Join our Team and make a difference with us! P.O. There are two ways you can asked to be disenrolled: To disenroll, please call Health Care Options (HCO) at 1-844-580-7272, 8am - 6pm (PST), Monday - Friday. 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. Your benefits as a member of our plan include coverage for many prescription drugs. The procedure is used with a mitral valve TEER system that has received premarket approval from the FDA. Note, the Member must be active with IEHP Direct on the date the services are performed. Please see below for more information. You must qualify for this benefit. If we agree to make an exception and waive a restriction for you, you can still ask for an exception to the co-pay amount we require you to pay for the drug. These forms are also available on the CMS website: 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. 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. If we dont give you our decision within 14 calendar days, you can appeal. This can speed up the IMR process. 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. Our plan includes doctors, hospitals, pharmacies, providers of long-term services and supports, behavioral health providers, and other providers. Suppose that you are temporarily outside our plans service area, but still in the United States. The clinical study must adhere to all the standards of scientific integrity and relevance to the Medicare population. your medical care and prescription drugs through our plan. 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. "Coordinating" your services includes checking or consulting with other Plan providers about your care and how it is going. The phone number is (888) 452-8609. The phone number for the Office for Civil Rights is (800) 368-1019. H8894_DSNP_23_3879734_M Pending Accepted. You can file a grievance online. 2. Handling problems about your Medi-Cal benefits. (Effective: February 10, 2022) The California Department of Managed Health Care (DMHC) is responsible for regulating health plans. They all work together to provide the care you need. Follow the appeals process. If we say no, you have the right to ask us to change this decision by making an appeal. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which IEHP DualChoice (HMO D-SNP) authorizes use of out-of-network providers. (Implementation Date: February 19, 2019) The benefit information is a brief summary, not a complete description of benefits. 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. 2023 Inland Empire Health Plan All Rights Reserved. according to the FDA-approved indications and the following conditions are met: The procedure and implantation system received FDA premarket approval (PMA) for that system's FDA approved indication. b. If possible, we will answer you right away. A Level 1 Appeal is the first appeal to our plan. You can change your Doctor by calling IEHP DualChoice Member Services. You have been in the plan for more than 90 days and live in a long-term care facility and need a supply right away. Have a Primary Care Provider who is responsible for coordination of your care. 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. If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize or give you the drug coverage within 72 hours after we get the decision. Or, if you are asking for an exception, 24 hours after we get your doctors or prescribers statement supporting your request. There are over 700 pharmacies in the IEHP DualChoice network. What Prescription Drugs Does IEHP DualChoice Cover? You do not need to do anything further to get this Extra Help. Click here for more information on study design and rationale requirements. You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. 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. effort to participate in the health care programs IEHP DualChoice offers you. How to Enroll with IEHP DualChoice (HMO D-SNP), IEHP Texting Program Terms and Conditions. According to IEHP, 99.4 percent of enrollees retained the same primary care physicians. Complain about IEHP DualChoice, its Providers, or your care. If you are asking for a standard appeal, you can make your appeal by sending a request in writing. Organized as a Joint Powers Agency, Inland Empire Health Plan (IEHP) is a local, not-for-profit, public health plan. 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. The diagnostic laboratory test using NGS must have: Food & Drug Administration (FDA) approval or clearance as a companion in vitro diagnostic and; FDA-approved or cleared indication for use in that patients cancer and; results provided to the treating physician for management of the patient using a report template to specify treatment options. 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. P.O. 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. An acute HBV infection could progress and lead to life-threatening complications. It attacks the liver, causing inflammation. PO2 may be performed by the treating practitioner or by a qualified provider or supplier of laboratory services. Reviewers at the Independent Review Entity will take a careful look at all of the information related to your appeal. You will get a letter from us about the change in your eligibility with instructions to correct your eligibility information. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. How to voluntarily end your membership in our plan? This is asking for a coverage determination about payment. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. 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. You will be notified when this happens. Get Help from an Independent Government Organization. If you prefer a different one, please call IEHP DualChoice Member Services and we can assist you in finding and selecting another provider. The clinical research study must critically evaluate each patient's quality of life pre- and post-TAVR for a minimum of 1 year, but must also address other various questions. Note: You can only make this request for services of Durable Medical Equipment (DME), transportation, or other ancillary services not included in our plan. (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. c. The Medicare Administrative Contractors (MACs) will review the arterial PO2 levels above and also take into consideration various oxygen measurements that can results from factors such as patients age, patients skin pigmentation, altitude level and the patients decreased oxygen carrying capacity. 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. If you do not stay continuously enrolled in Medicare Part A and Part B. You can give the completed form to any IEHP Provider or mail it to: Call: 1-888-452-8609(TTY 711) Monday through Friday, 9 a.m. to 5 p.m. If PO2 and arterial blood gas results are conflicting, the arterial blood gas results are preferred source to determine medical need. Medicare beneficiaries with LSS who are participating in an approved clinical study. Calls to this number are free. Patient must be evaluated for suitability for repair and must documented and made available to the Heart team members meeting the requirements of this determination. Your doctor will also know about this change and can work with you to find another drug for your condition. If your Level 2 Appeal was an Independent Medical Review, the Department of Managed Health Care will send you a letter explaining its decision. TTY/TDD (800) 718-4347. wounds affecting the skin. You can call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. of the appeals process. If we say no to part or all of your Level 1 Appeal, we will send you a letter. 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. Unleashing our creativity and courage to improve health & well-being. We determine an existing relationship by reviewing your available health information available or information you give us. Most complaints are answered in 30 calendar days. If your Level 2 Appeal was a State Hearing, you may ask for a rehearing within 30 days after you receive the decision. Your PCP should speak your language. For example, you can ask us to cover a drug even though it is not on the Drug List. Upon expiration, coverage will be determined by the local Medicare Administrative Contractors (MACs). The treatment is based upon efficacy from a change in surrogate endpoint such as amyloid reduction. How do I ask the plan to pay me back for the plans share of medical services or items I paid for? In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. (Implementation Date: January 17, 2022). You can fax the completed form to (909) 890-5877. Covering a Part D drug that is not on our List of Covered Drugs (Formulary). (Implementation Date: December 10, 2018). We check to see if we were following all the rules when we said No to your request. My Choice. Make necessary appointments for routine and sick care, and inform your Doctor when you are unable to make a scheduled appointment. You have access to a care coordinator. (Implementation Date: October 5, 2020). For other types of problems you need to use the process for making complaints. Can someone else make the appeal for me for Part C services? IEHP DualChoice, a Medicare Medi-Cal Plan, allows you to get your covered Medicare and Medi-Cal benefits through our plan. Topical Application of Oxygen for Chronic Wound Care. You have the right to ask us for a copy of the information about your appeal. H8894_DSNP_23_3241532_M. You or your provider must show documentation of an existing relationship and agree to certain terms when you make the request. (800) 718-4347 (TTY), IEHP 24-Hour Nurse Advice Line (for IEHP Members only) We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency. The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. 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. Rancho Cucamonga, CA 91729-1800 Infected individuals may develop symptoms such as nausea, anorexia, fatigue, fever, and abdominal pain, or may be asymptomatic. To start your appeal, you, your doctor or other prescriber, or your representative must contact us. Who is covered: Medicare beneficiaries will have their blood-based colorectal cancer screening test covered once every 3 years when ordered by a treating physician and the following conditions are met: (Effective: December 1, 2020)

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