TTY/TDD (800) 718-4347. Getting plan approval before we will agree to cover the drug for you. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. For example: We may make other changes that affect the drugs you take. We will notify you by letter if this happens. For inpatient hospital patients, the time of need is within 2 days of discharge. You dont have to do anything if you want to join this plan. The FDA provides new guidance or there are new clinical guidelines about a drug. 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. 2. Your PCP will also help you arrange or coordinate the rest of the covered services you get as a member of our Plan. The organization will send you a letter explaining its decision. The procedure must be performed by an interventional cardiologist or cardiac surgeon.<. You do not need to give your doctor or other prescriber written permission to ask us for a coverage determination on your behalf. This page provides you information on what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug. Angina pectoris (chest pain) in the absence of hypoxemia; or. TTY users should call 1-800-718-4347. (This is called upholding the decision. It is also called turning down your appeal.) The letter you get will explain additional appeal rights you may have. A new generic drug becomes available. Making an appeal means asking us to review our decision to deny coverage. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. Send copies of documents, not originals. To learn more about your prescription drug costs, call IEHP DualChoice Member Services. . 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. If the dollar value of the drug coverage you want meets a certain minimum amount, you can make another appeal at Level 3. =========== TABBED SINGLE CONTENT GENERAL. If our answer is No to part or all of what you asked for, we will send you a letter. 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. New to IEHP DualChoice. 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. 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. Rancho Cucamonga, CA 91729-1800. Until your membership ends, you are still a member of our plan. Here are a few examples: You will usually see your PCP first for most of your routine healthcare needs such as physical checkups, immunization, etc. We may contact you or your doctor or other prescriber to get more information. What is covered: Percutaneous Transluminal Angioplasty (PTA) is covered in the below instances in order to improve blood flow through the diseased segment of a vessel in order to dilate lesions of peripheral, renal and coronary arteries. How to obtain an aggregate number of grievances, appeals, and exceptions filed with IEHP DualChoice (HMO D-SNP)? If you are not satisfied with the result of the IMR, you can still ask for a State Hearing. 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%. a clinical indication for germline (inherited) testing for hereditary breast or ovarian cancer and; a risk factor for germline (inherited) breast or ovarian cancer and; not been previously tested with the same germline test using NGS for the same germline genetic content. 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. 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. The letter will explain why more time is needed. An acute HBV infection could progress and lead to life-threatening complications. We are also one of the largest employers in the region, designated as "Great Place to Work.". It is not connected with this plan and it is not a government agency. 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. According to IEHP, 99.4 percent of enrollees retained the same primary care physicians. Can someone else make the appeal for me for Part C services? All other indications of VNS for the treatment of depression are nationally non-covered. (Effective: September 28, 2016) The List of Covered Drugs and pharmacy and provider networks may change throughout the year. If you are taking the drug, we will let you know. Box 997413 This is not a complete list. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. Call at least 5 days before your appointment. Study data for CMS-approved prospective comparative studies may be collected in a registry. The procedure removes a portion of the lamina in order to debulk the ligamentum flavum, essentially widening the spinal canal in the affected area. You can ask for a copy of the information in your appeal and add more information. If the State Hearing decision is Yes to part or all of what you asked for, we must comply with the decision. You or your provider must show documentation of an existing relationship and agree to certain terms when you make the request. Patient must also present hypoxemia signs and symptoms such as nocturnal restlessness, insomnia, or impairment of cognitive process. The benefit information is a brief summary, not a complete description of benefits. Call: (877) 273-IEHP (4347). (Implementation Date: October 4, 2021). You can fax the completed form to (909) 890-5877. 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. If possible, we will answer you right away. If your provider says you have a good medical reason for an exception, he or she can help you ask for one. ii. There are two ways to make a Level 2 appeal for Medi-Cal services and items: 1) Independent Medical Review or 2) State Hearing. Utilities allowance of $40 for covered utilities. Prior to January 18, 2017, there was no national coverage determination (NCD) in effect. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. If you are asking to be paid back, you are asking for a coverage decision. IEHP DualChoice network providers are required to comply with minimum standards for pharmacy practices as established by the State of California. You may also ask for judicial review of a State Hearing denial by filing a petition in Superior Court (under Code of Civil Procedure Section 1094.5) within one year after you receive the decision. (Effective: January 19, 2021) For other types of problems you need to use the process for making complaints. IEHP DualChoice is very similar to your current Cal MediConnect plan. Interventional echocardiographer meeting the requirements listed in the determination. (Implementation Date: February 27, 2023). Removing a restriction on our coverage. We will also use the standard 14 calendar day deadline instead. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). An annual screening for lung cancer with LDCT will be available if specific eligibility criteria are met. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.). To stay a member of IEHP DualChoice, you must qualify again by the last day of the two-month period. 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). Click here for more information on MRI Coverage. We will give you our answer sooner if your health requires us to do so. If you have a fast complaint, it means we will give you an answer within 24 hours. (Implementation Date: January 17, 2022). If your Level 2 Appeal was a State Hearing, you may ask for a rehearing within 30 days after you receive the decision. 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. Noncoverage specifically includes the following: Click here for more information on Ambulatory Electroencephalographic Monitoring and Colorectal Cancer Screening Tests. The Office of the Ombudsmanis not connected with us or with any insurance company or health plan. and hickory trees (Carya spp.) 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. It stores all your advance care planning documents in one place online. TTY should call (800) 718-4347. 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 we do not meet this deadline, we will send your request to Level 2 of the appeals process. Breathlessness without cor pulmonale or evidence of hypoxemia; or. 711 (TTY), To Enroll with IEHP 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. Disrespect, poor customer service, or other negative behaviors, Timeliness of our actions related to coverage decisions or appeals, You can use our "Member Appeal and Grievance Form." The Heart team must participate in the national registry and track outcomes according to the requirements in this determination.>. 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. All physicians participating in the procedure must have device-specific training by the manufacturer of the device. CMS has added a new section, Section 220.2, to Chapter 1, Part 4 of the Medicare National Coverage Determinations Manual entitled Magnetic Resonance Imaging (MRI). How will the plan make the appeal decision? See Chapters 7 and 9 of the IEHP DualChoice Member Handbookto learn how to ask the plan to pay you back. TTY users should call 1-800-718-4347. For more information on Member Rights and Responsibilities refer to Chapter 8 of your. 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. If you have an urgent need for care, you probably will not be able to find or get to one of the providers in our plans network. How can I make a Level 2 Appeal? Unless you change plans, IEHP DualChoice (HMO D-SNP) will provide your Medicare benefits. The clinical test must be performed at the time of need: Concurrent with Intracranial Stent Placement in FDA-Approved Category B IDE Clinical Trials Receive Member informing materials in alternative formats, including Braille, large print, and audio. (Implementation Date: September 20, 2021). This is not a complete list. After the continuity of care period ends, you will need to use doctors and other providers in the IEHP DualChoice network that are affiliated with your primary care providers medical group, unless we make an agreement with your out-of-network doctor. You can ask for an Independent Medical Review (IMR) from the Help Center at the California Department of Managed Health Care (DMHC). We establish that you had an existing relationship with a primary or specialty care provider, with some exceptions. TAVR under CED when the procedure is related to the treatment of symptomatic aortic stenosis and according to the Food and Drug Administration (FDA) approved indication for use with an approved device, or in clinical studies when criteria are met, in addition to the coverage criteria outlined in the NCD Manual. Calls to this number are free. Please select one of the following: Primary Care Doctor Specialist Behavioral Health Hospitals You may contact the DMHC if you need help with a complaint involving an urgent issue or one that involves an immediate and serious threat to your health, you disagree with our plans decision about your complaint, or our plan has not resolved your complaint after 30 calendar days. Or, if you are asking for an exception, 24 hours after we get your doctors or prescribers statement supporting your request. (Effective: February 15. Its a good idea to make a copy of your bill and receipts for your records. 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. 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. IEHP DualChoice, a Medicare Medi-Cal Plan, allows you to get your covered Medicare and Medi-Cal benefits through our plan. Beneficiaries that demonstrate limited benefit from amplification. If you request a fast coverage decision coverage decision, start by calling or faxing our plan to ask us to cover the care you want. Previously, HBV screening and re-screening was only covered for pregnant women. b. (Effective: February 10, 2022) Vision Care: $350 limit every year for contact lenses and eyeglasses (frames and lenses). For example, you can ask us to cover a drug even though it is not on the Drug List. National Coverage determinations (NCDs) are made through an evidence-based process. When you file a fast complaint, we will give you an answer to your appeal within 24 hours. If we say No to your appeal, you then choose whether to accept this decision or continue by making another appeal. IEHP DualChoice is a Cal MediConnect Plan. (800) 718-4347 (TTY), IEHP DualChoice Member Services You have a right to appeal or ask for Formulary exception if you disagree with the information provided by the pharmacist. However, your PCP can always use Language Line Services to get help from an interpreter, if needed. This is a person who works with you, with our plan, and with your care team to help make a care plan. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. Box 1800 Beneficiaries who meet the coverage criteria, if determined eligible. P.O. 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. All Medicare covered services, doctors, hospitals, labs, and x-rays, You will have access to a Provider network that includes many of the same Providers as your current plan, Coordination of the services you get now or that you might need, Personal history of sustained VT or cardiac arrest due to Ventricular Fibrillation (VF), Prior Myocardial Infarction (MI) and measured Left Ventricular Ejection Fraction (LVEF) less than or equal to .03, Severe, ischemic, dilated cardiomyopathy without history of sustained VT or cardiac arrest due to VF, and have New York Heart Association (NYHA) Class II or III heart failure with a LVEF less than or equal to 35%, Severe, non-ischemic, dilated cardiomyopathy without history of cardiac arrest or sustained VT, NYHA Class II or II heart failure, LVEF less than or equal for 35%, and utilization of optimal medical therapy for at a minimum of three (3) months, Documented, familial or genetic disorders with a high risk of life-threating tachyarrhythmias, but not limited to long QT syndrome or hypertrophic cardiomyopathy, Existing ICD requiring replacement due to battery life, Elective Replacement Indicator (ERI), or malfunction, The procedure is performed in a Clinical Laboratory Improvement Act (CLIA)-certified laboratory. Limitations, copays, and restrictions may apply. You will be notified when this happens. If the coverage decision is No, how will I find out? Receive information about your rights and responsibilities as an IEHP DualChoice Member. You can call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. effort to participate in the health care programs IEHP DualChoice offers you. You should receive the IMR decision within 45 calendar days of the submission of the completed application. You can ask us for a standard appeal or a fast appeal.. This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision. There are extra rules or restrictions that apply to certain drugs on our Formulary. You, your representative, or your provider asks us to let you keep using your current provider. There are over 700 pharmacies in the IEHP DualChoice network. Level 2 Appeal for Part D drugs. IEHP (Inland Empire Health Plan) is a provider that contains a network of doctors, dentists, pyschs, therapists, and specialists. If your doctor says that you need a fast coverage decision, we will automatically give you one. Receive services without regard to race, ethnicity, national origin, religion, sex, age, mental or physical disability or medical condition, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), disability, genetic information, or source of payment. You have the right to ask us for a copy of the information about your appeal. You can still get a State Hearing. You can always contact your State Health Insurance Assistance Program (SHIP). The following criteria must be used to identify a beneficiary demonstrating treatment resistant depression: Beneficiary must be in a major depressive disorder episode for at least two years or have had at least four episodes, including the current episode. If your health requires it, ask the Independent Review Entity for a fast appeal.. Current or lifetime history of psychotic features in any MDE; Current or lifetime history of schizophrenia or schizoaffective disorder; Current or lifetime history of any other psychotic disorder; Current or lifetime history of rapid cycling bipolar disorder; Current secondary diagnosis of delirium, dementia, amnesia, or other cognitive disorder; Treatment with another investigational device or investigational drugs. IEHP DualChoice will give notice to IEHPDualChoice Members prior to removing Part D drug from the Part D formulary. P.O. 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). With IEHP DualChoice, you will still have an IEHP DualChoice Member Service team to get help for your needs. CMS has updated Chapter 1, section 160.18 of the Medicare National Coverage Determinations Manual. If your doctor or other prescriber tells us that your health requires a fast coverage decision, we will automatically agree to give you a fast coverage decision, and the letter will tell you that. The Difference Between ICD-10-CM & ICD-10-PCS. If you dont have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself. The services of SHIP counselors are free. Organized as a Joint Powers Agency, Inland Empire Health Plan (IEHP) is a local, not-for-profit, public health plan. 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 clinical research study must critically evaluate each patient's quality of life pre- and post-TAVR for a minimum of 1 year, but must also address other various questions. Dieticians and Nutritionist will determine how many units will be administered per day and must meet the requirements of this NCD as well at 42 CFR 410.130 410.134. This means that your PCP will be referring you to specialists and services that are affiliated with their medical group. Request a second opinion about a medical condition. 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). If you have questions, you can contact IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Beneficiaries receiving autologous treatment for cancer with T-cell expressing at least one. If we decide that your health does not meet the requirements for a fast coverage decision, we will send you a letter. Effective June 21, 2019, CMS will cover TAVR under CED when the procedure is related to the treatment of symptomatic aortic stenosis and according to the Food and Drug Administration (FDA) approved indication for use with an approved device, or in clinical studies when criteria are met, in addition to the coverage criteria outlined in the NCD Manual. Be treated with respect and courtesy. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition. Prescriptions written for drugs that have ingredients you are allergic to. iii. What is covered: The California Department of Managed Health Care (DMHC) is responsible for regulating health plans. Deadlines for standard appeal at Level 2. You or someone you name may file a grievance. Who is covered? 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. If the decision is No for all or part of what I asked for, can I make another appeal?
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