Click here for more information on study design and rationale requirements. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. Who is covered: (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.). Click here for more information on Cochlear Implantation. 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. It also needs to be an accepted treatment for your medical condition. Or, if you are asking for an exception, 24 hours after we get your doctors or prescribers statement supporting your request. 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. 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. IEHP DualChoice Medicare Team at (800) 741-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY users should call (800) 718-4347. IEP Defined The Individualized Educational Plan (IEP) is a plan or program developed to ensure that a child who has a disability identified under the law and is attending an elementary or secondary educational institution receives specialized instruction and related services. The State or Medicare may disenroll you if you are determined no longer eligible to the program. Click here for more information on Positron Emission Tomography NaF-18 (NaF-18 PET) to Identify Bone Metastasis of Cancer coverage. Changing your Primary Care Provider (PCP). The counselors at this program can help you understand which process you should use to handle a problem you are having. =========== TABBED SINGLE CONTENT GENERAL. A Level 1 Appeal is the first appeal to our plan. Deadlines for standard appeal at Level 2 View Plan Details. This gives you time to talk with your provider about getting a different drug or to ask us to cover the drug. Click here for more information on Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). effort to participate in the health care programs IEHP DualChoice offers you. After your application and supporting documents are received from your plan, the IMR decision will be made within 3 calendar days. TTY users should call 1-800-718-4347. The problem with using black walnuts in cooking is the fact that the black walnuts have a very tough shell and the nuts are difficult to extract. What is covered: Use of autologous Platelet-Derived Growth Factor (PDGF) for treatment of chronic, non-healing, cutaneous (affecting the skin) wounds, and. Breathlessness without cor pulmonale or evidence of hypoxemia; or. 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: Hepatitis B Virus (HBV) is transmitted by exposure to bodily fluids. You will keep all of your Medicare and Medi-Cal benefits. If you want to change plans, call IEHP DualChoice Member Services. Appointment of Representatives Form (PDF), 2023 Drugs Requiring Prior Authorization (PDF). IEHP offers a competitive salary and stellar benefit package . (Effective: January 1, 2022) 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. You will be automatically enrolled in IEHP DualChoice and do not need to do anything to keep these services. 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. If you call us with a complaint, we may be able to give you an answer on the same phone call. 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). Orthopedists care for patients with certain bone, joint, or muscle conditions. (888) 244-4347 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. 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. (800) 718-4347 (TTY), IEHP 24-Hour Nurse Advice Line (for IEHP Members only) TTY users should call 1-800-718-4347. H8894_DSNP_23_3241532_M. For other types of problems you need to use the process for making complaints. We have 30 days to respond to your request. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. You have a right to give the Independent Review Entity other information to support your appeal. The clinical study must adhere to all the standards of scientific integrity and relevance to the Medicare population. Within 10 days of the mailing date of our notice to you that the adverse benefit determination (Level 1 appeal decision) has been upheld; or. All other indications for colorectal cancer screening not otherwise specified in the Social Security Act, regulations, or the above remain nationally non-covered. (800) 440-4347 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. TTY users should call 1-800-718-4347. Review, request changes to, and receive a copy of your medical records in a timely fashion. We will review our coverage decision to see if it is correct. H5355_CMC_22_2746205Accepted, (Effective: September 27, 2021) Medicare Prescription Drug Coverage and Your Rights Notice- Posting of Member Drug Coverage Rights: Medicare requires pharmacies to provide notice to enrollees each time a member is denied coverage or disagrees with cost-sharing information. This is called a referral. TTY users should call 1-800-718-4347. (Effective: February 10, 2022) You can call the DMHC Help Center for help with complaints about Medi-Cal services. If you believe we should not take extra days, you can file a fast complaint about our decision to take extra days. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer and; has not been previously tested with the same test using NGS for the same cancer genetic content and; has decided to seek further cancer treatment (e.g., therapeutic chemotherapy). We take another careful look at all of the information about your coverage request. If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals). Send copies of documents, not originals. There are two ways to ask for a State Hearing: If you meet this deadline, you can keep getting the disputed service or item until the hearing decision is made. You or your provider must show documentation of an existing relationship and agree to certain terms when you make the request. 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. If we do not give you an answer within 30 calendar days or by the end of the extra days (if we took them), we will automatically send your case to Level 2 of the appeals process if your problem is about a Medicare service or item. Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. Complain about IEHP DualChoice, its Providers, or your care. If you dont have the IEHP DualChoice Provider and Pharmacy Directory, you can get a copy from IEHP DualChoice Member Services. A care team may include your doctor, a care coordinator, or other health person that you choose. The DMHC may accept your application after 6 months if it determines that circumstances kept you from submitting your application in time. P.O. What if the Independent Review Entity says No to your Level 2 Appeal? 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." Are a United States citizen or are lawfully present in the United States. If we answer no to your appeal and the service or item is usually covered by Medi-Cal, you can file a Level 2 Appeal yourself (see above). 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. 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. In most cases you have 120 days to ask for a State Hearing after the Your Hearing Rights notice is mailed to you. CMS has updated Chapter 1, section 20.32 of the Medicare National Coverage Determinations Manual. 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. Sprint from Voice Telephone: (800) 877-5379, Visit: 10801 Sixth Street, Suite 120, Rancho Cucamonga, CA 91730. Medicare beneficiaries who are diagnosed with Symptomatic Peripheral Artery Disease who would benefit from this therapy. 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. These reviews are especially important for members who have more than one provider who prescribes their drugs. There are extra rules or restrictions that apply to certain drugs on our Formulary. 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. Box 4259 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. How will you find out if your drugs coverage has been changed? You can call IEHP DualChoice at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. These different possibilities are called alternative drugs. 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. You can tell Medicare about your complaint. asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test), and, average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohns Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer). 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. Erythrocythemia (increased red blood cells) with a hematocrit greater than 56%. The formal name for making a complaint is filing a grievance. A grievance is the kinds of problems related to: How to file a Grievance with IEHP DualChoice (HMO D-SNP). Your PCP, along with the medical group or IPA, provides your medical care. 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. Other persons may already be authorized by the Court or in accordance with State law to act for you. 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. Yes. TTY users should call (800) 718-4347. Most complaints are answered in 30 calendar days. Will not pay for emergency or urgent Medi-Cal services that you already received. 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. Bringing focus and accountability to our work. No means the Independent Review Entity agrees with our decision not to approve your request. All other indications for colorectal cancer screening not otherwise specific in the regulations or the National Coverage Determination above. Receive emergency care whenever and wherever you need it. (Implementation Date: September 20, 2021). Coverage for future years is two hours for patients diagnosed with renal disease or diabetes. This section is about asking for coverage decisions and making appeals with problems related to your benefits and coverage. 3. You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage decision. (866) 294-4347 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. What is covered: If your doctor says that you need a fast coverage decision, we will automatically give you one. This includes getting authorization to see specialists or medical services such as lab tests, x-rays, and/or hospital admittance. 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. If you miss the deadline for a good reason, you may still appeal. If the Independent Medical Review decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. What if you are outside the plans service area when you have an urgent need for care? You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY (800) 718-4347. Box 997413 The letter will tell you how to make a complaint about our decision to give you a standard decision. If the service or item is not covered, or you did not follow all the rules, we will send you a letter telling you we will not pay for the service or item and explaining why. The form gives the other person permission to act for you. . If the Independent Review Entity approves a request to pay you back for a drug you already bought, we will send payment to you within 30 calendar days after we get the decision. 2023 IEHP DualChoice Member Handbook (PDF), Click here to download a free copy of Adobe Acrobat Reader. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. This is not a complete list. How to voluntarily end your membership in our plan? 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. The letter will also tell how you can file a fast appeal about our decision to give you a fast coverage decision instead of the fast coverage decision you requested. Copays for prescription drugs may vary based on the level of Extra Help you receive. Your doctor or other prescriber can fax or mail the statement to us. 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. Effective for claims with dates of service on or after 01/18/17, Medicare will cover leadless pacemakers under CED when procedures are performed in CMS-approved studies. 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. (Effective: June 21, 2019) Who is covered? Can I get a coverage decision faster for Part C services? We will also use the standard 14 calendar day deadline instead. 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. Infected individuals may develop symptoms such as nausea, anorexia, fatigue, fever, and abdominal pain, or may be asymptomatic. If there are no network pharmacies in that area, IEHP DualChoice Member Services may be able to make arrangements for you to get your prescriptions from an out-of-network pharmacy. When you make an appeal to the Independent Review Entity, we will send them your case file. You can ask us to make a faster decision, and we must respond in 15 days. You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug. The clinical test must be performed at the time of need: 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.