What is a Level 2 Appeal? Please see below for more information. IEHP DualChoice (HMO D-SNP) has a list of Covered Drugs called a Formulary. For more information on Grievances see Chapter 9 of your IEHP DualChoice Member Handbook. If you are taking the drug, we will let you know. (Implementation Date: March 24, 2023) You have a care team that you help put together. What is covered: If your case is urgent and you qualify for an IMR, the DMHC will review your case and send you a letter within 2 calendar days telling you that you qualify for an IMR. Your doctor or other prescriber can fax or mail the statement to us. 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. If we decide to change or stop coverage for a service or item that was previously approved, we will send you a notice before taking the action. We must respond whether we agree with the complaint or not. Please call or write to IEHP DualChoice Member Services. are similar in many respects. 504 Plan Defined The 504 Plan is a plan developed to ensure that a child who has a disability 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. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). Previously, PILD for LSS was covered for beneficiaries enrolled only in a CMS-approved prospective, randomized, controlled clinical trial (RCT) under the Coverage with Evidence Development (CED) paradigm. You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage decision. A specialist is a doctor who provides health care services for a specific disease or part of the body. If you need to change your PCP for any reason, your hospital and specialist may also change. It also has care coordinators and care teams to help you manage all your providers and services. If your provider says you have a good medical reason for an exception, he or she can help you ask for one. 1. 2023 Plan Benefits. Who is covered? Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. See below for a brief description of each NCD. Cardiologists care for patients with heart conditions. Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States. 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. Welcome to Inland Empire Health Plan \. Click here to learn more about IEHP DualChoice. Beneficiaries not meeting all the criteria for cochlear implants are deemed not eligible for Medicare coverage except for FDA-approved clinical trials as described in the NCD. You can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. To learn how to submit a paper claim, please refer to the paper claims process described below. A reasonable salary expectation is between $51,833.60 and $64,022.40, based upon experience and internal equity. 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. We do a review each time you fill a prescription. You can ask us to reimburse you for IEHP DualChoice's share of the cost. More . If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period. If we dont give you our decision within 14 calendar days, you can appeal. According to the FDA labeling in an MRI environment, MRI coverage will be provided for beneficiaries under certain conditions. (This is sometimes called prior authorization.), Being required to try a different drug first before we will agree to cover the drug you are asking for. . You can also visit https://www.hhs.gov/ocr/index.html for more information. If we are using the standard deadlines, we must give you our answer within 72 hours after we get your request or, if you are asking for an exception, after we get your doctors or prescribers supporting statement. For additional information on step therapy and quantity limits, refer to Chapter5 of theIEHP DualChoice Member Handbook. In most cases you have 120 days to ask for a State Hearing after the Your Hearing Rights notice is mailed to you. The program is not connected with us or with any insurance company or health plan. If you do not want to first appeal to the plan for a Medi-Cal service, in special cases you can ask for an Independent Medical Review. Please see below for more information. This person will also refer you to community resources, if IEHP DualChoice does not provide the services that you need. If you ask for a fast coverage decision on your own (without your doctors or other prescribers support), we will decide whether you get a fast coverage decision. If you put your complaint in writing, we will respond to your complaint in writing. 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. To learn how to name your representative, you may call IEHP DualChoice Member Services. Typically, our Formulary includes more than one drug for treating a particular condition. The procedure removes a portion of the lamina in order to debulk the ligamentum flavum, essentially widening the spinal canal in the affected area. If you are hospitalized on the day that your membership ends, you will usually be covered by our plan until you are discharged (even if you are discharged after your new health coverage begins). 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. 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. The Office of the Ombudsman. 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. It tells which Part D prescription drugs are covered by IEHP DualChoice. Send us your request for payment, along with your bill and documentation of any payment you have made. 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. 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, 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. 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. You must make the request on or before the later of the following in order to continue your benefits: If you meet this deadline, you can keep getting the disputed service or item while your appeal is processing. Making an appeal means asking us to review our decision to deny coverage. But if you do pay the bill, you can get a refund if you followed the rules for getting services and items. Click here for more information onICD Coverage. How to Enroll with IEHP DualChoice (HMO D-SNP), IEHP Texting Program Terms and Conditions. 1. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug. You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. In order to receive out-of-network services, your Primary Care Provider (PCP) or Specialist must submit a referral request to your plan or medical group. Make recommendations about IEHP DualChoice Members rights and responsibilities policies. This number requires special telephone equipment. You do not need to do anything further to get this Extra Help. This is called a referral. (You cannot get a fast coverage decision coverage decision if your request is about payment for care or an item you have already received.). 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. What is covered? For the purpose of this decision, cLBP is defined as: nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. This can speed up the IMR process. It also needs to be an accepted treatment for your medical condition. You can ask for an IMR if you have also asked for a State Hearing, but not if you have already had a State Hearing, on the same issue. Sprint from Voice Telephone: (800) 877-5379, Visit: 10801 Sixth Street, Suite 120, Rancho Cucamonga, CA 91730. 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. Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy: We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgently needed care. Medicare beneficiaries who meet either of the following criteria: Click here for more information on HBV Screenings. Follow the appeals process. The MAC may also approve the use of portable oxygen systems to beneficiaries who are mobile in home and benefit from of this unit alone, or in conjunction to a stationary oxygen system. (Implementation Date: June 16, 2020). Effective July 2, 2019, CMS will cover Ambulatory Blood Pressure Monitoring (ABPM) when beneficiaries are suspected of having white coat hypertension or masked hypertension in addition to the coverage criteria outlined in the NCD Manual. You may contact the DMHC if you need help with a complaint involving an urgent issue or one that involves an immediate and serious threat to your health, you disagree with our plans decision about your complaint, or our plan has not resolved your complaint after 30 calendar days. H8894_DSNP_23_3241532_M. You or your provider can ask for an exception from these changes. Your doctor or other provider can make the appeal for you. In most cases, you must start your appeal at Level 1. Usually, your prescription drugs are only covered if they are filled at a network pharmacy including through our mail-order pharmacy services. We also review our records on a regular basis. 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). CMS has issued a National Coverage Determination (NCD) which expands coverage to include leadless pacemakers when procedures are performed in CMS-approved Coverage with Evidence Development (CED) studies. TTY users should call (800) 537-7697. If PO2 and arterial blood gas results are conflicting, the arterial blood gas results are preferred source to determine medical need. During this time, you must continue to get your medical care and prescription drugs through our plan. You can contact Medicare. 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. You may also have rights under the Americans with Disability Act. When can you end your membership in our plan? If your Level 2 Appeal went to the Medicare Independent Review Entity, you can appeal again only if the dollar value of the service or item you want meets a certain minimum amount. All physicians participating in the procedure must have device-specific training by the manufacturer of the device. If the plan says No at Level 1, what happens next? Who is covered? If you continuously behave in a way that is disruptive and makes it difficult for us to provide medical care for you and other members of our plan. You will get a letter from us about the change in your eligibility with instructions to correct your eligibility information. New to IEHP DualChoice. If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize the medical care coverage within 72 hours or give you the service or item within 14 calendar days from the date we receive the IREs decision. If the IMR is decided in your favor, we must give you the service or item you requested. You will not have a gap in your coverage. You may be able to order your prescription drugs ahead of time through our network mail order pharmacy service or through a retail network pharmacy that offers an extended supply. 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. There are extra rules or restrictions that apply to certain drugs on our Formulary. After your application and supporting documents are received from your plan, the IMR decision will be made within 3 calendar days. You will be notified when this happens. To be a Member of IEHP DualChoice, you must keep your eligibility with Medi-Cal and Medicare. 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 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. When possible, take along all the medication you will need. If your Level 2 Appeal was a State Hearing, the California Department of Social Services will send you a letter explaining its decision. To the California Department of Social Services: To the State Hearings Division at fax number 916-651-5210 or 916-651-2789. If you have a standard appeal at Level 2, the Independent Review Entity must give you an answer to your Level 2 Appeal within 7 calendar days after it gets your appeal. Here are your choices: There may be a different drug covered by our plan that works for you. Be treated with respect and courtesy. TTY users should call (800) 537-7697. Effective for dates of service on or after August 7, 2019, CMS covers autologous treatment for cancer with T-cell expressing at least one chimeric antigen receptor (CAR) when administered at healthcare facilities enrolled in the Food and Drug Administrations (FDA) Risk Evaluation and Mitigation Strategies (REMS) and when specific requirements are met.