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. (Effective: June 21, 2019) Screening computed tomographic colonography (CTC), effective May 12, 2009. This is not a complete list. 1. If you are not satisfied with the result of the IMR, you can still ask for a State Hearing. i. (Effective: February 19, 2019) TTY users should call (800) 718-4347 or fax us at (909) 890-5877. If we do not meet this deadline, we will send your request to Level 2 of the appeals process. ), 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. How to obtain an aggregate number of grievances, appeals, and exceptions filed with IEHP DualChoice (HMO D-SNP)? If you are requesting an exception, provide the supporting statement. Your doctor or other prescriber must give us the medical reasons for the drug exception. You should provide all requested information such as your full name, address, telephone number, the name of the plan or county that took the action against you, the aid program(s) involved, and a detailed reason why you want a hearing. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. IEHP DualChoice (HMO D-SNP) helps make your Medicare and Medi-Cal benefits work better together and work better for you. Be prepared for important health decisions Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. Patient must be evaluated for suitability for repair and must documented and made available to the Heart team members meeting the requirements of this determination. Click here for more information on MRI Coverage. 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. What is covered: The List of Covered Drugs and pharmacy and provider networks may change throughout the year. IEHP (Inland Empire Health Plan) is a provider that contains a network of doctors, dentists, pyschs, therapists, and specialists. The form gives the other person permission to act for you. 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. Whether you call or write, you should contact IEHP DualChoice Member Services right away. 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. (Implementation Date: June 16, 2020). Treatment of Atherosclerotic Obstructive Lesions Important things to know about asking for exceptions. Your test results are shared with all of your doctors and other providers, as appropriate. If we decide to change or stop coverage for a service or item that was previously approved, we will send you a notice before taking the action. Because you get assistance from Medi-Cal, you can end your membership in IEHPDualChoice at any time. 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. Call IEHP DualChoice Member Services if you need help in choosing a PCP or changing your PCP. IEHP DualChoice is a Cal MediConnect Plan. Study data for CMS-approved prospective comparative studies may be collected in a registry. If we do not give you an answer within 30 calendar days or by the end of the extra days (if we took them), we will automatically send your case to Level 2 of the appeals process if your problem is about a Medicare service or item. We have arranged for these providers to deliver covered services to members in our plan. Here are two ways to get information directly from Medicare: By clicking on this link, you will be leaving the IEHP DualChoice website. You must qualify for this benefit. We do a review each time you fill a prescription. You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY (800) 718-4347. You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. If you want the Independent Review Organization to review your case, your appeal request must be in writing. Who is covered? Beneficiaries must be managed by a team of medical professionals meeting the minimum requirements in the National Coverage Determination Manual. 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. We do not allow our network providers to bill you for covered services and items. If you move out of our service area for more than six months. Yes. If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. If your health requires it, ask for a fast appeal, Our plan will review your appeal and give you our decision. (Effective: September 26, 2022) During this time, you must continue to get your medical care and prescription drugs through our plan. (Effective: February 15. An IMR is a review of your case by doctors who are not part of our plan. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. If your doctor says that you need a fast coverage decision, we will automatically give you one. If we do not give you an answer within 72 hours or by the end of the extra days (if we took them), we will automatically send your case to Level 2 of the appeals process if your problem is about a Medicare service or item. At level 2, an Independent Review Entity will review the decision. You can send your complaint to Medicare. . 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 your Level 2 Appeal went to the Medicare Independent Review Entity, you can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. The following information explains who qualifies for IEHP DualChoice (HMO D-SNP). 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). How can I make a Level 2 Appeal? Be informed regarding Advance Directives, Living Wills, and Power of Attorney, and to receive information regarding changes related to existing laws. Your PCP will send a referral to your plan or medical group. 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. We take another careful look at all of the information about your coverage request. Most of these drugs are Part D drugs. There are a few drugs that Medicare Part D does not cover but that Medi-Cal may cover. i. Most of the walnuts we eat in the United States are commonly known as English walnuts, but black walnuts are also prized and delicious. We will answer your request for an exception within 72 hours after we get your request (or your prescribers supporting statement). If you disagree with our decision, you can ask the DMHC Help Center for an IMR. At any time, you can call IEHP DualChoice Member Services to get up-to-date information about changes in the pharmacy network. These reviews are especially important for members who have more than one provider who prescribes their drugs. You, your doctor or other prescriber, or your representative can request the Level 2 Appeal. IEHP DualChoice (HMO D-SNP) has a process in place to identify and reduce medication errors. (Effective: September 28, 2016) and hickory trees (Carya spp.) You can file a fast complaint and get a response to your complaint within 24 hours. Your benefits as a member of our plan include coverage for many prescription drugs. For additional information on step therapy and quantity limits, refer to Chapter5 of theIEHP DualChoice Member Handbook. 2023 Inland Empire Health Plan All Rights Reserved. Please see below for more information. Beneficiaries who exhibit hypoxemia (low oxygen in your blood) when ALL (A, B, and C) of the following are met: A. Hypoxemia is based on results of a clinical test ordered and evaluated by a patients treating practitioner meeting either of the following: To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for an coverage decision. Oncologists care for patients with cancer. We may stop any aid paid pending you are receiving. Hazelnuts have more carbohydrates and dietary fibres than walnuts while walnuts have more calories, proteins, and fats than hazelnuts. Effective on September 26, 2022, CMS has updated section 50.3 of the National Coverage Determination (NCD) Manual that expands coverage on cochlear implants for the treatment of bilateral pre- or post- linguistic, sensorineural, moderate-to-profound hearing loss when the individual demonstrates limited benefit from amplification under Medicare Part B. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. i. PO2 measurements can be obtained via the ear or by pulse oximetry. Yes. If you need to change your PCP for any reason, your hospital and specialist may also change. If your health requires it, ask the Independent Review Entity for a fast appeal.. Concurrent with Carotid Stent Placement in Food and Drug Administration (FDA) Approved Category B Investigational Device Exemption (IDE) Clinical Trials A drug is taken off the market. Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). CMS has updated Section 110.24 of the Medicare National Coverage Determinations Manual to include coverage of chimeric antigen receptor (CAR) T-cell therapy when specific requirements are met. Noncoverage specifically includes the following: Click here for more information on Ambulatory Electroencephalographic Monitoring and Colorectal Cancer Screening Tests. You pay no costs for an IMR. We may contact you or your doctor or other prescriber to get more information. 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 give you our answer sooner if your health requires us to do so. All other indications for colorectal cancer screening not otherwise specific in the regulations or the National Coverage Determination above. Beneficiaries who meet the coverage criteria, if determined eligible. The leadless pacemaker eliminates the need for a device pocket and insertion of a pacing lead which are integral elements of traditional pacing systems. 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. Concurrent with Carotid Stent Placement in FDA-Approved Post-Approvals Studies If our answer is Yes to part or all of what you asked for, we must approve or give the coverage within 30 calendar days after we get your appeal. Direct and oversee the process of handling difficult Providers and/or escalated cases. Cardiologists care for patients with heart conditions. Effective for dates of service on or after January 19, 2021, CMS has updated section 20.33 of the National Coverage Determination Manual to cover Transcatheter Edge-to-Edge Repair (TEER) for Mitral Valve Regurgitation when specific requirements are met. 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. Follow the plan of treatment your Doctor feels is necessary. It usually takes up to 14 calendar days after you asked. You can fax the completed form to (909) 890-5877. Oxygen therapy can be renewed by the MAC if deemed medically necessary. To learn how to submit a paper claim, please refer to the paper claims process described below. When that happens, we may remove the current drug, but your cost for the new drug will stay the same or will be lower. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Effective for dates of service on or after August 7, 2019, CMS covers autologous treatment for cancer with T-cell expressing at least one chimeric antigen receptor (CAR) when administered at healthcare facilities enrolled in the Food and Drug Administrations (FDA) Risk Evaluation and Mitigation Strategies (REMS) and when specific requirements are met. 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 establish that you had an existing relationship with a primary or specialty care provider, with some exceptions. If the DMHC decides that your case is not eligible for IMR, the DMHC will review your case through its regular consumer complaint process. Breathlessness without cor pulmonale or evidence of hypoxemia; or. 504 Plan Defined The 504 Plan is a plan developed to ensure that a child who has a disability Flu shots as long as you get them from a network provider. When you file a fast complaint, we will give you an answer to your appeal within 24 hours. If the coverage decision is No, how will I find out? 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). You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. If patients with bipolar disorder are included, the condition must be carefully characterized. Previously, PILD for LSS was covered for beneficiaries enrolled only in a CMS-approved prospective, randomized, controlled clinical trial (RCT) under the Coverage with Evidence Development (CED) paradigm. PO2 may be performed by the treating practitioner or by a qualified provider or supplier of laboratory services. Change the coverage rules or limits for the brand name drug. b. We will give you our answer sooner if your health requires it. Use the IEHP DualChoice Provider and Pharmacy Directory below to find a network provider: What is a Primary Care Provider (PCP) and their role in your Plan? If we are using the standard deadlines, we must give you our answer within 7 calendar days after we get your appeal, or sooner if your health requires it. Then, we check to see if we were following all the rules when we said No to your request. If you decide to go on to a Level 2 Appeal, the Independent Review Entity (IRE) will review our decision. The English walnut has a soft and thin shell that makes it easy to crack, while the black walnut has a tougher shell, one of the hardest of all the nuts. Who is covered: Members must meet all of the following eligibility criteria: Click here for more information on LDCT coverage. The treatment is considered reasonably likely to predict a clinical benefit and is administrated in a randomized controlled trial under an investigational new drug application. It tells which Part D prescription drugs are covered by IEHP DualChoice. Sometimes a specialist, clinic, hospital or other network provider you are using might leave the plan. Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plans service area. We will tell you in advance about these other changes to the Drug List. We will send you a letter telling you that. IEHP Direct contracted PCPs who provide service to IEHP Direct DualChoice Members. (800) 718-4347 (TTY), IEHP DualChoice Member Services We will look into your complaint and give you our answer. You should receive the IMR decision within 7 calendar days of the submission of the completed application. 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. When you are discharged from the hospital, you will return to your PCP for your health care needs. Heart failure cardiologist with experience treating patients with advanced heart failure. Join our Team and make a difference with us! (Implementation date: June 27, 2017). (Implementation Date: July 27, 2021) If you decide to ask for a State Hearing by phone, you should be aware that the phone lines are very busy. To learn more about the plans benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook. What Prescription Drugs Does IEHP DualChoice Cover? They also have thinner, easier-to-crack shells. This is called prior authorization. Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. IEHP DualChoice network providers are required to comply with minimum standards for pharmacy practices as established by the State of California. What if the Independent Review Entity says No to your Level 2 Appeal? Coverage for future years is two hours for patients diagnosed with renal disease or diabetes. Click here for more information on Ventricular Assist Devices (VADs) coverage. For more information visit the. Rights and Responsibilities Upon Disenrollment, Ending your membership in IEHP DualChoice (HMO D-SNP) may be voluntary (your own choice) or involuntary (not your own choice). You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. For more information on Home Use of Oxygen coverage click here. Beneficiaries with either a renal disease or diabetes diagnosis as defined in 42 CFR 410.130. 3. 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. (You cannot get a fast coverage decision coverage decision if your request is about payment for care or an item you have already received.). Sprint from Voice Telephone: (800) 877-5379, Visit: 10801 Sixth Street, Suite 120, Rancho Cucamonga, CA 91730. The intended effective date of the action. When you make an appeal to the Independent Review Entity, we will send them your case file. In most cases you have 120 days to ask for a State Hearing after the Your Hearing Rights notice is mailed to you. 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. If you need help to fill out the form, IEHP Member Services can assist you. You will be automatically disenrolled from IEHPDualChoice, when your new plans coverage begins. 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.