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If we decide to change or stop coverage for a service or item that was previously approved, we will send you a notice before taking the action. The following criteria must also be met as described in the NCD: Non-Covered Use: Study data for CMS-approved prospective comparative studies may be collected in a registry. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. An interventional echocardiographer must perform transesophageal echocardiography during the procedure.>. Here are two ways to get information directly from Medicare: By clicking on this link, you will be leaving the IEHP DualChoice website. The letter will also explain how you can appeal our decision. 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. How to Enroll with IEHP DualChoice (HMO D-SNP), IEHP Texting Program Terms and Conditions. If you are asking for a standard appeal, you can make your appeal by sending a request in writing. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. All other indications for colorectal cancer screening not otherwise specific in the regulations or the National Coverage Determination above. 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. Organized as a Joint Powers Agency, Inland Empire Health Plan (IEHP) is a local, not-for-profit, public health plan. You can download a free copy here. 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. There are over 700 pharmacies in the IEHP DualChoice network. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more days (44 days total) to answer your complaint. For example, you can make a complaint about disability access or language assistance. If the Independent Medical Review decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. If the Independent Review Entity approves a request to pay you back for a drug you already bought, we will send payment to you within 30 calendar days after we get the decision. 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. 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.) Request and receive appeal data from IEHP DualChoice; Receive notice when an appeal is forwarded to the Independent Review Entity (IRE); Automatic reconsideration by the IRE when IEHP DualChoice upholds its original adverse determination in whole or in part; Administrative Law Judge (ALJ) hearing if the independent review entity upholds the original adverse determination in whole or in part and the remaining amount in controversy is $100 or more; Request Departmental Appeals Board (DAB) review if the ALJ hearing is unfavorable to the Member in whole or in part; Judicial review of the hearing decision if the ALJ hearing and/or DAB review is unfavorable to the Member in whole or in part and the amount remaining in controversy is $1,000 or more; Make a quality of care complaint under the QIO process; Request QIO review of a determination of noncoverage of inpatient hospital care; Request QIO review of a determination of noncoverage in skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities; Request a timely copy of your case file, subject to federal and state law regarding confidentiality of patient information; Challenge local and national Medicare coverage determination. 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. The diagnostic laboratory test using NGS must have: Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic and; FDA-approved or cleared indication for use in that patients cancer and; results provided to the treating physician for management of the patient using a report template to specify treatment options. You have access to a care coordinator. We will review our coverage decision to see if it is correct. Dependent edema (gravity related swelling due to excess fluid) suggesting congestive heart failure; or, For more information on Home Use of Oxygen coverage click here. Usually, your prescription drugs are only covered if they are filled at a network pharmacy including through our mail-order pharmacy services. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). 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. At Level 2, an Independent Review Entity will review our decision. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. (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. An IMR is available for any Medi-Cal covered service or item that is medical in nature. Sacramento, CA 95899-7413. TTY/TDD users should call 1-800-718-4347. Notify IEHP if your language needs are not met. (Implementation date: June 27, 2017). A medical group or IPA is a group of physicians, specialists, and other providers of health services that see IEHP Members. For more information, call IEHP DualChoice Member Services or read the IEHP DualChoice Member Handbook. If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan. If you do not qualify by the end of the two-month period, youll de disenrolled by IEHP DualChoice. If PO2 and arterial blood gas results are conflicting, the arterial blood gas results are preferred source to determine medical need. You will get a letter from us about the change in your eligibility with instructions to correct your eligibility information. Information on procedures for obtaining prior authorization of services, Quality Assurance, disenrollment, and other procedures affecting IEHP DualChoice Members. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer and; has not been previously tested with the same test using NGS for the same cancer genetic content and; has decided to seek further cancer treatment (e.g., therapeutic chemotherapy). You can ask for a State Hearing for Medi-Cal covered services and items. 2023 IEHP DualChoice Provider and Pharmacy Directory (PDF), http://www.dmhc.ca.gov/FileaComplaint/SubmitanIndependentMedicalReviewComplaintForm.aspx, Request for Medicare Prescription Drug Coverage Determination (PDF). Beneficiaries receiving treatment for Transcatheter Edge-to-Edge Repair (TEER) when either of the following are met: This determination will expire ten years after the effective date if a reconsideration is not made during this time. If we do not give you an answer within 30 calendar days 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 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. Click here for more information on Transcatheter Edge-to-Edge Repair [TEER] for Mitral Valve Regurgitation coverage . If you dont have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. This government program has trained counselors in every state. The care team helps coordinate the services you need. 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? 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. B. What is covered: Suppose that you are temporarily outside our plans service area, but still in the United States. (Implementation date: August 29, 2017 for MAC local edits; January 2, 2018 for MCS shared edits) 8am - 8pm (PST), 7 days a week, including holidays, TTY: (800) 718-4347. IEHP DualChoice Formulary consists of medications that are considered as first line therapies (drugs that should be used first for the indicated conditions). If you need to change your PCP for any reason, your hospital and specialist may also change. In these situations, please check first with IEHP DualChoice Member Services to see if there is a network pharmacy nearby. TTY users should call 1-877-486-2048. If you are traveling within the US, but outside of the Plans service area, and you become ill, lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy if you follow all other coverage rules identified within this document and a network pharmacy is not available. 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. (Effective: February 19, 2019) (Effective: April 13, 2021) Call (888) 466-2219, TTY (877) 688-9891. If you need help during the appeals process, you can call the Office of the Ombudsman at 1-888-452-8609. You can call SHIP at 1-800-434-0222. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision. Concurrent with Intracranial Stent Placement in FDA-Approved Category B IDE Clinical Trials We will cover your prescription at an out-of-network pharmacy if at least one of the following applies: If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than paying your normal share of the cost) when you fill your prescription. We call this the supporting statement.. Learn about your health needs and leading a healthy lifestyle. What Prescription Drugs Does IEHP DualChoice Cover? Or, if you havent paid for the service or item yet, we will send the payment directly to the provider. While the taste of the black walnut is a culinary treat the . You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. If your Level 2 Appeal was an Independent Medical Review, you can request a State Hearing. 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. A reasonable salary expectation is between $51,833.60 and $64,022.40, based upon experience and internal equity. It also has care coordinators and care teams to help you manage all your providers and services. You can also have a lawyer act on your behalf. You can ask for an Independent Medical Review (IMR) from the Help Center at the California Department of Managed Health Care (DMHC). In most cases, you must file an appeal with us before requesting an IMR. Medicare beneficiaries may be covered with an affirmative Coverage Determination. Members \. For reservations call Monday-Friday, 7am-6pm (PST). Changing your Primary Care Provider (PCP). 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. You can get the form at. This section is about asking for coverage decisions and making appeals with problems related to your benefits and coverage. Click here for more information on Positron Emission Tomography NaF-18 (NaF-18 PET) to Identify Bone Metastasis of Cancer coverage. They have a copay of $0. The procedure is used with a mitral valve TEER system that has received premarket approval from the FDA. (Effective: April 7, 2022) If our answer is No to part or all of what you asked for, we will send you a letter. Fill out the Authorized Assistant Form if someone is helping you with your IMR. For other types of problems you need to use the process for making complaints. Medicare beneficiaries who are diagnosed with Symptomatic Peripheral Artery Disease who would benefit from this therapy. Who is covered? With "Extra Help," there is no plan premium for IEHP DualChoice. The phone number is (888) 452-8609. We may not tell you before we make this change, but we will send you information about the specific change or changes we made. 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. This means within 24 hours after we get your request. To the California Department of Social Services: To the State Hearings Division at fax number 916-651-5210 or 916-651-2789. You can always contact your State Health Insurance Assistance Program (SHIP). An IMR is a review of your case by doctors who are not part of our plan. We will send you a letter within 5 calendar days of receiving your appeal letting you know that we received it. You, your representative, or your doctor (or other prescriber) can do this. You ask us to pay for a prescription drug you already bought. The Centers of Medicare and Medicaid Services (CMS) will cover Ambulatory Blood Pressure Monitoring (ABPM) when specific requirements are met. You can get a fast coverage decision coverage decision only if you are asking for coverage for care or an item you have not yet received. 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. Effective for dates of service on or after December 1, 2020, CMS has updated section 20.9.1 of the National Coverage Determination Manual to cover ventricular assist devices (VADs) when received at facilities credentialed by a CMS approved organization and when specific requirements are met. IEHP offers a competitive salary and stellar benefit package . The Help Center cannot return any documents. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. IEHP DualChoice network providers are required to comply with minimum standards for pharmacy practices as established by the State of California. 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). Patients must maintain a stable medication regimen for at least four weeks before device implantation. Who is covered: If your Level 2 Appeal went to the Medicare Independent Review Entity, it will send you a letter explaining its decision. If you put your complaint in writing, we will respond to your complaint in writing. Some hospitals have hospitalists who specialize in care for people during their hospital stay. Our plan includes doctors, hospitals, pharmacies, providers of long-term services and supports, behavioral health providers, and other providers. If your problem is about a Medi-Cal service or item, you can file a Level 2 Appeal yourself. 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. 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. All other indications of VNS for the treatment of depression are nationally non-covered. If you move out of our service area for more than six months. If we agree to make an exception and cover a drug that is not on the Formulary, you will need to pay the cost-sharing amount that applies to drug. We are the largest health plan in the Inland Empire, and one of the fastest-growing health plans in the nation. A drug is taken off the market. All have different pros and cons. What if you are outside the plans service area when you have an urgent need for care? Complex Care Management; Medi-Cal Demographic Updates . (Implementation Date: December 10, 2018). You have the right to ask us for a copy of your case file. You can tell Medicare about your complaint. C. Beneficiarys diagnosis meets one of the following defined groups below: You will need Adobe Acrobat Reader6.0 or later to view the PDF files. Fill out the Independent Medical Review/Complaint Form available at: If you have them, attach copies of letters or other documents about the service or item that we denied.