IEHP DualChoice is for people with both Medicare (Part A and B) and Medi-Cal. These different possibilities are called alternative drugs. 2023 IEHP DualChoice Member Handbook (PDF), Click here to download a free copy of Adobe Acrobat Reader. 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. All the changes are reviewed and approved by a selected group of Providers and Pharmacists that are currently in practice. This is known as Exclusively Aligned Enrollment, and. The Centers of Medicare and Medicaid Services (CMS) will cover claims for effective dates of service on or after February 15, 2018. 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. See Chapters 7 and 9 of the IEHP DualChoice Member Handbookto learn how to ask the plan to pay you back. 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). And routes with connections may be . (800) 440-4347 (Effective: June 21, 2019) All screenings DNA tests, effective April 28, 2008, through October 8, 2014. IEHP DualChoice (HMO D-SNP) helps make your Medicare and Medi-Cal benefits work better together and work better 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. Oxygen therapy can be renewed by the MAC if deemed medically necessary. 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. If you dont have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself. TDD users should call (800) 952-8349. Patients implanted with a VNS device for TRD may receive a VNS device replacement if it is required due to the end of battery life, or any other device-related malfunction. We determine an existing relationship by reviewing your available health information available or information you give us. Keep you and your family covered! P.O. The procedure must be performed by an interventional cardiologist or cardiac surgeon.<. Use the IEHP DualChoice Provider and Pharmacy Directory below to find a network provider: What is a Primary Care Provider (PCP) and their role in your Plan? Use the IEHP Medicare Prescription Drug Coverage Determination Form for a prior authorization. (Implementation Date: January 17, 2022). An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. 1. Kids and Teens. NCD. Topic: A program for persons with disabilities. 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. Provider Login. Quantity limits. 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. When we complete the review, we will give you our decision in writing. 2. Receive information about clinical programs, including staff qualifications, request a change of treatment choices, participate in decisions about your health care, and be informed of health care issues that require self-management. Say Yes to Physical Activity + Control Your Blood Pressure (in Spanish), Topic: Get Energized! Contact: Tel : 04 76 61 52 00 - E-Mail. When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. However, sometimes we need more time, and we will send you a letter telling you that we need to take up to 14 more calendar days. 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. If you request a fast coverage decision coverage decision, start by calling or faxing our plan to ask us to cover the care you want. We call this the supporting statement.. 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. Welcome to Inland Empire Health Plan \. 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. 711 (TTY), To Enroll with IEHP At Level 2, an Independent Review Entity will review your appeal. You may also call Health Care Options at 1-800-430-4263 or visit www.healthcareoptions.dhcs.ca.gov. IEHP DualChoice (HMO D-SNP) has a list of Covered Drugs called a Formulary. Autologous Platelet-Rich Plasma (PRP) treatment of acute surgical wounds when applied directly to the close incision, or for splitting or open wounds. Edit Tab. The Inland Empire Health Plan (IEHP) provides low-income and working-class individuals and families with access to health services through the Medi-Cal program. Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities; or. If we say No to your request for an exception, you can ask for a review of our decision by making an appeal. What is covered: 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). Will not pay for emergency or urgent Medi-Cal services that you already received. 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). Be treated with respect and courtesy. Tier 1 drugs are: generic, brand and biosimilar drugs. Request a second opinion about a medical condition. Breathlessness without cor pulmonale or evidence of hypoxemia; or. of the appeals process. Based on Income. ii. If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan. The following criteria must be used to identify a beneficiary demonstrating treatment resistant depression: Beneficiary must be in a major depressive disorder episode for at least two years or have had at least four episodes, including the current episode. 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. IEHP DualChoice Formulary consists of medications that are considered as first line therapies (drugs that should be used first for the indicated conditions). Group I: 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. When you make an appeal to the Independent Review Entity, we will send them your case file. If your health condition requires us to answer quickly, we will do that. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to our plan). 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. The letter you get from the IRE will explain additional appeal rights you may have. You can tell the California Department of Managed Health Care about your complaint. For example, a "drug-to-drug" interaction could: make your medicines not work as well (weaken . Members \. You can also have your doctor or your representative call us. TTY/TDD (877) 486-2048. 1. You must choose your PCP from your Provider and Pharmacy Directory. Please call or write to IEHP DualChoice Member Services. How to Enroll with IEHP DualChoice (HMO D-SNP), IEHP Texting Program Terms and Conditions. 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. If you dont know what you should have paid, or you receive bills and you dont know what to do about those bills, we can help. The Inland Empire Health Plan (IEHP) provides low-income and working-class individuals and families with access to health services through the Medi-Cal program. This is called a referral. You have a care team that you help put together. If you do not stay continuously enrolled in Medicare Part A and Part B. You can call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Information on this page is current as of October 01, 2022, Centers for Medicare and Medicaid Services. P.O. Or you can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. We will let you know of this change right away. 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. Mail your request for payment together with any bills or receipts to us at this address: IEHPDualChoice Dependent edema (gravity related swelling due to excess fluid) suggesting congestive heart failure; or, Review your Member Handbook, and call IEHP DualChoice Member Services if you do not understand something about your coverage and benefits. The clinical research study must meet the standards of scientific integrity and relevance to the Medicare population described in this determination. Call: (877) 273-IEHP (4347). 2. They have a copay of $0. We will give you our decision sooner if your health condition requires us to. We may not tell you before we make this change, but we will send you information about the specific change or changes we made. Will not cover an experimental or investigational Medi-Cal treatment for a serious medical condition. If you suspect fraud call the DHCS Medi-Cal Fraud Hotline at 1-800-822-6222. How will the plan make the appeal decision? We will notify you by letter if this happens. You will keep all of your Medicare and Medi-Cal benefits. (800) 718-4347 (TTY), IEHP DualChoice Member Services 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.
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