If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan. Click here to learn more about IEHP DualChoice. They all work together to provide the care you need. Are a United States citizen or are lawfully present in the United States. If you are admitted to one of these hospitals, a hospitalist may serve as your caregiver as long as you remain in the hospital. Cardiologists care for patients with heart conditions. TTY/TDD (800) 718-4347. When we send the payment, its the same as saying Yes to your request for a coverage decision. 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 can file a fast complaint and get a response to your complaint within 24 hours. (Implementation Date: January 17, 2022). Will my benefits continue during Level 1 appeals? If your doctor says that you need a fast coverage decision, we will automatically give you one. 2020) Yes. (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. TTY/TDD (877) 486-2048. 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. 2. Choose a PCP that is within 10 miles or 15 minutes of your home. i. Arterial PO2 at or below 55 mm Hg or arterial oxygen saturation at or below 88% when tested at rest in breathing room air, or; You will be automatically enrolled in IEHP DualChoice and do not need to do anything to keep these services. What is covered? In these situations, please check first with IEHP DualChoice Member Services to see if there is a network pharmacy nearby. Possible errors in the amount (dosage) or duration of a drug you are taking. https://www.medicare.gov/MedicareComplaintForm/home.aspx. Click here for more information on Cochlear Implantation. You may be able to get extra help to pay for your prescription drug premiums and costs. 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. You can also visit, You can make your complaint to the Quality Improvement Organization. ((Effective: December 7, 2016) You have the right to ask us for a copy of the information about your appeal. (Effective: April 7, 2022) Rancho Cucamonga, CA 91729-1800. Follow the appeals process. a. H8894_DSNP_23_3879734_M Pending Accepted. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. 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). Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities; or. You will need Adobe Acrobat Reader6.0 or later to view the PDF files. Medicare will cover both MNT and Diabetes Outpatient Self-Management Training (DSMT) during initial and subsequent years, if the physician determines treatment is medically necessary and as long as DSMT and MNT are not provided on the same date. 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). What is covered? 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. You can tell Medicare about your complaint. Effective for claims with dates of service on or after 01/18/17, Medicare will cover leadless pacemakers under CED when procedures are performed in CMS-approved studies. Handling problems about your Medi-Cal benefits. Certain combinations of drugs that could harm you if taken at the same time. Limitations, copays, and restrictions may apply. If you have any other feedback or concerns, or if you feel the plan is not addressing your problem, please call (800) MEDICARE (800) 633-4227). The Medicare Complaint Form is available at: The Office of the Ombudsman also helps solve problems from a neutral standpoint to make sure that our members get all the covered services that we must provide. Your PCP will also help you arrange or coordinate the rest of the covered services you get as a member of our Plan. Call our transportation vendor Call the Car (CTC) at (866) 880-3654, for TTY users, call your relay service or California Relay Service at 711. Send copies of documents, not originals. The person you name would be your representative. You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Try to choose a PCP that can admit you to the hospital you want within 30 miles or 45 minutes of your home. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. You have a right to appeal or ask for Formulary exception if you disagree with the information provided by the pharmacist. 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. Click here for more information on Topical Applications of Oxygen. To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for an coverage decision. The Centers of Medicare and Medicaid Services (CMS) will cover acupuncture for chronic low back pain (cLBP) when specific requirements are met. For more information see Chapter 9 of your IEHP DualChoice Member Handbook. 5. The form gives the other person permission to act for you. 2. You can call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. We also review our records on a regular basis. If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. If you are asking for a standard appeal or fast appeal, make your appeal in writing: You may also ask for an appeal by calling IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. You should receive the IMR decision within 7 calendar days of the submission of the completed application. Information on this page is current as of October 01, 2022. H8894_DSNP_23_3241532_M. ii. This service will be covered when the TAVR is used, for the treatment of symptomatic aortic valve stenosis. The clinical test must be performed at the time of need: Beneficiaries must be managed by a team of medical professionals meeting the minimum requirements in the National Coverage Determination Manual. If you miss this deadline and have a good reason for missing it, we may give you more time to make you appeal. This is asking for a coverage determination about payment. What if the Independent Review Entity says No to your Level 2 Appeal? A Level 1 Appeal is the first appeal to our plan. Please call or write to IEHP DualChoice Member Services. Call IEHP DualChoice Member Services if you need help in choosing a PCP or changing your PCP. A PCP is your Primary Care Provider. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. A reasonable salary expectation is between $51,833.60 and $64,022.40, based upon experience and internal equity. An interventional echocardiographer must perform transesophageal echocardiography during the procedure. 2023 IEHP DualChoice Provider and Pharmacy Directory (PDF), http://www.dmhc.ca.gov/FileaComplaint/SubmitanIndependentMedicalReviewComplaintForm.aspx, Request for Medicare Prescription Drug Coverage Determination (PDF). Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. Beneficiaries receiving autologous treatment for cancer with T-cell expressing at least one. (Effective: July 2, 2019) You may also contact the local Office for Civil Rights office at: U.S. Department of Health and Human Services. Effective for dates of service on or after January 19, 2021, CMS has updated section 20.33 of the National Coverage Determination Manual to cover Transcatheter Edge-to-Edge Repair (TEER) for Mitral Valve Regurgitation when specific requirements are met. 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. 2) State Hearing You can ask us to make a faster decision, and we must respond in 15 days. Program Services There are five services eligible for a financial incentive. You can get a fast coverage decision only if the standard 14 calendar day deadline could cause serious harm to your health or hurt your ability to function. How will the plan make the appeal decision? All physicians participating in the procedure must have device-specific training by the manufacturer of the device. There is no deductible for IEHP DualChoice. Some of the advantages include: You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. When your complaint is about quality of care. 4. 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. If you have a fast complaint, it means we will give you an answer within 24 hours. It tells which Part D prescription drugs are covered by IEHP DualChoice. There are also limited situations where you do not choose to leave, but we are required to end your membership. You pay no costs for an IMR. Call IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Treatment of Atherosclerotic Obstructive Lesions 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). By clicking on this link, you will be leaving the IEHP DualChoice website. 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. 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 the Independent Medical Review decision is Yes to part or all of what you asked for, we must provide the service or treatment. 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. We may stop any aid paid pending you are receiving. If the State Hearing decision is Yes to part or all of what you asked for, we must comply with the decision. You can call the California Department of Social Services at (800) 952-5253. This is known as Exclusively Aligned Enrollment, and. We have arranged for these providers to deliver covered services to members in our plan. The clinical study must address whether VNS treatment improves health outcomes for treatment resistant depression compared to a control group, by answering all research questions listed in 160.18 of the National Coverage Determination Manual. 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. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. You must apply for an IMR within 6 months after we send you a written decision about your appeal. Click here for more information on Positron Emission Tomography NaF-18 (NaF-18 PET) to Identify Bone Metastasis of Cancer coverage. Receive emergency care whenever and wherever you need it. When a provider leaves a network, we will mail you a letter informing you about your new provider. Get the My Life. After your coverage begins with IEHP DualChoice, you must receive medical services and prescription drug services in the IEHP DualChoice network. Here are examples of coverage determination you can ask us to make about your Part D drugs. Who is covered: Beneficiaries receiving treatment for chronic non-healing diabetic wounds for a duration of 20 weeks, when prepared by a device cleared by the Food and Drug Administration (FDA) for the management of exuding (bleeding, oozing, seeping, etc.) When possible, take along all the medication you will need. (Effective: August 7, 2019) 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. Click here to download a free copy of Adobe Acrobat Reader.By clicking on this link, you will be leaving the IEHP DualChoice website. This is called upholding the decision. It is also called turning down your appeal.. 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. IEHP Direct contracted PCPs who provide service to IEHP Direct DualChoice Members. Yes. Call, write, or fax us to make your request. For more information on Grievances see Chapter 9 of your IEHP DualChoice Member Handbook. Related Resources. For CMS-approved studies, the protocol, including the analysis plan, must meet requirements listed in this NCD. The English walnut has a soft and thin shell that makes it easy to crack, while the black walnut has a tougher shell, one of the hardest of all the nuts. Click here for more information on study design and rationale requirements. Who is covered: 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. IEHP DualChoice. Or your doctor or other prescriber can tell us on the phone, and then fax or mail a statement. Tier 1 drugs are: generic, brand and biosimilar drugs. 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. The benefit information is a brief summary, not a complete description of benefits. Be prepared for important health decisions 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%. ), and, Are age 21 and older at the time of enrollment, and, Have both Medicare Part A and Medicare Part B, and, Are a full-benefit dual eligible beneficiary and enroll in IEHP DualChoice for your Medicare benefits and Inland Empire Health Plan (IEHP) for your Medi-Cal benefits. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision. The USPTF has found that screening for HBV allows for early intervention which can help decrease disease acquisition, transmission and, through treatment, improve intermediate outcomes for those infected. 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. If you are requesting an exception, provide the supporting statement. Your doctor or other prescriber must give us the medical reasons for the drug exception. (If possible, please call IEHP DualChoice Member Services before you leave the service area so we can help arrange for you to have maintenance dialysis while you are away.). If your problem is about a Medi-Cal service or item, you can file a Level 2 Appeal yourself. 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. For more information on Medical Nutrition Therapy (MNT) coverage click here. This section is about asking for coverage decisions and making appeals with problems related to your benefits and coverage. If you dont know what you should have paid, or you receive bills and you dont know what to do about those bills, we can help. You, your representative, or your doctor (or other prescriber) can do this. You can ask us to reimburse you for IEHP DualChoice's share of the cost. If your Level 2 Appeal was an Independent Medical Review, you can request a State Hearing. (Implementation Date: July 2, 2018). 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. 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. The form gives the other person permission to act for you. The Help Center cannot return any documents.
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