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. You can also call if you want to give us more information about a request for payment you have already sent to us. This section is about asking for coverage decisions and making appeals with problems related to your benefits and coverage. To learn how to submit a paper claim, please refer to the paper claims process described below. Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). The Independent Review Entity is an independent organization that is hired by Medicare. 2023 Plan Benefits. If you no longer qualify for Medi-Cal or your circumstances have changed that make you no longer eligible for Dual Special Needs Plan, you may continue to get your benefits from IEHP DualChoice for an additional two-month period. Sacramento, CA 95899-7413. 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. Level 2 Appeal for Part D drugs. Infected individuals may develop symptoms such as nausea, anorexia, fatigue, fever, and abdominal pain, or may be asymptomatic. If you miss the deadline for a good reason, you may still appeal. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. The Office of Ombudsman is not connected with us or with any insurance company or health plan. If you need a response faster because of your health, you should ask us to make a fast coverage decision. If we approve the request, we will notify you of our coverage decision coverage decision within 72 hours. If our answer is No to part or all of what you asked for, we will send you a letter. We do not allow our network providers to bill you for covered services and items. 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. 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. This is called upholding the decision. It is also called turning down your appeal. The clinical research must evaluate the required twelve questions in this determination. Concurrent with Carotid Stent Placement in Patients at High Risk for Carotid Endarterectomy (CEA) Information on this page is current as of October 01, 2022. Click here for more information on Ventricular Assist Devices (VADs) coverage. IEHP DualChoice is for people with both Medicare (Part A and B) and Medi-Cal. A PCP is your Primary Care Provider. We will see if the service or item you paid for is a covered service or item, and we will check to see if you followed all the rules for using your coverage. If you miss this deadline and have a good reason for missing it, we may give you more time to make you appeal. When that happens, we may remove the current drug, but your cost for the new drug will stay the same or will be lower. IEHP DualChoice recognizes your dignity and right to privacy. If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. Information on this page is current as of October 01, 2022. 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. 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. Click here for more information on Topical Applications of Oxygen. Fax: (909) 890-5877. 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. Ask within 60 days of the decision you are appealing. 2. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. 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. A new generic drug becomes available. Who is covered: Members must meet all of the following eligibility criteria: Click here for more information on LDCT coverage. 1. If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. If a drug you are taking will be taken off the Drug List or limited in some way for next year, we will allow you to ask for an exception before next year. 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. Receive information about your rights and responsibilities as an IEHP DualChoice Member. You can send your complaint to Medicare. When will I hear about a standard appeal decision for Part C services? These forms are also available on the CMS website: Medicare Prescription Drug Determination Request Form (for use by enrollees and providers), Deadlines for a standard coverage decision about a drug you have not yet received, If our answer is Yes to part or all of what you asked for, we must approve or give the coverage within 72 hours after we get your request or, if you are asking for an exception, your doctors or prescribers supporting statement. Most recently, as of May 1, 2016, Medi-Cal now covers all low income children under the age of 19, regardless of immigration status. In these situations, please check first with IEHP DualChoice Member Services to see if there is a network pharmacy nearby. Yes, you and your doctor may give us more information to support your appeal. With IEHP DualChoice, you will still have an IEHP DualChoice Member Service team to get help for your needs. Interventional echocardiographer meeting the requirements listed in the determination. 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. The State or Medicare may disenroll you if you are determined no longer eligible to the program. 10820 Guilford Road, Suite 202 For more information on Medical Nutrition Therapy (MNT) coverage click here. If possible, we will answer you right away. Opportunities to Grow. All physicians participating in the procedure must have device-specific training by the manufacturer of the device. 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. (Effective: January 27, 20) You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function. and hickory trees (Carya spp.) The Centers for Medicare and Medical Services (CMS) has determined the following services to be necessary for the treatment of an illness or injury. You might leave our plan because you have decided that you want to leave. The counselors at this program can help you understand which process you should use to handle a problem you are having. The FDA provides new guidance or there are new clinical guidelines about a drug. Yes. Advance care planning (ACP) involves shared decision making to write down-in an advance care directive-a persons wishes about their future medical care. The organization will send you a letter explaining its decision. You can switch yourDoctor (and hospital) for any reason (once per month). We will use the standard deadlines unless we have agreed to use the fast deadlines., You can get a fast coverage decision only if you are asking for a drug you have not yet received. Please see below for more information. You can ask us for a standard appeal or a fast appeal.. To stay a member of IEHP DualChoice, you must qualify again by the last day of the two-month period. (Effective: February 10, 2022) You can ask us to reimburse you for IEHP DualChoice's share of the cost. TTY should call (800) 718-4347. 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. Will not cover an experimental or investigational Medi-Cal treatment for a serious medical condition. More . Our service area includes all of Riverside and San Bernardino counties. How will the plan make the appeal decision? If the State Hearing decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. Click here to download a free copy by clicking Adobe Acrobat Reader. What if you are outside the plans service area when you have an urgent need for care? CAR, when all the following requirements are met: Autologous treatment is for cancer with T-cells expressing at least one chimeric antigen receptor (CAR); and, Treatment is administered at a healthcare facility enrolled in the FDAs REMS; and. You must make the request on or before the later of the following in order to continue your benefits: If you meet this deadline, you can keep getting the disputed service or item while your appeal is processing. You will be notified when this happens. Medicare beneficiaries in need of a pacemaker who are participating in an approved clinical study. Benefits and copayments may change on January 1 of each year. 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. It tells which Part D prescription drugs are covered by IEHP DualChoice. 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. No-cost or low-cost health care coverage for low-income adults, families with children, seniors, and people with disabilities. Click here to learn more about IEHP DualChoice. (Effective: August 7, 2019) Treatment for patients with existing co-morbidities that would preclude the benefit from the procedure. The device must be approved by the Food and Drug Administration (FDA) for this purpose; OR. Which Pharmacies Does IEHP DualChoice Contract With? (Effective: February 15. Receive services without regard to race, ethnicity, national origin, religion, sex, age, mental or physical disability or medical condition, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), disability, genetic information, or source of payment. You will get a letter from us about the change in your eligibility with instructions to correct your eligibility information. The Difference Between ICD-10-CM & ICD-10-PCS. All Medicare covered services, doctors, hospitals, labs, and x-rays, You will have access to a Provider network that includes many of the same Providers as your current plan, Coordination of the services you get now or that you might need, Personal history of sustained VT or cardiac arrest due to Ventricular Fibrillation (VF), Prior Myocardial Infarction (MI) and measured Left Ventricular Ejection Fraction (LVEF) less than or equal to .03, Severe, ischemic, dilated cardiomyopathy without history of sustained VT or cardiac arrest due to VF, and have New York Heart Association (NYHA) Class II or III heart failure with a LVEF less than or equal to 35%, Severe, non-ischemic, dilated cardiomyopathy without history of cardiac arrest or sustained VT, NYHA Class II or II heart failure, LVEF less than or equal for 35%, and utilization of optimal medical therapy for at a minimum of three (3) months, Documented, familial or genetic disorders with a high risk of life-threating tachyarrhythmias, but not limited to long QT syndrome or hypertrophic cardiomyopathy, Existing ICD requiring replacement due to battery life, Elective Replacement Indicator (ERI), or malfunction, The procedure is performed in a Clinical Laboratory Improvement Act (CLIA)-certified laboratory. The benefit information is a brief summary, not a complete description of benefits. Here are two ways to get information directly from Medicare: By clicking on this link, you will be leaving the IEHP DualChoice website. 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. Terminal illnesses, unless it affects the patients ability to breathe. What is covered: TTY/TDD (877) 486-2048. The clinical research study must meet the standards of scientific integrity and relevance to the Medicare population described in this determination. iii. If we say No to your appeal, you then choose whether to accept this decision or continue by making another appeal. If the IMR is decided in your favor, we must give you the service or item you requested. Getting plan approval before we will agree to cover the drug for you. (Effective: January 18, 2017) If we uphold the denial after Redetermination, you have the right to request a Reconsideration. 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. 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. Click here for more detailed information on PTA coverage. 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. 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. You must ask to be disenrolled from IEHP DualChoice. All have different pros and cons. Ask for an exception from these changes. Beneficiaries must be managed by a team of medical professionals meeting the minimum requirements in the National Coverage Determination Manual. If you wish, you and your doctor or other prescriber may give us additional information to support your appeal. Call IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Receive information about clinical programs, including staff qualifications, request a change of treatment choices, participate in decisions about your health care, and be informed of health care issues that require self-management. 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). In this situation (when you are outside the service area and cannot get care from a network provider), our plan will cover urgently needed care that you get from any provider. To learn how to name your representative, you may call IEHP DualChoice Member Services. You ask us to pay for a prescription drug you already bought. 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 has approved the IEHP DualChoice Formulary. (888) 244-4347 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. If you are hospitalized on the day that your membership ends, you will usually be covered by our plan until you are discharged (even if you are discharged after your new health coverage begins). The procedure must be performed in a hospital with infrastructure and experience meeting the requirements in this determination. This includes denial of payment for a service after the service has been rendered (post-service) or denial of service prior to the service being rendered (pre-service). 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. The MAC may also approve the use of portable oxygen systems to beneficiaries who are mobile in home and benefit from of this unit alone, or in conjunction to a stationary oxygen system. If the answer is No, we will send you a letter telling you our reasons for saying No. At Level 2, an outside independent organization will review your request and our decision. Has not resolved your Level 1 Appeal on a Medi-Cal service within 30 calendar days for a standard appeal or 72 hours for a fast appeal. b. This is not a complete list. 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. Welcome to Inland Empire Health Plan \ Members \ Medi-Cal California Medical Insurance Requirements; main content TIER3 SUBLAYOUT. When possible, take along all the medication you will need. 3. disease); An additional 8 sessions will be covered for those patients demonstrating an improvement. You may be able to get extra help to pay for your prescription drug premiums and costs. To ask if your PCP or other providers are in our network in 2023, call IEHP DualChoice Member Services. The patient is under the care of a heart team, which consists of a cardiac surgeon, interventional cardiologist, and various Providers, nurses, and research personnel, The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the related aspects of TAVR, The hospital where the TAVR is complete must have various qualifications and implemented programs. 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. If you move out of our service area for more than six months. Call at least 5 days before your appointment. You must ask for an appeal within 60 calendar days from the date on the letter we sent to tell you our decision. We will tell you about any change in the coverage for your drug for next year. Oxygen therapy can be renewed by the MAC if deemed medically necessary. Group I: We take a careful look at all of the information about your request for coverage of medical care. If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we get your appeal. You have a right to appeal or ask for Formulary exception if you disagree with the information provided by the pharmacist. You can ask for an Independent Medical Review (IMR) from the Help Center at the California Department of Managed Health Care (DMHC). 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. Important things to know about asking for exceptions. You may be able to order your prescription drugs ahead of time through our network mail order pharmacy service or through a retail network pharmacy that offers an extended supply. 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. By clicking on this link, you will be leaving the IEHP DualChoice website. Usually, your prescription drugs are only covered if they are filled at a network pharmacy including through our mail-order pharmacy 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 with either a renal disease or diabetes diagnosis as defined in 42 CFR 410.130. 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 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. The DMHC may accept your application after 6 months if it determines that circumstances kept you from submitting your application in time. When you are discharged from the hospital, you will return to your PCP for your health care needs. If your Level 2 Appeal was an Independent Medical Review, the Department of Managed Health Care will send you a letter explaining its decision. 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. 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. Limitations, copays, and restrictions may apply. How will you find out if your drugs coverage has been changed? 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. Patients demonstrating arterial PO2 between 56-59 mm Hg, or whos arterial blood oxygen saturation is 89%, with any of the following condition: You can tell Medicare about your complaint. Receive emergency care whenever and wherever you need it. You can also visit https://www.hhs.gov/ocr/index.html for more information. When you are following these instructions, please note: If we answer no to your appeal and the service or item is usually covered by Medicare, we will automatically send your case to the Independent Review Entity. 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. Who is covered: Medicare beneficiaries will have their blood-based colorectal cancer screening test covered once every 3 years when ordered by a treating physician and the following conditions are met: (Effective: December 1, 2020) The PCP you choose can only admit you to certain hospitals. 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. For example, you can ask us to cover a drug even though it is not on the Drug List. Please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. You can also visit, You can make your complaint to the Quality Improvement Organization. See plan Providers, get covered services, and get your prescription filled timely. (Effective: February 19, 2019) 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: We may contact you or your doctor or other prescriber to get more information. 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. For example, you can make a complaint about disability access or language assistance. Inland Empire Health Plan (IEHP) has over 1,234 Doctors, 3,676 Specialists, 724 Pharmacies, 74 Urgent Care, 243 OB/GYNs, 383 Behavioral Health Providers, 40 major Hospitals, and 313 Vision doctors in Riverside and San Bernardino counties. An interventional echocardiographer must perform transesophageal echocardiography during the procedure. A standard coverage decision means we will give you an answer within 72 hours after we get your doctors statement. Who is covered? If the DMHC decides that your case is not eligible for IMR, the DMHC will review your case through its regular consumer complaint process. (Implementation date: June 27, 2017). Calls to this number are free. Click here to download a free copy of Adobe Acrobat Reader.By clicking on this link, you will be leaving the IEHP DualChoice website. wounds affecting the skin. P.O. You can call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. This service will be covered when the TAVR is used for the treatment of symptomatic aortic valve stenosis according to the FDA-approved indications and the following conditions are met: This service will be covered when the TAVR is not expressly listed as an FDA-approved indication, but when performed within a clinical study and the following conditions are met: Click here for more information on NGS coverage. For more information on Grievances see Chapter 9 of your IEHP DualChoice Member Handbook. ii. Upon expiration, coverage will be determined by the local Medicare Administrative Contractors (MACs). After your coverage begins with IEHP DualChoice, you must receive medical services and prescription drug services in the IEHP DualChoice network. An annual screening for lung cancer with LDCT will be available if specific eligibility criteria are met. (800) 720-4347 (TTY). (Implementation Date: February 19, 2019) For more information visit the. When we send the payment, its the same as saying Yes to your request for a coverage decision. Here are examples of coverage determination you can ask us to make about your Part D drugs. Certain combinations of drugs that could harm you if taken at the same time. You can call (800) MEDICARE (800) 633-4227, 24 hours a day, 7 days a week, TTY (877) 486-2048. The services of SHIP counselors are free. Ask for the type of coverage decision you want. 1. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drugs manufacturer takes a drug off the market, we will take it off the Drug List. 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. If you believe we should not take extra days, you can file a fast complaint about our decision to take extra days. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you. If you are asking for a standard appeal, you can make your appeal by sending a request in writing. If we do not agree with some or all of your complaint or dont take responsibility for the problem you are complaining about, we will let you know. All screenings DNA tests, effective April 28, 2008, through October 8, 2014. We will also use the standard 14 calendar day deadline instead. Topical Application of Oxygen for Chronic Wound Care. Transportation: $0. CMS approved studies must also adhere to the standards of scientific integrity that have been identified in section 5 of this NCD by the Agency for Healthcare Research and Quality (AHRQ). (Effective: June 21, 2019) Within 10 days of the mailing date of our notice of action; or. 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.