Unless you change plans, IEHP DualChoice (HMO D-SNP) will provide your Medicare benefits. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition. CMS has revised Chapter 1, Section 20.29, Subsection C Topical Application of Oxygen to remove the exclusion of this treatment. P.O. 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. 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. The removal of these elements eliminates an important source of complications associated with traditional pacing systems while providing similar benefits. To find the name, address, and phone number of the Quality Improvement Organization in your state, lookin Chapter 2 of your. This gives you time to talk with your provider about getting a different drug or to ask us to cover the drug. If you are taking the drug, we will let you know. With "Extra Help," there is no plan premium for IEHP DualChoice. 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. Can I ask for a coverage determination or make an appeal about Part D prescription drugs? Call (888) 466-2219, TTY (877) 688-9891. Will my benefits continue during Level 1 appeals? If your provider says you have a good medical reason for an exception, he or she can help you ask for one. This is true even if we pay the provider less than the provider charges for a covered service or item. The List of Covered Drugs and pharmacy and provider networks may change throughout the year. Effective for dates of service on or after January 27, 2020, CMS has determined that NGS, as a diagnostic laboratory test, is reasonable and necessary and covered nationally for patients with germline (inherited) cancer when performed in a CLIA-certified laboratory, when ordered by a treating physician and when specific requirements are met. For example, you can make a complaint about disability access or language assistance. Sacramento, CA 95899-7413. Black Walnuts on the other hand have a bolder, earthier flavor. In order to receive out-of-network services, your Primary Care Provider (PCP) or Specialist must submit a referral request to your plan or medical group. Be informed regarding Advance Directives, Living Wills, and Power of Attorney, and to receive information regarding changes related to existing laws. Beneficiaries with Somatic (acquired) cancer or Germline (inherited) cancer when performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all the following requirements are met: Medicare Administrative Contractors (MACs) may determine coverage of NGS as a diagnostic test when additional specific criteria are met. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. You do not need to do anything further to get this Extra Help. asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test), and, average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohns Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer). If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. Can someone else make the appeal for me for Part C services? A network provider is a provider who works with the health plan. 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. 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. If you or your doctor disagree with our decision, you can appeal. IEHP DualChoice will cover many of the Medicare and Medi-Cal benefits you get now, including: You will have access to a Provider network that includes many of the same Providers as your current plan. Welcome to Inland Empire Health Plan \. English Walnuts vs Black Walnuts: What's The Difference? Effective on January 1, 2023, CMS has updated section 210.3 of the NCD Manual that provides coverage for colorectal cancer (CRC) screening tests under Medicare Part B. Make your appeal request within 60 calendar days from the date on the notice we sent to tell you our decision. You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage decision. The services of SHIP counselors are free. Capable of producing standardized plots of BP measurements for 24 hours with daytime and nighttime windows and normal BP bands demarcated; Provided to patients with oral and written instructions, and a test run in the physicians office must be performed; and. IEHP DualChoice An IMR is a review of your case by doctors who are not part of our plan. 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. The procedure removes a portion of the lamina in order to debulk the ligamentum flavum, essentially widening the spinal canal in the affected area. Our plans Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B. The letter will also explain how you can appeal our decision. This is asking for a coverage determination about payment. We establish that you had an existing relationship with a primary or specialty care provider, with some exceptions. (Implementation Date: October 4, 2021). (Implementation date: June 27, 2017). You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. Medicare beneficiaries who meet either of the following criteria: Click here for more information on HBV Screenings. 3. 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. Is Medi-Cal and IEHP the same thing? This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision. Its a good idea to make a copy of your bill and receipts for your records. We will contact the provider directly and take care of the problem. Prior to January 18, 2017, there was no national coverage determination (NCD) in effect. Who is covered? IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. If your case is urgent and you qualify for an IMR, the DMHC will review your case and send you a letter within 2 calendar days telling you that you qualify for an IMR. (Implementation Date: June 12, 2020). Treatment for patients with existing co-morbidities that would preclude the benefit from the procedure. ((Effective: December 7, 2016) Click here for information on Next Generation Sequencing coverage. If your health requires it, ask us to give you a fast coverage decision You will need Adobe Acrobat Reader6.0 or later to view the PDF files. 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. Or you can ask us to cover the drug without limits. 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. Who is covered: As an IEHP DualChoice (HMO D-SNP) Member, you have the right to: As an IEHP DualChoice Member, you have the responsibility to: For more information on Member Rights and Responsibilities refer to Chapter 8 of your IEHP DualChoice Member Handbook. Please see Chapter 9 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]) of the Member Handbook for more information on exceptions. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period. Information on this page is current as of October 01, 2022. You can still get a State Hearing. PO2 may be performed by the treating practitioner or by a qualified provider or supplier of laboratory services. IEHP DualChoice is very similar to your current Cal MediConnect plan. 8am - 8pm (PST), 7 days a week, including holidays, TTY: (800) 718-4347. This is called a referral. Click here for more detailed information on PTA coverage. Who is covered? 1. Group II: 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. We have arranged for these providers to deliver covered services to members in our plan. Credentialing Specialist I Job in Rancho Cucamonga, CA at Inland Empire Rancho Cucamonga, CA 91729-1800 You do not need to give your doctor or other prescriber written permission to ask us for a coverage determination on your behalf. If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. If you do not qualify by the end of the two-month period, youll de disenrolled by IEHP DualChoice. Make necessary appointments for routine and sick care, and inform your Doctor when you are unable to make a scheduled appointment. 1. Hepatitis B Virus (HBV) is transmitted by exposure to bodily fluids. IEHP DualChoice will give notice to IEHPDualChoice Members prior to removing Part D drug from the Part D formulary. For example, this means that your care team makes sure: Your doctors know about all the medicines you take so they can make sure youre taking the right medicines and can reduce any side effects you may have from the medicines. To start your appeal, you, your doctor or other prescriber, or your representative must contact us. This page provides you information on what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug. 504 Plan Defined The 504 Plan is a plan developed to ensure that a child who has a disability 2020) 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. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. 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. Suppose that you are temporarily outside our plans service area, but still in the United States. Send us your request for payment, along with your bill and documentation of any payment you have made. 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. You can ask for a copy of the information in your appeal and add more information. CMS has issued a National Coverage Determination (NCD) which expands coverage to include leadless pacemakers when procedures are performed in CMS-approved Coverage with Evidence Development (CED) studies. The call is free. i. You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY (800) 718-4347. What is covered? Call IEHP DualChoice Member Services if you need help in choosing a PCP or changing your PCP. We will give you our answer sooner if your health requires us to do so. Erythrocythemia (increased red blood cells) with a hematocrit greater than 56%. Autologous Platelet-Rich Plasma (PRP) treatment of acute surgical wounds when applied directly to the close incision, or for splitting or open wounds. 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. are similar in many respects. 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. If your Primary Care Provider changes, your IEHP DualChoice benefits and required co-payments will stay the same. After your application and supporting documents are received from your plan, the IMR decision will be made within 30 calendar days. 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. Remember, you can request to change your PCP at any time. H5355_CMC_22_2746205Accepted, (Effective: September 27, 2021) We have 30 days to respond to your request. When you choose your PCP, you are also choosing the affiliated medical group. The letter will explain why more time is needed. 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. (Effective: September 26, 2022) You have access to a care coordinator. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. Information on this page is current as of October 01, 2022. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). Both of these processes have been approved by Medicare. We are also one of the largest employers in the region, designated as "Great Place to Work.". (Effective: May 25, 2017) This letter will tell you if the service or item is usually covered by Medicare or Medi-Cal. You have a right to give the Independent Review Entity other information to support your appeal. For more information on Medical Nutrition Therapy (MNT) coverage click here. You are never required to pay the balance of any bill. TTY users should call 1-800-718-4347. Review, request changes to, and receive a copy of your medical records in a timely fashion. For example, good reasons for missing the deadline would be if you have a serious illness that kept you from contacting us or if we gave you incorrect or incomplete information about the deadline for requesting an appeal. IEHP completes termination of Vantage contract; three plans extend 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. 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. If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. Your membership will usually end on the first day of the month after we receive your request to change plans. The leadless pacemaker eliminates the need for a device pocket and insertion of a pacing lead which are integral elements of traditional pacing systems. 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. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. Department of Health Care Services How will I find out about the decision? If we decide that your health does not meet the requirements for a fast coverage decision, we will send you a letter. After your coverage begins with IEHP DualChoice, you must receive medical services and prescription drug services in the IEHP DualChoice network. 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 possible, we will answer you right away. If we say no, you have the right to ask us to change this decision by making an appeal. For more information visit the. Sometimes a specialist, clinic, hospital or other network provider you are using might leave the plan. When will I hear about a standard appeal decision for Part C services? Our plan usually cannot cover off-label use. You can call the California Department of Social Services at (800) 952-5253. For some drugs, the plan limits the amount of the drug you can have. My problem is about a Medi-Cal service or item. An interventional echocardiographer must perform transesophageal echocardiography during the procedure.>. Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. The list must meet requirements set by Medicare. View Plan Details. (Effective: June 21, 2019) If you miss this deadline and have a good reason for missing it, we may give you more time to make you appeal. Get Help from an Independent Government Organization. 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. To learn how to submit a paper claim, please refer to the paper claims process described below. ICDs will be covered for the following patient indications: Please refer to section 20.4 of the NCD Manual for additional coverage criteria. Effective for claims with dates of service on or after February 10, 2022, CMS will cover, under Medicare Part B, a lung cancer screening counseling and shared decision-making visit. You will be automatically disenrolled from IEHPDualChoice, when your new plans coverage begins. (Implementation Date: October 5, 2020). A standard coverage decision means we will give you an answer within 72 hours after we get your doctors statement. You will be automatically enrolled in IEHP DualChoice and do not need to do anything to keep these services. IEHP DualChoice will honor authorizations for services already approved for you. 2023 Plan Benefits. Copays for prescription drugs may vary based on the level of Extra Help you receive. Arterial oxygen saturation at or above 89% when awake;or greater than normal decrease in oxygen level while sleeping represented by a decrease in arterial PO2 more than 10 mmHg or a decrease in arterial oxygen saturation more than 5%. Most of these drugs are Part D drugs. There are a few drugs that Medicare Part D does not cover but that Medi-Cal may cover. The reviewer will be someone who did not make the original decision. 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. You can call (800) MEDICARE (800) 633-4227, 24 hours a day, 7 days a week, TTY (877) 486-2048. You will be able to get the service or item within 14 calendar days (for a standard coverage decision) or 72 hours (for a fast coverage decision) of when you asked. The Medicare Complaint Form is available at:https://www.medicare.gov/MedicareComplaintForm/home.aspx. 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. This is called prior authorization. Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. 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 NCD Manual. (Effective: January 19, 2021) 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. Use of autologous Platelet-Derived Growth Factor (PDGF) for treatment of chronic, non-healing, cutaneous (affecting the skin) wounds, and. H8894_DSNP_23_3241532_M. At any time, you can call IEHP DualChoice Member Services to get up-to-date information about changes in the pharmacy network. We may stop any aid paid pending you are receiving. A specialist is a doctor who provides health care services for a specific disease or part of the body. Treatments must be discontinued if the patient is not improving or is regressing. A reasonable salary expectation is between $51,833.60 and $64,022.40, based upon experience and internal equity. (Effective: January 18, 2017) Who is covered: 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. Click here for more information on Transcatheter Edge-to-Edge Repair [TEER] for Mitral Valve Regurgitation coverage . If we tell you after our review that the service or item is not covered, your case can go to a Level 2 Appeal. Complain about IEHP DualChoice, its Providers, or your care. We also review our records on a regular basis. Will not cover an experimental or investigational Medi-Cal treatment for a serious medical condition. Or you can make your complaint to both at the same time. (Effective: December 15, 2017) IEHP About Us You dont have to do anything if you want to join this plan. Emergency services from network providers or from out-of-network providers. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contact renewal.
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