IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. You can call (800) MEDICARE (800) 633-4227, 24 hours a day, 7 days a week, TTY (877) 486-2048. TDD users should call (800) 952-8349. Follow the plan of treatment your Doctor feels is necessary. The Office of the Ombudsmanis not connected with us or with any insurance company or health plan. Box 1800 Non-Covered Use: Topical Application of Oxygen for Chronic Wound Care. For more information on Medical Nutrition Therapy (MNT) coverage click here. Tier 1 drugs are: generic, brand and biosimilar drugs. IEP Defined The Individualized Educational Plan (IEP) is a plan or program developed to ensure that a child who has a disability identified under the law and is attending an elementary or secondary educational institution receives specialized instruction and related services. 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. If we say Yes to your request for an exception, the exception usually lasts until the end of the calendar year. IEHP DualChoice (HMO D-SNP) has contracts with pharmacies that equals or exceeds CMS requirements for pharmacy access in your area. 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. (Implementation Date: November 13, 2020). For more information, call IEHP DualChoice Member Services or read the IEHP DualChoice Member Handbook. The services of SHIP counselors are free. Then you may submit your request one of these ways: To the county welfare department at the address shown on the notice. If your problem is about a Medi-Cal service or item, you can file a Level 2 Appeal yourself. Copays for prescription drugs may vary based on the level of Extra Help you receive. According to the FDA labeling in an MRI environment, MRI coverage will be provided for beneficiaries under certain conditions. If you let someone else use your membership card to get medical care. Click here to download a free copy by clicking Adobe Acrobat Reader. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). Yes. Utilities allowance of $40 for covered utilities. What if the Independent Review Entity says No to your Level 2 Appeal? Erythrocythemia (increased red blood cells) with a hematocrit greater than 56%. D-SNP Transition. Our plan includes doctors, hospitals, pharmacies, providers of long-term services and supports, behavioral health providers, and other providers. This number requires special telephone equipment. Can I ask for a coverage determination or make an appeal about Part D prescription drugs? This means that your PCP will be referring you to specialists and services that are affiliated with their medical group. All screenings DNA tests, effective April 28, 2008, through October 8, 2014. It also needs to be an accepted treatment for your medical condition. You will not have a gap in your coverage. The phone number for the Office for Civil Rights is (800) 368-1019. After your application and supporting documents are received from your plan, the IMR decision will be made within 30 calendar days. Live in our service area (incarcerated individuals are not considered living in the geographic service area even if they are physically located in it. Heart failure cardiologist with experience treating patients with advanced heart failure. Receive emergency care whenever and wherever you need it. Typically, our Formulary includes more than one drug for treating a particular condition. 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. There are many kinds of specialists. You, your representative, or your doctor (or other prescriber) can do this. If the State Hearing decision is Yes to part or all of what you asked for, we must comply with the decision. Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. You ask us if a drug is covered for you (for example, when your drug is on the plans Formulary but we require you to get approval from us before we will cover it for you). If the Independent Medical Review decision is Yes to part or all of what you asked for, we must provide the service or treatment. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. 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. Have grievances heard and resolved in accordance with Medicare guidelines; Request quality of care grievances data from IEHP DualChoice. Cardiologists care for patients with heart conditions. are similar in many respects. Handling problems about your Medi-Cal benefits. We will give you our answer sooner if your health requires it. For CMS-approved studies, the protocol, including the analysis plan, must meet requirements listed in this NCD. Never wavering in our commitment to our Members, Providers, Partners, and each other. C. Beneficiarys diagnosis meets one of the following defined groups below: 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. A network provider is a provider who works with the health plan. The DMHC may waive the requirement that you first follow our appeal process in extraordinary and compelling cases. If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. Other persons may already be authorized by the Court or in accordance with State law to act for you. They mostly grow wild across central and eastern parts of the country. 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. If you decide to ask for a State Hearing by phone, you should be aware that the phone lines are very busy. 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. Mail or fax your forms and any attachments to: You may complete the "Request for State Hearing" on the back of the notice of action. How do I make a Level 1 Appeal for Part C services? (Effective: February 15, 2018) Call IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. You can ask us for a standard appeal or a fast appeal.. What Prescription Drugs Does IEHP DualChoice Cover? Your care team and care coordinator work with you to make a care plan designed to meet your health needs. Limitations, copays, and restrictions may apply. Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative Form. Note: You can only make this request for services of Durable Medical Equipment (DME), transportation, or other ancillary services not included in our plan. The letter you get from the Independent Review Entity will tell you the dollar amount needed to continue with the appeals process. Dependent edema (gravity related swelling due to excess fluid) suggesting congestive heart failure; or, Medi-Cal is public-supported health care coverage. CMS has updated Chapter 1, section 30.3.3 of the Medicare National Coverage Determinations Manual. Breathlessness without cor pulmonale or evidence of hypoxemia; or. The California Department of Managed Health Care (DMHC) is responsible for regulating health plans. It also has care coordinators and care teams to help you manage all your providers and services. This is not a complete list. Are inotrope dependent OR have a Cardiac Index (CI) < 2.2 L/min/m2, while not on inotropes, and meet one of the following: Are on optimal medical management, based on current heart failure practice guidelines for at least 45 out of the last 60 days and are failing to respond; or. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. All requests for out-of-network services must be approved by your medical group prior to receiving services. Beneficiaries with Alzheimers Disease (AD) may be covered for treatment when the following conditions (A or B) are met: Click here for more information on Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimers Disease (AD). Click here for more detailed information on PTA coverage. In most cases you have 120 days to ask for a State Hearing after the Your Hearing Rights notice is mailed to you. "Coordinating" your services includes checking or consulting with other Plan providers about your care and how it is going. Orthopedists care for patients with certain bone, joint, or muscle conditions. Reviewers at the Independent Review Entity will take a careful look at all of the information related to your appeal. If you are asking for a standard appeal, you can make your appeal by sending a request in writing. Will not pay for emergency or urgent Medi-Cal services that you already received. You can make the complaint at any time unless it is about a Part D drug. If patients with bipolar disorder are included, the condition must be carefully characterized. Your test results are shared with all of your doctors and other providers, as appropriate. You can send your complaint to Medicare. If our answer is Yes to part or all of what you asked for, we must give the coverage within 72 hours after we get your appeal. When we say existing relationship, it means that you saw an out-of-network provider at least once for a non-emergency visit during the 12 months before the date of your initial enrollment in our plan. To start your appeal, you, your doctor or other prescriber, or your representative must contact us. CMS has added a new section, Section 20.35, to Chapter 1 entitled Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). IEHP DualChoice. We must give you our answer within 14 calendar days after we get your request. We may stop any aid paid pending you are receiving. You can also visit, You can make your complaint to the Quality Improvement Organization. We will look into your complaint and give you our answer. You, your representative, or your provider asks us to let you keep using your current provider. For example, we might decide that a service, item, or drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. 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). In most cases, you must file an appeal with us before requesting an IMR. 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. The call is free. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. If your doctor or other provider asks for a service or item that we will not approve, or we will not continue to pay for a service or item you already have and we said no to your Level 1 appeal, you have the right to ask for a State Hearing. Walnut trees (Juglans spp.) Coverage for future years is two hours for patients diagnosed with renal disease or diabetes. All of our plan participating providers also contract us to provide covered Medi-Cal benefits. Are a United States citizen or are lawfully present in the United States. By clicking on this link, you will be leaving the IEHP DualChoice website. After your application and supporting documents are received from your plan, the IMR decision will be made within 3 calendar days. We will tell you in advance about these other changes to the Drug List. If your provider says you have a good medical reason for an exception, he or she can help you ask for one. CMS has updated Chapter 1, section 20.19 of the Medicare National Coverage Determinations Manual. 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. 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. Effective for dates of service on or after August 7, 2019, CMS covers autologous treatment for cancer with T-cell expressing at least one chimeric antigen receptor (CAR) when administered at healthcare facilities enrolled in the Food and Drug Administrations (FDA) Risk Evaluation and Mitigation Strategies (REMS) and when specific requirements are met. See form below: Deadlines for a fast appeal at Level 2 If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. We will use the standard deadlines unless we have agreed to use the fast deadlines., You can get a fast coverage decision only if you are asking for a drug you have not yet received. Our plans Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B. You will get a care coordinator when you enroll in IEHP DualChoice. (877) 273-4347 This letter will tell you if the service or item is usually covered by Medicare or Medi-Cal. If you do not choose a PCP when you join IEHPDualChoice, we will choose one for you. If you have questions, you can contact IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. If you want a fast appeal, you may make your appeal in writing or you may call us. TTY should call (800) 718-4347. 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. 2023 IEHP DualChoice Provider and Pharmacy Directory (PDF), http://www.dmhc.ca.gov/FileaComplaint/SubmitanIndependentMedicalReviewComplaintForm.aspx, Request for Medicare Prescription Drug Coverage Determination (PDF). 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. If you are under a Doctors care for an acute condition, serious chronic condition, pregnancy, terminal illness, newborn care, or a scheduled surgery, you may ask to continue seeing your current Doctor. The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. Information on procedures for obtaining prior authorization of services, Quality Assurance, disenrollment, and other procedures affecting IEHP DualChoice Members. What is covered: Click here to download a free copy of Adobe Acrobat Reader.By clicking on this link, you will be leaving the IEHP DualChoice website. You may choose different health plans, or providers, under Medi-Cal, like IEHP or Molina Healthcare, Blue Shield, Health Net, etc. ii. We will see if the service or item you paid for is a covered service or item, and we will check to see if you followed all the rules for using your coverage. Welcome to Inland Empire Health Plan \ Members \ Medi-Cal California Medical Insurance Requirements; main content TIER3 SUBLAYOUT. 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.
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