Because you are eligible for Medi-Cal, you qualify for and are getting Extra Help from Medicare to pay for your prescription drug plan costs. The letter will tell you how to make a complaint about our decision to give you a standard decision. If you have Medi-Cal with IEHP and would like information on how to pursue appeals and grievances related to Medi-Cal covered services, please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), TTY (800) 718-4347, 8am - 8pm (PST), 7 days a week, including holidays. Our plan includes doctors, hospitals, pharmacies, providers of long-term services and supports, behavioral health providers, and other providers. 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. We will say Yes or No to your request for an exception. 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. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. (This is sometimes called step therapy.). 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. To start your appeal, you, your doctor or other prescriber, or your representative must contact us. We will use the standard deadlines unless we have agreed to use the fast deadlines., You can get a fast coverage decision only if you are asking for a drug you have not yet received. 1. IEHP DualChoice Cal MediConnect (Medicare-Medicaid Plan) is changing to IEHP DualChoice (HMO D-SNP) on January 1, 2023. You can also visit https://www.hhs.gov/ocr/index.html for more information. 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. This form is for IEHP DualChoice as well as other IEHP programs. Click here to download a free copy by clicking Adobe Acrobat Reader. Walnut trees (Juglans spp.) The reviewer will be someone who did not make the original decision. CMS reviews studies to determine if they meet the criteria listed in Section 160.18 of the National Coverage Determination Manual. For example, you can make a complaint about disability access or language assistance. What is covered: Effective for dates of service on or after April 13, 2021, CMS has updated section 270.3 of the National Coverage Determination Manual to cover Autologous (obtained from the same person) Platelet-Rich Plasma (PRP) when specific requirements are met. (Implementation date: August 29, 2017 for MAC local edits; January 2, 2018 for MCS shared edits) Drugs that may not be safe or appropriate because of your age or gender. You will usually see your PCP first for most of your routine health care needs. To learn more about the plans benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook. We may contact you or your doctor or other prescriber to get more information. (800) 720-4347 (TTY). We do a review each time you fill a prescription. 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). If your problem is urgent and involves an immediate and serious threat to your health, you may bring it immediately to the DMHCs attention. You have a right to appeal or ask for Formulary exception if you disagree with the information provided by the pharmacist. This section is about asking for coverage decisions and making appeals with problems related to your benefits and coverage. For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. Thus, this is the main difference between hazelnut and walnut. During this time, you must continue to get your medical care and prescription drugs through our plan. 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. We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency. An IMR is available for any Medi-Cal covered service or item that is medical in nature. (Effective: April 13, 2021) PCPs are usually linked to certain hospitals and specialists. Receive emergency care whenever and wherever you need it. If you prefer a different one, please call IEHP DualChoice Member Services and we can assist you in finding and selecting another provider. In the instance where there is not FDA labeling specific to use in an MRI environment, coverage is only provided under specific conditions including the following: Medicare beneficiaries with an Implanted pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy defibrillator (CRT-D). What if the Independent Review Entity says No to your Level 2 Appeal? If you disagree with our decision, you can ask the DMHC Help Center for an IMR. The State or Medicare may disenroll you if you are determined no longer eligible to the program. https://www.medicare.gov/MedicareComplaintForm/home.aspx. Explore Opportunities. You can get a fast coverage decision coverage decision only if you are asking for coverage for care or an item you have not yet received. 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. Click here for more information on MRI Coverage. 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 24 hours after we get the decision. By clicking on this link, you will be leaving the IEHP DualChoice website. . Sacramento, CA 95899-7413. 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. If your Level 2 Appeal was an Independent Medical Review, the Department of Managed Health Care will send you a letter explaining its decision. When we complete the review, we will give you our decision in writing. LSS is a narrowing of the spinal canal in the lower back. The Level 3 Appeal is handled by an administrative law judge. a. (Implementation Date: June 16, 2020). In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can call the California Department of Social Services at (800) 952-5253. This is true even if we pay the provider less than the provider charges for a covered service or item. Decide in advance how you want to be cared for in case you have a life-threatening illness or injury. It has been concluded that high-quality research illustrates the effectiveness of SET over more invasive treatment options and beneficiaries who are suffering from Intermittent Claudication (a common symptom of PAD) are now entitled to an initial treatment. Important things to know about asking for exceptions. (Implementation Date: October 5, 2020). You can fax the completed form to (909) 890-5877. Click here for more information on Leadless Pacemakers. TTY users should call (800) 718-4347 or fax us at (909) 890-5877. Box 1800 effort to participate in the health care programs IEHP DualChoice offers you. 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. Here are a few examples: You will usually see your PCP first for most of your routine healthcare needs such as physical checkups, immunization, etc. You can also visit, You can make your complaint to the Quality Improvement Organization. Read your Medicare Member Drug Coverage Rights. Call our transportation vendor Call the Car (CTC) at (866) 880-3654, for TTY users, call your relay service or California Relay Service at 711. Be under the direct supervision of a physician. Get the My Life. If our answer is Yes to part or all of what you asked for, we must give you the coverage within 24 hours after we get your request or your doctors or prescribers statement supporting your request. If you need help during the appeals process, you can call the Office of the Ombudsman at 1-888-452-8609. If you don't have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself. 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. 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. We do not allow our network providers to bill you for covered services and items. For additional information on step therapy and quantity limits, refer to Chapter5 of theIEHP DualChoice Member Handbook. Oxygen therapy can be renewed by the MAC if deemed medically necessary. A standard coverage decision means we will give you an answer within 72 hours after we get your doctors statement. (Effective: January 19, 2021) If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. Effective for dates of service on or after January 27, 2020, CMS has determined that NGS, as a diagnostic laboratory test, is reasonable and necessary and covered nationally for patients with germline (inherited) cancer when performed in a CLIA-certified laboratory, when ordered by a treating physician and when specific requirements are met. 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. 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. wounds affecting the skin. 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. 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. 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. For more information on Member Rights and Responsibilities refer to Chapter 8 of your. How to ask for coverage decision coverage decision to get medical, behavioral health, or certain long-term services and supports (CBAS, or NF services). Your benefits as a member of our plan include coverage for many prescription drugs. Information is also below. (Implementation Date: January 3, 2023) Careers | Inland Empire Health Plan Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. For other types of problems you need to use the process for making complaints. 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). Complain about IEHP DualChoice, its Providers, or your care. (Implementation Date: March 26, 2019). Information on procedures for obtaining prior authorization of services, Quality Assurance, disenrollment, and other procedures affecting IEHP DualChoice Members. 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. Oncologists care for patients with cancer. Opportunities to Grow. 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. (Effective: December 15, 2017) (Implementation Date: March 24, 2023) How do I make a Level 1 Appeal for Part C services? 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. IEHP DualChoice, a Medicare Medi-Cal Plan, allows you to get your covered Medicare and Medi-Cal benefits through our plan. If you want a fast appeal, you may make your appeal in writing or you may call us. What is covered? You, your doctor or other prescriber, or your representative can request the Level 2 Appeal. 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. All physicians participating in the procedure must have device-specific training by the manufacturer of the device. Request a second opinion about a medical condition. Interventional echocardiographer meeting the requirements listed in the determination. The clinical study must adhere to all the standards of scientific integrity and relevance to the Medicare population. At any time, you can call IEHP DualChoice Member Services to get up-to-date information about changes in the pharmacy network. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision. Treatment for patients with untreated severe aortic stenosis. Beneficiaries with Somatic (acquired) cancer or Germline (inherited) cancer when performed in a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory, when ordered by a treating physician, and when all the following requirements are met: Medicare Administrative Contractors (MACs) may determine coverage of NGS as a diagnostic test when additional specific criteria are met. The Medicare Complaint Form is available at: 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. (Effective: June 21, 2019) Who is covered? 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 cannot make this request for providers of DME, transportation or other ancillary providers. 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. Your benefits as a member of our plan include coverage for many prescription drugs. 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.