If you no longer qualify for Medi-Cal or your circumstances have changed that make you no longer eligible for Dual Special Needs Plan, you may continue to get your benefits from IEHP DualChoice for an additional two-month period. 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. Members \. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. 1. You must apply for an IMR within 6 months after we send you a written decision about your appeal. 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. Orthopedists care for patients with certain bone, joint, or muscle conditions. 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. If patients with bipolar disorder are included, the condition must be carefully characterized. You can also have your doctor or your representative call us. Or your doctor or other prescriber can tell us on the phone, and then fax or mail a statement. You should not pay the bill yourself. If you are admitted to one of these hospitals, a hospitalist may serve as your caregiver as long as you remain in the hospital. (Effective: December 15, 2017) Calls to this number are free. You can file a grievance online. Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States. 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. The letter you get from the IRE will explain additional appeal rights you may have. 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. 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. You should receive the IMR decision within 7 calendar days of the submission of the completed application. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. You will be automatically enrolled in IEHP DualChoice and do not need to do anything to keep these services. 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. 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. The State or Medicare may disenroll you if you are determined no longer eligible to the program. If you are asking for a standard appeal, you can make your appeal by sending a request in writing. Denies, changes, or delays a Medi-Cal service or treatment (not including IHSS) because our plan determines it is not medically necessary. The problem with using black walnuts in cooking is the fact that the black walnuts have a very tough shell and the nuts are difficult to extract. To find the name, address, and phone number of the Quality Improvement Organization in your state, lookin Chapter 2 of your. The DMHC may accept your application after 6 months if it determines that circumstances kept you from submitting your application in time. (Implementation Date: December 12, 2022) Drugs that may not be necessary because you are taking another drug to treat the same medical condition. You can call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. 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. Contact us promptly call IEHP DualChoice at (877) 273-IEHP (4347), 8am - 8pm, 7 days a week, including holidays.TTY users should call 1-800-718-4347. Can I get a coverage decision faster for Part C services? In most cases, you must file an appeal with us before requesting an IMR. You have a right to give the Independent Review Entity other information to support your appeal. Flu shots as long as you get them from a network provider. IEHP DualChoice network providers are required to comply with minimum standards for pharmacy practices as established by the State of California. You ask us to pay for a prescription drug you already bought. Within 10 days of the mailing date of our notice to you that the adverse benefit determination (Level 1 appeal decision) has been upheld; or. Asking us to cover a Part D drug that is not on the plans List of Covered Drugs (Formulary), Asking us to waive a restriction on the plans coverage for a drug (such as limits on the amount of the drug you can get). We determine an existing relationship by reviewing your available health information available or information you give us. TDD users should call (800) 952-8349. This is not a complete list. We must give you our answer within 14 calendar days after we get your request. 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. There are two ways to make a Level 2 appeal for Medi-Cal services and items: 1) Independent Medical Review or 2) State Hearing. 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. Remember, you can request to change your PCP at any time. Advance care planning (ACP) involves shared decision making to write down-in an advance care directive-a persons wishes about their future medical care. 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. In most cases, you must start your appeal at Level 1. 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. Request and receive appeal data from IEHP DualChoice; Receive notice when an appeal is forwarded to the Independent Review Entity (IRE); Automatic reconsideration by the IRE when IEHP DualChoice upholds its original adverse determination in whole or in part; Administrative Law Judge (ALJ) hearing if the independent review entity upholds the original adverse determination in whole or in part and the remaining amount in controversy is $100 or more; Request Departmental Appeals Board (DAB) review if the ALJ hearing is unfavorable to the Member in whole or in part; Judicial review of the hearing decision if the ALJ hearing and/or DAB review is unfavorable to the Member in whole or in part and the amount remaining in controversy is $1,000 or more; Make a quality of care complaint under the QIO process; Request QIO review of a determination of noncoverage of inpatient hospital care; Request QIO review of a determination of noncoverage in skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities; Request a timely copy of your case file, subject to federal and state law regarding confidentiality of patient information; Challenge local and national Medicare coverage determination. Click here for more information on Leadless Pacemakers. Your test results are shared with all of your doctors and other providers, as appropriate. IEHP: "Inland Empire Health Plan (IEHP) is a not-for-profit Medi-Cal and Medicare health plan headquartered in Rancho Cucamonga, California. 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. Please select one of the following: Primary Care Doctor Specialist Behavioral Health Hospitals Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. We add a generic drug that is not new to the market and: Replace a brand name drug currently on the Drug List or. 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. Your doctor or other provider can make the appeal for you. To start your appeal, you, your doctor or other prescriber, or your representative must contact us. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. 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. Please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. ((Effective: December 7, 2016) After your application and supporting documents are received from your plan, the IMR decision will be made within 30 calendar days. Never wavering in our commitment to our Members, Providers, Partners, and each other. (Implementation Date: June 12, 2020). It stores all your advance care planning documents in one place online. You have a care team that you help put together. You may also contact the local Office for Civil Rights office at: U.S. Department of Health and Human Services. Getting plan approval before we will agree to cover the drug for you. Some changes to the Drug List will happen immediately. 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). If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. It also needs to be an accepted treatment for your medical condition. There may be qualifications or restrictions on the procedures below. If IEHP DualChoice removes a covered Part D drug or makes any changes in the IEHP DualChoice Formulary, IEHP DualChoice will post the formulary changes on the IEHP DualChoice 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 will keep all of your Medicare and Medi-Cal benefits. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. 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. IEHP DualChoice develops and maintains the Formulary continuously by reviewing the efficacy (how effective) and safety (how safe) of new drugs, compare new versus existing drugs, and develops clinical practice guidelines based on clinical evidence. The reviewer will be someone who did not make the original coverage decision. This statement will also explain how you can appeal our decision. (800) 718-4347 (TTY), IEHP DualChoice Member Services If your Level 2 Appeal was an Independent Medical Review, the Department of Managed Health Care will send you a letter explaining its decision. If your Level 2 Appeal was an Independent Medical Review, you can request a State Hearing. You have the right to ask us for a copy of the information about your appeal. If your PCP leaves our Plan, we will let you know and help you choose another PCP so that you can keep getting covered services. 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. 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. (Implementation date: October 2, 2017 for design and coding; January 1, 2018 for testing and implementation) A care team can help you. TTY/TDD (800) 718-4347. disease); An additional 8 sessions will be covered for those patients demonstrating an improvement. Receive emergency care whenever and wherever you need it. When we complete the review, we will give you our decision in writing. If we decide to take extra days to make the decision, we will tell you by letter. He or she can work with you to find another drug for your condition. We will look into your complaint and give you our answer. How will I find out about the decision? If you miss this deadline and have a good reason for missing it, we may give you more time to make you appeal. What is covered: 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. You will be notified when this happens. IEHP offers a competitive salary and stellar benefit package . If you decide to go on to a Level 2 Appeal, the Independent Review Entity (IRE) will review our decision. 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 asking for exceptions, see Chapter 9 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]). If you or your doctor disagree with our decision, you can appeal. TTY users should call 1-800-718-4347. CMS has revised Chapter 1, Section 20.29, Subsection C Topical Application of Oxygen to remove the exclusion of this treatment. iii. You may use the following form to submit an appeal: Can someone else make the appeal for me? Rancho Cucamonga, CA 91729-1800. The Centers of Medicare and Medicaid Services (CMS) will cover Vagus Nerve Stimulation (VNS) for treatment-resistant depression when specific requirements are met. Unless you change plans, IEHP DualChoice (HMO D-SNP) will provide your Medicare benefits. TTY users should call 1-800-718-4347. Review, request changes to, and receive a copy of your medical records in a timely fashion. However, your PCP can always use Language Line Services to get help from an interpreter, if needed. At Level 2, an outside independent organization will review your request and our decision. Drugs that may not be safe or appropriate because of your age or gender. Medi-Cal is public-supported health care coverage. (800) 720-4347 (TTY). of the appeals process. Be informed regarding Advance Directives, Living Wills, and Power of Attorney, and to receive information regarding changes related to existing laws. You can ask for a State Hearing for Medi-Cal covered services and items. 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. Click here to download a free copy by clicking Adobe Acrobat Reader. The care team helps coordinate the services you need. If you don't have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself. You must submit your claim to us within 1 year of the date you received the service, item, or drug. Effective on January 1, 2023, CMS has updated section 210.3 of the NCD Manual that provides coverage for colorectal cancer (CRC) screening tests under Medicare Part B. Proven test performance characteristics for a blood-based screening test with both sensitivity greater than or equal to 74% and specificity greater than or equal to 90% in the detection of colorectal cancer compared to the recognized standard (accepted as colonoscopy at this time), based on the pivotal studies included in the FDA labeling. Click here for more detailed information on PTA coverage. In some cases, we can give you a temporary supply of a drug when the drug is not on the Drug List or when it is limited in some way. If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we get your appeal. Have advanced heart failure for at least 14 days and are dependent on an intraaortic balloon pump (IABP) or similar temporary mechanical circulatory support for at least 7 days. 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. The letter will tell you how to make a complaint about our decision to give you a standard decision. 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. 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 therapy is used for a medically accepted indication, which is defined as used for either and FDA approved indication according to the label of that product, or the use is supported in one or more CMS approved compendia. Box 997413 TTY users should call 1-800-718-4347. You can tell Medi-Cal about your complaint. The services are free. If the Independent Medical Review decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. Receive information about clinical programs, including staff qualifications, request a change of treatment choices, participate in decisions about your health care, and be informed of health care issues that require self-management. 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.