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Please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. My problem is about a Medi-Cal service or item. Learn about your health needs and leading a healthy lifestyle. There are many kinds of specialists. IEHP offers a competitive salary and stellar benefit package . Call our transportation vendor Call the Car (CTC) at (866) 880-3654, for TTY users, call your relay service or California Relay Service at 711. It attacks the liver, causing inflammation. 3. 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. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. Generally, IEHP DualChoice (HMO D-SNP) will cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Medicare has approved the IEHP DualChoice Formulary. Pulmonary hypertension or cor pulmonale (high blood pressure in pulmonary arteries), determined by the measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVFL; or, i. Beneficiaries with Alzheimers Disease (AD) may be covered for treatment when the following conditions (A or B) are met: Click here for more information on Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimers Disease (AD). While the taste of the black walnut is a culinary treat the . Upon expiration, coverage will be determined by the local Medicare Administrative Contractors (MACs). Can my doctor give you more information about my appeal for Part C services? We call this the supporting statement.. a. (Implementation date: December 18, 2017) A care coordinator is a person who is trained to help you manage the care you need. Visit the Department of Managed Health Care's website: 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. Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. 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. A standard coverage decision means we will give you an answer within 72 hours after we get your doctors statement. CMS has revised Chapter 1, Section 20.29, Subsection C Topical Application of Oxygen to remove the exclusion of this treatment. 504 Plan Defined The 504 Plan is a plan developed to ensure that a child who has a disability To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for an coverage decision. Arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88%, tested during functional performance of the patient or a formal exercise, Your benefits as a member of our plan include coverage for many prescription drugs. For the treatment of symptomatic moderate to severe mitral regurgitation (MR) when the patient still has symptoms, despite stable doses of maximally tolerated guideline directed medical therapy (GDMT) and cardiac resynchronization therapy, when appropriate and the following are met: Treatment is a Food and Drug Administration (FDA) approved indication. You are not responsible for Medicare costs except for Part D copays. The registry shall collect necessary data and have a written analysis plan to address various questions. You must submit your claim to us within 1 year of the date you received the service, item, or drug. 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. Medicare beneficiaries who are diagnosed with Symptomatic Peripheral Artery Disease who would benefit from this therapy. The phone number for the Office for Civil Rights is (800) 368-1019. 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. Patients demonstrating arterial PO2 between 56-59 mm Hg, or whos arterial blood oxygen saturation is 89%, with any of the following condition: Previously, HBV screening and re-screening was only covered for pregnant women. What Prescription Drugs Does IEHP DualChoice Cover? IEHP DualChoice (HMO D-SNP) helps make your Medicare and Medi-Cal benefits work better together and work better for you. This service will be covered when the TAVR is used, for the treatment of symptomatic aortic valve stenosis. This is called upholding the decision. It is also called turning down your appeal.. 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. Patients must maintain a stable medication regimen for at least four weeks before device implantation. Opportunities to Grow. You and your provider can ask us to make an exception. A care team can help you. If you are admitted to one of these hospitals, a hospitalist may serve as your caregiver as long as you remain in the hospital. As an IEHP DualChoice (HMO D-SNP) Member, you have the right to: As an IEHP DualChoice Member, you have the responsibility to: For more information on Member Rights and Responsibilities refer to Chapter 8 of your IEHP DualChoice Member Handbook. If you want to change plans, call IEHP DualChoice Member Services. Limited benefit from amplification is defined by test scores of less than or equal to 60% correct in the best-aided listening condition on recorded tests of open-set sentence recognition. He or she can help you decide if there is a similar drug on the Drug List you can take instead or whether to ask for an exception. (Implementation Date: October 8, 2021) You can call Member Services to ask for a list of covered drugs that treat the same medical condition. Livanta is not connect with our plan. Try to choose a PCP that can admit you to the hospital you want within 30 miles or 45 minutes of your home. Call IEHP DualChoice at 1-877-273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. We will give you our decision sooner if your health condition requires us to. If you ask for a fast appeal, we will give you your answer within 72 hours after we get your appeal. You can download a free copy here. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. 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. Drugs that may not be safe or appropriate because of your age or gender. 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. If we tell you after our review that the service or item is not covered, your case can go to a Level 2 Appeal. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Sign up for the free app through our secure Member portal. Information is also below. This means within 24 hours after we get your request. You can always contact your State Health Insurance Assistance Program (SHIP). If we do not give you an answer within 72 hours, we will send your request to Level 2. to part or all of what you asked for, we must give the coverage within 72 hours after we get your appeal. At Level 2, an Independent Review Entity will review our decision. 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. and hickory trees (Carya spp.) CMS has added a new section, Section 20.35, to Chapter 1 entitled Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). You will not have a gap in your coverage. If we do not agree with some or all of your complaint or dont take responsibility for the problem you are complaining about, we will let you know. In most cases, you must file an appeal with us before requesting an IMR. Our plans PCPs are affiliated with medical groups or Independent Physicians Associations (IPA). 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. (Implementation Date: June 16, 2020). IEHP DualChoice will give notice to IEHPDualChoice Members prior to removing Part D drug from the Part D formulary. If our answer is Yes to part or all of what you asked for, we must give the coverage within 72 hours after we get your appeal. (Implementation Date: July 22, 2020). If you wish, you can make your complaint about quality of care to our plan and also to the Quality Improvement Organization. If your Level 2 Appeal was an Independent Medical Review, you can request a State Hearing. Sometimes a specialist, clinic, hospital or other network provider you are using might leave the plan. Follow the plan of treatment your Doctor feels is necessary. H8894_DSNP_23_3241532_M. (Implementation Date: July 27, 2021) Or, if you are asking for an exception, 24 hours after we get your doctors or prescribers statement supporting your request. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). 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. Our response will include our reasons for this answer. We will generally cover a drug on the plans Formulary as long as you follow the other coverage rules explained in Chapter 6 of the IEHP DualChoice Member Handbookand the drug is medically necessary, meaning reasonable and necessary for treatment of your injury or illness. Their shells are thick, tough to crack, and will likely stain your hands. IEHP DualChoice Member Services can assist you in finding and selecting another provider. When you choose your PCP, you are also choosing the affiliated medical group. If you or your doctor disagree with our decision, you can appeal. Who is covered? (Implementation Date: October 3, 2022) How to obtain an aggregate number of grievances, appeals, and exceptions filed with IEHP DualChoice (HMO D-SNP)? The Office of the Ombudsman. 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. Note: You can only make this request for services of Durable Medical Equipment (DME), transportation, or other ancillary services not included in our plan. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. For more information on Member Rights and Responsibilities refer to Chapter 8 of your. PCPs are usually linked to certain hospitals and specialists. An IMR is available for any Medi-Cal covered service or item that is medical in nature. The following medical conditions are not covered for oxygen therapy and oxygen equipment in the home setting: Other: Your enrollment in your new plan will also begin on this day. You should not pay the bill yourself. when beneficiaries are suspected of having white coat hypertension or masked hypertension in addition to the coverage criteria outlined in the, Ambulatory Blood Pressure Monitoring (ABPM), for the diagnosis of hypertension when either there is suspected white coat or masked hypertension. View Plan Details. CMS-approved studies of a monoclonal antibody directed against amyloid approved by the FDA for the treatment of AD based upon evidence of efficacy from a direct measure of clinical benefit must address all of the questions included in section B.4 of this National Coverage Determination. Medicare beneficiaries with LSS who are participating in an approved clinical study. 2) State Hearing If you disagree with a coverage decision we have made, you can appeal our decision. See form below: Deadlines for a fast appeal at Level 2 If you ask for a fast coverage decision, without your doctors support, we will decide if you get a fast coverage decision. Black walnut trees are not really cultivated on the same scale of English walnuts. We will let you know of this change right away. Screening computed tomographic colonography (CTC), effective May 12, 2009. You can fax the completed form to (909) 890-5877. If you move out of our service area for more than six months. You will be automatically enrolled in a Medicare Medi-Cal Plan offered by IEHP DualChoice. You may choose different health plans, or providers, under Medi-Cal, like IEHP or Molina Healthcare, Blue Shield, Health Net, etc. If you need to change your PCP for any reason, your hospital and specialist may also change. My Choice. The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. Receive information about your rights and responsibilities as an IEHP DualChoice Member. You do not need to do anything further to get this Extra Help. You can switch yourDoctor (and hospital) for any reason (once per month). Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. 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. Complain about IEHP DualChoice, its Providers, or your care. If your health requires it, ask the Independent Review Entity for a fast appeal.. 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. (Implementation Date: September 20, 2021). CMS has updated Chapter 1, Part 2, Section 90.2 of the Medicare National Coverage Determinations Manual to include NGS testing for Germline (inherited) cancer when specific requirements are met and updated criteria for coverage of Somatic (acquired) cancer. You can ask for an Independent Medical Review (IMR) from the Help Center at the California Department of Managed Health Care (DMHC). If we do not give you an answer within 72 hours 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. Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities; or. We take another careful look at all of the information about your coverage request. All other indications for colorectal cancer screening not otherwise specific in the regulations or the National Coverage Determination above. Change the coverage rules or limits for the brand name drug. This is a group of doctors and other health care professionals who help improve the quality of care for people with Medicare. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision. (888) 244-4347 You must apply for an IMR within 6 months after we send you a written decision about your appeal. IEHP DualChoice is for people with both Medicare (Part A and B) and Medi-Cal. Beneficiaries participating in a CMS approved clinical study undergoing Vagus Nerve Stimulation (VNS) for treatment resistant depression and the following requirements are met: Click here for more information on Vagus Nerve Stimulation. 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. Non-Covered Use: The following uses are considered non-covered: Click here for more information on Blood-Derived Products for Chronic, Non-Healing Wounds coverage. Angina pectoris (chest pain) in the absence of hypoxemia; or. We will say Yes or No to your request for an exception. Receive emergency care whenever and wherever you need it. Initial coverage for patients experiencing conditions not described above can be limited to a prescription shorter than 90 days, or less than the numbers of days indicated on the practitioners prescription. We will review our coverage decision to see if it is correct. You will be notified when this happens. 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). If you lie about or withhold information about other insurance you have that provides prescription drug coverage. 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. A network provider is a provider who works with the health plan. Patient must also present hypoxemia signs and symptoms such as nocturnal restlessness, insomnia, or impairment of cognitive process. (Implementation date: August 29, 2017 for MAC local edits; January 2, 2018 for MCS shared edits) 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.