Here are two ways to get information directly from Medicare: By clicking on this link, you will be leaving the IEHP DualChoice website. 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. 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). TTY users should call 1-877-486-2048. Routine womens health care, which includes breast exams, screening mammograms (X-rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider. Yes. 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. The Office of Ombudsman is not connected with us or with any insurance company or health plan. Refer to Chapter 3 of your Member Handbook for more information on getting care. 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 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. Hepatitis B Virus (HBV) is transmitted by exposure to bodily fluids. If your Primary Care Provider changes, your IEHP DualChoice benefits and required co-payments will stay the same. Topical Application of Oxygen for Chronic Wound Care. 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). Information on this page is current as of October 01, 2022. Our plans PCPs are affiliated with medical groups or Independent Physicians Associations (IPA). iv. To learn more about the plans benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook. Please see below for more information. An interventional echocardiographer must perform transesophageal echocardiography during the procedure. If you ask for a fast coverage decision, without your doctors support, we will decide if you get a fast coverage decision. (Effective: January 1, 2022) The call is free. Information on this page is current as of October 01, 2022. For some types of problems, you need to use the process for coverage decisions and making appeals. After your application and supporting documents are received from your plan, the IMR decision will be made within 30 calendar days. H5355_CMC_22_2746205Accepted, (Effective: September 27, 2021) Click here for more information on MRI Coverage. You can contact Medicare. In this situation (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. We will send you a notice before we make a change that affects you. If you move out of our service area for more than six months. 1. 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. You must submit your claim to us within 1 year of the date you received the service, item, or drug. They are considered to be at high-risk for infection; or. 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. If we agree to make an exception and waive a restriction for you, you can still ask for an exception to the co-pay amount we require you to pay for the drug. This government program has trained counselors in every state. Your provider will also know about this change. For more information on network providers refer to Chapter 1 of the IEHP DualChoice Member Handbook. There is no deductible for IEHP DualChoice. Call: (877) 273-IEHP (4347). If the coverage decision is No, how will I find out? TTY/TDD (800) 718-4347. Have grievances heard and resolved in accordance with Medicare guidelines; Request quality of care grievances data from IEHP DualChoice. Receive information about your rights and responsibilities as an IEHP DualChoice Member. 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. View Plan Details. Call (888) 466-2219, TTY (877) 688-9891. The procedure removes a portion of the lamina in order to debulk the ligamentum flavum, essentially widening the spinal canal in the affected area. The organization will send you a letter explaining its decision. 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. 2. This is a group of doctors and other health care professionals who help improve the quality of care for people with Medicare. Breathlessness without cor pulmonale or evidence of hypoxemia; or. Your doctor or other provider can make the appeal for you. CMS has updated Chapter 1, section 160.18 of the Medicare National Coverage Determinations Manual. Cardiologists care for patients with heart conditions. 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. Click here to learn more about IEHP DualChoice. We will look into your complaint and give you our answer. 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. If we say No to your appeal, you then choose whether to accept this decision or continue by making another appeal. 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. a. If your doctor or other provider asks for a service or item that we will not approve, or we will not continue to pay for a service or item you already have and we said no to your Level 1 appeal, you have the right to ask for a State Hearing. For the treatment of symptomatic moderate to severe mitral regurgitation (MR) when the patient still has symptoms, despite stable doses of maximally tolerated guideline directed medical therapy (GDMT) and cardiac resynchronization therapy, when appropriate and the following are met: Treatment is a Food and Drug Administration (FDA) approved indication. Our plan includes doctors, hospitals, pharmacies, providers of long-term services and supports, behavioral health providers, and other providers. IEHP DualChoice Member Services can assist you in finding and selecting another provider. To learn more about asking for exceptions, see Chapter 9 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]). For example, you can ask us to cover a drug even though it is not on the Drug List. A PCP is your Primary Care Provider. 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. The phone number is (888) 452-8609. of the appeals process. (Implementation Date: September 20, 2021). 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. Eligible beneficiaries are entitled to 36 sessions over a 12-week period after meeting with the physician responsible for PAD treatment and receiving a referral. Our plan cannot cover a drug purchased outside the United States and its territories. If the complaint is about a Part D drug, you must file it within 60 calendar days after you had the problem you want to complain about. Pay rate will commensurate with experience. 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. The letter will explain why more time is needed. Black Walnuts on the other hand have a bolder, earthier flavor. This includes: The device is used following post-cardiotomy (period following open heart surgery) to support blood circulation. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug. P.O. Please call or write to IEHP DualChoice Member Services. For more information on Member Rights and Responsibilities refer to Chapter 8 of your. What is covered: You must apply for an IMR within 6 months after we send you a written decision about your appeal. If you prefer a different one, please call IEHP DualChoice Member Services and we can assist you in finding and selecting another provider. For additional information on step therapy and quantity limits, refer to Chapter5 of theIEHP DualChoice Member Handbook. The USPTF has found that screening for HBV allows for early intervention which can help decrease disease acquisition, transmission and, through treatment, improve intermediate outcomes for those infected. 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. 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. You, your representative, or your doctor (or other prescriber) can do this. You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. Prior to the beneficiarys first lung cancer LDCT screening, the beneficiary must receive a counseling and shared decision-making visit that meets specific criteria. Rights and Responsibilities Upon Disenrollment, Ending your membership in IEHP DualChoice (HMO D-SNP) may be voluntary (your own choice) or involuntary (not your own choice). You can call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. 3. Try to choose a PCP that can admit you to the hospital you want within 30 miles or 45 minutes of your home. Here are examples of coverage determination you can ask us to make about your Part D drugs. There are many kinds of specialists. 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. When can you end your membership in our plan? The therapy is used for a medically accepted indication, which is defined as used for either and FDA approved indication according to the label of that product, or the use is supported in one or more CMS approved compendia. If you dont have the IEHP DualChoice Provider and Pharmacy Directory, you can get a copy from IEHP DualChoice Member Services. Your benefits as a member of our plan include coverage for many prescription drugs. You are never required to pay the balance of any bill. You can call the California Department of Social Services at (800) 952-5253. 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. You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function. It is not connected with this plan and it is not a government agency. We do a review each time you fill a prescription. 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. TTY users should call (800) 718-4347 or fax us at (909) 890-5877. Who is covered: You dont have to do anything if you want to join this plan. Medicare beneficiaries may be covered with an affirmative Coverage Determination. Click here to download a free copy of Adobe Acrobat Reader.By clicking on this link, you will be leaving the IEHP DualChoice website. A new generic drug becomes available. The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. Benefits and copayments may change on January 1 of each year. 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. The Independent Review Entity is an independent organization that is hired by Medicare. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative Form. 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. 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. With a network of more than 6,000 Providers and 2,000 Team Members, we provide . Proven test performance characteristics for a blood-based screening test with both sensitivity greater than or equal to 74% and specificity greater than or equal to 90% in the detection of colorectal cancer compared to the recognized standard (accepted as colonoscopy at this time), based on the pivotal studies included in the FDA labeling. i. To learn how to submit a paper claim, please refer to the paper claims process described below. 2023 Inland Empire Health Plan All Rights Reserved. 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. However, your PCP can always use Language Line Services to get help from an interpreter, if needed. A reasonable salary expectation is between $153,670.40 and $195,936.00, based upon experience and internal equity. When you make an appeal to the Independent Review Entity, we will send them your case file. Then, we check to see if we were following all the rules when we said No to your request. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. The letter you get from the IRE will explain additional appeal rights you may have. We are the largest health plan in the Inland Empire, and one of the fastest-growing health plans in the nation. 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 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.). The services are free. Follow the appeals process. We will generally cover a drug on the plans Formulary as long as you follow the other coverage rules explained in Chapter 6 of the IEHP DualChoice Member Handbookand the drug is medically necessary, meaning reasonable and necessary for treatment of your injury or illness. No more than 20 acupuncture treatments may be administered annually. The following information explains who qualifies for IEHP DualChoice (HMO D-SNP). The care team helps coordinate the services you need. TTY users should call 1-800-718-4347. . More . We take another careful look at all of the information about your coverage request. The treatment is based upon efficacy from a change in surrogate endpoint such as amyloid reduction. Department of Health Care Services 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 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.

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