For example, you can ask us to cover a drug even though it is not on the Drug List. They receive a left ventricular device (LVADs) if the device is FDA approved for short- or long-term use for mechanical circulatory support for beneficiaries with heart failure who meet the following requirements: Have New York Heart Association (NYHA) Class IV heart failure; and, Have a left ventricular ejection fraction (LVEF) 25%; and. 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. You can contact Medicare. Autologous Platelet-Rich Plasma (PRP) treatment of acute surgical wounds when applied directly to the close incision, or for splitting or open wounds. Related Resources. To learn how to name your representative, you may call IEHP DualChoice Member Services. They are considered to be at high-risk for infection; or. 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. LSS is a narrowing of the spinal canal in the lower back. Please be sure to contact IEHP DualChoice Member Services if you have any questions. If the DMHC decides that your case is not eligible for IMR, the DMHC will review your case through its regular consumer complaint process. If you are appealing a decision our plan made about a drug you have not yet received, you and your doctor or other prescriber will need to decide if you need a fast appeal., The requirements for getting a fast appeal are the same as those for getting a fast coverage decision.. (Implementation Date: June 16, 2020). A PCP is your Primary Care Provider. (888) 244-4347 Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. You can work with us for all of your health care needs. Medicare beneficiaries who meet either of the following criteria: Click here for more information on HBV Screenings. Click here for more information on Ventricular Assist Devices (VADs) coverage. We will send you a notice with the steps you can take to ask for an exception. If the IMR is decided in your favor, we must give you the service or item you requested. You can contact the Office of the Ombudsman for assistance. You may also contact the local Office for Civil Rights office at: U.S. Department of Health and Human Services. 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 National Coverage Determination Manual. The procedure is used with a mitral valve TEER system that has received premarket approval from the FDA. You will be automatically enrolled in IEHP DualChoice and do not need to do anything to keep these services. We must respond whether we agree with the complaint or not. Box 997413 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. (Effective: April 3, 2017) to part or all of what you asked for, we will make payment to you within 14 calendar days. Sometimes a specialist, clinic, hospital or other network provider you are using might leave the plan. Other persons may already be authorized by the Court or in accordance with State law to act for you. 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. The DMHC may accept your application after 6 months if it determines that circumstances kept you from submitting your application in time. 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. During these events, supplemental oxygen is provided during exercise, if the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air. 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. We may stop any aid paid pending you are receiving. Black Walnuts on the other hand have a bolder, earthier flavor. Make your appeal request within 60 calendar days from the date on the notice we sent to tell you our decision. 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. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contact renewal. Level 2 Appeal for Part D drugs. Here are your choices: There may be a different drug covered by our plan that works for you. Review your Member Handbook, and call IEHP DualChoice Member Services if you do not understand something about your coverage and benefits. a clinical indication for germline (inherited) testing for hereditary breast or ovarian cancer and; a risk factor for germline (inherited) breast or ovarian cancer and; not been previously tested with the same germline test using NGS for the same germline genetic content. What is covered? (Effective: February 19, 2019) Follow the plan of treatment your Doctor feels is necessary. Your benefits as a member of our plan include coverage for many prescription drugs. 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. 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. We take a careful look at all of the information about your request for coverage of medical care. IEHP DualChoice If you decide to make an appeal, it means you are going on to Level 1 of the appeals process. TTY users should call 1-800-718-4347. Effective for claims with dates of service on or after February 10, 2022, CMS will cover, under Medicare Part B, a lung cancer screening counseling and shared decision-making visit. To stay a member of IEHP DualChoice, you must qualify again by the last day of the two-month period. Appointment of Representatives Form (PDF), 2023 Drugs Requiring Prior Authorization (PDF). To the California Department of Social Services: To the State Hearings Division at fax number 916-651-5210 or 916-651-2789. Portable oxygen would not be covered. (Implementation date: October 2, 2017 for design and coding; January 1, 2018 for testing and implementation) All other indications for colorectal cancer screening not otherwise specific in the regulations or the National Coverage Determination above. We may contact you or your doctor or other prescriber to get more information. Our plan includes doctors, hospitals, pharmacies, providers of long-term services and supports, behavioral health providers, and other providers. Direct and oversee the process of handling difficult Providers and/or escalated cases. Effective June 21, 2019, CMS will cover TAVR under CED when the procedure is related to the treatment of symptomatic aortic stenosis and according to the Food and Drug Administration (FDA) approved indication for use with an approved device, or in clinical studies when criteria are met, in addition to the coverage criteria outlined in the NCD Manual. You can make a complaint to the Department of Health and Human Services Office for Civil Rights if you think you have not been treated fairly. 2023 Plan Benefits. (Effective: July 2, 2019) If you do not choose a PCP when you join IEHPDualChoice, we will choose one for you. Follow the appeals process. 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 we decide that your health does not meet the requirements for a fast coverage decision, we will send you a letter. Asymptomatic (no signs or symptoms of lung cancer); Tobacco smoking history of at least 20 pack-years (one pack-year = smoking one pack per day for one year; 1 pack =20 cigarettes); Current smoker or one who has quit smoking within the last 15 years; Receive an order for lung cancer screening with LDCT. Changing your Primary Care Provider (PCP). If we dont give you our decision within 14 calendar days, you can appeal. There is no deductible for IEHP DualChoice. Removing a restriction on our coverage. If you do not wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. P.O. Request a second opinion about a medical condition. Annapolis Junction, Maryland 20701. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. IEHP DualChoice is very similar to your current Cal MediConnect plan. If your Level 2 Appeal was an Independent Medical Review, the Department of Managed Health Care will send you a letter explaining its decision. 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. You can get a fast coverage decision coverage decision only if you are asking for coverage for care or an item you have not yet received. We will use the standard deadlines unless we have agreed to use the fast deadlines., You can get a fast coverage decision only if you are asking for a drug you have not yet received. 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 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 drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. If you have an urgent need for care, you probably will not be able to find or get to one of the providers in our plans network. Sprint from Voice Telephone: (800) 877-5379, Visit: 10801 Sixth Street, Suite 120, Rancho Cucamonga, CA 91730. At Level 2, an outside independent organization will review your request and our decision. 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. You can get services such as those listed below without getting approval in advance from your Primary Care Provider (PCP). Your IEHP DualChoice Doctor cannot charge you for covered health care services, except for required co-payments. 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. 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. The treatment is based upon efficacy from a direct measure of clinical benefit in CMS-approved prospective comparative studies. This number requires special telephone equipment. 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 Denies, changes, or delays a Medi-Cal service or treatment (not including IHSS) because our plan determines it is not medically necessary. For additional information on step therapy and quantity limits, refer to Chapter5 of theIEHP DualChoice Member Handbook. 2023 IEHP DualChoice Member Handbook (PDF), Click here to download a free copy of Adobe Acrobat Reader. Additional hours of treatment are considered medically necessary if a physician determines there has been a shift in the patients medical condition, diagnosis or treatment regimen that requires an adjustment in MNT order or additional hours of care. 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 if the plan says they will not pay? Effective on or after April 10, 2018, MRI coverage will be provided when used in accordance to the FDA labeling in an MRI environment. (800) 440-4347 When you are discharged from the hospital, you will return to your PCP for your health care needs. We do not allow our network providers to bill you for covered services and items. H8894_DSNP_23_3879734_M Pending Accepted. You can then ask us to make an exception and cover the drug in the way you would like it to be covered for next year. We establish that you had an existing relationship with a primary or specialty care provider, with some exceptions. A care coordinator is a person who is trained to help you manage the care you need. 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). 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 list can help your provider find a covered drug that might work for you. Please see below for more information. Information on the page is current as of December 28, 2021 You have a right to appeal or ask for Formulary exception if you disagree with the information provided by the pharmacist. My Choice. The clinical test must be performed at the time of need: You can call SHIP at 1-800-434-0222. All other indications of VNS for the treatment of depression are nationally non-covered. They have a copay of $0. All screenings DNA tests, effective April 28, 2008, through October 8, 2014. 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. IEHP DualChoice (HMO D-SNP) has contracts with pharmacies that equals or exceeds CMS requirements for pharmacy access in your area. Who is covered: The PTA is covered under the following conditions: 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. Also, its possible that your PCP might leave our plans network of providers and you would have to find a new PCP. 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. Handling problems about your Medi-Cal benefits. Our service area includes all of Riverside and San Bernardino counties. If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. These reviews are especially important for members who have more than one provider who prescribes their drugs. The State or Medicare may disenroll you if you are determined no longer eligible to the program. This is a person who works with you, with our plan, and with your care team to help make a care plan. Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative Form. If you disagree with our decision, you can ask the DMHC Help Center for an IMR. If you disagree with a coverage decision we have made, you can appeal our decision. For reservations call Monday-Friday, 7am-6pm (PST). Beneficiaries receiving treatment for Transcatheter Edge-to-Edge Repair (TEER) when either of the following are met: This determination will expire ten years after the effective date if a reconsideration is not made during this time. Who is covered: What is covered? How do I ask the plan to pay me back for the plans share of medical services or items I paid for? For problems and concerns regarding eligibility determinations, assessments, and care delivered by our contracted Community Based Adult Services (CBAS) centers, or Nursing Facilities/Sub-Acute Care Facilities, you should follow the process outlined below. Medicare has approved the IEHP DualChoice Formulary. The registry shall collect necessary data and have a written analysis plan to address various questions. 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. If you are asking for a standard appeal, you can make your appeal by sending a request in writing. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. Who is covered: 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. You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage decision. Yes, you and your doctor may give us more information to support your appeal. i. Can I ask for a coverage determination or make an appeal about Part D prescription drugs?