You can ask us to make a faster decision, and we must respond in 15 days. If you are asking to be paid back, you are asking for a coverage decision. During these reviews, we look for potential problems such as: If we see a possible problem in your use of medications, we will work with your Doctor to correct the problem. Routine womens health care, which includes breast exams, screening mammograms (X-rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider. You can call (800) MEDICARE (800) 633-4227, 24 hours a day, 7 days a week, TTY (877) 486-2048. (Effective: July 2, 2019) Your provider will also know about this change. The State or Medicare may disenroll you if you are determined no longer eligible to the program. Some of the advantages include: You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. After your application and supporting documents are received from your plan, the IMR decision will be made within 3 calendar days. You must apply for an IMR within 6 months after we send you a written decision about your appeal. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period. This is a group of doctors and other health care professionals who help improve the quality of care for people with Medicare. If you are asking for a standard appeal, you can make your appeal by sending a request in writing. Black walnut trees are not really cultivated on the same scale of English walnuts. For example, you can make a complaint about disability access or language assistance. We must respond whether we agree with the complaint or not. (This is sometimes called prior authorization.), Being required to try a different drug first before we will agree to cover the drug you are asking for. You will be able to get the service or item within 14 calendar days (for a standard coverage decision) or 72 hours (for a fast coverage decision) of when you asked. Has not resolved your Level 1 Appeal on a Medi-Cal service within 30 calendar days for a standard appeal or 72 hours for a fast appeal. If you decide to make an appeal, it means you are going on to Level 1 of the appeals process. Information on this page is current as of October 01, 2022, Centers for Medicare and Medicaid Services. Consist of 30-60 minute sessions comprising of therapeutic exercise-training program for PAD; Be conducted in a hospital outpatient setting or physicians office; Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD; and. Changing your Primary Care Provider (PCP). Members \. With a network of more than 6,000 Providers and 2,000 Team Members, we provide . You may be able to order your prescription drugs ahead of time through our network mail order pharmacy service or through a retail network pharmacy that offers an extended supply. CMS has updated Chapter 1, section 20.19 of the Medicare National Coverage Determinations Manual. For more information on Grievances see Chapter 9 of your IEHP DualChoice Member Handbook. Beneficiaries with Somatic (acquired) cancer or Germline (inherited) cancer when performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all the following requirements are met: Medicare Administrative Contractors (MACs) may determine coverage of NGS as a diagnostic test when additional specific criteria are met. H8894_DSNP_23_3241532_M. The DMHC may waive the requirement that you first follow our appeal process in extraordinary and compelling cases. The treatment is based upon efficacy from a direct measure of clinical benefit in CMS-approved prospective comparative studies. (800) 720-4347 (TTY). You can contact Medicare. Medi-Cal provides free or low-cost health coverage to low-income individuals and their families.California has been expanding Medi-Cal to a larger and more diverse group of people. (800) 718-4347 (TTY), IEHP DualChoice Member Services If you disagree with a coverage decision we have made, you can appeal our decision. Fecal Occult Blood Tests (gFOBT) once every 12 months, The Cologuard Multi-target Stool DNA (sDNA) Test once every 3 years, Blood-based Biomarker Tests once every 3 years, Diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with limited benefit, Cognitive ability to use hearing clues and a willingness to undergo an extended program of rehabilitation, Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, and freedom from lesions in the hearing nerve and acoustic areas of the central nervous system, No indicated risks to surgery that are determined harmful or inadvisable, The device must be used in accordance with Food and Drug Administration (FDA) approved labeling, You can complete the Member Complaint Form. Your enrollment in your new plan will also begin on this day. a. The patient is under the care of a heart team, which consists of a cardiac surgeon, interventional cardiologist, and various Providers, nurses, and research personnel, The heart team's interventional cardiologist(s) and cardiac surgeon(s) must jointly participate in the related aspects of TAVR, The hospital where the TAVR is complete must have various qualifications and implemented programs. Concurrent with Carotid Stent Placement in Food and Drug Administration (FDA) Approved Category B Investigational Device Exemption (IDE) Clinical Trials Study data for CMS-approved prospective comparative studies may be collected in a registry. You can ask for an Independent Medical Review (IMR) from the Help Center at the California Department of Managed Health Care (DMHC). If the review organization agrees to give you a fast appeal, it must give you an answer to your Level 2 Appeal within 72 hours after getting your appeal request. 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; Refer to Chapter 3 of your Member Handbook for more information on getting care. We will also use the standard 14 calendar day deadline instead. 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. Yes. This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision. Effective January 21, 2020, CMS will cover acupuncture for chronic low back pain (cLBP) for up to 12 visits in 90 days and an additional 8 sessions for those beneficiaries that demonstrate improvement, in addition to the coverage criteria outlined in the NCD Manual. 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. CMS has added a new section, Section 20.35, to Chapter 1 entitled Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). effort to participate in the health care programs IEHP DualChoice offers you. CMS has updated Chapter 1, section 20.32 of the Medicare National Coverage Determinations Manual. According to the FDA labeling in an MRI environment, MRI coverage will be provided for beneficiaries under certain conditions. We will contact the provider directly and take care of the problem. 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). Effective for claims with dates of service on or after 01/18/17, Medicare will cover leadless pacemakers under CED when procedures are performed in CMS-approved studies. For some types of problems, you need to use the process for coverage decisions and making appeals. All physicians participating in the procedure must have device-specific training by the manufacturer of the device. These changes might happen if: When these changes happen, we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill. Effective on or after April 10, 2018, MRI coverage will be provided when used in accordance to the FDA labeling in an MRI environment. 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. See below for a brief description of each NCD. It also has care coordinators and care teams to help you manage all your providers and services. Rancho Cucamonga, CA 91729-1800 You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You cannot make this request for providers of DME, transportation or other ancillary providers. asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test), and, average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohns Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer). All other indications for colorectal cancer screening not otherwise specific in the regulations or the National Coverage Determination above. What to do if you have a problem or concern with IEHP DualChoice (HMO D-SNP): You can call IEHP Member Services at (877) 273-IEHP (4347) and ask for a Member Complaint Form. (Implementation date: August 29, 2017 for MAC local edits; January 2, 2018 for MCS shared edits) Here are examples of coverage determination you can ask us to make about your Part D drugs. 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. The phone number for the Office for Civil Rights is (800) 368-1019. 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. If possible, we will answer you right away. 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. They can also answer your questions, give you more information, and offer guidance on what to do. There are many kinds of specialists. It also needs to be an accepted treatment for your medical condition. 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 can file a grievance. Appeal any decision IEHP DualChoice makes regarding, but not limited to, a denial, termination, payment, or reduction of services. To find the name, address, and phone number of the Quality Improvement Organization in your state, lookin Chapter 2 of your. If you move out of our service area for more than six months. You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage decision. Your care team and care coordinator work with you to make a care plan designed to meet your health needs. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contact renewal. 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). Quantity limits. 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. The treatment is based upon efficacy from a change in surrogate endpoint such as amyloid reduction. TTY users should call (800) 537-7697. Possible errors in the amount (dosage) or duration of a drug you are taking. If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize the medical care coverage within 72 hours or give you the service or item within 14 calendar days from the date we receive the IREs decision. Who is covered: Important things to know about asking for exceptions. A reasonable salary expectation is between $153,670.40 and $195,936.00, based upon experience and internal equity. Calls to this number are free. 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. A Level 2 Appeal is the second appeal, which is done by an independent organization that is not connected to the plan. The clinical research must evaluate the required twelve questions in this determination. You can still get a State Hearing. Will not cover an experimental or investigational Medi-Cal treatment for a serious medical condition. You can change your Doctor by calling IEHP DualChoice Member Services. Hepatitis B Virus (HBV) is transmitted by exposure to bodily fluids. Heart failure cardiologist with experience treating patients with advanced heart failure. IEHP DualChoice is very similar to your current Cal MediConnect plan. IEHP DualChoice will give notice to IEHPDualChoice Members prior to removing Part D drug from the Part D formulary. If our answer is Yes to part or all of what you asked for, we must authorize or provide the coverage within 72 hours after we get your appeal. Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities; or. Box 4259 ICDs will be covered for the following patient indications: Please refer to section 20.4 of the NCD Manual for additional coverage criteria. The phone number for the Office of the Ombudsman is 1-888-452-8609. If you lose your zero share-of-cost, full scope Medi-Cal, you will be disenrolled from our plan (for your Medicare benefits) the first day of the following month andwill be covered by the Original Medicare. H8894_DSNP_23_3241532_M. The procedure is used with a mitral valve TEER system that has received premarket approval from the FDA. For patients whose initial prescription for oxygen did not originate during an inpatient hospital stay, the time of need occurs when the treating practitioner identifies signs and symptoms of hypoxemia that can be relieved with at home oxygen therapy. b. A care team can help you. A Cal MediConnect Plan is an organization made up of Doctors, Hospitals, Pharmacies, Providers of long-term services and supports, Behavioral Health Providers, and other Providers. Prior to the beneficiarys first lung cancer LDCT screening, the beneficiary must receive a counseling and shared decision-making visit that meets specific criteria. If you or your doctor disagree with our decision, you can appeal. 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. Yes. When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. 10820 Guilford Road, Suite 202 TTY (800) 718-4347. The list must meet requirements set by Medicare. We will tell you in advance about these other changes to the Drug List. The time of need is indicated when the presumption of oxygen therapy within the home setting will improve the patients condition. (Effective: January 18, 2017) TTY users should call 1-800-718-4347. 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. 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. Learn about your health needs and leading a healthy lifestyle. IEHP DualChoice Member Services can assist you in finding and selecting another provider. This means that your PCP will be referring you to specialists and services that are affiliated with their medical group. If you have questions, you can contact IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Within 10 days of the mailing date of our notice of action; or. Its a good idea to make a copy of your bill and receipts for your records. The device must be approved by the Food and Drug Administration (FDA) for this purpose; OR. The Centers for Medicare and Medical Services (CMS) has determined the following services to be necessary for the treatment of an illness or injury. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You must qualify for this benefit. Yes. This government program has trained counselors in every state. Treatment for patients with untreated severe aortic stenosis. How to Enroll with IEHP DualChoice (HMO D-SNP) Information is also below. (Effective: April 10, 2017) What Prescription Drugs Does IEHP DualChoice Cover? 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. The plan's block transfer filing indicated that the termination was the result of conduct by Vantage that resulted in the inappropriate delay, denial or modification of authorizations for services and care provide to IEHP's Medi-Cal managed care enrollees. Interpreted by the treating physician or treating non-physician practitioner. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Or you can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. PCPs are usually linked to certain hospitals and specialists. Click here for more information on study design and rationale requirements. 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. Our plan cannot cover a drug purchased outside the United States and its territories. The Difference Between ICD-10-CM & ICD-10-PCS. Erythrocythemia (increased red blood cells) with a hematocrit greater than 56%. At Level 2, an Independent Review Entity will review the decision. VNS is non-covered for the treatment of TRD when furnished outside of a CMS-approved CED study. If your Level 2 Appeal was an Independent Medical Review, the Department of Managed Health Care will send you a letter explaining its decision. Appointment of Representatives Form (PDF), 2023 Drugs Requiring Prior Authorization (PDF). If the DMHC decides that your case is not eligible for IMR, the DMHC will review your case through its regular consumer complaint process. If the answer to your appeal is Yes at any stage of the appeals process after Level 2, we must send the payment you asked for to you or to the provider within 60 calendar days. It tells which Part D prescription drugs are covered by IEHP DualChoice. If your health condition requires us to answer quickly, we will do that. The procedure must be performed in a hospital with infrastructure and experience meeting the requirements in this determination. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). To learn more about your prescription drug costs, call IEHP DualChoice Member Services. Medicare beneficiaries who are diagnosed with Symptomatic Peripheral Artery Disease who would benefit from this therapy. 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 care coordinator is a person who is trained to help you manage the care you need. Terminal illnesses, unless it affects the patients ability to breathe. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug. Dependent edema (gravity related swelling due to excess fluid) suggesting congestive heart failure; or, We are also one of the largest employers in the region, designated as "Great Place to Work.". If an alternative drug would be just as effective as the drug you are asking for, and would not cause more side effects or other health problems, we will generally not approve your request for an exception. Pay rate will commensurate with experience. Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. An interventional echocardiographer must perform transesophageal echocardiography during the procedure.>. Ask within 60 days of the decision you are appealing. (Implementation Date: March 26, 2019). What if you are outside the plans service area when you have an urgent need for care? It stores all your advance care planning documents in one place online. For other types of problems you need to use the process for making complaints. If your health requires it, ask us to give you a fast coverage decision According to IEHP, 99.4 percent of enrollees retained the same primary care physicians. We are always available to help you. We will send you a letter telling you that. Then you may submit your request one of these ways: To the county welfare department at the address shown on the notice. Patients must maintain a stable medication regimen for at least four weeks before device implantation. Opportunities to Grow. As an IEHP DualChoice (HMO D-SNP) Member, you have the right to: As an IEHP DualChoice Member, you have the responsibility to: For more information on Member Rights and Responsibilities refer to Chapter 8 of your IEHP DualChoice Member Handbook. Program Services There are five services eligible for a financial incentive. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. 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. You, your doctor or other prescriber, or your representative can request the Level 2 Appeal. If you want a fast appeal, you may make your appeal in writing or you may call us. 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. Who is covered? The DMHC may accept your application after 6 months if it determines that circumstances kept you from submitting your application in time. 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. At Level 2, an Independent Review Entity will review your appeal. Eligible Members The population for this P4P program includes IEHP Direct DualChoice Members. Drugs that may not be safe or appropriate because of your age or gender. Information on this page is current as of October 01, 2022. Send copies of documents, not originals. Be treated with respect and courtesy. If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. 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. Most complaints are answered in 30 calendar days. You must choose your PCP from your Provider and Pharmacy Directory. Click here for more information on Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). 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. Walnuts grow in U.S. Department of Agriculture plant hardiness zones 4 through 9, and hickories can be . But in some situations, you may also want help or guidance from someone who is not connected with us. We are also one of the largest employers in the region, designated as "Great Place to Work.". Will my benefits continue during Level 1 appeals? 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). (800) 718-4347 (TTY), IEHP 24-Hour Nurse Advice Line (for IEHP Members only) TTY/TDD (800) 718-4347. We must give you our answer within 14 calendar days after we get your request. Our state has an organization called Livanta Beneficiary & Family Centered Care (BFCC) Quality Improvement Organization (QIO). No more than 20 acupuncture treatments may be administered annually. We have 30 days to respond to your request. How do I make a Level 1 Appeal for Part C services? What is covered: Noncoverage specifically includes the following: Click here for more information on Ambulatory Electroencephalographic Monitoring and Colorectal Cancer Screening Tests. We will send you a notice before we make a change that affects you. You can also have your doctor or your representative call us. (Effective: January 27, 20) If we decide to take extra days to make the decision, we will tell you by letter. What is a Level 2 Appeal? IEHP DualChoice (Implementation Date: November 13, 2020). P.O. You can also have a lawyer act on your behalf. Submit the required study information to CMS for approval. Suppose that you are temporarily outside our plans service area, but still in the United States. In order to receive out-of-network services, your Primary Care Provider (PCP) or Specialist must submit a referral request to your plan or medical group. The List of Covered Drugs and pharmacy and provider networks may change throughout the year.