(800) 718-4347 (TTY), IEHP DualChoice Member Services 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). A reasonable salary expectation is between $51,833.60 and $64,022.40, based upon experience and internal equity. My problem is about a Medi-Cal service or item. 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. Department of Health Care Services If the Independent Medical Review decision is Yes to part or all of what you asked for, we must provide the service or treatment. a. 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. At any time, you can call IEHP DualChoice Member Services to get up-to-date information about changes in the pharmacy network. (Effective: July 2, 2019) You will be automatically enrolled in IEHP DualChoice and do not need to do anything to keep these services. Our service area includes all of Riverside and San Bernardino counties. This number requires special telephone equipment. You will need Adobe Acrobat Reader6.0 or later to view the PDF files. IEHP DualChoice If you are under a Doctors care for an acute condition, serious chronic condition, pregnancy, terminal illness, newborn care, or a scheduled surgery, you may ask to continue seeing your current Doctor. Please see below for more information. Your benefits as a member of our plan include coverage for many prescription drugs. To learn how to submit a paper claim, please refer to the paper claims process described below. The form gives the other person permission to act for you. We will tell you in advance about these other changes to the Drug List. This is not a complete list. (Implementation date: October 2, 2017 for design and coding; January 1, 2018 for testing and implementation) Learn about your health needs and leading a healthy lifestyle. If you do not get this approval, your drug might not be covered by the plan. To stay a member of IEHP DualChoice, you must qualify again by the last day of the two-month period. What Prescription Drugs Does IEHP DualChoice Cover? (Effective: January 19, 2021) If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. Never wavering in our commitment to our Members, Providers, Partners, and each other. 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. 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 procedure is used with a mitral valve TEER system that has received premarket approval from the FDA. NOTE: If you ask for a State Hearing because we told you that a service you currently get will be changed or stopped, you have fewer days to submit your request if you want to keep getting that service while your State Hearing is pending. We will cover your prescription at an out-of-network pharmacy if at least one of the following applies: If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than paying your normal share of the cost) when you fill your prescription. You can download a free copy here. (Implementation date: December 18, 2017) Asking us to cover a Part D drug that is not on the plans List of Covered Drugs (Formulary), Asking us to waive a restriction on the plans coverage for a drug (such as limits on the amount of the drug you can get). The Centers of Medicare and Medicaid Services (CMS) will cover transcatheter aortic valve replacement (TAVR) under Coverage with Evidence Development (CED) when specific requirements are met. When you file a fast complaint, we will give you an answer to your appeal within 24 hours. (This is called upholding the decision. It is also called turning down your appeal.) The letter you get will explain additional appeal rights you may have. My Choice. This will give you time to talk to your doctor or other prescriber. (Effective: April 3, 2017) 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. Note, the Member must be active with IEHP Direct on the date the services are performed. After the continuity of care period ends, you will need to use doctors and other providers in the IEHP DualChoice network that are affiliated with your primary care providers medical group, unless we make an agreement with your out-of-network doctor. 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. H8894_DSNP_23_3241532_M. We will also use the standard 14 calendar day deadline instead. 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. What kinds of medical care and other services can you get without getting approval in advance from your Primary Care Provider (PCP) in IEHP DualChoice (HMO D-SNP)? If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. 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. 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. Your benefits as a member of our plan include coverage for many prescription drugs. 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. This is a person who works with you, with our plan, and with your care team to help make a care plan. You may change your PCP for any reason, at any time. Click here for more information on Positron Emission Tomography NaF-18 (NaF-18 PET) to Identify Bone Metastasis of Cancer coverage. 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. Group II: Whether you call or write, you should contact IEHP DualChoice Member Services right away. 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. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. 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. You will be automatically enrolled in a Medicare Medi-Cal Plan offered by IEHP DualChoice. 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. Medicare has approved the IEHP DualChoice Formulary. They all work together to provide the care you need. Arterial PO2 at or below 55 mm Hg, or arterial oxygen saturation at or below 88% when tested during sleep for patients that demonstrate an arterial PO2 at or above 56 mmHg, or 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. (Implementation Date: June 16, 2020). The care team helps coordinate the services you need. 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. ii. We call this the supporting statement.. You must qualify for this benefit. Certain combinations of drugs that could harm you if taken at the same time. What is covered: 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. Change the coverage rules or limits for the brand name drug. Your membership will usually end on the first day of the month after we receive your request to change plans. Program Services There are five services eligible for a financial incentive. Information on the page is current as of December 28, 2021 You can call the California Department of Social Services at (800) 952-5253. Receive emergency care whenever and wherever you need it. Black Walnuts on the other hand have a bolder, earthier flavor. Information on this page is current as of October 01, 2022, Centers for Medicare and Medicaid Services. 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. It also has care coordinators and care teams to help you manage all your providers and services. You can contact Medicare. 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. IEHP (Inland Empire Health Plan) is a provider that contains a network of doctors, dentists, pyschs, therapists, and specialists. If you wish, you and your doctor or other prescriber may give us additional information to support your appeal. Please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. The Medicare Complaint Form is available at:https://www.medicare.gov/MedicareComplaintForm/home.aspx. We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency. A Cal MediConnect Plan is an organization made up of Doctors, Hospitals, Pharmacies, Providers of long-term services and supports, Behavioral Health Providers, and other Providers. TDD users should call (800) 952-8349. 1. If our answer is No to part or all of what you asked for, we will send you a letter. Can my doctor give you more information about my appeal for Part C services? We determine an existing relationship by reviewing your available health information available or information you give us. This is not a complete list. VNS is non-covered for the treatment of TRD when furnished outside of a CMS-approved CED study. Be prepared for important health decisions (Effective: May 25, 2017) After your coverage begins with IEHP DualChoice, you must receive medical services and prescription drug services in the IEHP DualChoice network. 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. Note: You can only make this request for services of Durable Medical Equipment (DME), transportation, or other ancillary services not included in our plan. Medicare beneficiaries who meet either of the following criteria: Click here for more information on HBV Screenings. You do not need to do anything further to get this Extra Help. Read your Medicare Member Drug Coverage Rights. H8894_DSNP_23_3241532_M. Cardiologists care for patients with heart conditions. Or, if you havent paid for the service or item yet, we will send the payment directly to the provider. For patients whose initial prescription for oxygen did not originate during an inpatient hospital stay, the time of need occurs when the treating practitioner identifies signs and symptoms of hypoxemia that can be relieved with at home oxygen therapy. Be informed regarding Advance Directives, Living Wills, and Power of Attorney, and to receive information regarding changes related to existing laws. A fast coverage decision means we will give you an answer within 24 hours after we get your doctors statement. It tells which Part D prescription drugs are covered by IEHP DualChoice. More . A clinical test providing a measurement of the partial pressure of oxygen (PO2) in arterial blood. Limitations, copays, and restrictions may apply. 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. Use of other PET radiopharmaceutical tracers for cancer may be covered at the discretion of local Medicare Administrative Contractors (MACs), when used in accordance to their Food and Drug Administration (FDA) approval indications. They also have thinner, easier-to-crack shells. Unless you change plans, IEHP DualChoice (HMO D-SNP) will provide your Medicare benefits. 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. An interventional echocardiographer must perform transesophageal echocardiography during the procedure.>. Who is covered: You must choose your PCP from your Provider and Pharmacy Directory. i. See form below: Deadlines for a fast appeal at Level 2 We will give you our answer sooner if your health requires it. These different possibilities are called alternative drugs. If we say no to part or all of your Level 1 Appeal, we will send you a letter. 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. To learn how to submit a paper claim, please refer to the paper claims process described below. 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. An annual screening for lung cancer with LDCT will be available if specific eligibility criteria are met. 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. (Effective: August 7, 2019) 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. What is covered: This gives you time to talk with your provider about getting a different drug or to ask us to cover the drug. You cannot make this request for providers of DME, transportation or other ancillary providers. If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. Direct and oversee the process of handling difficult Providers and/or escalated cases. Erythrocythemia (increased red blood cells) with a hematocrit greater than 56%. If you have questions, you can contact IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Yes. At level 2, an Independent Review Entity will review the decision. (Implementation Date: July 5, 2022). 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. You will be notified when this happens. 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. It also includes problems with payment. Send us your request for payment, along with your bill and documentation of any payment you have made. Click here to download a free copy by clicking Adobe Acrobat Reader. If you need help during the appeals process, you can call the Office of the Ombudsman at 1-888-452-8609. Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. 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. All screenings DNA tests, effective April 28, 2008, through October 8, 2014. CMS has updated Chapter 1, section 20.19 of the Medicare National Coverage Determinations Manual. (You cannot get a fast coverage decision coverage decision if your request is about payment for care or an item you have already received.). An interventional echocardiographer must perform transesophageal echocardiography during the procedure. We add a generic drug that is not new to the market and: Replace a brand name drug currently on the Drug List or. 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. Click here for more information on Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). 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. to part or all of what you asked for, we will make payment to you within 14 calendar days. Receive services without regard to race, ethnicity, national origin, religion, sex, age, mental or physical disability or medical condition, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), disability, genetic information, or source of payment. We will give you our answer sooner if your health requires us to do so. Members \. i. Arterial PO2 at or below 55 mm Hg or arterial oxygen saturation at or below 88% when tested at rest in breathing room air, or; You wont pay a premium, or pay for doctor visits or other medical care if you go to a provider that works with our health plan. (888) 244-4347 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. 3. IEHP DualChoice is for people with both Medicare (Part A and B) and Medi-Cal. Call at least 5 days before your appointment. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. 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. Beneficiaries receiving treatment for implanting a ventricular assist device (VAD), when the following requirements are met and: All other indications for the use of VADs not otherwise listed remain non-covered, except in the context of Category B investigational device exemption clinical trials (42 CFR 405) or as a routine cost in clinical trials defined under section 310.1 of the National Coverage Determinations (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. . Then, we check to see if we were following all the rules when we said No to your request. The following link will take you to the Centers for Medicaid and Medicare Services website, where you can look through the CMS Best Available Evidence Policy using the following link: CMS Best Available Evidence Policy.