If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we get your appeal. For inpatient hospital patients, the time of need is within 2 days of discharge. Notify IEHP if your language needs are not met. We are the largest health plan in the Inland Empire, and one of the fastest-growing health plans in the nation. 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. When your PCP thinks that you need specialized treatment or supplies, your PCP will need to get prior authorization (i.e., prior approval) from your Plan and/or medical group. 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. After your application and supporting documents are received from your plan, the IMR decision will be made within 3 calendar days. IEHP Direct contracted PCPs who provide service to IEHP Direct DualChoice Members. CMS reviews studies to determine if they meet the criteria listed in Section 160.18 of the National Coverage Determination Manual. Make your appeal request within 60 calendar days from the date on the notice we sent to tell you our decision. Now, the NCD will cover PILD for LSS under both RCT and longitudinal studies. For more information visit the. We check to see if we were following all the rules when we said No to your request. Never wavering in our commitment to our Members, Providers, Partners, and each other. 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. But in some situations, you may also want help or guidance from someone who is not connected with us. 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 do not need to give your doctor or other prescriber written permission to ask us for a coverage determination on your behalf. TTY users should call (800) 718-4347. Pulmonary hypertension or cor pulmonale (high blood pressure in pulmonary arteries), determined by the measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVFL; or, We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency. 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. Refer to Chapter 3 of your Member Handbook for more information on getting care. If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. When you make an appeal to the Independent Review Entity, we will send them your case file. We will also give notice if there are any changes regarding prior authorizations, quantity limits, step therapy or moving a drug to a higher cost-sharing tier. If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. It also has care coordinators and care teams to help you manage all your providers and services. You cannot make this request for providers of DME, transportation or other ancillary providers. 711 (TTY), To Enroll with IEHP 10820 Guilford Road, Suite 202 You do not need to do anything further to get this Extra Help. 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). Deadlines for a standard coverage decision about payment for a drug you have already bought, If our answer is Yes to part or all of what you asked for, we will make payment to you within 14 calendar days. Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plans service area. No more than 20 acupuncture treatments may be administered annually. The Centers of Medicare and Medicaid Services (CMS) will cover claims for effective dates of service on or after February 15, 2018. Breathlessness without cor pulmonale or evidence of hypoxemia; or. To the California Department of Social Services: To the State Hearings Division at fax number 916-651-5210 or 916-651-2789. Covering a Part D drug that is not on our List of Covered Drugs (Formulary). CMS has updated Chapter 1, section 30.3.3 of the Medicare National Coverage Determinations Manual. Here are two ways to get information directly from Medicare: By clicking on this link, you will be leaving the IEHP DualChoice website. c. The Medicare Administrative Contractors (MACs) will review the arterial PO2 levels above and also take into consideration various oxygen measurements that can results from factors such as patients age, patients skin pigmentation, altitude level and the patients decreased oxygen carrying capacity. 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. (Implementation Date: December 12, 2022) You will be automatically enrolled in a Medicare Medi-Cal Plan offered by IEHP DualChoice. Effective for dates of service on or after December 15, 2017, CMS has updated section 220.6.19 of the National Coverage Determination Manual clarifying there are no nationally covered indications for Positron Emission Tomography NaF-18 (NaF-18 PET). To stay a member of IEHP DualChoice, you must qualify again by the last day of the two-month period. A Level 1 Appeal is the first appeal to our plan. 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. In most cases you have 120 days to ask for a State Hearing after the Your Hearing Rights notice is mailed to you. You can call SHIP at 1-800-434-0222. Your care team and care coordinator work with you to make a care plan designed to meet your health needs. 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. These reviews are especially important for members who have more than one provider who prescribes their drugs. Effective for claims with dates of service on or after 09/28/2016, CMS covers screening for HBV infection. You can call the California Department of Social Services at (800) 952-5253. If the answer is No, we will send you a letter telling you our reasons for saying No. Per the recommendation of the United States Preventive Services Task Force (USPSTF), CMS has issued a National Coverage Determination (NCD) which expands coverage to include screening for HBV infection. (You cannot get a fast coverage decision coverage decision if your request is about payment for care or an item you have already received.). Because you get assistance from Medi-Cal, you can end your membership in IEHPDualChoice at any time. If you have any authorizations pending approval, if you are in them idle of treatment, or if specialty care has been scheduled for you by your current Doctor, contact IEHP to help you coordinate your care during this transition time. Remember, if you get a bill that is more than your copay for covered services and items, you should not pay the bill yourself. a. This means that your PCP will be referring you to specialists and services that are affiliated with their medical group. Generally, you must receive all routine care from plan providers and network pharmacies to access their prescription drug benefits, except in non-routine circumstances, quantity limitations and restrictions may apply. If a drug you are taking will be taken off the Drug List or limited in some way for next year, we will allow you to ask for an exception before next year. The reviewer will be someone who did not make the original coverage decision. They are considered to be at high-risk for infection; or. If your health requires it, ask the Independent Review Entity for a fast appeal.. Here are two ways to get help from the Help Center: You can file a complaint with the Office for Civil Rights. How do I ask the plan to pay me back for the plans share of medical services or items I paid for? The Centers of Medicare and Medicaid Services (CMS) will cover acupuncture for chronic low back pain (cLBP) when specific requirements are met. Can I get a coverage decision faster for Part C services? Effective June 21, 2019, CMS will cover 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. Oncologists care for patients with cancer. Bringing focus and accountability to our work. 1. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). If you request a fast coverage decision coverage decision, start by calling or faxing our plan to ask us to cover the care you want. If your Level 2 Appeal was an Independent Medical Review, you can request a State Hearing. The Office of the Ombudsman. Patient must also present hypoxemia signs and symptoms such as nocturnal restlessness, insomnia, or impairment of cognitive process. You will get a letter from us about the change in your eligibility with instructions to correct your eligibility information. H8894_DSNP_23_3241532_M. The California Department of Managed Health Care (DMHC) is responsible for regulating health plans. Medicare beneficiaries with LSS who are participating in an approved clinical study. You can contact Medicare. The State or Medicare may disenroll you if you are determined no longer eligible to the program. The letter will also tell how you can file a fast appeal about our decision to give you a fast coverage decision instead of the fast coverage decision you requested. Please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. The letter will tell you how to make a complaint about our decision to give you a standard decision. Treatments must be discontinued if the patient is not improving or is regressing. Click here for more information on Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). 1. IEP Defined The Individualized Educational Plan (IEP) is a plan or program developed to ensure that a child who has a disability identified under the law and is attending an elementary or secondary educational institution receives specialized instruction and related services. Fecal Occult Blood Tests (gFOBT) once every 12 months, The Cologuard Multi-target Stool DNA (sDNA) Test once every 3 years, Blood-based Biomarker Tests once every 3 years, Diagnosis of bilateral moderate-to-profound sensorineural hearing impairment with limited benefit, Cognitive ability to use hearing clues and a willingness to undergo an extended program of rehabilitation, Freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, and freedom from lesions in the hearing nerve and acoustic areas of the central nervous system, No indicated risks to surgery that are determined harmful or inadvisable, The device must be used in accordance with Food and Drug Administration (FDA) approved labeling, You can complete the Member Complaint Form. These different possibilities are called alternative drugs. Limited benefit from amplification is defined by test scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of open-set sentence recognition. An ICD is an electronic device to diagnose and treat life threating Ventricular Tachyarrhythmias (VTs) that has demonstrated improvement in survival rates and reduced cardiac death for certain patients. To speak with a care coordinator, please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. 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. This is not a complete list. 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. 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. You have a right to give the Independent Review Entity other information to support your appeal. The FDA provides new guidance or there are new clinical guidelines about a drug. To see if you qualify for getting extra help, you can contact: Do you need help getting the care you need? Copays for prescription drugs may vary based on the level of Extra Help you receive. You must apply for an IMR within 6 months after we send you a written decision about your appeal. Who is covered? Your doctor or other provider can make the appeal for you. Beneficiaries with Alzheimers Disease (AD) may be covered for treatment when the following conditions (A or B) are met: Click here for more information on Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimers Disease (AD). If your health requires it, ask us to give you a fast coverage decision This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition. Click here for information on Next Generation Sequencing coverage. If you ask for a fast coverage decision, without your doctors support, we will decide if you get a fast coverage decision. You can ask us to make a faster decision, and we must respond in 15 days. 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. 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. Related Resources. (800) 718-4347 (TTY), IEHP DualChoice Member Services This service will be covered when the Ambulatory Blood Pressure Monitoring (ABPM) is used for the diagnosis of hypertension when either there is suspected white coat or masked hypertension and the following conditions are met: Coverage of other indications for ABPM is at the discretion of the Medicare Administrative Contractors. A clinical test providing the measurement of arterial blood gas. 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. This is a group of doctors and other health care professionals who help improve the quality of care for people with Medicare. You can get services such as those listed below without getting approval in advance from your Primary Care Provider (PCP). Sprint from Voice Telephone: (800) 877-5379, Visit: 10801 Sixth Street, Suite 120, Rancho Cucamonga, CA 91730. How will the plan make the appeal decision? 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. Screening computed tomographic colonography (CTC), effective May 12, 2009. This service will be covered when the TAVR is used for the treatment of symptomatic aortic valve stenosis according to the FDA-approved indications and the following conditions are met: This service will be covered when the TAVR is not expressly listed as an FDA-approved indication, but when performed within a clinical study and the following conditions are met: Click here for more information on NGS coverage. You can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. Click here to learn more about IEHP DualChoice. 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. All other indications for colorectal cancer screening not otherwise specified in the Social Security Act, regulations, or the above remain nationally non-covered. Learn about your health needs and leading a healthy lifestyle. If the coverage decision is No, how will I find out? If we uphold the denial after Redetermination, you have the right to request a Reconsideration. Hepatitis B Virus (HBV) is transmitted by exposure to bodily fluids.
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