Getting plan approval before we will agree to cover the drug for you. 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. Group I: If you are asking to be paid back, you are asking for a coverage decision. CMS has expanded the PILD for LSS National Coverage Determination (NCD) to now cover beneficiaries that are enrolled in a CMS-approved prospective longitudinal study. 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. 1. If we say No to your appeal, you then choose whether to accept this decision or continue by making another appeal. Upon expiration, coverage will be determined by the local Medicare Administrative Contractors (MACs). Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States. What Prescription Drugs Does IEHP DualChoice Cover? All of our plan participating providers also contract us to provide covered Medi-Cal benefits. 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. 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. Calls to this number are free. (Implementation Date: February 27, 2023). If you are not satisfied with the result of the IMR, you can still ask for a State Hearing. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.). 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. If your doctor or other provider asks for a service or item that we will not approve, or we will not continue to pay for a service or item you already have and we said no to your Level 1 appeal, you have the right to ask for a State Hearing. When that happens, we may remove the current drug, but your cost for the new drug will stay the same or will be lower. You have a right to appeal or ask for Formulary exception if you disagree with the information provided by the pharmacist. When your PCP thinks that you need specialized treatment or supplies, your PCP will need to get prior authorization (i.e., prior approval) from your Plan and/or medical group. If 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). If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. disease); An additional 8 sessions will be covered for those patients demonstrating an improvement. If your doctor says that you need a fast coverage decision, we will automatically give you one. (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. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. What is covered: You may choose different health plans, or providers, under Medi-Cal, like IEHP or Molina Healthcare, Blue Shield, Health Net, etc. However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. A medical group or IPA is a group of physicians, specialists, and other providers of health services that see IEHP Members. TTY/TDD users should call 1-800-718-4347. 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. ii. Can someone else make the appeal for me for Part C services? To make this request, or if you have any concerns about your continuity of care, please call IEHP DualChoice Member Services at 1-877-273-IEHP (4347). For additional information on step therapy and quantity limits, refer to Chapter5 of theIEHP DualChoice Member Handbook. Call IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. For example, we might decide that a service, item, or drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. We take a careful look at all of the information about your request for coverage of medical care. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. You must submit your claim to us within 1 year of the date you received the service, item, or drug. TTY: 1-800-718-4347. This is a group of doctors and other health care professionals who help improve the quality of care for people with Medicare. Review your Member Handbook, and call IEHP DualChoice Member Services if you do not understand something about your coverage and benefits. 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). P.O. (Implementation date: August 29, 2017 for MAC local edits; January 2, 2018 for MCS shared edits) No more than 20 acupuncture treatments may be administered annually. We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. Yes. H8894_DSNP_23_3241532_M. Additional hours of treatment are considered medically necessary if a physician determines there has been a shift in the patients medical condition, diagnosis or treatment regimen that requires an adjustment in MNT order or additional hours of care. Make recommendations about IEHP DualChoice Members rights and responsibilities policies. We will answer your request for an exception within 72 hours after we get your request (or your prescribers supporting statement). CMS has updated section 240.2 of the National Coverage Determination Manual to amend the period of initial coverage for patients in section D of NCD 240.2 from 120 days to 90 days, to align with the 90-day statutory time period. If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. 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. Beneficiaries participating in a CMS approved clinical study undergoing Vagus Nerve Stimulation (VNS) for treatment resistant depression and the following requirements are met: Click here for more information on Vagus Nerve Stimulation. VNS is non-covered for the treatment of TRD when furnished outside of a CMS-approved CED study. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. TTY users should call (800) 537-7697. If you are asking for a standard appeal, you can make your appeal by sending a request in writing. Rancho Cucamonga, CA 91729-1800 Our response will include our reasons for this answer. Our IEHP DualChoice (HMO D-SNP) Provider and Pharmacy Directory gives you a complete list of our network pharmacies that means all of the pharmacies that have agreed to fill covered prescriptions for our plan members. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. IEHP DualChoice. 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. ii. If you dont have the IEHP DualChoice Provider and Pharmacy Directory, you can get a copy from IEHP DualChoice Member Services. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. Click here for information on Next Generation Sequencing coverage. 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. You do not need to do anything further to get this Extra Help. IEHP DualChoice recognizes your dignity and right to privacy. This includes getting authorization to see specialists or medical services such as lab tests, x-rays, and/or hospital admittance. If you do not qualify by the end of the two-month period, youll de disenrolled by IEHP DualChoice. effort to participate in the health care programs IEHP DualChoice offers you. If our answer is Yes to part or all of what you asked for, we must authorize or provide the coverage within 72 hours after we get your appeal. These reviews are especially important for members who have more than one provider who prescribes their drugs. If you ask for a fast coverage decision, without your doctors support, we will decide if you get a fast coverage decision. Please see below for more information. How to voluntarily end your membership in our plan? 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. They receive a left ventricular device (LVADs) if the device is FDA approved for short- or long-term use for mechanical circulatory support for beneficiaries with heart failure who meet the following requirements: Have New York Heart Association (NYHA) Class IV heart failure; and, Have a left ventricular ejection fraction (LVEF) 25%; and. If we are using the standard deadlines, we must give you our answer within 72 hours after we get your request or, if you are asking for an exception, after we get your doctors or prescribers supporting statement. If you believe we should not take extra days, you can file a fast complaint about our decision to take extra days. Opportunities to Grow. PO2 may be performed by the treating practitioner or by a qualified provider or supplier of laboratory services. Can my doctor give you more information about my appeal for Part C services? Emergency services from network providers or from out-of-network providers. Beneficiaries with either a renal disease or diabetes diagnosis as defined in 42 CFR 410.130. 3. 10820 Guilford Road, Suite 202 The clinical research study must meet the standards of scientific integrity and relevance to the Medicare population described in this determination. Click here for more information on acupuncture for chronic low back pain coverage. By clicking on this link, you will be leaving the IEHP DualChoice website. i. If our answer is Yes 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. This number requires special telephone equipment. 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. Choose a PCP that is within 10 miles or 15 minutes of your home. 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. are similar in many respects. 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. 1. We must give you our answer within 14 calendar days after we get your request. Your PCP, along with the medical group or IPA, provides your medical care. 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 must qualify for this benefit. (Implementation Date: January 17, 2022). Here are two ways to get information directly from Medicare: By clicking on this link, you will be leaving the IEHP DualChoice website. Generally, you must receive all routine care from plan providers and network pharmacies to access their prescription drug benefits, except in non-routine circumstances, quantity limitations and restrictions may apply. You can also have your doctor or your representative call us. Here are your choices: There may be a different drug covered by our plan that works for you. If you disagree with our decision, you can ask the DMHC Help Center for an IMR. If you would like to switch from our plan to Original Medicare but you have not selected a separate Medicare prescription drug plan. What is covered: Percutaneous Transluminal Angioplasty (PTA) is covered in the below instances in order to improve blood flow through the diseased segment of a vessel in order to dilate lesions of peripheral, renal and coronary arteries. P.O. What is covered: H8894_DSNP_23_3241532_M. You can make the complaint at any time unless it is about a Part D drug. If we are using the fast deadlines, we must give you our answer within 24 hours. Effective on or after April 10, 2018, MRI coverage will be provided when used in accordance to the FDA labeling in an MRI environment. What is covered? If the decision is No for all or part of what I asked for, can I make another 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. If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. 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. Prior to January 18, 2017, there was no national coverage determination (NCD) in effect. The list can help your provider find a covered drug that might work for you. The clinical study must adhere to all the standards of scientific integrity and relevance to the Medicare population. A care coordinator is a person who is trained to help you manage the care you need. 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. If you have questions, you can contact IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. You can give the completed form to any IEHP Provider or mail it to: Call: 1-888-452-8609(TTY 711) Monday through Friday, 9 a.m. to 5 p.m. During this time, you must continue to get your medical care and prescription drugs through our plan. Quantity limits. A new generic drug becomes available. An interventional echocardiographer must perform transesophageal echocardiography during the procedure. Our service area includes all of Riverside and San Bernardino counties. 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). Our state has an organization called Livanta Beneficiary & Family Centered Care (BFCC) Quality Improvement Organization (QIO). (Effective: April 3, 2017) TDD users should call (800) 952-8349. The clinical research study must critically evaluate each patient's quality of life pre- and post-TAVR for a minimum of 1 year, but must also address other various questions. 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. You pay no costs for an IMR. How to obtain an aggregate number of grievances, appeals, and exceptions filed with IEHP DualChoice (HMO D-SNP)? With IEHP DualChoice, you will still have an IEHP DualChoice Member Service team to get help for your needs. You have access to a care coordinator. Yes, you and your doctor may give us more information to support your appeal. 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. 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. See below for a brief description of each NCD. If you decide to go on to a Level 2 Appeal, the Independent Review Entity (IRE) will review our decision. Deadlines for a standard coverage decision about payment for a drug you have already bought, If our answer is Yes to part or all of what you asked for, we will make payment to you within 14 calendar days. a. Covering a Part D drug that is not on our List of Covered Drugs (Formulary). Orthopedists care for patients with certain bone, joint, or muscle conditions. H8894_DSNP_23_3879734_M Pending Accepted. You can then ask us to make an exception and cover the drug in the way you would like it to be covered for next year. 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. Click here for more information on PILD for LSS Screenings. You do not need to give your doctor or other prescriber written permission to ask us for a coverage determination on your behalf. Never wavering in our commitment to our Members, Providers, Partners, and each other. Medicare beneficiaries in need of a pacemaker who are participating in an approved clinical study. Concurrent with Carotid Stent Placement in Patients at High Risk for Carotid Endarterectomy (CEA) You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Effective for dates of service on or after January 1, 2022, CMS has updated section 180.1 of the National Coverage Determination Manual to cover three hours of administration during one year of Medical Nutrition Therapy (MNT) in patients with a diagnosis of renal disease or diabetes, as defined in 42 CFR 410.130. They mostly grow wild across central and eastern parts of the country. What is covered? Notify IEHP if your language needs are not met. 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. TTY users should call 1-877-486-2048. Who is covered: Suppose that you are temporarily outside our plans service area, but still in the United States. We establish that you had an existing relationship with a primary or specialty care provider, with some exceptions. Who is covered: According to IEHP, 99.4 percent of enrollees retained the same primary care physicians. Arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88%, tested during functional performance of the patient or a formal exercise, By clicking on this link, you will be leaving the IEHP DualChoice website. 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. 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. A drug is taken off the market. A reasonable salary expectation is between $153,670.40 and $195,936.00, based upon experience and internal equity. An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. A standard coverage decision means we will give you an answer within 72 hours after we get your doctors statement. It has been updated that coverage determinations for providing Topical Application of Oxygen for the treatment of chronic wounds can be made by the local Contractors. 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. You may change your PCP for any reason, at any time. With this app, you or a designated person with Power of Attorney can access your advance health care directives at any time from a home computer or smartphone. This section is about asking for coverage decisions and making appeals with problems related to your benefits and coverage. Follow the plan of treatment your Doctor feels is necessary. If your problem is about a Medicare service or item, the letter will tell you that we sent your case to the Independent Review Entity for a Level 2 Appeal. The procedure must be performed by an interventional cardiologist or cardiac surgeon.<. TTY/TDD (800) 718-4347. If our answer is No to part or all of what you asked for, we will send you a letter. The removal of these elements eliminates an important source of complications associated with traditional pacing systems while providing similar benefits. 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. Contact us promptly call IEHP DualChoice at (877) 273-IEHP (4347), 8am - 8pm, 7 days a week, including holidays.TTY users should call 1-800-718-4347. 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). You may also have rights under the Americans with Disability Act. The Centers of Medicare and Medicaid Services (CMS) will cover claims for effective dates of service on or after February 15, 2018. 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. Then, we check to see if we were following all the rules when we said No to your request. Coverage for future years is two hours for patients diagnosed with renal disease or diabetes. Can I ask for a coverage determination or make an appeal about Part D prescription drugs? 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. Remember, if you get a bill that is more than your copay for covered services and items, you should not pay the bill yourself. (Implementation Date: July 22, 2020). We will give you our decision sooner if your health condition requires us to. 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 and your provider can ask us to make an exception. If you need help to fill out the form, IEHP Member Services can assist you. CMS has updated Chapter 1, section 30.3.3 of the Medicare National Coverage Determinations Manual. The procedure removes a portion of the lamina in order to debulk the ligamentum flavum, essentially widening the spinal canal in the affected area. The clinical test must be performed at the time of need: Please select one of the following: Primary Care Doctor Specialist Behavioral Health Hospitals 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. P.O. There are two ways to make a Level 2 appeal for Medi-Cal services and items: 1) Independent Medical Review or 2) State Hearing. If you decide to ask for a State Hearing by phone, you should be aware that the phone lines are very busy. You wont pay a premium, or pay for doctor visits or other medical care if you go to a provider that works with our health plan. For more information on Medical Nutrition Therapy (MNT) coverage click here. However, your PCP can always use Language Line Services to get help from an interpreter, if needed. 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 the plan says No at Level 1, what happens next? Click here for more information on ambulatory blood pressure monitoring coverage. (Effective: February 19, 2019) Concurrent with Carotid Stent Placement in FDA-Approved Post-Approvals Studies If we agree to make an exception and waive a restriction for you, you can still ask for an exception to the co-pay amount we require you to pay for the drug. The services are free. Call at least 5 days before your appointment. More. Will not pay for emergency or urgent Medi-Cal services that you already received. Are a United States citizen or are lawfully present in the United States. Who is covered: Here are examples of coverage determination you can ask us to make about your Part D drugs. (Effective: January 19, 2021) (Effective: September 28, 2016) Box 997413 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. D-SNP Transition. To see if you qualify for getting extra help, you can contact: Do you need help getting the care you need? (800) 718-4347 (TTY), IEHP 24-Hour Nurse Advice Line (for IEHP Members only) Get the My Life. Send copies of documents, not originals. The following link will take you to the Centers for Medicaid and Medicare Services website, where you can look through the CMS Best Available Evidence Policy using the following link: CMS Best Available Evidence Policy. 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.
