(Implementation date: August 29, 2017 for MAC local edits; January 2, 2018 for MCS shared edits) We may not tell you before we make this change, but we will send you information about the specific change or changes we made. (Implementation Date: November 13, 2020). You ask us if a drug is covered for you (for example, when your drug is on the plans Formulary but we require you to get approval from us before we will cover it for you). (Implementation Date: February 14, 2022) 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. 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. What is a Level 2 Appeal? What is a Level 1 Appeal for Part C services? 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. IEHP DualChoice recognizes your dignity and right to privacy. For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. Sign up for the free app through our secure Member portal. An IMR is a review of your case by doctors who are not part of our plan. Diagnostic Tests, X-Rays & Lab Services: $0, Home and Community Based Services (HCBS): $0, Community Based Adult Services (CBAS): $0, Long Term Care that includes custodial care and facility: $0. TDD users should call (800) 952-8349. If your Level 2 Appeal was a State Hearing, you may ask for a rehearing within 30 days after you receive the decision. You might leave our plan because you have decided that you want to leave. Bringing focus and accountability to our work. You pay no costs for an IMR. We will send you a notice before we make a change that affects you. Welcome to Inland Empire Health Plan \. 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. When we add the new generic drug, we may also decide to keep the current drug on the list but change its coverage rules or limits. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. For additional details on how to reach us for appeals, see Chapter 9 of the IEHP DualChoice Member Handbook. IEHP DualChoice is very similar to your current Cal MediConnect plan. 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. (Effective: February 15. The program is not connected with us or with any insurance company or health plan. Call, write, or fax us to make your request. The time of need is indicated when the presumption of oxygen therapy within the home setting will improve the patients condition. Information on this page is current as of October 01, 2022, Centers for Medicare and Medicaid Services. Please see below for more information. Click here for more information on Ventricular Assist Devices (VADs) coverage. If IEHP DualChoice removes a Covered Part D drug or makes any changes in the IEHP DualChoice Formulary, we will post the formulary changes on IEHPDualChoice website and notify the affected Members at least thirty (30) days prior to effective date of the change made on the IEHP DualChoice Formulary. An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. This government program has trained counselors in every state. If you put your complaint in writing, we will respond to your complaint in writing. Inland Empire Health Plan (IEHP) has over 1,234 Doctors, 3,676 Specialists, 724 Pharmacies, 74 Urgent Care, 243 OB/GYNs, 383 Behavioral Health Providers, 40 major Hospitals, and 313 Vision doctors in Riverside and San Bernardino counties. Call IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. To learn how to submit a paper claim, please refer to the paper claims process described below. Study data for CMS-approved prospective comparative studies may be collected in a registry. Box 4259 All screenings DNA tests, effective April 28, 2008, through October 8, 2014. Limitations, copays, and restrictions may apply. When will I hear about a standard appeal decision for Part C services? For more information, call IEHP DualChoice Member Services or read the IEHP DualChoice Member Handbook. Ask within 60 days of the decision you are appealing. 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. C. Beneficiarys diagnosis meets one of the following defined groups below: Will not pay for emergency or urgent Medi-Cal services that you already received. Can my doctor give you more information about my appeal for Part C services? We have 30 days to respond to your request. The PCP you choose can only admit you to certain hospitals. If you ask for a fast appeal, we will give you your answer within 72 hours after we get your appeal. This is not a complete list. The letter will also explain how you can appeal our decision. When you choose a PCP, it also determines what hospital and specialist you can use. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. This means within 24 hours after we get your request. 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. Have advanced heart failure for at least 14 days and are dependent on an intraaortic balloon pump (IABP) or similar temporary mechanical circulatory support for at least 7 days. If the service or item you paid for is covered and you followed all the rules, we will send you the payment for our share of the cost of the service or item within 60 calendar days after we get your request. We will send you a letter telling you that. Concurrent with Intracranial Stent Placement in FDA-Approved Category B IDE Clinical Trials View Plan Details. H8894_DSNP_23_3879734_M Pending Accepted. If you think your health requires it, you should ask for a fast appeal. If you are asking us to pay you back for a drug you already bought, we must give you our answer within 14 calendar days after we get your appeal. 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. When you are discharged from the hospital, you will return to your PCP for your health care needs. What is covered: This includes denial of payment for a service after the service has been rendered (post-service) or denial of service prior to the service being rendered (pre-service). How much time do I have to make an appeal for Part C services? This is called a referral. Information on the page is current as of March 2, 2023 With IEHP DualChoice, you will still have an IEHP DualChoice Member Service team to get help for your needs. What is covered? IEHP (Inland Empire Health Plan) is a provider that contains a network of doctors, dentists, pyschs, therapists, and specialists. 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. Usually, your prescription drugs are only covered if they are filled at a network pharmacy including through our mail-order pharmacy services. Medicare beneficiaries in need of a pacemaker who are participating in an approved clinical study. ), 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. 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. What if the plan says they will not pay? 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. a. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. 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. 4. Effective on January 1, 2023, CMS has updated section 210.3 of the NCD Manual that provides coverage for colorectal cancer (CRC) screening tests under Medicare Part B. Information on this page is current as of October 01, 2022. Click here for more information on Cochlear Implantation. Make your appeal request within 60 calendar days from the date on the notice we sent to tell you our decision. Please call or write to IEHP DualChoice Member Services. The Office of the Ombudsman. We will give you our answer sooner if your health requires it. Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative Form. If your Level 2 Appeal was a State Hearing, the California Department of Social Services will send you a letter explaining its decision. For additional information on step therapy and quantity limits, refer to Chapter5 of theIEHP DualChoice Member Handbook. 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 Heart team must participate in the national registry and track outcomes according to the requirements in this determination.>. At level 2, an Independent Review Entity will review the decision. Breathlessness without cor pulmonale or evidence of hypoxemia; or. To be a Member of IEHP DualChoice, you must keep your eligibility with Medi-Cal and Medicare. This is not a complete list. What is covered: 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. 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. (You cannot get a fast coverage decision coverage decision if your request is about payment for care or an item you have already received.). 2. What is covered: In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. IEHP DualChoice also provides information to the Centers for Medicare and Medicaid Services (CMS) regarding its quality assurance measures according to the guidelines specified by CMS. Please see below for more information. To learn more about your prescription drug costs, call IEHP DualChoice Member Services. Our plans Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B. 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. 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. TTY users should call (800) 718-4347 or fax us at (909) 890-5877. Opportunities to Grow. 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. Please be sure to contact IEHP DualChoice Member Services if you have any questions. You can contact the Office of the Ombudsman for assistance. See form below: Deadlines for a fast appeal at Level 2 You can ask us to reimburse you for IEHP DualChoice's share of the cost. If you get a bill that is more than your copay for covered services and items, send the bill to us. Make recommendations about IEHP DualChoice Members rights and responsibilities policies. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer and; has not been previously tested with the same test using NGS for the same cancer genetic content and; has decided to seek further cancer treatment (e.g., therapeutic chemotherapy). They are considered to be at high-risk for infection; or. Our response will include our reasons for this answer. When you choose your PCP, remember the following: You will usually see your Primary Care Provider (PCP) first for most of your routine healthcare needs such as physical check-ups, immunization, etc. See Chapters 7 and 9 of the IEHP DualChoice Member Handbookto learn how to ask the plan to pay you back. You must ask to be disenrolled from IEHP DualChoice. Our service area includes all of Riverside and San Bernardino counties. 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. 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. IEHP DualChoice (HMO D-SNP) helps make your Medicare and Medi-Cal benefits work better together and work better for you. Dieticians and Nutritionist will determine how many units will be administered per day and must meet the requirements of this NCD as well at 42 CFR 410.130 410.134. Sacramento, CA 95899-7413. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire.