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These reviews are especially important for members who have more than one provider who prescribes their drugs. You have the right to ask us for a copy of your case file. For example, you can make a complaint about disability access or language assistance. (Effective: April 7, 2022) If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. 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. (SeeChapter 10 ofthe. 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. How will I find out about the decision? =========== TABBED SINGLE CONTENT GENERAL. This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision. If you are not satisfied with the result of the IMR, you can still ask for a State Hearing. We will contact the provider directly and take care of the problem. How do I make a Level 1 Appeal for Part C services? The call is free. Thus, this is the main difference between hazelnut and walnut. If you qualify for an IMR, the DMHC will review your case and send you a letter within 7 calendar days telling you that you qualify for an IMR. Who is covered? Copays for prescription drugs may vary based on the level of Extra Help you receive. We have 30 days to respond to your request. (Implementation Date: September 20, 2021). You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY (800) 718-4347. H5355_CMC_22_2746205Accepted, (Effective: September 27, 2021) 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. We establish that you had an existing relationship with a primary or specialty care provider, with some exceptions. IEHP DualChoice is very similar to your current Cal MediConnect plan. Previously, PILD for LSS was covered for beneficiaries enrolled only in a CMS-approved prospective, randomized, controlled clinical trial (RCT) under the Coverage with Evidence Development (CED) paradigm. 5. Denies, changes, or delays a Medi-Cal service or treatment (not including IHSS) because our plan determines it is not medically necessary. H8894_DSNP_23_3241532_M. P.O. Here are examples of coverage determination you can ask us to make about your Part D drugs. You must qualify for this benefit. IEHP DualChoice will help you with the process. Some of the advantages include: You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. There are two ways to make a Level 2 appeal for Medi-Cal services and items: 1) Independent Medical Review or 2) State Hearing. The phone number for the Office for Civil Rights is (800) 368-1019. 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. 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. We also review our records on a regular basis. 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. All the changes are reviewed and approved by a selected group of Providers and Pharmacists that are currently in practice. If you get a bill that is more than your copay for covered services and items, send the bill to us. IEHP DualChoice. If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. Information on this page is current as of October 01, 2022. What is covered: The Centers of Medicare and Medicaid Services (CMS) will cover claims for effective dates of service on or after February 15, 2018. IEHP DualChoice Cal MediConnect (Medicare-Medicaid Plan) is changing to IEHP DualChoice (HMO D-SNP) on January 1, 2023. If we do not meet this deadline, we will send your request to Level 2 of the appeals process. The letter you get from the IRE will explain additional appeal rights you may have. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. 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. Certain combinations of drugs that could harm you if taken at the same time. It usually takes up to 14 calendar days after you asked. If you prefer a different one, please call IEHP DualChoice Member Services and we can assist you in finding and selecting another provider. IEHP DualChoice recognizes your dignity and right to privacy. 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. 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. You ask us to pay for a prescription drug you already bought. Other persons may already be authorized by the Court or in accordance with State law to act for you. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. If we answer no to your appeal and the service or item is usually covered by Medi-Cal, you can file a Level 2 Appeal yourself (see above). (800) 720-4347 (TTY). However, your PCP can always use Language Line Services to get help from an interpreter, if needed. Box 1800 New to IEHP DualChoice. 2. During this time, you must continue to get your medical care and prescription drugs through our plan. (Implementation Date: October 3, 2022) 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. 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. What if the plan says they will not pay? (Implementation date: August 29, 2017 for MAC local edits; January 2, 2018 for MCS shared edits) You, your representative, or your provider asks us to let you keep using your current provider. For some types of problems, you need to use the process for coverage decisions and making appeals. Then you may submit your request one of these ways: To the county welfare department at the address shown on the notice. There are extra rules or restrictions that apply to certain drugs on our Formulary. After your application and supporting documents are received from your plan, the IMR decision will be made within 3 calendar days. We must respond whether we agree with the complaint or not. Some hospitals have hospitalists who specialize in care for people during their hospital stay. TTY users should call (800) 537-7697. Routine womens health care, which includes breast exams, screening mammograms (X-rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider. This service will be covered when the Ambulatory Blood Pressure Monitoring (ABPM) is used for the diagnosis of hypertension when either there is suspected white coat or masked hypertension and the following conditions are met: Coverage of other indications for ABPM is at the discretion of the Medicare Administrative Contractors. See form below: Deadlines for a fast appeal at Level 2 CMS has updated Chapter 1, section 20.32 of the Medicare National Coverage Determinations Manual. If you want a fast appeal, you may make your appeal in writing or you may call us. Autologous Platelet-Rich Plasma (PRP) treatment of acute surgical wounds when applied directly to the close incision, or for splitting or open wounds. Notify IEHP if your language needs are not met. 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. Beneficiaries who meet the coverage criteria, if determined eligible. 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). 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. (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. If the Independent Medical Review decision is Yes to part or all of what you asked for, we must provide the service or treatment. An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. See Chapters 7 and 9 of the IEHP DualChoice Member Handbookto learn how to ask the plan to pay you back. The following medical conditions are not covered for oxygen therapy and oxygen equipment in the home setting: Other: Will not cover an experimental or investigational Medi-Cal treatment for a serious medical condition. 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. Patients must maintain a stable medication regimen for at least four weeks before device implantation. You can file a grievance. At IEHP, you will find opportunities to take initiative, expand your knowledge and advance your career while working a position that's both challenging and rewarding. 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. Becaplermin, a non-autologous growth factor for chronic, non-healing, subcutaneous (beneath the skin) wounds, and. 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. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. Who is covered? The List of Covered Drugs and pharmacy and provider networks may change throughout the year. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drugs manufacturer takes a drug off the market, we will take it off the Drug List. Concurrent with Carotid Stent Placement in FDA-Approved Post-Approvals Studies Our response will include our reasons for this answer. If you want to change plans, call IEHP DualChoice Member Services. CMS reviews studies to determine if they meet the criteria listed in Section 160.18 of the National Coverage Determination Manual. CMS has updated Chapter 1, section 160.18 of the Medicare National Coverage Determinations Manual. To stay a member of IEHP DualChoice, you must qualify again by the last day of the two-month period. 4. Possible errors in the amount (dosage) or duration of a drug you are taking. (Implementation date: October 2, 2017 for design and coding; January 1, 2018 for testing and implementation) Your PCP, along with the medical group or IPA, provides your medical care. If you need help to fill out the form, IEHP Member Services can assist you. Diagnostic Tests, X-Rays & Lab Services: $0, Home and Community Based Services (HCBS): $0, Community Based Adult Services (CBAS): $0, Long Term Care that includes custodial care and facility: $0. . PO2 may be performed by the treating practitioner or by a qualified provider or supplier of laboratory services. 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. We will give you our answer sooner if your health requires us to do so. For more detailed information on each of the NCDs including restrictions and qualifications click on the link after each NCD or call IEHP DualChoice Member Services at (877) 273-IEHP (4347) 8am-8pm (PST), 7 days a week, including holidays, or. If you need help during the appeals process, you can call the Office of the Ombudsman at 1-888-452-8609. Their shells are thick, tough to crack, and will likely stain your hands. If you need to change your PCP for any reason, your hospital and specialist may also change. IEHP Medi-Cal Member Services You do not need to do anything further to get this Extra Help. Then you can: 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 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. You can file a fast complaint and get a response to your complaint within 24 hours. (Effective: April 10, 2017) The letter will also tell how you can file a fast appeal about our decision to give you a fast coverage decision instead of the fast coverage decision you requested. Or, if you are asking for an exception, 24 hours after we get your doctors or prescribers statement supporting your request. You can contact Medicare. You can get services such as those listed below without getting approval in advance from your Primary Care Provider (PCP). We may not tell you before we make this change, but we will send you information about the specific change or changes we made. When can you end your membership in our plan? 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. 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. 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. We do the right thing by: Placing our Members at the center of our universe. If an alternative drug would be just as effective as the drug you are asking for, and would not cause more side effects or other health problems, we will generally not approve your request for an exception. If you would like to switch from our plan to Original Medicare but you have not selected a separate Medicare prescription drug plan. It also has care coordinators and care teams to help you manage all your providers and services. Consist of 30-60 minute sessions comprising of therapeutic exercise-training program for PAD; Be conducted in a hospital outpatient setting or physicians office; Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD; and. You will get a care coordinator when you enroll in IEHP DualChoice. Send us your request for payment, along with your bill and documentation of any payment you have made. Upon expiration, coverage will be determined by the local Medicare Administrative Contractors (MACs). There may be qualifications or restrictions on the procedures below. Mitral valve TEERs are covered for other uses not listed as an FDA-approved indication when performed in a clinical study and the following requirements are met: The procedure must be performed by an interventional cardiologist or cardiac surgeon. 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. Yes. If you have a fast complaint, it means we will give you an answer within 24 hours. Patients implanted with a VNS device for TRD may receive a VNS device replacement if it is required due to the end of battery life, or any other device-related malfunction. (Implementation Date: December 12, 2022) The treatment is considered reasonably likely to predict a clinical benefit and is administrated in a randomized controlled trial under an investigational new drug application. Organized as a Joint Powers Agency, Inland Empire Health Plan (IEHP) is a local, not-for-profit, public health plan. For more information on Grievances see Chapter 9 of your IEHP DualChoice Member Handbook. 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 you call us with a complaint, we may be able to give you an answer on the same phone call. When you are discharged from the hospital, you will return to your PCP for your health care needs. Call IEHP DualChoice Member Services if you need help in choosing a PCP or changing your PCP. Ask for an exception from these changes. The Office of the Ombudsmanis not connected with us or with any insurance company or health plan. The clinical research must evaluate the patients quality of life pre and post for a minimum of one year and answer at least one of the questions in this determination section. 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. Yes. Changing your Primary Care Provider (PCP). For the treatment of symptomatic moderate to severe mitral regurgitation (MR) when the patient still has symptoms, despite stable doses of maximally tolerated guideline directed medical therapy (GDMT) and cardiac resynchronization therapy, when appropriate and the following are met: Treatment is a Food and Drug Administration (FDA) approved indication. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. If you decide to make an appeal, it means you are going on to Level 1 of the appeals process. Transportation: $0. Drugs that may not be safe or appropriate because of your age or gender. 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, 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. If you decide to go on to a Level 2 Appeal, the Independent Review Entity (IRE) will review our decision. We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. If your health requires it, ask for a fast appeal, Our plan will review your appeal and give you our decision. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. Sacramento, CA 95899-7413. You must choose your PCP from your Provider and Pharmacy Directory. Oxygen therapy can be renewed by the MAC if deemed medically necessary. (Implementation Date: January 3, 2023) 2. You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage decision. 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. Screening computed tomographic colonography (CTC), effective May 12, 2009. chimeric antigen receptor (CAR) T-cell therapy coverage. The Independent Review Entity is an independent organization that is hired by Medicare. If we decide to take extra days to make the decision, we will tell you by letter. 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. You must apply for an IMR within 6 months after we send you a written decision about your appeal. Emergency services from network providers or from out-of-network providers. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. 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. IEHP DualChoice. D-SNP Transition. If you disagree with a coverage decision we have made, you can appeal our decision. i. What is a Level 2 Appeal? You will be notified when this happens. P.O. You may change your PCP for any reason, at any time. This is not a complete list. With "Extra Help," there is no plan premium for IEHP DualChoice. 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. Deadlines for standard appeal at Level 2. Level 2 Appeal for Part D drugs. For a patient demonstrating arterial PO2 at or above 56 mm Hg, or an arterial oxygen saturation at or above 89%, at rest and during the day. (Implementation Date: February 14, 2022) 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. The Level 3 Appeal is handled by an administrative law judge. Both of these processes have been approved by Medicare. You can also visit, You can make your complaint to the Quality Improvement Organization. The letter will tell you how to do this. Infected individuals may develop symptoms such as nausea, anorexia, fatigue, fever, and abdominal pain, or may be asymptomatic. If the coverage decision is No, how will I find out? CMS has updated Chapter 1, Part 1, Section 20.4 of the Medicare National Coverage Determinations Manual providing additional coverage criteria for Implantable Cardiac Defibrillators (ICD) for Ventricular Tachyarrhythmias (VTs). If IEHP DualChoice removes a Covered Part D drug or makes any changes in the IEHP DualChoice Formulary, we will post the formulary changes on IEHPDualChoice website and notify the affected Members at least thirty (30) days prior to effective date of the change made on the IEHP DualChoice Formulary. You do not need to give your doctor or other prescriber written permission to ask us for a coverage determination on your behalf. 8am - 8pm (PST), 7 days a week, including holidays, TTY: (800) 718-4347. You can get the form at. Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative Form. 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). (Effective: August 7, 2019) What is covered? Complex Care Management; Medi-Cal Demographic Updates . Use of autologous Platelet-Derived Growth Factor (PDGF) for treatment of chronic, non-healing, cutaneous (affecting the skin) wounds, and. If you have an urgent need for care, you probably will not be able to find or get to one of the providers in our plans network. This is not a complete list. 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 you disagree with our decision, you can ask the DMHC Help Center for an IMR. Click here for more information on study design and rationale requirements. 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 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. Remember, you can request to change your PCP at any time. Use of other PET radiopharmaceutical tracers for cancer may be covered at the discretion of local Medicare Administrative Contractors (MACs), when used in accordance to their Food and Drug Administration (FDA) approval indications. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. Also, its possible that your PCP might leave our plans network of providers and you would have to find a new PCP. Handling problems about your Medi-Cal benefits. 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. 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. If you ask for a fast appeal, we will give you your answer within 72 hours after we get your appeal.