You, your representative, or your provider asks us to let you keep using your current provider. A fast coverage decision means we will give you an answer within 24 hours after we get your doctors statement. Patients demonstrating arterial PO2 between 56-59 mm Hg, or whos arterial blood oxygen saturation is 89%, with any of the following condition: We will let you know of this change right away. A specialist is a doctor who provides health care services for a specific disease or part of the body. This includes denial of payment for a service after the service has been rendered (post-service) or denial of service prior to the service being rendered (pre-service). Click here for more information on PILD for LSS Screenings. The following link will take you to the Centers for Medicaid and Medicare Services website, where you can look through the CMS Best Available Evidence Policy using the following link: CMS Best Available Evidence Policy. 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). You will need Adobe Acrobat Reader6.0 or later to view the PDF files. If you need to change your PCP for any reason, your hospital and specialist may also change. MRI field strength of 1.5 Tesla using Normal Operating Mode, The Implanted pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy defibrillator (CRT-D) system has no fractured, epicardial, or abandoned leads, The facility has implemented a specific checklist. CMS has issued a National Coverage Determination (NCD) which expands coverage to include leadless pacemakers when procedures are performed in CMS-approved Coverage with Evidence Development (CED) studies. An IMR is a review of your case by doctors who are not part of our plan. IEHP DualChoice must end your membership in the plan if any of the following happen: The IEHPDualChoice Privacy Notice describes how medical information about you may be used and disclosed, and how you can get access to this information. What is covered? Arterial PO2 at or below 55 mm Hg, or arterial oxygen saturation at or below 88% when tested during sleep for patients that demonstrate an arterial PO2 at or above 56 mmHg, or You can tell the California Department of Managed Health Care about your complaint. IEHP DualChoice Medicare Team at (800) 741-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY users should call (800) 718-4347. If we say Yes to your request for an exception, the exception usually lasts until the end of the calendar year. If you believe we should not take extra days, you can file a fast complaint about our decision to take extra days. At any time, you can call IEHP DualChoice Member Services to get up-to-date information about changes in the pharmacy network. After your application and supporting documents are received from your plan, the IMR decision will be made within 30 calendar days. IEHP DualChoice will help you with the process. Important things to know about asking for exceptions. Orthopedists care for patients with certain bone, joint, or muscle conditions. 10820 Guilford Road, Suite 202 A clinical test providing a measurement of the partial pressure of oxygen (PO2) in arterial blood. We are always available to help you. =========== TABBED SINGLE CONTENT GENERAL. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). to part or all of what you asked for, we must approve or give the coverage within 72 hours after we get your request or, if you are asking for an exception, your doctors or prescribers supporting statement. You will get a letter from us about the change in your eligibility with instructions to correct your eligibility information. If you decide to ask for a State Hearing by phone, you should be aware that the phone lines are very busy. We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. How to Enroll with IEHP DualChoice (HMO D-SNP) We may not tell you before we make this change, but we will send you information about the specific change or changes we made. The leadless pacemaker eliminates the need for a device pocket and insertion of a pacing lead which are integral elements of traditional pacing systems. Unleashing our creativity and courage to improve health & well-being. 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. (Implementation Date: February 19, 2019) 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. Then you can: Again, if a drug is suddenly recalled because its been found to be unsafe or for other reasons, the plan will immediately remove the drug from the Formulary. The procedure must be performed in a hospital with infrastructure and experience meeting the requirements in this determination. For example, this means that your care team makes sure: Your doctors know about all the medicines you take so they can make sure youre taking the right medicines and can reduce any side effects you may have from the medicines. Please select one of the following: Primary Care Doctor Specialist Behavioral Health Hospitals 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. We will say Yes or No to your request for an exception. Drugs that may not be necessary because you are taking another drug to treat the same medical condition. This is called upholding the decision. It is also called turning down your appeal.. (Effective: April 10, 2017) If you are not satisfied with the result of the IMR, you can still ask for a State Hearing. Governing Board. You, your doctor or other prescriber, or your representative can request the Level 2 Appeal. We will send you a notice before we make a change that affects you. 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. A care coordinator is a person who is trained to help you manage the care you need. 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). A reasonable salary expectation is between $51,833.60 and $64,022.40, based upon experience and internal equity. He or she can work with you to find another drug for your condition. Sign up for the free app through our secure Member portal. Please note: If your pharmacy tells you that your prescription cannot be filled, you will get a notice explaining how to contact us to ask for a coverage determination. What is covered: You must ask to be disenrolled from IEHP DualChoice. You can download a free copy by clicking here. Interpreted by the treating physician or treating non-physician practitioner. We do the right thing by: Placing our Members at the center of our universe. 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. These reviews are especially important for members who have more than one provider who prescribes their drugs. Topical Application of Oxygen for Chronic Wound Care. Oxygen therapy can be renewed by the MAC if deemed medically necessary. The letter will tell you how to make a complaint about our decision to give you a standard decision. While the taste of the black walnut is a culinary treat the . At Level 2, an Independent Review Entity will review your appeal. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. They all work together to provide the care you need. We serve 1.5 million residents of Riverside and San Bernardino counties through government-sponsored programs including Medi-Cal (families, adults, seniors and people with disabilities) and Cal MediConnect. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contact renewal. Calls to this number are free. Also, its possible that your PCP might leave our plans network of providers and you would have to find a new PCP. (Effective: September 28, 2016) ), 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. Have grievances heard and resolved in accordance with Medicare guidelines; Request quality of care grievances data from IEHP DualChoice. 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). The MAC may also approve the use of portable oxygen systems to beneficiaries who are mobile in home and benefit from of this unit alone, or in conjunction to a stationary oxygen system. Then you may submit your request one of these ways: To the county welfare department at the address shown on the notice. To see if you qualify for getting extra help, you can contact: Do you need help getting the care you need? (Implementation Date: January 3, 2023) Drugs that may not be safe or appropriate because of your age or gender. Please see below for more information. A reasonable salary expectation is between $153,670.40 and $195,936.00, based upon experience and internal equity. Who is covered? TTY users should call (800) 537-7697. You do not need to do anything further to get this Extra Help. The Office of the Ombudsmanis not connected with us or with any insurance company or health plan. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more days (44 days total) to answer your complaint. English Walnuts. Department of Health Care Services You or your provider must show documentation of an existing relationship and agree to certain terms when you make the request. Or you can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. If you decide to make an appeal, it means you are going on to Level 1 of the appeals process. Send copies of documents, not originals. H5355_CMC_22_2746205Accepted, (Effective: September 27, 2021) Box 4259 Patients must maintain a stable medication regimen for at least four weeks before device implantation. It tells which Part D prescription drugs are covered by IEHP DualChoice. You pay no costs for an IMR. IEHP DualChoice recognizes your dignity and right to privacy. (Implementation Date: October 8, 2021) If you miss this deadline and have a good reason for missing it, we may give you more time to make you appeal. The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. 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 program is not connected with us or with any insurance company or health plan. 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. For the benefit year of 2023 here is what youll get and what you will pay: With IEHP DualChoice, you pay nothing for covered drugs as long as you follow the plans rules. View Plan Details. 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. How long does it take to get a coverage decision coverage decision for Part C services? You can also visit, You can make your complaint to the Quality Improvement Organization. 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. 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. This is not a complete list. Ask for the type of coverage decision you want. It also has care coordinators and care teams to help you manage all your providers and services. If we dont give you our decision within 14 calendar days, you can appeal. Click here to learn more about IEHP DualChoice. Group II: During these events, supplemental oxygen is provided during exercise, if the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air. You can ask us to reimburse you for IEHP DualChoice's share of the cost. IEHP offers a competitive salary and stellar benefit package . We will give you our decision sooner if your health condition requires us to. You will not have a gap in your coverage. Removing a restriction on our coverage. A standard coverage decision means we will give you an answer within 72 hours after we get your doctors statement. Urgently needed care from in-network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible, e.g., when you are temporarily outside of the plans service area. 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. Make necessary appointments for routine and sick care, and inform your Doctor when you are unable to make a scheduled appointment. When you make an appeal to the Independent Review Entity, we will send them your case file. You can call IEHP DualChoice at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. Who is covered? 711 (TTY), To Enroll with IEHP Here are three general rules about drugs that Medicare drug plans will not cover under Part D: For more information refer to Chapter 6 of yourIEHP DualChoice Member Handbook. (Implementation Date: March 24, 2023) You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. This is asking for a coverage determination about payment. They can also answer your questions, give you more information, and offer guidance on what to do. 4. You might leave our plan because you have decided that you want to leave. IEHP DualChoice If you disagree with a coverage decision we have made, you can appeal our decision. Change the coverage rules or limits for the brand name drug. We do a review each time you fill a prescription. Medicare beneficiaries with LSS who are participating in an approved clinical study. The DMHC may accept your application after 6 months if it determines that circumstances kept you from submitting your application in time. Yes. You must make the request on or before the later of the following in order to continue your benefits: If you meet this deadline, you can keep getting the disputed service or item while your appeal is processing. If you have a fast complaint, it means we will give you an answer within 24 hours. 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. Remember, you can request to change your PCP at any time. disease); An additional 8 sessions will be covered for those patients demonstrating an improvement. Read Will my benefits continue during Level 2 appeals in Chapter 9 of the Member Handbook for more information. Your provider will also know about this change. 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. It is not connected with this plan and it is not a government agency. (800) 720-4347 (TTY). If the answer is No, we will send you a letter telling you our reasons for saying No. Concurrent with Carotid Stent Placement in Patients at High Risk for Carotid Endarterectomy (CEA) IEHP DualChoice is very similar to your current Cal MediConnect plan. The registry shall collect necessary data and have a written analysis plan to address various questions. We must respond whether we agree with the complaint or not. Our plan includes doctors, hospitals, pharmacies, providers of long-term services and supports, behavioral health providers, and other providers. It also needs to be an accepted treatment for your medical condition. TTY users should call (800) 718-4347 or fax us at (909) 890-5877. What is covered: Interventional Cardiologist meeting the requirements listed in the determination. Click here for more detailed information on PTA coverage. Or, if you havent paid for the service or item yet, we will send the payment directly to the provider. The NCR serves as a liaison for matters involving the contract between IEHP and both Network and Non-Network Providers. Your benefits as a member of our plan include coverage for many prescription drugs. This is called upholding the decision. It is also called turning down your appeal. IEHP (Inland Empire Health Plan) is a provider that contains a network of doctors, dentists, pyschs, therapists, and specialists. The Difference Between ICD-10-CM & ICD-10-PCS. There are extra rules or restrictions that apply to certain drugs on our Formulary. (Implementation Date: December 10, 2018). . Eligible beneficiaries are entitled to 36 sessions over a 12-week period after meeting with the physician responsible for PAD treatment and receiving a referral. Advance care planning (ACP) involves shared decision making to write down-in an advance care directive-a persons wishes about their future medical care. IEHP DualChoice is a Cal MediConnect Plan. According to IEHP, 99.4 percent of enrollees retained the same primary care physicians. What is covered: 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. CMS has updated Chapter 1, section 160.18 of the Medicare National Coverage Determinations Manual. If your Level 2 Appeal was a State Hearing, you may ask for a rehearing within 30 days after you receive the decision. If the State Hearing decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period. Most recently, as of May 1, 2016, Medi-Cal now covers all low income children under the age of 19, regardless of immigration status. We will also use the standard 14 calendar day deadline instead. 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; Initial coverage for patients experiencing conditions not described above can be limited to a prescription shorter than 90 days, or less than the numbers of days indicated on the practitioners prescription.