Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. The removal of these elements eliminates an important source of complications associated with traditional pacing systems while providing similar benefits. a. Have grievances heard and resolved in accordance with Medicare guidelines; Request quality of care grievances data from IEHP DualChoice. If your health requires it, ask for a fast appeal, Our plan will review your appeal and give you our decision. To learn how to submit a paper claim, please refer to the paper claims process described below. IEHP DualChoice is for people with both Medicare (Part A and B) and Medi-Cal. The Social Security Office at (800) 772-1213 between 7 a.m. and 7 p.m., Monday through Friday, TTY users should call (800) 325-0778; or. We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency. We must respond whether we agree with the complaint or not. What if the plan says they will not pay? If the State Hearing decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. At Level 2, an Independent Review Entity will review the decision. We are also one of the largest employers in the region, designated as "Great Place to Work.". All the changes are reviewed and approved by a selected group of Providers and Pharmacists that are currently in practice. CMS approved studies must also adhere to the standards of scientific integrity that have been identified in section 5 of this NCD by the Agency for Healthcare Research and Quality (AHRQ). Your membership will usually end on the first day of the month after we receive your request to change plans. Here are three general rules about drugs that Medicare drug plans will not cover under Part D: For more information refer to Chapter 6 of yourIEHP DualChoice Member Handbook. The Centers for Medicare and Medical Services (CMS) has determined the following services to be necessary for the treatment of an illness or injury. 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. 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. 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. We are the largest health plan in the Inland Empire, and one of the fastest-growing health plans in the nation. 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. Please call or write to IEHP DualChoice Member Services. We will give you our answer sooner if your health requires it. CMS has expanded the PILD for LSS National Coverage Determination (NCD) to now cover beneficiaries that are enrolled in a CMS-approved prospective longitudinal study. 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. This is called a referral. If you put your complaint in writing, we will respond to your complaint in writing. Use of autologous Platelet-Derived Growth Factor (PDGF) for treatment of chronic, non-healing, cutaneous (affecting the skin) wounds, and. If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. In most cases you have 120 days to ask for a State Hearing after the Your Hearing Rights notice is mailed to you. 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. For more information on network providers refer to Chapter 1 of the IEHP DualChoice Member Handbook. This is called upholding the decision. It is also called turning down your appeal.. National Coverage determinations (NCDs) are made through an evidence-based process. IEHP DualChoice must end your membership in the plan if any of the following happen: The IEHPDualChoice Privacy Notice describes how medical information about you may be used and disclosed, and how you can get access to this information. If you are traveling within the US, but outside of the Plans service area, and you become ill, lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy if you follow all other coverage rules identified within this document and a network pharmacy is not available. Breathlessness without cor pulmonale or evidence of hypoxemia; or. The procedure removes a portion of the lamina in order to debulk the ligamentum flavum, essentially widening the spinal canal in the affected area. For additional information on step therapy and quantity limits, refer to Chapter5 of theIEHP DualChoice Member Handbook. Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. Sprint from Voice Telephone: (800) 877-5379, Visit: 10801 Sixth Street, Suite 120, Rancho Cucamonga, CA 91730. 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. Your PCP should speak your language. Angina pectoris (chest pain) in the absence of hypoxemia; or. You can send your complaint to Medicare. You can get services such as those listed below without getting approval in advance from your Primary Care Provider (PCP). 2) State Hearing are similar in many respects. To learn how to submit a paper claim, please refer to the paper claims process described below. If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan. We take another careful look at all of the information about your coverage request. 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. (800) 718-4347 (TTY), IEHP 24-Hour Nurse Advice Line (for IEHP Members only) Your IEHP DualChoice Doctor cannot charge you for covered health care services, except for required co-payments. This form is for IEHP DualChoice as well as other IEHP programs. Join our Team and make a difference with us! We will send you a notice before we make a change that affects you. We will tell you about any change in the coverage for your drug for next year. The following criteria must also be met as described in the NCD: Non-Covered Use: 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 possible, we will answer you right away. Medicare beneficiaries in need of a pacemaker who are participating in an approved clinical study. You will get a letter from us about the change in your eligibility with instructions to correct your eligibility information. All physicians participating in the procedure must have device-specific training by the manufacturer of the device. How to voluntarily end your membership in our plan? From time to time (during the benefit year), IEHP DualChoice revises (adding or removing drugs) the Formulary based on new clinical evidence and availability of products in the market. iii. 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. An IMR is available for any Medi-Cal covered service or item that is medical in nature. We must give you our answer within 30 calendar days after we get your appeal. This statement will also explain how you can appeal our decision. to part or all of what you asked for, we must approve or give the coverage within 72 hours after we get your request or, if you are asking for an exception, your doctors or prescribers supporting statement. IEHP DualChoice will give notice to IEHPDualChoice Members prior to removing Part D drug from the Part D formulary. Information on the page is current as of March 2, 2023 Please see below for more information. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. You, your doctor or other prescriber, or your representative can request the Level 2 Appeal. These forms are also available on the CMS website: Beneficiaries that are at least 45 years of age or older can be screened for the following tests when all Medicare criteria found in this national coverage determination is met: Non-Covered Use: You or your provider can ask for an exception from these changes. To get a temporary supply of a drug, you must meet the two rules below: When you get a temporary supply of a drug, you should talk with your provider to decide what to do when your supply runs out. You can also have a lawyer act on your behalf. Your doctor will also know about this change and can work with you to find another drug for your condition. What is covered: (Effective: September 28, 2016) With this app, you or a designated person with Power of Attorney can access your advance health care directives at any time from a home computer or smartphone. TTY (800) 718-4347. An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. Information is also below. (Implementation Date: September 20, 2021). If you get a bill that is more than your copay for covered services and items, send the bill to us. However, if the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drugs manufacturer removes the drug from the market we will immediately remove the drug from our formulary. Black walnut trees are not really cultivated on the same scale of English walnuts. 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. 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. Sometimes a specialist, clinic, hospital or other network provider you are using might leave the plan. The MAC may determine necessary coverage for in home oxygen therapy for patients that do not meet the criteria described above. Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. A clinical test providing the measurement of arterial blood gas. If you disagree with our decision, you can ask the DMHC Help Center for an IMR. Receive emergency care whenever and wherever you need it. The State or Medicare may disenroll you if you are determined no longer eligible to the program. This is not a complete list. There are many kinds of specialists. If you have been receiving care from a health care provider, you may have a right to keep your provider for a designated time period. If your Level 2 Appeal was a State Hearing, the California Department of Social Services will send you a letter explaining its decision. How to ask for coverage decision coverage decision to get medical, behavioral health, or certain long-term services and supports (CBAS, or NF services). If the IMR is decided in your favor, we must give you the service or item you requested. Network providers are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with us to accept our paymentas payment in full. IEHP DualChoice develops and maintains the Formulary continuously by reviewing the efficacy (how effective) and safety (how safe) of new drugs, compare new versus existing drugs, and develops clinical practice guidelines based on clinical evidence. Annapolis Junction, Maryland 20701. An annual screening for lung cancer with LDCT will be available if specific eligibility criteria are met. Read Will my benefits continue during Level 2 appeals in Chapter 9 of the Member Handbook for more information. 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. (Effective: January 21, 2020) Oxygen therapy can be renewed by the MAC if deemed medically necessary. 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. If you decide to go on to a Level 2 Appeal, the Independent Review Entity (IRE) will review our decision. If we uphold the denial after Redetermination, you have the right to request a Reconsideration. You will be notified when this happens. 2023 Inland Empire Health Plan All Rights Reserved. The following information explains who qualifies for IEHP DualChoice (HMO D-SNP). (Effective: January 1, 2023) What is covered? Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). Hazelnuts have more carbohydrates and dietary fibres than walnuts while walnuts have more calories, proteins, and fats than hazelnuts. How much time do I have to make an appeal for Part C services? Or you can make your complaint to both at the same time. When possible, take along all the medication you will need. They mostly grow wild across central and eastern parts of the country. However, your PCP can always use Language Line Services to get help from an interpreter, if needed. TTY should call (800) 718-4347. You can work with us for all of your health care needs. A specialist is a doctor who provides health care services for a specific disease or part of the body. Information on procedures for obtaining prior authorization of services, Quality Assurance, disenrollment, and other procedures affecting IEHP DualChoice Members. Yes. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. (Implementation Date: June 12, 2020). CMS has updated Chapter 1, section 20.19 of the Medicare National Coverage Determinations Manual. Effective on April 7, 2022, CMS has updated section 200.3 of the National Coverage Determination (NCD) Manual to cover Food and Drug Administration (FDA) approved monoclonal antibodies directed against amyloid for treatment of Alzheimers Disease (AD) when the coverage criteria below is met. You can call the California Department of Social Services at (800) 952-5253. The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. You can contact Medicare. If you are making a complaint because we denied your request for a fast coverage determination or fast appeal, we will automatically give you a fast complaint. We will give you our decision sooner if your health condition requires us to. For more detailed information on each of the NCDs including restrictions and qualifications click on the link after each NCD or call IEHP DualChoice Member Services at (877) 273-IEHP (4347) 8am-8pm (PST), 7 days a week, including holidays, or. Rancho Cucamonga, CA 91729-1800. Pay rate will commensurate with experience. You should receive the IMR decision within 45 calendar days of the submission of the completed application. If you are taking the drug, we will let you know. This is asking for a coverage determination about payment. You will usually see your PCP first for most of your routine health care needs. You may use the following form to submit an appeal: Can someone else make the appeal for me? How long does it take to get a coverage decision coverage decision for Part C services? Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). You are not responsible for Medicare costs except for Part D copays. You should not pay the bill yourself. (Effective: January 19, 2021) If your health requires it, ask the Independent Review Entity for a fast appeal.. (Implementation Date: July 27, 2021) You can call SHIP at 1-800-434-0222. If you have a fast complaint, it means we will give you an answer within 24 hours. CMS has added a new section, Section 20.35, to Chapter 1 entitled Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). They all work together to provide the care you need. Sign up for the free app through our secure Member portal. The program is not connected with us or with any insurance company or health plan. Calls to this number are free. Live in our service area (incarcerated individuals are not considered living in the geographic service area even if they are physically located in it. IEHP Medi-Cal Member Services 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. ICDs will be covered for the following patient indications: Please refer to section 20.4 of the NCD Manual for additional coverage criteria. Important things to know about asking for exceptions. 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. At Level 2, an outside independent organization will review your request and our decision. Within 10 days of the mailing date of our notice of action; or. b. Group I: It attacks the liver, causing inflammation. Beneficiaries who meet the coverage criteria, if determined eligible. Review your Member Handbook, and call IEHP DualChoice Member Services if you do not understand something about your coverage and benefits. Eligible Members The population for this P4P program includes IEHP Direct DualChoice Members. TTY should call (800) 718-4347. 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. If you move out of our service area for more than six months. You, your representative, or your provider asks us to let you keep using your current provider. 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. IEHP: "Inland Empire Health Plan (IEHP) is a not-for-profit Medi-Cal and Medicare health plan headquartered in Rancho Cucamonga, California. Most recently, as of May 1, 2016, Medi-Cal now covers all low income children under the age of 19, regardless of immigration status. 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. For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. The benefit information is a brief summary, not a complete description of benefits. This is a group of doctors and other health care professionals who help improve the quality of care for people with Medicare. Information on the page is current as of December 28, 2021 You or your provider must show documentation of an existing relationship and agree to certain terms when you make the request. IEHP DualChoice. B. (You cannot get a fast coverage decision coverage decision if your request is about payment for care or an item you have already received.). Bringing focus and accountability to our work. If your doctor says that you need a fast coverage decision, we will automatically give you one. Off-label use is any use of the drug other than those indicated on a drugs label as approved by the Food and Drug Administration. What if you are outside the plans service area when you have an urgent need for care? How do I ask the plan to pay me back for the plans share of medical services or items I paid for? There are extra rules or restrictions that apply to certain drugs on our Formulary. Information on this page is current as of October 01, 2022. Disrespect, poor customer service, or other negative behaviors, Timeliness of our actions related to coverage decisions or appeals, You can use our "Member Appeal and Grievance Form." IEHP DualChoice is a Cal MediConnect Plan. If we say Yes to your request for an exception, the exception usually lasts until the end of the calendar year. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. Try to choose a PCP that can admit you to the hospital you want within 30 miles or 45 minutes of your home. If you do not agree with our decision, you can make an appeal. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. For the benefit year of 2023 here is what youll get and what you will pay: With IEHP DualChoice, you pay nothing for covered drugs as long as you follow the plans rules. 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. There are two ways you can asked to be disenrolled: To disenroll, please call Health Care Options (HCO) at 1-844-580-7272, 8am - 6pm (PST), Monday - Friday. Typically, our Formulary includes more than one drug for treating a particular condition. The phone number for the Office for Civil Rights is (800) 368-1019. Both of these processes have been approved by Medicare. If you are asking to be paid back, you are asking for a coverage decision. Your provider will also know about this change. The call is free. 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. 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. We establish that you had an existing relationship with a primary or specialty care provider, with some exceptions. You can also have your doctor or your representative call us. Click here for more information on MRI Coverage. If patients with bipolar disorder are included, the condition must be carefully characterized. The California Department of Managed Health Care (DMHC) is responsible for regulating health plans. Erythrocythemia (increased red blood cells) with a hematocrit greater than 56%. If this happens, you will have to switch to another provider who is part of our Plan. These forms are also available on the CMS website: Medicare Prescription Drug Determination Request Form (for use by enrollees and providers), Deadlines for a standard coverage decision about a drug you have not yet received, If our answer is Yes to part or all of what you asked for, we must approve or give the coverage within 72 hours after we get your request or, if you are asking for an exception, your doctors or prescribers supporting statement. If we are using the fast deadlines, we will give you our answer within 72 hours after we get your appeal, or sooner if your health requires it. You can ask for a State Hearing for Medi-Cal covered services and items. See plan Providers, get covered services, and get your prescription filled timely. This is true even if we pay the provider less than the provider charges for a covered service or item. Can I ask for a coverage determination or make an appeal about Part D prescription drugs? Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. There may be qualifications or restrictions on the procedures below. Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States. You may change your PCP for any reason, at any time. 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. Who is covered: You can also visit, You can make your complaint to the Quality Improvement Organization. Click here to learn more about IEHP DualChoice. If the decision is No for all or part of what I asked for, can I make another appeal? You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage decision. Will my benefits continue during Level 1 appeals? 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. Information on this page is current as of October 01, 2022 Non-Covered Use: Initial coverage for patients experiencing conditions not described above can be limited to a prescription shorter than 90 days, or less than the numbers of days indicated on the practitioners prescription. You can ask us to reimburse you for IEHP DualChoice's share of the cost. Receive information about your rights and responsibilities as an IEHP DualChoice Member. We will give you our answer sooner if your health requires us to. You can send your complaint to Medicare. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug. 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. In most cases, you must start your appeal at Level 1. Welcome to Inland Empire Health Plan \. All requests for out-of-network services must be approved by your medical group prior to receiving services. You have the right to ask us for a copy of the information about your appeal. Typically, our Formulary includes more than one drug for treating a particular condition. 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. 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. H8894_DSNP_23_3241532_M. If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we get your appeal. What is covered? (Effective: January 27, 20) IEHP DualChoice will cover many of the Medicare and Medi-Cal benefits you get now, including: You will have access to a Provider network that includes many of the same Providers as your current plan. Calls to this number are free. Beneficiaries with either a renal disease or diabetes diagnosis as defined in 42 CFR 410.130. C. Beneficiarys diagnosis meets one of the following defined groups below: These changes might happen if: When these changes happen, we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill. Click here for more information on Positron Emission Tomography NaF-18 (NaF-18 PET) to Identify Bone Metastasis of Cancer coverage. You will not have a gap in your coverage. All other indications of VNS for the treatment of depression are nationally non-covered. Click here for more information on acupuncture for chronic low back pain coverage. Click here for more information on Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). The organization will send you a letter explaining its decision. 5. If the answer is No, we will send you a letter telling you our reasons for saying No. If you do not stay continuously enrolled in Medicare Part A and Part B. Black Walnuts on the other hand have a bolder, earthier flavor. 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. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. If we say no to part or all of your Level 1 Appeal, we will send you a letter. You can ask for a copy of the information in your appeal and add more information. (Implementation Date: July 5, 2022). 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. We call this the supporting statement.. With IEHP DualChoice, you will still have an IEHP DualChoice Member Service team to get help for your needs. Hazelnuts are the round brown hard-shelled nuts of the trees of genus Corylus while walnuts are the wrinkled edible nuts of the trees of genus Juglans. Walnut trees (Juglans spp.) 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. 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. 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.