Request a second opinion about a medical condition. 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. We will send you your ID Card with your PCPs information. The Heart team must participate in the national registry and track outcomes according to the requirements in this determination.>. To learn how to submit a paper claim, please refer to the paper claims process described below. To learn more about asking for exceptions, see Chapter 9 (What to do if you have a problem or complaint [coverage decisions, appeals, complaints]). All other indications for colorectal cancer screening not otherwise specified in the Social Security Act, regulations, or the above remain nationally non-covered. The form gives the other person permission to act for you. IEHP DualChoice will help you with the process. 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. If your problem is about a Medi-Cal service or item, the letter will tell you how to file a Level 2 Appeal yourself. Ask within 60 days of the decision you are appealing. Making an appeal means asking us to review our decision to deny coverage. If you get a bill that is more than your copay for covered services and items, send the bill to us. How will you find out if your drugs coverage has been changed? Unleashing our creativity and courage to improve health & well-being. To ask for a coverage decision, call, write, or fax us, or ask your representative or doctor to ask us for an coverage decision. How will the plan make the appeal decision? You dont have to do anything if you want to join this plan. The clinical study must adhere to all the standards of scientific integrity and relevance to the Medicare population. If you decide to ask for a State Hearing by phone, you should be aware that the phone lines are very busy. We check to see if we were following all the rules when we said No to your request. Your provider will also know about this change. IEHP DualChoice (HMO D-SNP) has contracts with pharmacies that equals or exceeds CMS requirements for pharmacy access in your area. Complain about IEHP DualChoice, its Providers, or your care. During these reviews, we look for potential problems such as: If we see a possible problem in your use of medications, we will work with your Doctor to correct the problem. 1. For reservations call Monday-Friday, 7am-6pm (PST). CMS has updated Chapter 1, section 30.3.3 of the Medicare National Coverage Determinations Manual. If you miss this deadline and have a good reason for missing it, we may give you more time to make you appeal. A standard coverage decision means we will give you an answer within 72 hours after we get your doctors statement. 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 A Level 1 Appeal is the first appeal to our plan. IEHP DualChoice (HMO D-SNP) has a process in place to identify and reduce medication errors. All physicians participating in the procedure must have device-specific training by the manufacturer of the device. If possible, we will answer you right away. Yes. You should provide all requested information such as your full name, address, telephone number, the name of the plan or county that took the action against you, the aid program(s) involved, and a detailed reason why you want a hearing. 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. IEHP DualChoice Positron Emission Tomography NaF-18 (NaF-18 PET) services to identify bone metastases of cancer provided on or after December 15, 2017, are nationally non-covered. IEHP Direct contracted PCPs who provide service to IEHP Direct DualChoice Members. We take a careful look at all of the information about your request for coverage of medical care. For a patient demonstrating arterial PO2 at or above 56 mm Hg, or an arterial oxygen saturation at or above 89%, at rest and during the day. We may stop any aid paid pending you are receiving. The patient is experiencing a major depressive episode, as measured by a guideline recommended depression scale assessment tool on two visits, within a 45-day span prior to implantation of the VNS device. If the dollar value of the drug coverage you want meets a certain minimum amount, you can make another appeal at Level 3. For example, we might decide that a service, item, or drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plans service area. Facilities must be credentialed by a CMS approved organization. You can ask us to reimburse you for IEHP DualChoice's share of the cost. What is a Level 2 Appeal? Who is covered: The PTA is covered under the following conditions: ii. You have a right to give the Independent Review Entity other information to support your appeal. Program Services There are five services eligible for a financial incentive. The list can help your provider find a covered drug that might work for you. If you move out of our service area for more than six months. Who is covered: Members must meet all of the following eligibility criteria: Click here for more information on LDCT coverage. Information on this page is current as of October 01, 2022. (888) 244-4347 If the IRE reverses our decision and says we should pay you, we must send the payment to you or to the provider within 30 calendar days. Becaplermin, a non-autologous growth factor for chronic, non-healing, subcutaneous (beneath the skin) wounds, and. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You do not need to give your doctor or other prescriber written permission to ask us for a coverage determination on your behalf. i. However, your PCP can always use Language Line Services to get help from an interpreter, if needed. 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. Please note: If your pharmacy tells you that your prescription cannot be filled, you will get a notice explaining how to contact us to ask for a coverage determination. If you need help during the appeals process, you can call the Office of the Ombudsman at 1-888-452-8609. Here are two ways to get information directly from Medicare: By clicking on this link, you will be leaving the IEHP DualChoice website. Possible errors in the amount (dosage) or duration of a drug you are taking. This can speed up the IMR 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. Flu shots as long as you get them from a network provider. Deadlines for standard appeal at Level 2. C. Beneficiarys diagnosis meets one of the following defined groups below: 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). What is covered? Tier 1 drugs are: generic, brand and biosimilar drugs. We will give you our answer sooner if your health requires us to. Department of Health Care Services (Effective: January 21, 2020) 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. You can download a free copy by clicking here. How to ask for coverage decision coverage decision to get medical, behavioral health, or certain long-term services and supports (CBAS, or NF services). But in some situations, you may also want help or guidance from someone who is not connected with us. (800) 720-4347 (TTY). The clinical research must evaluate the required twelve questions in this determination. This is not a complete list. An IMR is a review of your case by doctors who are not part of our plan. These different possibilities are called alternative drugs. Whether you call or write, you should contact IEHP DualChoice Member Services right away. For inpatient hospital patients, the time of need is within 2 days of discharge. Transportation: $0. If we are using the fast deadlines, we must give you our answer within 24 hours. Our state has an organization called Livanta Beneficiary & Family Centered Care (BFCC) Quality Improvement Organization (QIO). According to IEHP, 99.4 percent of enrollees retained the same primary care physicians. 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. 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. Utilities allowance of $40 for covered utilities. You have a right to appeal or ask for Formulary exception if you disagree with the information provided by the pharmacist. If we say Yes to your request for an exception, the exception usually lasts until the end of the calendar year. If we decide to change or stop coverage for a service or item that was previously approved, we will send you a notice before taking the action. Terminal illnesses, unless it affects the patients ability to breathe. The MAC may also approve the use of portable oxygen systems to beneficiaries who are mobile in home and benefit from of this unit alone, or in conjunction to a stationary oxygen system. (Implementation Date: July 22, 2020). (Implementation Date: October 3, 2022) Here are your choices: There may be a different drug covered by our plan that works for you. Click here for more information on Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. What is covered: 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. All of our plan participating providers also contract us to provide covered Medi-Cal benefits. 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. 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. The clinical research study must meet the standards of scientific integrity and relevance to the Medicare population described in this determination. 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. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Heart failure cardiologist with experience treating patients with advanced heart failure. b. Concurrent with Carotid Stent Placement in Patients at High Risk for Carotid Endarterectomy (CEA) IEHP DualChoice (HMO D-SNP) has a list of Covered Drugs called a Formulary. CMS has updated Section 110.24 of the Medicare National Coverage Determinations Manual to include coverage of chimeric antigen receptor (CAR) T-cell therapy when specific requirements are met. These changes might happen if: When these changes happen, we will tell you at least 30 days before we make the change to the Drug List or when you ask for a refill. PILD is a posterior decompression of the lumbar spine performed under indirect image guidance without any direct visualization of the surgical area. H8894_DSNP_23_3241532_M. These forms are also available on the CMS website: Please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. These reviews are especially important for members who have more than one provider who prescribes their drugs. (Implementation Date: October 5, 2020). TTY users should call (800) 537-7697. (Effective: April 3, 2017) You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. How do I ask the plan to pay me back for the plans share of medical services or items I paid for? CMS has updated Chapter 1, section 20.32 of the Medicare National Coverage Determinations Manual. ), and, Are age 21 and older at the time of enrollment, and, Have both Medicare Part A and Medicare Part B, and, Are a full-benefit dual eligible beneficiary and enroll in IEHP DualChoice for your Medicare benefits and Inland Empire Health Plan (IEHP) for your Medi-Cal benefits. We will send you a letter telling you that. 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 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. 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. You have a care team that you help put together. (Effective: February 19, 2019) TDD users should call (800) 952-8349. TTY (800) 718-4347. If our answer is No to part or all of what you asked for, we will send you a letter. (Implementation Date: December 12, 2022)