Deadlines for standard appeal at Level 2. You will be notified when this happens. If we say No to your appeal, you then choose whether to accept this decision or continue by making another appeal. The services of SHIP counselors are free. Interventional Cardiologist meeting the requirements listed in the determination. Prescriptions written for drugs that have ingredients you are allergic to. 3. IEHP DualChoice, a Medicare Medi-Cal Plan, allows you to get your covered Medicare and Medi-Cal benefits through our plan. TTY/TDD users should call 1-800-718-4347. IEHP DualChoice (HMO D-SNP) has a process in place to identify and reduce medication errors. (Implementation Date: October 5, 2020). We take another careful look at all of the information about your coverage request. The letter you get from the IRE will explain additional appeal rights you may have. The Help Center cannot return any documents. Yes. The Centers of Medicare and Medicaid Services (CMS) will cover Ambulatory Blood Pressure Monitoring (ABPM) when specific requirements are met. This includes getting authorization to see specialists or medical services such as lab tests, x-rays, and/or hospital admittance. This service will be covered when the TAVR is used, for the treatment of symptomatic aortic valve stenosis. With "Extra Help," there is no plan premium for IEHP DualChoice. Effective September 27, 2021, CMS has updated section 240.2 of the National Coverage Determination Manual to cover oxygen therapy and oxygen equipment for in home use of both acute and chronic conditions, short- or long- term, when a patient exhibits hypoxemia. You must ask to be disenrolled from IEHP DualChoice. There is no deductible for IEHP DualChoice. If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we get your appeal. If you want the Independent Review Organization to review your case, your appeal request must be in writing. Effective on September 26, 2022, CMS has updated section 50.3 of the National Coverage Determination (NCD) Manual that expands coverage on cochlear implants for the treatment of bilateral pre- or post- linguistic, sensorineural, moderate-to-profound hearing loss when the individual demonstrates limited benefit from amplification under Medicare Part B. All the changes are reviewed and approved by a selected group of Providers and Pharmacists that are currently in practice. Fecal Occult Blood Tests (gFOBT) once every 12 months, The Cologuard Multi-target Stool DNA (sDNA) Test once every 3 years, Blood-based Biomarker Tests once every 3 years, Diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with limited benefit, Cognitive ability to use hearing clues and a willingness to undergo an extended program of rehabilitation, Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, and freedom from lesions in the hearing nerve and acoustic areas of the central nervous system, No indicated risks to surgery that are determined harmful or inadvisable, The device must be used in accordance with Food and Drug Administration (FDA) approved labeling, You can complete the Member Complaint Form. You or someone you name may file a grievance. If your Level 2 Appeal went to the Medicare Independent Review Entity, it will send you a letter explaining its decision. 2023 IEHP DualChoice Member Handbook (PDF), Click here to download a free copy of Adobe Acrobat Reader. Covering a Part D drug that is not on our List of Covered Drugs (Formulary). The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. Program Services There are five services eligible for a financial incentive. According to the FDA labeling in an MRI environment, MRI coverage will be provided for beneficiaries under certain conditions. 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. A drug is taken off the market. We will send you a notice before we make a change that affects you. Direct and oversee the process of handling difficult Providers and/or escalated cases. 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. Beneficiaries not meeting all the criteria for cochlear implants are deemed not eligible for Medicare coverage except for FDA-approved clinical trials as described in the NCD. 10820 Guilford Road, Suite 202 Click here for information on Next Generation Sequencing coverage. (Implementation date: December 18, 2017) 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. 2. Who is covered: Your doctor will also know about this change and can work with you to find another drug for your condition. 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. If you are having a problem with your care, you can call the Office of Ombudsman at 1-888-452-8609for help. What is a Level 1 Appeal for Part C services? Receive Member informing materials in alternative formats, including Braille, large print, and audio. According to IEHP, 99.4 percent of enrollees retained the same primary care physicians. Within 10 days of the mailing date of our notice of action; or. When you choose a PCP, it also determines what hospital and specialist you can use. Sign up for the free app through our secure Member portal. Removing a restriction on our coverage. 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). TTY users should call 1-800-718-4347. To find the name, address, and phone number of the Quality Improvement Organization in your state, lookin Chapter 2 of your. according to the FDA-approved indications and the following conditions are met: The procedure and implantation system received FDA premarket approval (PMA) for that system's FDA approved indication. To learn more about the plans benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook. This will give you time to talk to your doctor or other prescriber. TTY should call (800) 718-4347. Have a Primary Care Provider who is responsible for coordination of your care. Drugs that may not be necessary because you are taking another drug to treat the same medical condition. TTY/TDD users should call 1-800-430-7077. My Choice. You have a right to appeal or ask for Formulary exception if you disagree with the information provided by the pharmacist. 2. Concurrent with Carotid Stent Placement in FDA-Approved Post-Approvals Studies Decide in advance how you want to be cared for in case you have a life-threatening illness or injury. This service will be covered only for beneficiaries diagnosed with chronic Lower Back Pain (cLBP) when the following conditions are met: All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare. Choose a PCP that is within 10 miles or 15 minutes of your home. This can speed up the IMR process. Patients depressive illness meets a minimum criterion of four prior failed treatments of adequate dose and duration as measured by a tool designed for this purpose. The phone number for the Office of the Ombudsman is 1-888-452-8609. (SeeChapter 10 ofthe. 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. Calls to this number are free. We will let you know of this change right away. The Office of the Ombudsman. IEHP DualChoice will help you with the process. VNS is non-covered for the treatment of TRD when furnished outside of a CMS-approved CED study. This gives you time to talk with your provider about getting a different drug or to ask us to cover the drug. If you do not stay continuously enrolled in Medicare Part A and Part B. You should not pay the bill yourself. Our plan usually cannot cover off-label use. If our answer is No to part or all of what you asked for, we will send you a letter. 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. Suppose that you are temporarily outside our plans service area, but still in the United States. If you do not want to first appeal to the plan for a Medi-Cal service, in special cases you can ask for an Independent Medical Review. It usually takes up to 14 calendar days after you asked. Some of the advantages include: You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. 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. TTY users should call 1-877-486-2048. Join our Team and make a difference with us! 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. ((Effective: December 7, 2016) Your benefits as a member of our plan include coverage for many prescription drugs. Medicare beneficiaries may be covered with an affirmative Coverage Determination. We will contact the provider directly and take care of the problem. What if the Independent Review Entity says No to your Level 2 Appeal? After your application and supporting documents are received from your plan, the IMR decision will be made within 30 calendar days. 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. Bringing focus and accountability to our work. We must give you our answer within 30 calendar days after we get your appeal. Yes. What is covered: If you are making a complaint because we denied your request for a fast coverage determination or fast appeal, we will automatically give you a fast complaint. Livanta is not connect with our plan. Or, if you havent paid for the service or item yet, we will send the payment directly to the provider. ii. Breathlessness without cor pulmonale or evidence of hypoxemia; or. A clinical test providing the measurement of arterial blood gas. Click here for more information on MRI Coverage. You, your doctor or other prescriber, or your representative can request the Level 2 Appeal. Or you can make your complaint to both at the same time. You can call the California Department of Social Services at (800) 952-5253. The Independent Review Entity is an independent organization that is hired by Medicare. https://www.medicare.gov/MedicareComplaintForm/home.aspx. 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. 2023 IEHP DualChoice Provider and Pharmacy Directory (PDF), http://www.dmhc.ca.gov/FileaComplaint/SubmitanIndependentMedicalReviewComplaintForm.aspx, Request for Medicare Prescription Drug Coverage Determination (PDF). Follow the appeals process. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. TTY users should call (800) 537-7697. Effective for claims with dates of service on or after 12/07/16, Medicare will cover PILD under CED for beneficiaries with LSS when provided in an approved clinical study. Terminal illnesses, unless it affects the patients ability to breathe. All of our Doctors offices and service providers have the form or we can mail one to you. 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. Whether you call or write, you should contact IEHP DualChoice Member Services right away. (Implementation Date: December 10, 2018). Please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. When that happens, we may remove the current drug, but your cost for the new drug will stay the same or will be lower. In most cases you have 120 days to ask for a State Hearing after the Your Hearing Rights notice is mailed to you. Get a 31-day supply of the drug before the change to the Drug List is made, or. 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. But if you do pay the bill, you can get a refund if you followed the rules for getting services and items. Click here for more detailed information on PTA coverage. Then, we check to see if we were following all the rules when we said No to your request. More. See Chapters 7 and 9 of the IEHP DualChoice Member Handbookto learn how to ask the plan to pay you back. Generally, IEHP DualChoice (HMO D-SNP) will cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. We will give you our answer sooner if your health requires us to. You can send your complaint to Medicare. Concurrent with Carotid Stent Placement in Food and Drug Administration (FDA) Approved Category B Investigational Device Exemption (IDE) Clinical Trials ii. a clinical indication for germline (inherited) testing for hereditary breast or ovarian cancer and; a risk factor for germline (inherited) breast or ovarian cancer and; not been previously tested with the same germline test using NGS for the same germline genetic content. A Cal MediConnect Plan is an organization made up of Doctors, Hospitals, Pharmacies, Providers of long-term services and supports, Behavioral Health Providers, and other Providers. 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. Be prepared for important health decisions 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. We will give you our decision sooner if your health condition requires us to. You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage decision. Your IEHP DualChoice Doctor cannot charge you for covered health care services, except for required co-payments. Sometimes a specialist, clinic, hospital or other network provider you are using might leave the plan. Click here for more information onICD Coverage. PILD is a posterior decompression of the lumbar spine performed under indirect image guidance without any direct visualization of the surgical area. The Heart team must participate in the national registry and track outcomes according to the requirements in this determination.>. Use the IEHP Medicare Prescription Drug Coverage Determination Form for a prior authorization. Pay rate will commensurate with experience. In most cases, you must file an appeal with us before requesting an IMR. Beneficiaries receiving treatment for implanting a ventricular assist device (VAD), when the following requirements are met and: All other indications for the use of VADs not otherwise listed remain non-covered, except in the context of Category B investigational device exemption clinical trials (42 CFR 405) or as a routine cost in clinical trials defined under section 310.1 of the National Coverage Determinations (NCD) Manual. You or your provider can ask for an exception from these changes. If your treatment was denied because it was experimental or investigational, you do not have to take part in our appeal process before you apply for an IMR. If PO2 and arterial blood gas results are conflicting, the arterial blood gas results are preferred source to determine medical need. 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. 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. Noncoverage specifically includes the following: Click here for more information on Ambulatory Electroencephalographic Monitoring and Colorectal Cancer Screening Tests. At Level 2, an outside independent organization will review your request and our decision. You will get a letter from us about the change in your eligibility with instructions to correct your eligibility information. A care team can help you. When will I hear about a standard appeal decision for Part C services? The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.). 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. To be a Member of IEHP DualChoice, you must keep your eligibility with Medi-Cal and Medicare. If your Level 2 Appeal went to the Medicare Independent Review Entity, you can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. If you have been receiving care from a health care provider, you may have a right to keep your provider for a designated time period. Rancho Cucamonga, CA 91729-1800. You have the right to choose someone to represent you during your appeal or grievance process and for your grievancesand appeals to be reviewed as quickly as possible and be told how long it will take. If the answer is No, we will send you a letter telling you our reasons for saying No. (Effective: August 7, 2019) 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. How to Enroll with IEHP DualChoice (HMO D-SNP), IEHP Texting Program Terms and Conditions. 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. If we say no to part or all of your Level 1 Appeal, we will send you a letter. We will cover your prescription at an out-of-network pharmacy if at least one of the following applies: If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than paying your normal share of the cost) when you fill your prescription. You can ask us to reimburse you for IEHP DualChoice's share of the cost. 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. This section is about asking for coverage decisions and making appeals with problems related to your benefits and coverage. 1. How do I make a Level 1 Appeal for Part C services? The intended effective date of the action. 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. (Implementation Date: January 3, 2023) Complain about IEHP DualChoice, its Providers, or your care. Get the My Life. For more information on Medical Nutrition Therapy (MNT) coverage click here. 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. 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. TTY: 1-800-718-4347. The Centers of Medicare and Medicaid Services (CMS) will cover acupuncture for chronic low back pain (cLBP) when specific requirements are met. You must apply for an IMR within 6 months after we send you a written decision about your appeal. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug. 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. Your care team and care coordinator work with you to make a care plan designed to meet your health needs. CMS has added a new section, Section 20.35, to Chapter 1 entitled Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). To learn how to submit a paper claim, please refer to the paper claims process described below. Department of Health Care Services 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. What is covered? 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). CMS reviews studies to determine if they meet the criteria listed in Section 160.18 of the National Coverage Determination Manual. You can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. 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. There are two ways to ask for a State Hearing: If you meet this deadline, you can keep getting the disputed service or item until the hearing decision is made. (You cannot get a fast coverage decision coverage decision if your request is about payment for care or an item you have already received.). If you think your health requires it, you should ask for a fast appeal. If you are asking us to pay you back for a drug you already bought, we must give you our answer within 14 calendar days after we get your appeal. Mail your request for payment together with any bills or receipts to us at this address: IEHPDualChoice Previous Next ===== TABBED SINGLE CONTENT GENERAL. Remember, you can request to change your PCP at any time.
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