Opportunities to Grow. You can send your complaint to Medicare. What is covered: If we say No to your request for an exception, you can ask for a review of our decision by making an appeal. 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, The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. This is not a complete list. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. Program Services There are five services eligible for a financial incentive. If you prefer a different one, please call IEHP DualChoice Member Services and we can assist you in finding and selecting another provider. Information on this page is current as of October 01, 2022. It also has care coordinators and care teams to help you manage all your providers and services. The phone number is (888) 452-8609. CMS has updated Chapter 1, Part 2, Section 90.2 of the Medicare National Coverage Determinations Manual to include NGS testing for Germline (inherited) cancer when specific requirements are met and updated criteria for coverage of Somatic (acquired) cancer. If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan. You pay no costs for an IMR. A Level 2 Appeal is the second appeal, which is done by an independent organization that is not connected to the plan. To ask if your PCP or other providers are in our network in 2023, call IEHP DualChoice Member Services. 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. What kinds of medical care and other services can you get without getting approval in advance from your Primary Care Provider (PCP) in IEHP DualChoice (HMO D-SNP)? 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. For example, you can make a complaint about disability access or language assistance. a. You can also have a lawyer act on your behalf. 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). Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. ii. What if the plan says they will not pay? If your health requires it, ask us to give you a fast coverage decision Most complaints are answered in 30 calendar days. TTY should call (800) 718-4347. Sign up for the free app through our secure Member portal. If the service or item you paid for is covered and you followed all the rules, we will send you the payment for our share of the cost of the service or item within 60 calendar days after we get your request. You can change your Doctor by calling IEHP DualChoice Member Services. Effective on April 7, 2022, CMS has updated section 200.3 of the National Coverage Determination (NCD) Manual to cover Food and Drug Administration (FDA) approved monoclonal antibodies directed against amyloid for treatment of Alzheimers Disease (AD) when the coverage criteria below is met. If your health condition requires us to answer quickly, we will do that. 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. Ask for the type of coverage decision you want. What is covered? You should receive the IMR decision within 45 calendar days of the submission of the completed application. 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. For additional details on how to reach us for appeals, see Chapter 9 of the IEHP DualChoice Member Handbook. Information on this page is current as of October 01, 2022 10820 Guilford Road, Suite 202 The letter will also explain how you can appeal our decision. Please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals). We will review our coverage decision to see if it is correct. For some drugs, the plan limits the amount of the drug you can have. 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 72 hours after we get the decision. They can also answer your questions, give you more information, and offer guidance on what to do. We determine an existing relationship by reviewing your available health information available or information you give us. Click here for more information on chimeric antigen receptor (CAR) T-cell therapy coverage. If your doctor says that you need a fast coverage decision, we will automatically give you one. This includes: The device is used following post-cardiotomy (period following open heart surgery) to support blood circulation. How to obtain an aggregate number of grievances, appeals, and exceptions filed with IEHP DualChoice (HMO D-SNP)? Breathlessness without cor pulmonale or evidence of hypoxemia; or. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. The letter will tell you how to make a complaint about our decision to give you a standard decision. If you let someone else use your membership card to get medical care. National Coverage determinations (NCDs) are made through an evidence-based process. (Implementation Date: September 20, 2021). If you wish, you and your doctor or other prescriber may give us additional information to support your appeal. 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. Information on this page is current as of October 01, 2022. How to Enroll with IEHP DualChoice (HMO D-SNP) To learn how to submit a paper claim, please refer to the paper claims process described below. You can call IEHP DualChoice at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. What if you are outside the plans service area when you have an urgent need for care? (Implementation Date: June 12, 2020). If we say Yes to your request for an exception, the exception usually lasts until the end of the calendar year. 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. 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. For more information on Member Rights and Responsibilities refer to Chapter 8 of your. 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. The procedure must be performed by an interventional cardiologist or cardiac surgeon.<. If you are unable to get a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service. If your Level 2 Appeal was an Independent Medical Review, you can request a State Hearing. English Walnuts. Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. 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). We take another careful look at all of the information about your coverage request. 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. IEHP DualChoice will honor authorizations for services already approved for you. Information is also below. View Plan Details. Your doctor or other provider can make the appeal for you. We have arranged for these providers to deliver covered services to members in our plan. These different possibilities are called alternative drugs. Box 1800 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). How to Enroll with IEHP DualChoice (HMO D-SNP), IEHP Texting Program Terms and Conditions. If the Independent Review Entity says No to part or all of what you asked for, it means they agree with the Level 1 decision. For example, you can make a complaint about disability access or language assistance. This government program has trained counselors in every state. Yes. You can always contact your State Health Insurance Assistance Program (SHIP). When we add the new generic drug, we may also decide to keep the current drug on the list but change its coverage rules or limits. 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. When possible, take along all the medication you will need. CMS-approved studies of a monoclonal antibody directed against amyloid approved by the FDA for the treatment of AD based upon evidence of efficacy from a direct measure of clinical benefit must address all of the questions included in section B.4 of this National Coverage Determination. The extra rules and restrictions on coverage for certain drugs include: Being required to use the generic version of a drug instead of the brand name drug. Make your appeal request within 60 calendar days from the date on the notice we sent to tell you our decision. 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. Interventional Cardiologist meeting the requirements listed in the determination. Members \. Get Help from an Independent Government Organization. IEHP DualChoice TTY users should call (800) 537-7697. Box 1800 The care team helps coordinate the services you need. The Centers of Medicare and Medicaid Services (CMS) will cover Vagus Nerve Stimulation (VNS) for treatment-resistant depression when specific requirements are met. Black walnut trees are not really cultivated on the same scale of English walnuts. However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. The procedure removes a portion of the lamina in order to debulk the ligamentum flavum, essentially widening the spinal canal in the affected area. 2020) We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. You can still get a State Hearing. Get a 31-day supply of the drug before the change to the Drug List is made, or. To the California Department of Social Services: To the State Hearings Division at fax number 916-651-5210 or 916-651-2789. P.O. ii. Appointment of Representatives Form (PDF), 2023 Drugs Requiring Prior Authorization (PDF). 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. From time to time (during the benefit year), IEHP DualChoice revises (adding or removing drugs) the Formulary based on new clinical evidence and availability of products in the market. Here are examples of coverage determination you can ask us to make about your Part D drugs. 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. 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. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you. For other types of problems you need to use the process for making complaints. If this happens, you will have to switch to another provider who is part of our Plan. All the changes are reviewed and approved by a selected group of Providers and Pharmacists that are currently in practice. H8894_DSNP_23_3241532_M. Who is covered: You may also ask for an appeal by calling IEHP DualChoice Member Services at 1-877-273-IEHP (4347), 8am 8pm (PST), 7 days a week, including holidays. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. (Implementation Date: October 3, 2022) 2) State Hearing IEHP DualChoice (HMO D-SNP) has a list of Covered Drugs called a Formulary. Here are two ways to get help from the Help Center: You can file a complaint with the Office for Civil Rights. (SeeChapter 10 ofthe. 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. The reviewer will be someone who did not make the original coverage decision. How will the plan make the appeal decision? The leadless pacemaker eliminates the need for a device pocket and insertion of a pacing lead which are integral elements of traditional pacing systems. If you need help to fill out the form, IEHP Member Services can assist you. If you move out of our service area for more than six months. 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. This is true even if we pay the provider less than the provider charges for a covered service or item. Rancho Cucamonga, CA 91729-1800 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. It also includes problems with payment. The program is not connected with us or with any insurance company or health plan. 2023 IEHP DualChoice Member Handbook (PDF), Click here to download a free copy of Adobe Acrobat Reader. You can ask for a copy of the information in your appeal and add more information. If we dont give you our decision within 14 calendar days, you can appeal.
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