It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. Change the coverage rules or limits for the brand name drug. 2. 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. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. If you ask for a fast coverage decision, without your doctors support, we will decide if you get a fast coverage decision. Coverage for future years is two hours for patients diagnosed with renal disease or diabetes. Can I ask for a coverage determination or make an appeal about Part D prescription drugs? 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. to part or all of what you asked for, we will make payment to you within 14 calendar days. Follow the appeals process. All requests for out-of-network services must be approved by your medical group prior to receiving services. If your Primary Care Provider changes, your IEHP DualChoice benefits and required co-payments will stay the same. Your benefits as a member of our plan include coverage for many prescription drugs. If you miss this deadline and have a good reason for missing it, we may give you more time to make you appeal. The clinical study must address whether VNS treatment improves health outcomes for treatment resistant depression compared to a control group, by answering all research questions listed in 160.18 of the National Coverage Determination Manual. 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. Please select one of the following: Primary Care Doctor Specialist Behavioral Health Hospitals Until your membership ends, you are still a member of our plan. The following information explains who qualifies for IEHP DualChoice (HMO D-SNP). What is covered: TTY users should call 1-877-486-2048. There is no deductible for IEHP DualChoice.
IEHP Welcome to Inland Empire Health Plan You, your representative, or your provider asks us to let you keep using your current provider. 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. Click here for more information onICD Coverage. Click here to download a free copy of Adobe Acrobat Reader.By clicking on this link, you will be leaving the IEHP DualChoice website. Effective on September 26, 2022, CMS has updated section 50.3 of the National Coverage Determination (NCD) Manual that expands coverage on cochlear implants for the treatment of bilateral pre- or post- linguistic, sensorineural, moderate-to-profound hearing loss when the individual demonstrates limited benefit from amplification under Medicare Part B. Most of these drugs are Part D drugs. There are a few drugs that Medicare Part D does not cover but that Medi-Cal may cover. If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. Please see below for more information. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug. You dont have to do anything if you want to join this plan. How long does it take to get a coverage decision coverage decision for Part C services? The clinical research study must meet the standards of scientific integrity and relevance to the Medicare population described in this determination. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. If you move out of our service area for more than six months. (You cannot get a fast coverage decision coverage decision if your request is about payment for care or an item you have already received.). You do not need to give your doctor or other prescriber written permission to ask us for a coverage determination on your behalf. Receive emergency care whenever and wherever you need it. Possible errors in the amount (dosage) or duration of a drug you are taking. Please see below for more information. This includes getting authorization to see specialists or medical services such as lab tests, x-rays, and/or hospital admittance. Medi-Cal is public-supported health care coverage. 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. If you call us with a complaint, we may be able to give you an answer on the same phone call. Patients depressive illness meets a minimum criterion of four prior failed treatments of adequate dose and duration as measured by a tool designed for this purpose. What if the plan says they will not pay? Be informed regarding Advance Directives, Living Wills, and Power of Attorney, and to receive information regarding changes related to existing laws. 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. This is asking for a coverage determination about payment. If you lie about or withhold information about other insurance you have that provides prescription drug coverage. Group I: (Effective: September 28, 2016) (Effective: February 10, 2022) We must give you our answer within 14 calendar days after we get your request. At Level 2, an outside independent organization will review your request and our decision. The extra rules and restrictions on coverage for certain drugs include: Being required to use the generic version of a drug instead of the brand name drug. 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. When that happens, we may remove the current drug, but your cost for the new drug will stay the same or will be lower. Information on this page is current as of October 01, 2022. (Implementation date: December 18, 2017) Effective September 27, 2021, CMS has updated section 240.2 of the National Coverage Determination Manual to cover oxygen therapy and oxygen equipment for in home use of both acute and chronic conditions, short- or long- term, when a patient exhibits hypoxemia. The organization will send you a letter explaining its decision. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. (Implementation Date: February 14, 2022) Providers from other groups including patient practitioners, nurses, research personnel, and administrators. At Level 2, an Independent Review Entity will review our decision. There are two ways to make a Level 2 appeal for Medi-Cal services and items: 1) Independent Medical Review or 2) State Hearing. 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 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. All other indications for colorectal cancer screening not otherwise specified in the Social Security Act, regulations, or the above remain nationally non-covered. (Implementation Date: July 2, 2018). Members \. Submit the required study information to CMS for approval. In some cases, IEHP is your medical group or IPA. They mostly grow wild across central and eastern parts of the country. This includes: Primary Care Providers (PCPs) are usually linked to certain hospitals. If the DMHC decides that your case is not eligible for IMR, the DMHC will review your case through its regular consumer complaint process. 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. Calls to this number are free. TTY users should call (800) 718-4347 or fax us at (909) 890-5877. 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. Mitral valve TEERs are covered for other uses not listed as an FDA-approved indication when performed in a clinical study and the following requirements are met: The procedure must be performed by an interventional cardiologist or cardiac surgeon. We may stop any aid paid pending you are receiving. 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. (Implementation date: October 2, 2017 for design and coding; January 1, 2018 for testing and implementation) 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. Be treated with respect and courtesy. Study data for CMS-approved prospective comparative studies may be collected in a registry. The reviewer will be someone who did not make the original decision. 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. Get the My Life. Click here for more information on Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative Form. The letter will also explain how you can appeal our decision. For other types of problems you need to use the process for making complaints. We do a review each time you fill a prescription. The clinical test must be performed at the time of need: The following criteria must also be met as described in the NCD: Non-Covered Use: Yes. 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. If you need help during the appeals process, you can call the Office of the Ombudsman at 1-888-452-8609. 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. 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.
What is the difference between an IEP and a 504 Plan? What is covered? You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. 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). Appeal any decision IEHP DualChoice makes regarding, but not limited to, a denial, termination, payment, or reduction of services. Interventional Cardiologist meeting the requirements listed in the determination. Effective for dates of service on or after January 19, 2021, CMS has updated section 20.33 of the National Coverage Determination Manual to cover Transcatheter Edge-to-Edge Repair (TEER) for Mitral Valve Regurgitation when specific requirements are met. B. 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 we tell you after our review that the service or item is not covered, your case can go to a Level 2 Appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Entity (IRE) will review our decision. The English walnut has a soft and thin shell that makes it easy to crack, while the black walnut has a tougher shell, one of the hardest of all the nuts. Information on this page is current as of October 01, 2022 You can ask for a State Hearing for Medi-Cal covered services and items. Concurrent with Intracranial Stent Placement in FDA-Approved Category B IDE Clinical Trials 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. 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. Consist of 30-60 minute sessions comprising of therapeutic exercise-training program for PAD; Be conducted in a hospital outpatient setting or physicians office; Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD; and. All Medicare covered services, doctors, hospitals, labs, and x-rays, You will have access to a Provider network that includes many of the same Providers as your current plan, Coordination of the services you get now or that you might need, Personal history of sustained VT or cardiac arrest due to Ventricular Fibrillation (VF), Prior Myocardial Infarction (MI) and measured Left Ventricular Ejection Fraction (LVEF) less than or equal to .03, Severe, ischemic, dilated cardiomyopathy without history of sustained VT or cardiac arrest due to VF, and have New York Heart Association (NYHA) Class II or III heart failure with a LVEF less than or equal to 35%, Severe, non-ischemic, dilated cardiomyopathy without history of cardiac arrest or sustained VT, NYHA Class II or II heart failure, LVEF less than or equal for 35%, and utilization of optimal medical therapy for at a minimum of three (3) months, Documented, familial or genetic disorders with a high risk of life-threating tachyarrhythmias, but not limited to long QT syndrome or hypertrophic cardiomyopathy, Existing ICD requiring replacement due to battery life, Elective Replacement Indicator (ERI), or malfunction, The procedure is performed in a Clinical Laboratory Improvement Act (CLIA)-certified laboratory. Eligible Members The population for this P4P program includes IEHP Direct DualChoice Members. 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. You, your representative, or your doctor (or other prescriber) can do this. If the answer to your appeal is Yes at any stage of the appeals process after Level 2, we must send the payment you asked for to you or to the provider within 60 calendar days. TTY should call (800) 718-4347. Asking for a fast coverage decision coverage decision: Here are the rules for asking for a fast coverage decision coverage decision: You must meet the following two requirements to get a fast coverage decision coverage decision: If the coverage decision is Yes, when will I get the service or item? With IEHP DualChoice, you will still have an IEHP DualChoice Member Service team to get help for your needs. 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. 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. The FDA provides new guidance or there are new clinical guidelines about a drug. We do the right thing by: Placing our Members at the center of our universe. Make your appeal request within 60 calendar days from the date on the notice we sent to tell you our decision. Click here for more information on Positron Emission Tomography NaF-18 (NaF-18 PET) to Identify Bone Metastasis of Cancer coverage. Your test results are shared with all of your doctors and other providers, as appropriate.
IEHP IEHP DualChoice 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. It stores all your advance care planning documents in one place online. 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. The registry shall collect necessary data and have a written analysis plan to address various questions. The NCR serves as a liaison for matters involving the contract between IEHP and both Network and Non-Network Providers. Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). TTY/TDD users should call 1-800-430-7077.