If you have a standard appeal at Level 2, the Independent Review Entity must give you an answer to your Level 2 Appeal within 7 calendar days after it gets your appeal. You should receive the IMR decision within 45 calendar days of the submission of the completed application. All requests for out-of-network services must be approved by your medical group prior to receiving services. The List of Covered Drugs and pharmacy and provider networks may change throughout the year. Beneficiaries must be managed by a team of medical professionals meeting the minimum requirements in the National Coverage Determination Manual. Your PCP should speak your language. 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. Your doctor or other prescriber can fax or mail the statement to us. Then, we check to see if we were following all the rules when we said No to your request. 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. PCPs are usually linked to certain hospitals and specialists. IEHP DualChoice network providers are required to comply with minimum standards for pharmacy practices as established by the State of California. You can tell the California Department of Managed Health Care about your complaint. Hazelnuts are the round brown hard-shelled nuts of the trees of genus Corylus while walnuts are the wrinkled edible nuts of the trees of genus Juglans. 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. 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 have any authorizations pending approval, if you are in them idle of treatment, or if specialty care has been scheduled for you by your current Doctor, contact IEHP to help you coordinate your care during this transition time. Or, if you havent paid for the service or item yet, we will send the payment directly to the provider. 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 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: Other persons may already be authorized by the Court or in accordance with State law to act for you. 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. Complain about IEHP DualChoice, its Providers, or your care. They have a copay of $0. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period. For some types of problems, you need to use the process for coverage decisions and making appeals. How to ask for coverage decision coverage decision to get medical, behavioral health, or certain long-term services and supports (CBAS, or NF services). For more information on Grievances see Chapter 9 of your IEHP DualChoice Member Handbook. A specialist is a doctor who provides health care services for a specific disease or part of the body. The following medical conditions are not covered for oxygen therapy and oxygen equipment in the home setting: Other: (Implementation Date: October 3, 2022) However, if the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drugs manufacturer removes the drug from the market we will immediately remove the drug from our formulary. Click here to download a free copy by clicking Adobe Acrobat Reader. The phone number is (888) 452-8609. Angina pectoris (chest pain) in the absence of hypoxemia; or. 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. You or someone you name may file a grievance. Try to choose a PCP that can admit you to the hospital you want within 30 miles or 45 minutes of your home. 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. Note, the Member must be active with IEHP Direct on the date the services are performed. The time of need is indicated when the presumption of oxygen therapy within the home setting will improve the patients condition. If you are not satisfied with the result of the IMR, you can still ask for a State Hearing. 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. We must respond whether we agree with the complaint or not. CMS has updated Chapter 1, section 20.19 of the Medicare National Coverage Determinations Manual. For additional information on step therapy and quantity limits, refer to Chapter5 of theIEHP DualChoice Member Handbook. Positron Emission Tomography NaF-18 (NaF-18 PET) services to identify bone metastases of cancer provided on or after December 15, 2017, are nationally non-covered. The services of SHIP counselors are free. The care team helps coordinate the services you need. The Office of Ombudsman is not connected with us or with any insurance company or health plan. Patient must be evaluated for suitability for repair and must documented and made available to the Heart team members meeting the requirements of this determination. 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. 2. If the IRE reverses our decision and says we should pay you, we must send the payment to you or to the provider within 30 calendar days. Rancho Cucamonga, CA 91729-4259. You must apply for an IMR within 6 months after we send you a written decision about your appeal. The organization will send you a letter explaining its decision. We will say Yes or No to your request for an exception. P.O. (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. Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plans service area. Beneficiaries with Alzheimers Disease (AD) may be covered for treatment when the following conditions (A or B) are met: Click here for more information on Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimers Disease (AD). An acute HBV infection could progress and lead to life-threatening complications. (Implementation Date: December 12, 2022) An annual screening for lung cancer with LDCT will be available if specific eligibility criteria are met. You can ask for a copy of the information in your appeal and add more information. You will not have a gap in your coverage. If you miss the deadline for a good reason, you may still appeal. All of our Doctors offices and service providers have the form or we can mail one to you. 2023 Plan Benefits. Our service area includes all of Riverside and San Bernardino counties. No means the Independent Review Entity agrees with our decision not to approve your request. You can work with us for all of your health care needs. (Effective: September 26, 2022) What Prescription Drugs Does IEHP DualChoice Cover? (Effective: January 1, 2022) The call is free. This means that your PCP will be referring you to specialists and services that are affiliated with their medical group. 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. Call IEHP DualChoice Member Services if you need help in choosing a PCP or changing your PCP. What is covered? Our plan cannot cover a drug purchased outside the United States and its territories. Group I: You can also have your doctor or your representative call us. At Level 2, an Independent Review Entity will review the decision. Click here for more information on Cochlear Implantation. 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). 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. Medicare beneficiaries who meet either of the following criteria: Click here for more information on HBV Screenings. Vision Care: $350 limit every year for contact lenses and eyeglasses (frames and lenses). The call is free. 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. You can also visit https://www.hhs.gov/ocr/index.html for more information. (866) 294-4347 We will send you your ID Card with your PCPs information. The reviewer will be someone who did not make the original coverage decision. a. TTY (800) 718-4347. What if the plan says they will not pay? Breathlessness without cor pulmonale or evidence of hypoxemia; or. Click here for more information on Positron Emission Tomography NaF-18 (NaF-18 PET) to Identify Bone Metastasis of Cancer coverage. 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). ICDs will be covered for the following patient indications: Please refer to section 20.4 of the NCD Manual for additional coverage criteria. If you decide to ask for a State Hearing by phone, you should be aware that the phone lines are very busy. If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. All the changes are reviewed and approved by a selected group of Providers and Pharmacists that are currently in practice. 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. By clicking on this link, you will be leaving the IEHP DualChoice website. You can tell Medi-Cal about your complaint. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. All of our plan participating providers also contract us to provide covered Medi-Cal benefits. 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. 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%. What if you are outside the plans service area when you have an urgent need for care? CMS has updated Chapter 1, section 30.3.3 of the Medicare National Coverage Determinations Manual. See plan Providers, get covered services, and get your prescription filled timely. 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. 1501 Capitol Ave., The reviewer will be someone who did not make the original decision. 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). No-cost or low-cost health care coverage for low-income adults, families with children, seniors, and people with disabilities. (Implementation Date: December 10, 2018). If we decide that your health does not meet the requirements for a fast coverage decision, we will send you a letter. The patient is experiencing a major depressive episode, as measured by a guideline recommended depression scale assessment tool on two visits, within a 45-day span prior to implantation of the VNS device. The letter will also explain how you can appeal our decision. If we say no to part or all of your Level 1 Appeal, we will send you a letter. 2023 IEHP DualChoice Member Handbook (PDF), Click here to download a free copy of Adobe Acrobat Reader. IEHP DualChoice Click here for more information on acupuncture for chronic low back pain coverage. IEHP Direct contracted PCPs who provide service to IEHP Direct DualChoice Members. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. We will contact the provider directly and take care of the problem. To get a temporary supply of a drug, you must meet the two rules below: When you get a temporary supply of a drug, you should talk with your provider to decide what to do when your supply runs out. Their shells are thick, tough to crack, and will likely stain your hands. TTY: 1-800-718-4347. 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 phone number for the Office for Civil Rights is (800) 368-1019. If you lose your zero share-of-cost, full scope Medi-Cal, you will be disenrolled from our plan (for your Medicare benefits) the first day of the following month andwill be covered by the Original Medicare. You are not responsible for Medicare costs except for Part D copays. What is a Level 2 Appeal? If your problem is about a Medicare service or item, we will automatically send your case to Level 2 of the appeals process as soon as the Level 1 Appeal is complete. IEHP DualChoice is very similar to your current Cal MediConnect plan. 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. Mail your request for payment together with any bills or receipts to us at this address: IEHPDualChoice If you disagree with a coverage decision we have made, you can appeal our decision. To be a Member of IEHP DualChoice, you must keep your eligibility with Medi-Cal and Medicare. You can download a free copy here. You can call the DMHC Help Center for help with complaints about Medi-Cal services. 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. You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage decision. Remember, you can request to change your PCP at any time. 5. (877) 273-4347 With "Extra Help," there is no plan premium for IEHP DualChoice. 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, your representative, or your doctor (or other prescriber) can do this. If you disagree with our decision, you can ask the DMHC Help Center for an IMR. The leadless pacemaker eliminates the need for a device pocket and insertion of a pacing lead which are integral elements of traditional pacing systems. Calls to this number are free. The California Department of Managed Health Care (DMHC) is responsible for regulating health plans. If the plan says No at Level 1, what happens next? It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. Ask for an exception from these changes. But if you do pay the bill, you can get a refund if you followed the rules for getting services and items. Rights and Responsibilities Upon Disenrollment, Ending your membership in IEHP DualChoice (HMO D-SNP) may be voluntary (your own choice) or involuntary (not your own choice). 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. There are extra rules or restrictions that apply to certain drugs on our Formulary. How can I make a Level 2 Appeal? iii. For more information see Chapter 9 of your IEHP DualChoice Member Handbook. Please be sure to contact IEHP DualChoice Member Services if you have any questions. How will you find out if your drugs coverage has been changed? Your IEHP DualChoice Doctor cannot charge you for covered health care services, except for required co-payments. 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. Typically, our Formulary includes more than one drug for treating a particular condition. You can switch yourDoctor (and hospital) for any reason (once per month). See form below: Deadlines for a fast appeal at Level 2 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. If you let someone else use your membership card to get medical care. You will be notified when this happens. To learn more about your prescription drug costs, call IEHP DualChoice Member Services. This means within 24 hours after we get your request. Heart failure cardiologist with experience treating patients with advanced heart failure. The clinical study must adhere to all the standards of scientific integrity and relevance to the Medicare population. Including bus pass. a. A standard coverage decision means we will give you an answer within 72 hours after we get your doctors statement. The formal name for making a complaint is filing a grievance. A grievance is the kinds of problems related to: How to file a Grievance with IEHP DualChoice (HMO D-SNP). However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. IEHP DualChoice also provides information to the Centers for Medicare and Medicaid Services (CMS) regarding its quality assurance measures according to the guidelines specified by CMS. Who is covered? This is not a complete list. 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. Treatment of Atherosclerotic Obstructive Lesions If you have a fast complaint, it means we will give you an answer within 24 hours. H8894_DSNP_23_3241532_M. It also has care coordinators and care teams to help you manage all your providers and services. Limited benefit from amplification is defined by test scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of open-set sentence recognition. Possible errors in the amount (dosage) or duration of a drug you are taking. You will need Adobe Acrobat Reader6.0 or later to view the PDF files. Click here to learn more about IEHP DualChoice. Change the coverage rules or limits for the brand name drug. You can call SHIP at 1-800-434-0222. 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. 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. All other indications for colorectal cancer screening not otherwise specified in the Social Security Act, regulations, or the above remain nationally non-covered. If you ask for a fast coverage decision, without your doctors support, we will decide if you get a fast coverage decision. IEHP DualChoice is for people with both Medicare (Part A and B) and Medi-Cal. You, your doctor or other prescriber, or your representative can request the Level 2 Appeal. The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. For more information, call IEHP DualChoice Member Services or read the IEHP DualChoice Member Handbook. The clinical research study must meet the standards of scientific integrity and relevance to the Medicare population described in this determination. When your complaint is about quality of care. 2. We do a review each time you fill a prescription. Medi-Cal provides free or low-cost health coverage to low-income individuals and their families.California has been expanding Medi-Cal to a larger and more diverse group of people. Complex Care Management; Medi-Cal Demographic Updates . All other indications for colorectal cancer screening not otherwise specific in the regulations or the National Coverage Determination above. For inpatient hospital patients, the time of need is within 2 days of discharge. The NCR serves as a liaison for matters involving the contract between IEHP and both Network and Non-Network Providers. 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. You can also have a lawyer act on your behalf. When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider.



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