Flu shots as long as you get them from a network provider. The letter will tell you how to do this. These different possibilities are called alternative drugs. For example, you can ask us to cover a drug even though it is not on the Drug List. 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). (877) 273-4347 Interventional echocardiographer meeting the requirements listed in the determination. We have arranged for these providers to deliver covered services to members in our plan. Yes. It tells which Part D prescription drugs are covered by IEHP DualChoice. The NCR serves as a liaison for matters involving the contract between IEHP and both Network and Non-Network Providers. The Centers for Medicare and Medical Services (CMS) has determined the following services to be necessary for the treatment of an illness or injury. Who is covered: Members must meet all of the following eligibility criteria: Click here for more information on LDCT coverage. If we decide to take extra days to make the decision, we will tell you by letter. Your doctor or other provider can make the appeal for you. The Centers of Medicare and Medicaid Services (CMS) will cover Vagus Nerve Stimulation (VNS) for treatment-resistant depression when specific requirements are met. This is called prior authorization. Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. The phone number is (888) 452-8609. The removal of these elements eliminates an important source of complications associated with traditional pacing systems while providing similar benefits. The USPTF has found that screening for HBV allows for early intervention which can help decrease disease acquisition, transmission and, through treatment, improve intermediate outcomes for those infected. At Level 2, an Independent Review Entity will review our decision. No-cost or low-cost health care coverage for low-income adults, families with children, seniors, and people with disabilities. What if the Independent Review Entity says No to your Level 2 Appeal? Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). IEHP DualChoice (HMO D-SNP) has a process in place to identify and reduce medication errors. This additional time will allow you to correct your eligibility information if you believe that you are still eligible. (If possible, please call IEHP DualChoice Member Services before you leave the service area so we can help arrange for you to have maintenance dialysis while you are away.). Topical Application of Oxygen for Chronic Wound Care. If your PCP leaves our Plan, we will let you know and help you choose another PCP so that you can keep getting covered services. P.O. With a network of more than 6,000 Providers and 2,000 Team Members, we provide . When you are discharged from the hospital, you will return to your PCP for your health care needs. This means within 24 hours after we get your request. Disrespect, poor customer service, or other negative behaviors, Timeliness of our actions related to coverage decisions or appeals, You can use our "Member Appeal and Grievance Form." Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities; or. We will review our coverage decision to see if it is correct. (Implementation Date: February 19, 2019) The FDA provides new guidance or there are new clinical guidelines about a drug. (This is sometimes called prior authorization.), Being required to try a different drug first before we will agree to cover the drug you are asking for. You will not have a gap in your coverage. You will usually see your PCP first for most of your routine health care needs. Change the coverage rules or limits for the brand name drug. 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. Within 10 days of the mailing date of our notice of action; or. MRI field strength of 1.5 Tesla using Normal Operating Mode, The Implanted pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy defibrillator (CRT-D) system has no fractured, epicardial, or abandoned leads, The facility has implemented a specific checklist. Organized as a Joint Powers Agency, Inland Empire Health Plan (IEHP) is a local, not-for-profit, public health plan. If you have questions, you can contact IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Click here for more information on ambulatory blood pressure monitoring coverage. Portable oxygen would not be covered. (Implementation Date: July 5, 2022). The device must be approved by the Food and Drug Administration (FDA) for this purpose; OR. When your complaint is about quality of care. How do I make a Level 1 Appeal for Part C services? If you disagree with the action, you can file a Level 1 Appeal and ask that we continue your benefits for the service or item. Can I get a coverage decision faster for Part C services? Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. If you are under a Doctors care for an acute condition, serious chronic condition, pregnancy, terminal illness, newborn care, or a scheduled surgery, you may ask to continue seeing your current Doctor. Level 2 Appeal for Part D drugs. You will be notified when this happens. Effective on September 26, 2022, CMS has updated section 50.3 of the National Coverage Determination (NCD) Manual that expands coverage on cochlear implants for the treatment of bilateral pre- or post- linguistic, sensorineural, moderate-to-profound hearing loss when the individual demonstrates limited benefit from amplification under Medicare Part B. If your health requires it, ask the Independent Review Entity for a fast appeal.. P.O. Make your appeal request within 60 calendar days from the date on the notice we sent to tell you our decision. What is covered? If the answer is No, we will send you a letter telling you our reasons for saying No. You can file a fast complaint and get a response to your complaint within 24 hours. (Implementation Date: June 12, 2020). Patients demonstrating arterial PO2 between 56-59 mm Hg, or whos arterial blood oxygen saturation is 89%, with any of the following condition: We will give you our answer sooner if your health requires us to do so. IEHP DualChoice network providers are required to comply with minimum standards for pharmacy practices as established by the State of California. Then, we check to see if we were following all the rules when we said No to your request. You may change your PCP for any reason, at any time. Previous Next ===== TABBED SINGLE CONTENT GENERAL. If you want the Independent Review Organization to review your case, your appeal request must be in writing. They also have thinner, easier-to-crack shells. Who is covered? Receive emergency care whenever and wherever you need it. Our plan cannot cover a drug purchased outside the United States and its territories. You can always contact your State Health Insurance Assistance Program (SHIP). The Office of Ombudsman is not connected with us or with any insurance company or health plan. You can ask for an Independent Medical Review (IMR) from the Help Center at the California Department of Managed Health Care (DMHC). Some changes to the Drug List will happen immediately. Yes. Beneficiaries not meeting all the criteria for cochlear implants are deemed not eligible for Medicare coverage except for FDA-approved clinical trials as described in the NCD. TTY users should call (800) 718-4347. If our answer is No to part or all of what you asked for, we will send you a letter. (Effective: September 28, 2016) We must give you our answer within 30 calendar days after we get your appeal. In most cases you have 120 days to ask for a State Hearing after the Your Hearing Rights notice is mailed to you. 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. Walnut trees (Juglans spp.) To learn how to submit a paper claim, please refer to the paper claims process described below. chimeric antigen receptor (CAR) T-cell therapy coverage. 1501 Capitol Ave., 2020) 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.) to part or all of what you asked for, we will make payment to you within 14 calendar days. If your health condition requires us to answer quickly, we will do that. You will be notified when this happens. If the DMHC decides that your case is not eligible for IMR, the DMHC will review your case through its regular consumer complaint process. 2. 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 have a right to give the Independent Review Entity other information to support your appeal. 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. according to the FDA-approved indications and the following conditions are met: The procedure and implantation system received FDA premarket approval (PMA) for that system's FDA approved indication. Click here for more information on Cochlear Implantation. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. 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 National Coverage Determination Manual. How to obtain an aggregate number of grievances, appeals, and exceptions filed with IEHP DualChoice (HMO D-SNP)? The form gives the other person permission to act for you. If you have Medi-Cal with IEHP and would like information on how to pursue appeals and grievances related to Medi-Cal covered services, please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), TTY (800) 718-4347, 8am - 8pm (PST), 7 days a week, including holidays. It also includes problems with payment. We will send you your ID Card with your PCPs information. TTY: 1-800-718-4347. An annual screening for lung cancer with LDCT will be available if specific eligibility criteria are met. Possible errors in the amount (dosage) or duration of a drug you are taking. Your provider will also know about this change. If you are unable to get a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service. Prescriptions written for drugs that have ingredients you are allergic to. If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. Tier 1 drugs are: generic, brand and biosimilar drugs. TTY users should call (800) 537-7697. 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. You will be automatically disenrolled from IEHPDualChoice, when your new plans coverage begins. How to voluntarily end your membership in our plan? i. Off-label use is any use of the drug other than those indicated on a drugs label as approved by the Food and Drug Administration. The phone number for the Office of the Ombudsman is 1-888-452-8609. Sprint from Voice Telephone: (800) 877-5379, Visit: 10801 Sixth Street, Suite 120, Rancho Cucamonga, CA 91730. CMS has revised Chapter 1, Section 20.29, Subsection C Topical Application of Oxygen to remove the exclusion of this treatment. If our answer is No to part or all of what you asked for, we will send you a letter. Black Walnuts on the other hand have a bolder, earthier flavor. (This is called upholding the decision. It is also called turning down your appeal.) The letter you get will explain additional appeal rights you may have. 2023 Plan Benefits. Read Will my benefits continue during Level 2 appeals in Chapter 9 of the Member Handbook for more information. Call, write, or fax us to make your request. If we tell you after our review that the service or item is not covered, your case can go to a Level 2 Appeal. We will say Yes or No to your request for an exception. We will answer your request for an exception within 72 hours after we get your request (or your prescribers supporting statement). We establish that you had an existing relationship with a primary or specialty care provider, with some exceptions. Beneficiaries that demonstrate limited benefit from amplification. If you do not stay continuously enrolled in Medicare Part A and Part B. Yes, you and your doctor may give us more information to support your appeal. 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 is a person who works with you, with our plan, and with your care team to help make a care plan. For more information on Medical Nutrition Therapy (MNT) coverage click here. The Office of the Ombudsman. Facilities must be credentialed by a CMS approved organization. We also review our records on a regular basis. A new generic drug becomes available. The services of SHIP counselors are free. Your test results are shared with all of your doctors and other providers, as appropriate. Oncologists care for patients with cancer. Click here to download a free copy by clicking Adobe Acrobat Reader. https://www.medicare.gov/MedicareComplaintForm/home.aspx. Advance care planning (ACP) involves shared decision making to write down-in an advance care directive-a persons wishes about their future medical care. In the instance where there is not FDA labeling specific to use in an MRI environment, coverage is only provided under specific conditions including the following: Medicare beneficiaries with an Implanted pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy defibrillator (CRT-D). When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. When possible, take along all the medication you will need. During these reviews, we look for potential problems such as: If we see a possible problem in your use of medications, we will work with your Doctor to correct the problem. IEHP DualChoice Be informed regarding Advance Directives, Living Wills, and Power of Attorney, and to receive information regarding changes related to existing laws. ((Effective: December 7, 2016) All other indications for colorectal cancer screening not otherwise specified in the Social Security Act, regulations, or the above remain nationally non-covered. We may not tell you before we make this change, but we will send you information about the specific change or changes we made. . (Effective: July 2, 2019) Click here for more information on acupuncture for chronic low back pain coverage. You must qualify for this benefit. Be under the direct supervision of a physician. 504 Plan Defined The 504 Plan is a plan developed to ensure that a child who has a disability The letter will also explain how you can appeal our decision. The call is free. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. 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. H8894_DSNP_23_3879734_M Pending Accepted. This includes getting authorization to see specialists or medical services such as lab tests, x-rays, and/or hospital admittance. 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. To learn how to name your representative, you may call IEHP DualChoice Member Services. New to IEHP DualChoice. We will give you our answer sooner if your health requires us to. 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. 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. IEHP DualChoice Member Services can assist you in finding and selecting another provider. Can I ask for a coverage determination or make an appeal about Part D prescription drugs? A care coordinator is a person who is trained to help you manage the care you need. The PCP you choose can only admit you to certain hospitals. (Implementation Date: July 2, 2018). Pulmonary hypertension or cor pulmonale (high blood pressure in pulmonary arteries), determined by the measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVFL; or, Changing your Primary Care Provider (PCP). Drugs that may not be necessary because you are taking another drug to treat the same medical condition. TTY users should call (800) 537-7697. 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. (Effective: April 7, 2022) 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. You or your provider can ask for an exception from these changes. You and your provider can ask us to make an exception. This is not a complete list. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. For more information on Member Rights and Responsibilities refer to Chapter 8 of your. 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. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. 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. NOTE: If you ask for a State Hearing because we told you that a service you currently get will be changed or stopped, you have fewer days to submit your request if you want to keep getting that service while your State Hearing is pending. Your benefits as a member of our plan include coverage for many prescription drugs. Click here for more information on Ventricular Assist Devices (VADs) coverage. Box 1800 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 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. If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will use the standard deadlines instead. Can someone else make the appeal for me for Part C services? 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. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contact renewal. Who is covered? Review your Member Handbook, and call IEHP DualChoice Member Services if you do not understand something about your coverage and benefits. b. You can get the form at. You can call the California Department of Social Services at (800) 952-5253. Our service area includes all of Riverside and San Bernardino counties. ii. Call: (877) 273-IEHP (4347). Dieticians and Nutritionist will determine how many units will be administered per day and must meet the requirements of this NCD as well at 42 CFR 410.130 410.134. The California Department of Managed Health Care (DMHC) is responsible for regulating health plans. 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. No more than 20 acupuncture treatments may be administered annually. (Effective: December 15, 2017) 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. You can work with us for all of your health care needs.
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