(Effective: January 19, 2021) (Implementation Date: December 10, 2018). 3. Treatment for patients with untreated severe aortic stenosis. Prescriptions written for drugs that have ingredients you are allergic to. 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. You may change your PCP for any reason, at any time. You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage decision. If you have a fast complaint, it means we will give you an answer within 24 hours. Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). Who is covered: If we do not meet this deadline, we will send your request to Level 2 of the appeals process. If you ask for a fast appeal, we will give you your answer within 72 hours after we get your appeal. If IEHP DualChoice removes a covered Part D drug or makes any changes in the IEHP DualChoice Formulary, IEHP DualChoice will post the formulary changes on the IEHP DualChoice website and notify the affected Members at least thirty (30) days prior to effective date of the change made on the IEHP DualChoice Formulary. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. If you are asking us to pay you back for medical care you have already received and paid for yourself, you are not allowed to ask for a fast appeal. 504 Plan Defined The 504 Plan is a plan developed to ensure that a child who has a disability If you need help to fill out the form, IEHP Member Services can assist you. disease); An additional 8 sessions will be covered for those patients demonstrating an improvement. Livanta is not connect with our plan. This is called upholding the decision. It is also called turning down your appeal.. 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. 2023 Plan Benefits. Our plan cannot cover a drug purchased outside the United States and its territories. For example: We may make other changes that affect the drugs you take. Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plans service area. 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. Be prepared for important health decisions 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. Click here to download a free copy of Adobe Acrobat Reader.By clicking on this link, you will be leaving the IEHP DualChoice website. Our service area includes all of Riverside and San Bernardino counties. The procedure is used with a mitral valve TEER system that has received premarket approval from the FDA. Can I ask for a coverage determination or make an appeal about Part D prescription drugs? 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. You wont pay a premium, or pay for doctor visits or other medical care if you go to a provider that works with our health plan. Prior to filling your prescription at an out-of-network pharmacy, call IEHP DualChoice Member Services to find out if there is a network pharmacy in the area where you are traveling. ii. Our plan usually cannot cover off-label use. (Effective: January 1, 2023) We do the right thing by: Placing our Members at the center of our universe. We will look into your complaint and give you our answer. 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. You may also ask for judicial review of a State Hearing denial by filing a petition in Superior Court (under Code of Civil Procedure Section 1094.5) within one year after you receive the decision. Level 2 Appeal for Part D drugs. 711 (TTY), To Enroll with IEHP How will the plan make the appeal decision? Call IEHP DualChoice Member Services if you need help in choosing a PCP or changing your PCP. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which IEHP DualChoice (HMO D-SNP) authorizes use of out-of-network providers. Emergency services from network providers or from out-of-network providers. 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. 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. There is no deductible for IEHP DualChoice. The List of Covered Drugs and pharmacy and provider networks may change throughout the year. Thus, this is the main difference between hazelnut and walnut. (Effective: July 2, 2019) We are always available to help you. Call (888) 466-2219, TTY (877) 688-9891. We may contact you or your doctor or other prescriber to get more information. 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. Call IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Black Walnuts on the other hand have a bolder, earthier flavor. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.). 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. It is not connected with this plan and it is not a government agency. You can call IEHP DualChoice at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. 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. (Effective: May 25, 2017) If possible, we will answer you right away. If you qualify for an IMR, the DMHC will review your case and send you a letter within 7 calendar days telling you that you qualify for an IMR. TTY (800) 718-4347. 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. 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. (Implementation Date: September 20, 2021). IEHP DualChoice is a Cal MediConnect Plan. During this time, you must continue to get your medical care and prescription drugs through our plan. Reviewers at the Independent Review Entity will take a careful look at all of the information related to your appeal. This means within 24 hours after we get your request. Transportation: $0. After cracking, the nutmeat is easy to remove from the English walnut shell, while the nutmeat from the black walnut is much more difficult to remove after it has been cracked . (Implementation Date: January 3, 2023) Contact us promptly call IEHP DualChoice at (877) 273-IEHP (4347), 8am - 8pm, 7 days a week, including holidays.TTY users should call 1-800-718-4347. You or someone you name may file a grievance. Cardiologists care for patients with heart conditions. If we say no to part or all of your Level 1 Appeal, we will send you a letter. You have a care team that you help put together. 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. 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. How much time do I have to make an appeal for Part C services? All other indications for colorectal cancer screening not otherwise specified in the Social Security Act, regulations, or the above remain nationally non-covered. Including bus pass. No more than 20 acupuncture treatments may be administered annually. Use the IEHP Medicare Prescription Drug Coverage Determination Form for a prior authorization. We establish that you had an existing relationship with a primary or specialty care provider, with some exceptions. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug. 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. We will send you a letter within 5 calendar days of receiving your appeal letting you know that we received it. ((Effective: December 7, 2016) When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. 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. If we say No to your appeal, you then choose whether to accept this decision or continue by making another appeal. You may also ask for an appeal by calling IEHP DualChoice Member Services at 1-877-273-IEHP (4347), 8am 8pm (PST), 7 days a week, including holidays. You can make the complaint at any time unless it is about a Part D drug. What is a Level 1 Appeal for Part C services? 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. IEHP DualChoice. You can ask us for a standard appeal or a fast appeal.. When we send the payment, its the same as saying Yes to your request for a coverage decision. What if the Independent Review Entity says No to your Level 2 Appeal? This is not a complete list. The Difference Between ICD-10-CM & ICD-10-PCS. You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY (800) 718-4347. 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. 2020) How to obtain an aggregate number of grievances, appeals, and exceptions filed with IEHP DualChoice (HMO D-SNP)? The Medicare Complaint Form is available at:https://www.medicare.gov/MedicareComplaintForm/home.aspx. The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. 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). You can get the form at. What is covered? He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. When we say existing relationship, it means that you saw an out-of-network provider at least once for a non-emergency visit during the 12 months before the date of your initial enrollment in our plan. (Implementation Date: June 12, 2020). Then, we check to see if we were following all the rules when we said No to your request. We will send you a letter telling you that. You may be able to get extra help to pay for your prescription drug premiums and costs. Please note: If your pharmacy tells you that your prescription cannot be filled, you will get a notice explaining how to contact us to ask for a coverage determination. Oncologists care for patients with cancer. Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. What is covered: If the appeal comes from someone besides you or your doctor or other provider, we must receive the completed Appointment of Representative form before we can review the appeal. Or, if you havent paid for the service or item yet, we will send the payment directly to the provider. If you dont know what you should have paid, or you receive bills and you dont know what to do about those bills, we can help. 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. 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. (Effective: September 28, 2016) You will be automatically disenrolled from IEHPDualChoice, when your new plans coverage begins. If you have questions, you can contact IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. You will be notified when this happens. You may use the following form to submit an appeal: Can someone else make the appeal for me? 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. 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. You have a right to appeal or ask for Formulary exception if you disagree with the information provided by the pharmacist. We will let you know of this change right away. 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. When can you end your membership in our plan? For example, you can make a complaint about disability access or language assistance. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period. If you no longer qualify for Medi-Cal or your circumstances have changed that make you no longer eligible for Dual Special Needs Plan, you may continue to get your benefits from IEHP DualChoice for an additional two-month period. a. Effective for claims with dates of service on or after 09/28/2016, CMS covers screening for HBV infection. 2. Fax: (909) 890-5877. You will need Adobe Acrobat Reader6.0 or later to view the PDF files. CMS has updated Chapter 1, section 160.18 of the Medicare National Coverage Determinations Manual. Your benefits as a member of our plan include coverage for many prescription drugs. Typically, our Formulary includes more than one drug for treating a particular condition. If you or your doctor disagree with our decision, you can appeal. You can always contact your State Health Insurance Assistance Program (SHIP). By clicking on this link, you will be leaving the IEHP DualChoice website. You can get services such as those listed below without getting approval in advance from your Primary Care Provider (PCP). IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan. The phone number for the Office for Civil Rights is (800) 368-1019. If you want the Independent Review Organization to review your case, your appeal request must be in writing. You can download a free copy here. Program Services There are five services eligible for a financial incentive. The California Department of Managed Health Care (DMHC) is responsible for regulating health plans. Whether you call or write, you should contact IEHP DualChoice Member Services right away. Information on the page is current as of March 2, 2023 The MAC may determine necessary coverage for in home oxygen therapy for patients that do not meet the criteria described above. Information on this page is current as of October 01, 2022. Non-Covered Use: The following uses are considered non-covered: Click here for more information on Blood-Derived Products for Chronic, Non-Healing Wounds coverage. Click here to download a free copy by clicking Adobe Acrobat Reader. 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. 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. For more information on Member Rights and Responsibilities refer to Chapter 8 of your. Information on procedures for obtaining prior authorization of services, Quality Assurance, disenrollment, and other procedures affecting IEHP DualChoice Members. The letter will explain why more time is needed. VNS is non-covered for the treatment of TRD when furnished outside of a CMS-approved CED study. 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. (Implementation Date: June 16, 2020). iii. The letter will also explain how you can appeal our decision. If your problem is about a Medi-Cal service or item, you can file a Level 2 Appeal yourself. 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. The procedure must be performed by an interventional cardiologist or cardiac surgeon.<. (888) 244-4347 If your problem is urgent and involves an immediate and serious threat to your health, you may bring it immediately to the DMHCs attention. Will not cover an experimental or investigational Medi-Cal treatment for a serious medical condition. If the Independent Review Entity approves a request to pay you back for a drug you already bought, we will send payment to you within 30 calendar days after we get the decision. 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. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. You will not have a gap in your coverage. Most of the walnuts we eat in the United States are commonly known as English walnuts, but black walnuts are also prized and delicious. 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. You can ask us to reimburse you for our share of the cost by submitting a claim form. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. To learn more about the plans benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you. 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). IEHP Medi-Cal Member Services The Centers for Medicare and Medical Services (CMS) has determined the following services to be necessary for the treatment of an illness or injury. There are many kinds of specialists. In most cases, you must file an appeal with us before requesting an IMR. Get the My Life. You will get a letter from us about the change in your eligibility with instructions to correct your eligibility information. Sacramento, CA 95899-7413. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. 8am - 8pm (PST), 7 days a week, including holidays, TTY: (800) 718-4347. If you do not want to first appeal to the plan for a Medi-Cal service, in special cases you can ask for an Independent Medical Review. How will I find out about the decision? Be informed regarding Advance Directives, Living Wills, and Power of Attorney, and to receive information regarding changes related to existing laws. For reservations call Monday-Friday, 7am-6pm (PST). 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. 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. 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. This includes: The device is used following post-cardiotomy (period following open heart surgery) to support blood circulation. (This is sometimes called step therapy.). You, your doctor or other prescriber, or your representative can request the Level 2 Appeal. Suppose that you are temporarily outside our plans service area, but still in the United States. For problems and concerns regarding eligibility determinations, assessments, and care delivered by our contracted Community Based Adult Services (CBAS) centers, or Nursing Facilities/Sub-Acute Care Facilities, you should follow the process outlined below. The reviewer will be someone who did not make the original coverage decision. These reviews are especially important for members who have more than one provider who prescribes their drugs. The form gives the other person permission to act for you. For additional information on step therapy and quantity limits, refer to Chapter5 of theIEHP DualChoice Member Handbook. IEHP DualChoice Cal MediConnect (Medicare-Medicaid Plan) is changing to IEHP DualChoice (HMO D-SNP) on January 1, 2023. Group I: a. What if the plan says they will not pay? If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more days (44 days total) to answer your complaint. 2023 IEHP DualChoice Provider and Pharmacy Directory (PDF), http://www.dmhc.ca.gov/FileaComplaint/SubmitanIndependentMedicalReviewComplaintForm.aspx, Request for Medicare Prescription Drug Coverage Determination (PDF). How do I ask the plan to pay me back for the plans share of medical services or items I paid for? Tier 1 drugs are: generic, brand and biosimilar drugs. Previous Next ===== TABBED SINGLE CONTENT GENERAL. b. Here are two ways to get information directly from Medicare: By clicking on this link, you will be leaving the IEHP DualChoice website. It tells which Part D prescription drugs are covered by IEHP DualChoice. For the purpose of this decision, cLBP is defined as: nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. ), 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. You may choose different health plans, or providers, under Medi-Cal, like IEHP or Molina Healthcare, Blue Shield, Health Net, etc. For inpatient hospital patients, the time of need is within 2 days of discharge. TTY users should call 1-800-718-4347. We may not tell you before we make this change, but we will send you information about the specific change or changes we made. IEHP DualChoice Medicare Team at (800) 741-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY users should call (800) 718-4347. Information is also below. 3. ICDs will be covered for the following patient indications: Please refer to section 20.4 of the NCD Manual for additional coverage criteria. ii. 1501 Capitol Ave., Use of autologous Platelet-Derived Growth Factor (PDGF) for treatment of chronic, non-healing, cutaneous (affecting the skin) wounds, and. Medicare has approved the IEHP DualChoice Formulary. 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. Ask for an exception from these changes. If you put your complaint in writing, we will respond to your complaint in writing. The list can help your provider find a covered drug that might work for you. 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. Your PCP, along with the medical group or IPA, provides your medical care. 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? 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. Click here for more information on Topical Applications of Oxygen. If your case is urgent and you qualify for an IMR, the DMHC will review your case and send you a letter within 2 calendar days telling you that you qualify for an IMR. If your PCP leaves our Plan, we will let you know and help you choose another PCP so that you can keep getting covered services. We will tell you about any change in the coverage for your drug for next year. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. If the answer is No, we will send you a letter telling you our reasons for saying No. Click here for more information on Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). See Chapters 7 and 9 of the IEHP DualChoice Member Handbookto learn how to ask the plan to pay you back. Welcome to Inland Empire Health Plan \. Treatment for patients with existing co-morbidities that would preclude the benefit from the procedure. "Coordinating" your services includes checking or consulting with other Plan providers about your care and how it is going. (SeeChapter 10 oftheIEHP DualChoiceMember Handbookfor information on when your new coverage begins.) Who is covered: Click here for information on Next Generation Sequencing coverage. 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 National Coverage Determination Manual. 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. If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave.