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. 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. ACP and the advance health care directive can bridge the gap between the care someone wants and the care they receive if they lose the capacity to make their own decisions. You or someone you name may file a grievance. Click here to learn more about IEHP DualChoice. If the answer is No, we will send you a letter telling you our reasons for saying No. To learn more about the plans benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook. You will get a letter from us about the change in your eligibility with instructions to correct your eligibility information. This section is about asking for coverage decisions and making appeals with problems related to your benefits and coverage. 2. Information on this page is current as of October 01, 2022, Centers for Medicare and Medicaid Services. We will review our coverage decision to see if it is correct. There are extra rules or restrictions that apply to certain drugs on our Formulary. If your health condition requires us to answer quickly, we will do that. Who is covered? To make this request, or if you have any concerns about your continuity of care, please call IEHP DualChoice Member Services at 1-877-273-IEHP (4347). Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. CMS has revised Chapter 1, Section 20.29, Subsection C Topical Application of Oxygen to remove the exclusion of this treatment. It also has care coordinators and care teams to help you manage all your providers and services. 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. How to obtain an aggregate number of grievances, appeals, and exceptions filed with IEHP DualChoice (HMO D-SNP)? IEHP: "Inland Empire Health Plan (IEHP) is a not-for-profit Medi-Cal and Medicare health plan headquartered in Rancho Cucamonga, California. This additional time will allow you to correct your eligibility information if you believe that you are still eligible. This is not a complete list. You can send your complaint to Medicare. If you do not choose a PCP when you join IEHPDualChoice, we will choose one for you. By clicking on this link, you will be leaving the IEHP DualChoice website. 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). How can I make a Level 2 Appeal? The form gives the other person permission to act for you. Patients demonstrating arterial PO2 between 56-59 mm Hg, or whos arterial blood oxygen saturation is 89%, with any of the following condition: Your doctor will also know about this change and can work with you to find another drug for your condition. 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. You can get a fast coverage decision only if the standard 14 calendar day deadline could cause serious harm to your health or hurt your ability to function. H8894_DSNP_23_3241532_M. We determine an existing relationship by reviewing your available health information available or information you give us. Information on this page is current as of October 01, 2022. Beneficiaries with either a renal disease or diabetes diagnosis as defined in 42 CFR 410.130. IEHP DualChoice Your doctor or other provider can make the appeal for you. These different possibilities are called alternative drugs. Medicare beneficiaries who are diagnosed with Symptomatic Peripheral Artery Disease who would benefit from this therapy. You can also visit https://www.hhs.gov/ocr/index.html for more information. Sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 calendar more days. The beneficiary is under pre- or post-operative care of a heart team meeting the following: Cardiac Surgeon meeting the requirements listed in the determination. (Effective: April 10, 2017) You must submit your claim to us within 1 year of the date you received the service, item, or drug. 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. Possible errors in the amount (dosage) or duration of a drug you are taking. Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities; or. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. We will let you know of this change right away. Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plans service area. Organized as a Joint Powers Agency, Inland Empire Health Plan (IEHP) is a local, not-for-profit, public health plan. (If possible, please call IEHP DualChoice Member Services before you leave the service area so we can help arrange for you to have maintenance dialysis while you are away.). You can change your Doctor by calling IEHP DualChoice Member Services. Effective for claims with dates of service on or after 12/07/16, Medicare will cover PILD under CED for beneficiaries with LSS when provided in an approved clinical study. Program Services There are five services eligible for a financial incentive. A medical group or IPA is a group of physicians, specialists, and other providers of health services that see IEHP Members. Interventional Cardiologist meeting the requirements listed in the determination. This includes getting authorization to see specialists or medical services such as lab tests, x-rays, and/or hospital admittance. The formal name for making a complaint is filing a grievance. A grievance is the kinds of problems related to: How to file a Grievance with IEHP DualChoice (HMO D-SNP). When you are outside the service area and cannot get care from a network provider, our plan will cover urgently needed care that you get from any provider. 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. 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. i. IEHP DualChoice (HMO D-SNP) helps make your Medicare and Medi-Cal benefits work better together and work better for you. Some of the advantages include: You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Our response will include our reasons for this answer. Note, the Member must be active with IEHP Direct on the date the services are performed. You will usually see your PCP first for most of your routine health care needs. Typically, our Formulary includes more than one drug for treating a particular condition. To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for an coverage decision. The procedure is used with a mitral valve TEER system that has received premarket approval from the FDA. You may also have rights under the Americans with Disability Act. You should receive the IMR decision within 45 calendar days of the submission of the completed application. To learn how to submit a paper claim, please refer to the paper claims process described below. The clinical research must evaluate the patients quality of life pre and post for a minimum of one year and answer at least one of the questions in this determination section. We have arranged for these providers to deliver covered services to members in our plan. At level 2, an Independent Review Entity will review the decision. Click here for more information on PILD for LSS Screenings. (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. Portable oxygen would not be covered. If we say Yes to your request for an exception, the exception usually lasts until the end of the calendar year. For more information on Member Rights and Responsibilities refer to Chapter 8 of your. If you want a fast appeal, you may make your appeal in writing or you may call us. The Centers of Medicare and Medicaid Services (CMS) will cover transcatheter aortic valve replacement (TAVR) under Coverage with Evidence Development (CED) when specific requirements are met. The MAC may also approve the use of portable oxygen systems to beneficiaries who are mobile in home and benefit from of this unit alone, or in conjunction to a stationary oxygen system. Make your appeal request within 60 calendar days from the date on the notice we sent to tell you our decision. 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). 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. . 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 your problem is about a Medicare service or item, the letter will tell you that we sent your case to the Independent Review Entity for a Level 2 Appeal. You can ask for an IMR if you have also asked for a State Hearing, but not if you have already had a State Hearing, on the same issue. 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. To stay a member of IEHP DualChoice, you must qualify again by the last day of the two-month period. Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States. Remember, you can request to change your PCP at any time. A PCP is your Primary Care Provider. For more information on Grievances see Chapter 9 of your IEHP DualChoice Member Handbook. The services of SHIP counselors are free. You must apply for an IMR within 6 months after we send you a written decision about your appeal. 2) State Hearing 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 decide to make an appeal, it means you are going on to Level 1 of the appeals process. Call, write, or fax us to make your request. By clicking on this link, you will be leaving the IEHP DualChoice website. CMS has added a new section, Section 20.35, to Chapter 1 entitled Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). Additional hours of treatment are considered medically necessary if a physician determines there has been a shift in the patients medical condition, diagnosis or treatment regimen that requires an adjustment in MNT order or additional hours of care. The Office of Ombudsman is not connected with us or with any insurance company or health plan. What is covered: Ask us for a copy by calling Member Services at (877) 273-IEHP (4347). ii. If you are appealing a decision our plan made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a fast appeal., The requirements for getting a fast appeal are the same as those for getting a fast coverage 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. Choose a PCP that is within 10 miles or 15 minutes of your home. Initial coverage for patients experiencing conditions not described above can be limited to a prescription shorter than 90 days, or less than the numbers of days indicated on the practitioners prescription. Prior to January 18, 2017, there was no national coverage determination (NCD) in effect. The Help Center cannot return any documents. Box 1800 (Effective: December 15, 2017) ii. A reasonable salary expectation is between $153,670.40 and $195,936.00, based upon experience and internal equity. (Implementation Date: March 24, 2023) If we dont give you our decision within 14 calendar days, you can appeal. Providers from other groups including patient practitioners, nurses, research personnel, and administrators. When you choose a PCP, it also determines what hospital and specialist you can use. If your change request is received byIEHP by the 25th of the month, the change will be effective the first of the following month; if your change request is received byIEHP after the 25th of the month, the change will be effective the first day of the subsequent month (for some providers, you may need a referral from your PCP). (Implementation Date: October 3, 2022) Call: (877) 273-IEHP (4347). 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. You might leave our plan because you have decided that you want to leave. Will not pay for emergency or urgent Medi-Cal services that you already received. Read your Medicare Member Drug Coverage Rights. You will not have a gap in your coverage. It also has care coordinators and care teams to help you manage all your providers and services. After your application and supporting documents are received from your plan, the IMR decision will be made within 30 calendar days. If you do not qualify by the end of the two-month period, youll de disenrolled by IEHP DualChoice. What if the Independent Review Entity says No to your Level 2 Appeal? CAR, when all the following requirements are met: Autologous treatment is for cancer with T-cells expressing at least one chimeric antigen receptor (CAR); and, Treatment is administered at a healthcare facility enrolled in the FDAs REMS; and. CMS has updated Chapter 1, section 20.19 of the Medicare National Coverage Determinations Manual. Orthopedists care for patients with certain bone, joint, or muscle conditions. (Implementation Date: December 10, 2018). 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. By clicking on this link, you will be leaving the IEHP DualChoice website. The procedure must be performed by an interventional cardiologist or cardiac surgeon.<. The letter will also explain how you can appeal our decision. 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. In most cases, you must start your appeal at Level 1. Beneficiaries receiving treatment for implanting a ventricular assist device (VAD), when the following requirements are met and: All other indications for the use of VADs not otherwise listed remain non-covered, except in the context of Category B investigational device exemption clinical trials (42 CFR 405) or as a routine cost in clinical trials defined under section 310.1 of the National Coverage Determinations (NCD) Manual. They are considered to be at high-risk for infection; or. A clinical test providing a measurement of the partial pressure of oxygen (PO2) in arterial blood. How do I make a Level 1 Appeal for Part C services? If your Level 2 Appeal was an Independent Medical Review, you can request a State Hearing. With "Extra Help," there is no plan premium for IEHP DualChoice. With IEHP DualChoice, you will still have an IEHP DualChoice Member Service team to get help for your needs. Click here for information on Next Generation Sequencing coverage. TTY/TDD (800) 718-4347. Live in our service area (incarcerated individuals are not considered living in the geographic service area even if they are physically located in it. The diagnostic laboratory test using NGS must have: Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic and; FDA-approved or cleared indication for use in that patients cancer and; results provided to the treating physician for management of the patient using a report template to specify treatment options. According to the FDA labeling in an MRI environment, MRI coverage will be provided for beneficiaries under certain conditions. You will get a care coordinator when you enroll in IEHP DualChoice. 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. IEHP DualChoice is for people with both Medicare (Part A and B) and Medi-Cal. The letter will tell you how to do this. If you miss this deadline and have a good reason for missing it, we may give you more time to make you appeal. For example: We may make other changes that affect the drugs you take. 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. (800) 720-4347 (TTY). Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. To learn more about asking for exceptions, see Chapter 9 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]). It tells which Part D prescription drugs are covered by IEHP DualChoice. We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency. Box 997413 Medicare beneficiaries in need of a pacemaker who are participating in an approved clinical study. This is called prior authorization. Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. 2. The services are free. Explore Opportunities. All of our Doctors offices and service providers have the form or we can mail one to you. If we decide that your medical condition does not meet the requirements for a fast coverage decision, we will use the standard deadlines instead. Concurrent with Carotid Stent Placement in FDA-Approved Post-Approvals Studies You can tell Medicare about your complaint. 10820 Guilford Road, Suite 202 The Centers of Medicare and Medicaid Services (CMS) will cover Vagus Nerve Stimulation (VNS) for treatment-resistant depression when specific requirements are met. We will look into your complaint and give you our answer. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision. This is not a complete list. Then, we check to see if we were following all the rules when we said No to your request. The benefit information is a brief summary, not a complete description of benefits. 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. To get a temporary supply of a drug, you must meet the two rules below: When you get a temporary supply of a drug, you should talk with your provider to decide what to do when your supply runs out. 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). You dont have to do anything if you want to join this plan. You can tell the California Department of Managed Health Care about your complaint. If the Independent Medical Review decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. 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 give the coverage within 72 hours after we get your appeal. You will not have a gap in your coverage. You can also call if you want to give us more information about a request for payment you have already sent to us. What is covered? Learn about your health needs and leading a healthy lifestyle. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. The Difference Between ICD-10-CM & ICD-10-PCS. Receive Member informing materials in alternative formats, including Braille, large print, and audio. You are never required to pay the balance of any bill. Patient must also present hypoxemia signs and symptoms such as nocturnal restlessness, insomnia, or impairment of cognitive process. 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. It attacks the liver, causing inflammation. 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. 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. You ask us to pay for a prescription drug you already bought. 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. At Level 2, an Independent Review Entity will review our decision. When can you end your membership in our plan? P.O. H8894_DSNP_23_3241532_M. You can download a free copy here. You can also visit, You can make your complaint to the Quality Improvement Organization. Inform your Doctor about your medical condition, and concerns. If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. Beneficiaries receiving treatment for Transcatheter Edge-to-Edge Repair (TEER) when either of the following are met: This determination will expire ten years after the effective date if a reconsideration is not made during this time. Call IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. What is covered: IEHP offers a competitive salary and stellar benefit package . These forms are also available on the CMS website: This means that your PCP will be referring you to specialists and services that are affiliated with their medical group. If your health requires it, ask us to give you a fast coverage decision When you make an appeal to the Independent Review Entity, we will send them your case file. Our IEHP DualChoice (HMO D-SNP) Provider and Pharmacy Directory gives you a complete list of our network pharmacies that means all of the pharmacies that have agreed to fill covered prescriptions for our plan members. A reasonable salary expectation is between $51,833.60 and $64,022.40, based upon experience and internal equity. According to IEHP, 99.4 percent of enrollees retained the same primary care physicians. Be under the direct supervision of a physician. Our plans PCPs are affiliated with medical groups or Independent Physicians Associations (IPA). There are over 700 pharmacies in the IEHP DualChoice network. For a patient demonstrating arterial PO2 at or above 56 mm Hg, or an arterial oxygen saturation at or above 89%, at rest and during the day. This form is for IEHP DualChoice as well as other IEHP programs. Network providers are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with us to accept our paymentas payment in full. 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. There are two ways you can asked to be disenrolled: To disenroll, please call Health Care Options (HCO) at 1-844-580-7272, 8am - 6pm (PST), Monday - Friday. Yes. 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. The list must meet requirements set by Medicare. However, sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 more calendar days. (Effective: April 13, 2021) You do not need to give your doctor or other prescriber written permission to ask us for a coverage determination on your behalf. A specialist is a doctor who provides health care services for a specific disease or part of the body. Are inotrope dependent OR have a Cardiac Index (CI) < 2.2 L/min/m2, while not on inotropes, and meet one of the following: Are on optimal medical management, based on current heart failure practice guidelines for at least 45 out of the last 60 days and are failing to respond; or.