You will keep all of your Medicare and Medi-Cal benefits. After your application and supporting documents are received from your plan, the IMR decision will be made within 3 calendar days. Fax: (909) 890-5877. (Effective: February 19, 2019) This letter will tell you if the service or item is usually covered by Medicare or Medi-Cal. You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage decision. You dont have to do anything if you want to join this plan. The intended effective date of the action. (Implementation Date: September 20, 2021). Box 4259 You can get the form at. 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. To ask if your PCP or other providers are in our network in 2023, call IEHP DualChoice Member Services. You can send your complaint to Medicare. Portable oxygen would not be covered. (Effective: January 21, 2020) Can I get a coverage decision faster for Part C services? 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. This service will be covered only for beneficiaries diagnosed with chronic Lower Back Pain (cLBP) when the following conditions are met: All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer and; has not been previously tested with the same test using NGS for the same cancer genetic content and; has decided to seek further cancer treatment (e.g., therapeutic chemotherapy). This will give you time to talk to your doctor or other prescriber. It also has care coordinators and care teams to help you manage all your providers and services. All have different pros and cons. What is covered? Handling problems about your Medi-Cal benefits. If we are using the fast deadlines, we must give you our answer within 24 hours. You can then ask us to make an exception and cover the drug in the way you would like it to be covered for next year. You will be automatically enrolled in a Medicare Medi-Cal Plan offered by IEHP DualChoice. (SeeChapter 10 oftheIEHP DualChoiceMember Handbookfor information on when your new coverage begins.) You are never required to pay the balance of any bill. 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. We will review our coverage decision to see if it is correct. Information on this page is current as of October 01, 2022. For example, you can make a complaint about disability access or language assistance. This is called upholding the decision. It is also called turning down your appeal.. Live in our service area (incarcerated individuals are not considered living in the geographic service area even if they are physically located in it. a. wounds affecting the skin. If we say No to your appeal, you then choose whether to accept this decision or continue by making another appeal. (Effective: April 3, 2017) Noncoverage specifically includes the following: Click here for more information on Ambulatory Electroencephalographic Monitoring and Colorectal Cancer Screening Tests. This includes: Primary Care Providers (PCPs) are usually linked to certain hospitals. How to voluntarily end your membership in our plan? i. These reviews are especially important for members who have more than one provider who prescribes their drugs. We must respond whether we agree with the complaint or not. IEHP DualChoice Cal MediConnect (Medicare-Medicaid Plan) is changing to IEHP DualChoice (HMO D-SNP) on January 1, 2023. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. (Implementation date: August 29, 2017 for MAC local edits; January 2, 2018 for MCS shared edits) They can also answer your questions, give you more information, and offer guidance on what to do. If we dont give you our decision within 14 calendar days, you can appeal. You should receive the IMR decision within 7 calendar days of the submission of the completed application. There are over 700 pharmacies in the IEHP DualChoice network. If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize or give you the drug coverage within 72 hours after we get the decision. You will get a care coordinator when you enroll in IEHP DualChoice. . Quantity limits. 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. TTY/TDD (877) 486-2048. (Effective: September 26, 2022) Within 10 days of the mailing date of our notice of action; or. We are always available to help you. H8894_DSNP_23_3241532_M. Medicare beneficiaries with LSS who are participating in an approved clinical study. 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. Medicare beneficiaries in need of a pacemaker who are participating in an approved clinical study. Or you can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. These forms are also available on the CMS website: Medicare Prescription Drug Determination Request Form (for use by enrollees and providers), Deadlines for a standard coverage decision about a drug you have not yet received, If our answer is Yes 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 must submit your claim to us within 1 year of the date you received the service, item, or drug. The phone number is (888) 452-8609. If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. Treatment of Atherosclerotic Obstructive Lesions Yes. To learn more about the plans benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook. Our plan usually cannot cover off-label use. At Level 2, an Independent Review Entity will review our decision. You can call (800) MEDICARE (800) 633-4227, 24 hours a day, 7 days a week, TTY (877) 486-2048. The counselors at this program can help you understand which process you should use to handle a problem you are having. 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%. Please see below for more information. Click here for more information on study design and rationale requirements. If we say No to your request for an exception, you can ask for a review of our decision by making an appeal. This includes getting authorization to see specialists or medical services such as lab tests, x-rays, and/or hospital admittance. 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. How to ask for coverage decision coverage decision to get medical, behavioral health, or certain long-term services and supports (CBAS, or NF services). Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. See below for a brief description of each NCD. The PCP you choose can only admit you to certain hospitals. 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. The List of Covered Drugs and pharmacy and provider networks may change throughout the year. We will look into your complaint and give you our answer. Breathlessness without cor pulmonale or evidence of hypoxemia; or. 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. The care team helps coordinate the services you need. What kinds of medical care and other services can you get without getting approval in advance from your Primary Care Provider (PCP) in IEHP DualChoice (HMO D-SNP)? 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. (Implementation Date: January 3, 2023) The Office of the Ombudsmanis not connected with us or with any insurance company or health plan. You must choose your PCP from your Provider and Pharmacy Directory. 1. An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. Note: You can only make this request for services of Durable Medical Equipment (DME), transportation, or other ancillary services not included in our plan. PCPs are usually linked to certain hospitals and specialists. Information on procedures for obtaining prior authorization of services, Quality Assurance, disenrollment, and other procedures affecting IEHP DualChoice Members. The procedure is used with a mitral valve TEER system that has received premarket approval from the FDA. Yes. Receive information about IEHP DualChoice, its programs and services, its Doctors, Providers, health care facilities, and your drug coverage and costs, which you can understand. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. 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. Follow the plan of treatment your Doctor feels is necessary. The DMHC may accept your application after 6 months if it determines that circumstances kept you from submitting your application in time. Who is covered: The PTA is covered under the following conditions: If we do not give you a decision within 7 calendar days, or 14 days if you asked us to pay you back for a drug you already bought, we will send your request to Level 2 of the appeals process. What if the Independent Review Entity says No to your Level 2 Appeal? Then, we check to see if we were following all the rules when we said No to your request. With a network of more than 6,000 Providers and 2,000 Team Members, we provide . IEHP DualChoice, a Medicare Medi-Cal Plan, allows you to get your covered Medicare and Medi-Cal benefits through our plan. If you want a fast appeal, you may make your appeal in writing or you may call us. 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. 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. If we agree to make an exception and cover a drug that is not on the Formulary, you will need to pay the cost-sharing amount that applies to drug. TTY users should call 1-800-718-4347. Review, request changes to, and receive a copy of your medical records in a timely fashion. If the decision is No for all or part of what I asked for, can I make another appeal? IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. A network provider is a provider who works with the health plan. However, if the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drugs manufacturer removes the drug from the market we will immediately remove the drug from our formulary. If you have a standard appeal at Level 2, the Independent Review Entity must give you an answer to your Level 2 Appeal within 7 calendar days after it gets your appeal. Interventional Cardiologist meeting the requirements listed in the determination. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. If we tell you after our review that the service or item is not covered, your case can go to a Level 2 Appeal. Treatment is furnished as part of a CMS approved trial through Coverage with Evidence Development (CED).Detailed clinical trial criteria can be found in section 160.18 of the National Coverage Determination Manual. Our state has an organization called Livanta Beneficiary & Family Centered Care (BFCC) Quality Improvement Organization (QIO). Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative Form. The Centers of Medicare and Medicaid Services (CMS) will cover Ambulatory Blood Pressure Monitoring (ABPM) when specific requirements are met. H8894_DSNP_23_3241532_M. 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. You or someone you name may file a grievance. With this app, you or a designated person with Power of Attorney can access your advance health care directives at any time from a home computer or smartphone. The Help Center cannot return any documents. H8894_DSNP_23_3241532_M. Medicare beneficiaries may be covered with an affirmative Coverage Determination. Calls to this number are free. Try to choose a PCP that can admit you to the hospital you want within 30 miles or 45 minutes of your home. If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals). 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. If you are not satisfied with the result of the IMR, you can still ask for a State Hearing. Your PCP, along with the medical group or IPA, provides your medical care. Governing Board. No means the Independent Review Entity agrees with our decision not to approve your request. Decide in advance how you want to be cared for in case you have a life-threatening illness or injury. If we decide that your health does not meet the requirements for a fast coverage decision, we will send you a letter. 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. Treatments must be discontinued if the patient is not improving or is regressing. "Coordinating" your services includes checking or consulting with other Plan providers about your care and how it is going. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). If your health requires it, ask the Independent Review Entity for a fast appeal.. If you dont have the IEHP DualChoice Provider and Pharmacy Directory, you can get a copy from IEHP DualChoice Member Services. This form is for IEHP DualChoice as well as other IEHP programs. Your PCP should speak your language. 2. Explore Opportunities. 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. But if you do pay the bill, you can get a refund if you followed the rules for getting services and items. 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. (Effective: April 10, 2017) If you are asking to be paid back, you are asking for a coverage decision. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. Screening computed tomographic colonography (CTC), effective May 12, 2009. (Effective: January 1, 2023) You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Click here for more information on Leadless Pacemakers. You can work with us for all of your health care needs. An IMR is available for any Medi-Cal covered service or item that is medical in nature. This is a group of doctors and other health care professionals who help improve the quality of care for people with Medicare. For example, good reasons for missing the deadline would be if you have a serious illness that kept you from contacting us or if we gave you incorrect or incomplete information about the deadline for requesting an appeal. Here are two ways to get information directly from Medicare: By clicking on this link, you will be leaving the IEHP DualChoice website. If you miss the deadline for a good reason, you may still appeal. You may also have rights under the Americans with Disability Act. Get Help from an Independent Government Organization. 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. You have a right to appeal or ask for Formulary exception if you disagree with the information provided by the pharmacist. You will not have a gap in your coverage. B. Effective February 15, 2020, CMS will cover FDA approved Vagus Nerve Stimulation (VNS) devices for treatment-resistant depression through Coverage with Evidence Development (CED) in a CMS approved clinical trial in addition to the coverage criteria outlined in the. If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. These forms are also available on the CMS website: If you have questions, you can contact IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Click here for information on Next Generation Sequencing coverage. What is a Level 2 Appeal? Benefits and copayments may change on January 1 of each year. The phone number for the Office for Civil Rights is (800) 368-1019. If you prefer a different one, please call IEHP DualChoice Member Services and we can assist you in finding and selecting another provider. Effective for dates of service on or after December 1, 2020, CMS has updated section 20.9.1 of the National Coverage Determination Manual to cover ventricular assist devices (VADs) when received at facilities credentialed by a CMS approved organization and when specific requirements are met. (Effective: July 2, 2019) The phone number for the Office for Civil Rights is (800) 368-1019. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. The following medical conditions are not covered for oxygen therapy and oxygen equipment in the home setting: Other: If we need more information, we may ask you or your doctor for it. To speak with a care coordinator, please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. There are two ways to ask for a State Hearing: If you meet this deadline, you can keep getting the disputed service or item until the hearing decision is made. We will send you your ID Card with your PCPs information. The procedure must be performed in a hospital with infrastructure and experience meeting the requirements in this determination. At Level 2, an Independent Review Entity will review the decision. Or your doctor or other prescriber can tell us on the phone, and then fax or mail a statement. Here are two ways to get help from the Help Center: You can file a complaint with the Office for Civil Rights. We must give you our answer within 14 calendar days after we get your request. If your treatment was denied because it was experimental or investigational, you do not have to take part in our appeal process before you apply for an IMR. 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). For example: We may make other changes that affect the drugs you take. You have a care team that you help put together. We check to see if we were following all the rules when we said No to your request. A standard coverage decision means we will give you an answer within 72 hours after we get your doctors statement. By clicking on this link, you will be leaving the IEHP DualChoice website. 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). Appeal any decision IEHP DualChoice makes regarding, but not limited to, a denial, termination, payment, or reduction of services. You can tell Medicare about your complaint. Make recommendations about IEHP DualChoice Members rights and responsibilities policies. When you choose your PCP, remember the following: You will usually see your Primary Care Provider (PCP) first for most of your routine healthcare needs such as physical check-ups, immunization, etc. If you have any authorizations pending approval, if you are in them idle of treatment, or if specialty care has been scheduled for you by your current Doctor, contact IEHP to help you coordinate your care during this transition time. Off-label use is any use of the drug other than those indicated on a drugs label as approved by the Food and Drug Administration. 2. If you are taking the drug, we will let you know. 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. 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. Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States. Yes, you and your doctor may give us more information to support your appeal. The reviewer will be someone who did not make the original coverage decision. Use of autologous Platelet-Derived Growth Factor (PDGF) for treatment of chronic, non-healing, cutaneous (affecting the skin) wounds, and. 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. A Level 2 Appeal is the second appeal, which is done by an independent organization that is not connected to the plan. We have 30 days to respond to your request. Remember, if you get a bill that is more than your copay for covered services and items, you should not pay the bill yourself. Make your appeal request within 60 calendar days from the date on the notice we sent to tell you our decision. What is covered: How to obtain an aggregate number of grievances, appeals, and exceptions filed with IEHP DualChoice (HMO D-SNP)? You can file a grievance online. If we are using the fast deadlines, we will give you our answer within 72 hours after we get your appeal, or sooner if your health requires it. Thus, this is the main difference between hazelnut and walnut. Yes. In most cases, you must start your appeal at Level 1. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. If you do not stay continuously enrolled in Medicare Part A and Part B. 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. We will give you our answer sooner if your health requires us to do so. You may choose different health plans, or providers, under Medi-Cal, like IEHP or Molina Healthcare, Blue Shield, Health Net, etc. What is covered? 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. Now, the NCD will cover PILD for LSS under both RCT and longitudinal studies. When can you end your membership in our plan? To learn how to submit a paper claim, please refer to the paper claims process described below. TTY should call (800) 718-4347. (Effective: April 13, 2021) Hazelnuts are the round brown hard-shelled nuts of the trees of genus Corylus while walnuts are the wrinkled edible nuts of the trees of genus Juglans. According to the FDA labeling in an MRI environment, MRI coverage will be provided for beneficiaries under certain conditions. Asking for a fast coverage decision coverage decision: Here are the rules for asking for a fast coverage decision coverage decision: You must meet the following two requirements to get a fast coverage decision coverage decision: If the coverage decision is Yes, when will I get the service or item? Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy: We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgently needed care. CMS has revised Chapter 1, Section 20.29, Subsection C Topical Application of Oxygen to remove the exclusion of this treatment. You are eligible for our plan as long as you: Only people who live in our service area can join IEHP DualChoice. You can tell Medi-Cal about your complaint. 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). How will the plan make the appeal decision? 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. Learn about your health needs and leading a healthy lifestyle. We are also one of the largest employers in the region, designated as "Great Place to Work.". 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. IEHP DualChoice network providers are required to comply with minimum standards for pharmacy practices as established by the State of California.