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. Information on this page is current as of October 01, 2022. If you ask for a fast coverage decision, without your doctors support, we will decide if you get a fast coverage decision. Use the IEHP Medicare Prescription Drug Coverage Determination Form for a prior authorization. IEHP DualChoice is very similar to your current Cal MediConnect plan. When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. (866) 294-4347 How to obtain an aggregate number of grievances, appeals, and exceptions filed with IEHP DualChoice (HMO D-SNP)? Click here for more information on acupuncture for chronic low back pain coverage. Information on this page is current as of October 01, 2022. CMS has updated Chapter 1, section 20.32 of the Medicare National Coverage Determinations Manual. Remember, if you get a bill that is more than your copay for covered services and items, you should not pay the bill yourself. 1. How much time do I have to make an appeal for Part C services? In this situation (when you are outside the service area and cannot get care from a network provider), our plan will cover urgently needed care that you get from any provider. At Level 2, an Independent Review Entity will review your appeal. If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. If you are requesting an exception, provide the supporting statement. Your doctor or other prescriber must give us the medical reasons for the drug exception. If the Independent Medical Review decision is Yes to part or all of what you asked for, we must provide the service or treatment. (This is sometimes called step therapy.). 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). You can get a fast coverage decision only if using the standard deadlines could cause serious harm to your health or hurt your ability to function. a. Copays for prescription drugs may vary based on the level of Extra Help you receive. You may choose different health plans, or providers, under Medi-Cal, like IEHP or Molina Healthcare, Blue Shield, Health Net, etc. In most cases, you must file an appeal with us before requesting an IMR. Medicare has approved the IEHP DualChoice Formulary. We take a careful look at all of the information about your request for coverage of medical care. 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 put your complaint in writing, we will respond to your complaint in writing. The services are free. (Implementation Date: December 10, 2018). If you or your doctor disagree with our decision, you can appeal. H8894_DSNP_23_3241532_M. If you want to change plans, call IEHP DualChoice Member Services. If we need more information, we may ask you or your doctor for it. Note: You can only make this request for services of Durable Medical Equipment (DME), transportation, or other ancillary services not included in our plan. Get the My Life. You can also visit https://www.hhs.gov/ocr/index.html for more information. This is a group of doctors and other health care professionals who help improve the quality of care for people with Medicare. Treatments must be discontinued if the patient is not improving or is regressing. Typically, our Formulary includes more than one drug for treating a particular condition. You can always contact your State Health Insurance Assistance Program (SHIP). Group II: If our answer is No to part or all of what you asked for, we will send you a letter. 1. (Implementation Date: October 8, 2021) (This is sometimes called prior authorization.), Being required to try a different drug first before we will agree to cover the drug you are asking for. Whether you call or write, you should contact IEHP DualChoice Member Services right away. For CMS-approved studies, the protocol, including the analysis plan, must meet requirements listed in this NCD. Effective on September 26, 2022, CMS has updated section 50.3 of the National Coverage Determination (NCD) Manual that expands coverage on cochlear implants for the treatment of bilateral pre- or post- linguistic, sensorineural, moderate-to-profound hearing loss when the individual demonstrates limited benefit from amplification under Medicare Part B. Here are two ways to get information directly from Medicare: By clicking on this link, you will be leaving the IEHP DualChoice website. P.O. When you choose your PCP, you are also choosing the affiliated medical group. C. Beneficiarys diagnosis meets one of the following defined groups below: You must submit your claim to us within 1 year of the date you received the service, item, or drug. These different possibilities are called alternative drugs. Including bus pass. Who is covered? Your care team and care coordinator work with you to make a care plan designed to meet your health needs. You, your representative, or your provider asks us to let you keep using your current provider. The Difference Between ICD-10-CM & ICD-10-PCS. Are a United States citizen or are lawfully present in the United States. Please see below for more information. CMS approved studies must also adhere to the standards of scientific integrity that have been identified in section 5 of this NCD by the Agency for Healthcare Research and Quality (AHRQ). A care team can help you. We have 30 days to respond to your request. To ask if your PCP or other providers are in our network in 2023, call IEHP DualChoice Member Services. See form below: Deadlines for a fast appeal at Level 2 It also has care coordinators and care teams to help you manage all your providers and services. Patient must also present hypoxemia signs and symptoms such as nocturnal restlessness, insomnia, or impairment of cognitive process. 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. There are over 700 pharmacies in the IEHP DualChoice network. Your benefits as a member of our plan include coverage for many prescription drugs. If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. 2023 IEHP DualChoice Provider and Pharmacy Directory (PDF), http://www.dmhc.ca.gov/FileaComplaint/SubmitanIndependentMedicalReviewComplaintForm.aspx, Request for Medicare Prescription Drug Coverage Determination (PDF). Handling problems about your Medi-Cal benefits. 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. You may also have rights under the Americans with Disability Act. You may also contact the local Office for Civil Rights office at: U.S. Department of Health and Human Services. Make recommendations about IEHP DualChoice Members rights and responsibilities policies. 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. Call: (877) 273-IEHP (4347). You can call Member Services to ask for a list of covered drugs that treat the same medical condition. If we do not meet this deadline, we will send your request to Level 2 of the appeals process. Thus, this is the main difference between hazelnut and walnut. A PCP is your Primary Care Provider. It also needs to be an accepted treatment for your medical condition. A network provider is a provider who works with the health plan. a. Effective for dates of service on or after January 1, 2022, CMS has updated section 180.1 of the National Coverage Determination Manual to cover three hours of administration during one year of Medical Nutrition Therapy (MNT) in patients with a diagnosis of renal disease or diabetes, as defined in 42 CFR 410.130. (Effective: July 2, 2019) For example, you can make a complaint about disability access or language assistance. Becaplermin, a non-autologous growth factor for chronic, non-healing, subcutaneous (beneath the skin) wounds, and. IEHP (Inland Empire Health Plan) is a provider that contains a network of doctors, dentists, pyschs, therapists, and specialists. 2023 Inland Empire Health Plan All Rights Reserved. It has been updated that coverage determinations for providing Topical Application of Oxygen for the treatment of chronic wounds can be made by the local Contractors. 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. It also includes problems with payment. Livanta is not connect with our plan. Heart failure cardiologist with experience treating patients with advanced heart failure. (Implementation Date: September 20, 2021). Ask us for a copy by calling Member Services at (877) 273-IEHP (4347). The intended effective date of the action. Information on the page is current as of December 28, 2021 Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. If you are unable to get a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service. 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. PILD is a posterior decompression of the lumbar spine performed under indirect image guidance without any direct visualization of the surgical area. Information on this page is current as of October 01, 2022. In most cases, you must start your appeal at Level 1. You have the right to ask us for a copy of your case file. 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. You can ask for an IMR if you have also asked for a State Hearing, but not if you have already had a State Hearing, on the same issue. 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. 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. Get Help from an Independent Government Organization. If you would like to switch from our plan to Original Medicare but you have not selected a separate Medicare prescription drug plan. What is covered: Effective for dates of service on or after April 13, 2021, CMS has updated section 270.3 of the National Coverage Determination Manual to cover Autologous (obtained from the same person) Platelet-Rich Plasma (PRP) when specific requirements are met.