. The list must meet requirements set by Medicare. Both of these processes have been approved by Medicare. Usually, your prescription drugs are only covered if they are filled at a network pharmacy including through our mail-order pharmacy services. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. If the review organization agrees to give you a fast appeal, it must give you an answer to your Level 2 Appeal within 72 hours after getting your appeal request. when beneficiaries are suspected of having white coat hypertension or masked hypertension in addition to the coverage criteria outlined in the, Ambulatory Blood Pressure Monitoring (ABPM), for the diagnosis of hypertension when either there is suspected white coat or masked hypertension. This government program has trained counselors in every state. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. Also, its possible that your PCP might leave our plans network of providers and you would have to find a new PCP. Because you are eligible for Medi-Cal, you qualify for and are getting Extra Help from Medicare to pay for your prescription drug plan costs. 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. Because you get assistance from Medi-Cal, you can end your membership in IEHPDualChoice at any time. TTY users should call (800) 718-4347. IEHP DualChoice Becaplermin, a non-autologous growth factor for chronic, non-healing, subcutaneous (beneath the skin) wounds, and. b. 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. If you have questions, you can contact IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. chimeric antigen receptor (CAR) T-cell therapy coverage. If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will use the standard deadlines instead. The phone number for the Office for Civil Rights is (800) 368-1019. What is covered: Welcome to Inland Empire Health Plan \ Members \ Medi-Cal California Medical Insurance Requirements; main content TIER3 SUBLAYOUT. The treatment is considered reasonably likely to predict a clinical benefit and is administrated in a randomized controlled trial under an investigational new drug application. Visit the Department of Managed Health Care's website: You can make a complaint to the Department of Health and Human Services Office for Civil Rights if you think you have not been treated fairly. If you disagree with our decision, you can ask the DMHC Help Center for an IMR. My problem is about a Medi-Cal service or item. This service will be covered when the Ambulatory Blood Pressure Monitoring (ABPM) is used for the diagnosis of hypertension when either there is suspected white coat or masked hypertension and the following conditions are met: Coverage of other indications for ABPM is at the discretion of the Medicare Administrative Contractors. Study data for CMS-approved prospective comparative studies may be collected in a registry. The screen test must have all the following: Food and Drug Administration (FDA) market authorization with an indication for colorectal cancer screening; and. Click here for more information on Cochlear Implantation. 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. The Independent Review Entity is an independent organization that is hired by Medicare. Drugs that may not be necessary because you are taking another drug to treat the same medical condition. 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. 1501 Capitol Ave., We will contact the provider directly and take care of the problem. We determine an existing relationship by reviewing your available health information available or information you give us. You cannot make this request for providers of DME, transportation or other ancillary providers. If the answer to your appeal is Yes at any stage of the appeals process after Level 2, we must send the payment you asked for to you or to the provider within 60 calendar days. a. 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 your health requires it, ask the Independent Review Entity for a fast appeal.. 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. Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plans service area. IEHP DualChoice will give notice to IEHPDualChoice Members prior to removing Part D drug from the Part D formulary. You will need Adobe Acrobat Reader6.0 or later to view the PDF files. 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. 2) State Hearing Advance care planning (ACP) involves shared decision making to write down-in an advance care directive-a persons wishes about their future medical care. To learn how to submit a paper claim, please refer to the paper claims process described below. Prior to the beneficiarys first lung cancer LDCT screening, the beneficiary must receive a counseling and shared decision-making visit that meets specific criteria. All the changes are reviewed and approved by a selected group of Providers and Pharmacists that are currently in practice. effort to participate in the health care programs IEHP DualChoice offers you. We will let you know of this change right away. H5355_CMC_22_2746205Accepted, (Effective: September 27, 2021) There are two ways to ask for a State Hearing: If you meet this deadline, you can keep getting the disputed service or item until the hearing decision is made. 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.) You can switch yourDoctor (and hospital) for any reason (once per month). (Effective: January 1, 2023) Please see below for more information. Ask for an exception from these changes. You may also ask for an appeal by calling IEHP DualChoice Member Services at 1-877-273-IEHP (4347), 8am 8pm (PST), 7 days a week, including holidays. Our plan cannot cover a drug purchased outside the United States and its territories. Will not pay for emergency or urgent Medi-Cal services that you already received. If you prefer a different one, please call IEHP DualChoice Member Services and we can assist you in finding and selecting another provider. You do not need to do anything further to get this Extra Help. You may also have rights under the Americans with Disability Act. TTY/TDD users should call 1-800-430-7077. For example, you can make a complaint about disability access or language assistance. ICDs will be covered for the following patient indications: Please refer to section 20.4 of the NCD Manual for additional coverage criteria. You dont have to do anything if you want to join this plan. What is covered: Effective for dates of service on or after April 13, 2021, CMS has updated section 270.3 of the National Coverage Determination Manual to cover Autologous (obtained from the same person) Platelet-Rich Plasma (PRP) when specific requirements are met. If the Independent Medical Review decision is Yes to part or all of what you asked for, we must provide the service or treatment. Note: You can only make this request for services of Durable Medical Equipment (DME), transportation, or other ancillary services not included in our plan. i. Erythrocythemia (increased red blood cells) with a hematocrit greater than 56%. The benefit information is a brief summary, not a complete description of benefits. We take another careful look at all of the information about your coverage request. To learn how to submit a paper claim, please refer to the paper claims process described below. You pay no costs for an IMR. 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. Beneficiaries who meet the coverage criteria, if determined eligible. You should not pay the bill yourself. 1. What is covered: It has been concluded that high-quality research illustrates the effectiveness of SET over more invasive treatment options and beneficiaries who are suffering from Intermittent Claudication (a common symptom of PAD) are now entitled to an initial treatment. At IEHP, you will find opportunities to take initiative, expand your knowledge and advance your career while working a position that's both challenging and rewarding. 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. Note, the Member must be active with IEHP Direct on the date the services are performed. 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. 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. Effective for dates of service on or after October 9, 2014, all other screening sDNA tests not otherwise specified above remain nationally non-covered. 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. (Effective: December 15, 2017) Calls to this number are free. IEHP DualChoice is for people with both Medicare (Part A and B) and Medi-Cal. 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. Consist of 30-60 minute sessions comprising of therapeutic exercise-training program for PAD; Be conducted in a hospital outpatient setting or physicians office; Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD; and. This letter will tell you if the service or item is usually covered by Medicare or Medi-Cal. If possible, we will answer you right away. Click here for more information on Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). We will let you know of this change right away. Receive information about IEHP DualChoice, its programs and services, its Doctors, Providers, health care facilities, and your drug coverage and costs, which you can understand. 2. Oncologists care for patients with cancer. Removing a restriction on our coverage. Current or lifetime history of psychotic features in any MDE; Current or lifetime history of schizophrenia or schizoaffective disorder; Current or lifetime history of any other psychotic disorder; Current or lifetime history of rapid cycling bipolar disorder; Current secondary diagnosis of delirium, dementia, amnesia, or other cognitive disorder; Treatment with another investigational device or investigational drugs. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision. =========== TABBED SINGLE CONTENT GENERAL. 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. We do not allow our network providers to bill you for covered services and items. 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. You can file a grievance online. While the taste of the black walnut is a culinary treat the . 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. You can ask for an Independent Medical Review (IMR) from the Help Center at the California Department of Managed Health Care (DMHC). Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. 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. Making an appeal means asking us to review our decision to deny coverage. IEHP Medi-Cal Member Services 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. For more information on Grievances see Chapter 9 of your IEHP DualChoice Member Handbook. (877) 273-4347 Previous Next ===== TABBED SINGLE CONTENT GENERAL. If you ask for a fast coverage decision on your own (without your doctors or other prescribers support), we will decide whether you get a fast coverage decision. Your benefits as a member of our plan include coverage for many prescription drugs. Your membership will usually end on the first day of the month after we receive your request to change plans. If you decide to ask for a State Hearing by phone, you should be aware that the phone lines are very busy. IEHP Direct contracted PCPs who provide service to IEHP Direct DualChoice Members. The Help Center cannot return any documents. Our state has an organization called Livanta Beneficiary & Family Centered Care (BFCC) Quality Improvement Organization (QIO). (888) 244-4347 (Implementation Date: June 16, 2020). However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. 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. Including bus pass. To learn more about your prescription drug costs, call IEHP DualChoice Member Services. PO2 may be performed by the treating practitioner or by a qualified provider or supplier of laboratory services. Your test results are shared with all of your doctors and other providers, as appropriate. We must give you our answer within 30 calendar days after we get your appeal. We will give you our answer sooner if your health requires it. 2023 Plan Benefits. With a network of more than 6,000 Providers and 2,000 Team Members, we provide . You may use the following form to submit an appeal: Can someone else make the appeal for me? The phone number for the Office of the Ombudsman is 1-888-452-8609. Send copies of documents, not originals. your medical care and prescription drugs through our plan. When will I hear about a standard appeal decision for Part C services? (Implementation Date: July 5, 2022). If this happens, you will have to switch to another provider who is part of our Plan. A care team can help you. This person will also refer you to community resources, if IEHP DualChoice does not provide the services that you need. The DMHC may waive the requirement that you first follow our appeal process in extraordinary and compelling cases. A Level 1 Appeal is the first appeal to our plan. A care team may include your doctor, a care coordinator, or other health person that you choose. What if the plan says they will not pay? Group I: 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. 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. iv. Black Walnuts on the other hand have a bolder, earthier flavor. 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. The patient is experiencing a major depressive episode, as measured by a guideline recommended depression scale assessment tool on two visits, within a 45-day span prior to implantation of the VNS device. The clinical research study must meet the standards of scientific integrity and relevance to the Medicare population described in this determination. To find the name, address, and phone number of the Quality Improvement Organization in your state, lookin Chapter 2 of your. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Make your appeal request within 60 calendar days from the date on the notice we sent to tell you our decision. If an alternative drug would be just as effective as the drug you are asking for, and would not cause more side effects or other health problems, we will generally not approve your request for an exception. This is called a referral. Use the IEHP Medicare Prescription Drug Coverage Determination Form for a prior authorization. CMS has updated Chapter 1, section 20.19 of the Medicare National Coverage Determinations Manual. You have the right to ask us for a copy of the information about your appeal. (Implementation Date: October 3, 2022) Ask for the type of coverage decision you want. This form is for IEHP DualChoice as well as other IEHP programs. Facilities must be credentialed by a CMS approved organization. To learn more about asking for exceptions, see Chapter 9 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]). 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. How will you find out if your drugs coverage has been changed? 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. If the IRE reverses our decision and says we should pay you, we must send the payment to you or to the provider within 30 calendar days. The Medicare Complaint Form is available at:https://www.medicare.gov/MedicareComplaintForm/home.aspx. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period. You can get services such as those listed below without getting approval in advance from your Primary Care Provider (PCP). IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Angina pectoris (chest pain) in the absence of hypoxemia; or. Concurrent with Carotid Stent Placement in Food and Drug Administration (FDA) Approved Category B Investigational Device Exemption (IDE) Clinical Trials Information on procedures for obtaining prior authorization of services, Quality Assurance, disenrollment, and other procedures affecting IEHP DualChoice Members. Unleashing our creativity and courage to improve health & well-being. 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. 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. (Effective: May 25, 2017) 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. Your doctor or other provider can make the appeal for you. This is asking for a coverage determination about payment. This is not a complete list. Livanta BFCC-QIO Program Information on this page is current as of October 01, 2022. You, your doctor or other prescriber, or your representative can request the Level 2 Appeal. What is covered: Mail your request for payment together with any bills or receipts to us at this address: IEHPDualChoice We will say Yes or No to your request for an exception. The program is not connected with us or with any insurance company or health plan. Call IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. In most cases you have 120 days to ask for a State Hearing after the Your Hearing Rights notice is mailed to you. (This is sometimes called step therapy.). If you need to change your PCP for any reason, your hospital and specialist may also change. Explore Opportunities. If the dollar value of the drug coverage you want meets a certain minimum amount, you can make another appeal at Level 3. 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. Level 2 Appeal for Part D drugs. We have 30 days to respond to your request. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. If you need help during the appeals process, you can call the Office of the Ombudsman at 1-888-452-8609. The extra rules and restrictions on coverage for certain drugs include: Being required to use the generic version of a drug instead of the brand name drug. Bringing focus and accountability to our work. Inform your Doctor about your medical condition, and concerns. Members \. 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? (Implementation Date: October 4, 2021). You have the right to ask us for a copy of your case file. You will keep all of your Medicare and Medi-Cal benefits. H8894_DSNP_23_3241532_M. For example: We may make other changes that affect the drugs you take. IEHP: "Inland Empire Health Plan (IEHP) is a not-for-profit Medi-Cal and Medicare health plan headquartered in Rancho Cucamonga, California. The person you name would be your representative. You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Hepatitis B Virus (HBV) is transmitted by exposure to bodily fluids. No more than 20 acupuncture treatments may be administered annually. Your PCP will also help you arrange or coordinate the rest of the covered services you get as a member of our Plan. Related Resources. (SeeChapter 10 oftheIEHP DualChoiceMember Handbookfor information on when your new coverage begins.) Calls to this number are free. You can tell Medicare about your complaint. Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. My Choice. During these events, supplemental oxygen is provided during exercise, if the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air.