The Medicare Complaint Form is available at:https://www.medicare.gov/MedicareComplaintForm/home.aspx. IEHP DualChoice network providers are required to comply with minimum standards for pharmacy practices as established by the State of California. Never wavering in our commitment to our Members, Providers, Partners, and each other. CAR, when all the following requirements are met: Autologous treatment is for cancer with T-cells expressing at least one chimeric antigen receptor (CAR); and, Treatment is administered at a healthcare facility enrolled in the FDAs REMS; and. 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. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. i. Arterial PO2 at or below 55 mm Hg or arterial oxygen saturation at or below 88% when tested at rest in breathing room air, or; If the appeal comes from someone besides you or your doctor or other provider, we must receive the completed Appointment of Representative form before we can review the appeal. If the Independent Review Entity says No to part or all of what you asked for, it means they agree with the Level 1 decision. When you file a fast complaint, we will give you an answer to your appeal within 24 hours. If your Primary Care Provider changes, your IEHP DualChoice benefits and required co-payments will stay the same. ii. To learn more about the plans benefits, cost-sharing, applicable conditions and limitations, refer to the IEHP DualChoice Member Handbook. If you are making a complaint because we denied your request for a fast coverage determination or fast appeal, we will automatically give you a fast complaint. Topical Application of Oxygen for Chronic Wound Care. P.O. Our plans PCPs are affiliated with medical groups or Independent Physicians Associations (IPA). Click here for more information on Topical Applications of Oxygen. If you wish, you and your doctor or other prescriber may give us additional information to support your appeal. You or your doctor (or other prescriber) or someone else who is acting on your behalf can ask for a coverage decision. CMS has updated Chapter 1, section 20.19 of the Medicare National Coverage Determinations Manual. You or your provider can ask for an exception from these changes. Have a Primary Care Provider who is responsible for coordination of your care. 2. Call, write, or fax us to make your request. All other indications for colorectal cancer screening not otherwise specified in the Social Security Act, regulations, or the above remain nationally non-covered. For the purpose of this decision, cLBP is defined as: nonspecific, in that it has no identifiable systemic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. Your benefits as a member of our plan include coverage for many prescription drugs. are similar in many respects. 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. If you do not qualify by the end of the two-month period, youll de disenrolled by IEHP DualChoice. Other persons may already be authorized by the Court or in accordance with State law to act for you. In order to receive out-of-network services, your Primary Care Provider (PCP) or Specialist must submit a referral request to your plan or medical group. (Implementation Date: March 26, 2019). CMS has updated Chapter 1, Part 1, Section 20.7 of the Medicare National Coverage Determinations Manual providing additional information regarding PTA. You can file a grievance online. IEHP: "Inland Empire Health Plan (IEHP) is a not-for-profit Medi-Cal and Medicare health plan headquartered in Rancho Cucamonga, California. Note, the Member must be active with IEHP Direct on the date the services are performed. TTY users should call 1-800-718-4347. All other indications for colorectal cancer screening not otherwise specific in the regulations or the National Coverage Determination above. See form below: Deadlines for a fast appeal at Level 2 After your application and supporting documents are received from your plan, the IMR decision will be made within 30 calendar days. If our answer is Yes to part or all of what you asked for, we must approve or give the coverage within 30 calendar days after we get your appeal. Fill out the Independent Medical Review/Complaint Form available at: If you have them, attach copies of letters or other documents about the service or item that we denied. VNS is non-covered for the treatment of TRD when furnished outside of a CMS-approved CED study. Prior to filling your prescription at an out-of-network pharmacy, call IEHP DualChoice Member Services to find out if there is a network pharmacy in the area where you are traveling. We must give you our answer within 14 calendar days after we get your request. If we do not meet this deadline, we will send your request to Level 2 of the appeals process. Receive emergency care whenever and wherever you need it. There are extra rules or restrictions that apply to certain drugs on our Formulary. If you are traveling within the US, but outside of the Plans service area, and you become ill, lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy if you follow all other coverage rules identified within this document and a network pharmacy is not available. Additional hours of treatment are considered medically necessary if a physician determines there has been a shift in the patients medical condition, diagnosis or treatment regimen that requires an adjustment in MNT order or additional hours of care. All the changes are reviewed and approved by a selected group of Providers and Pharmacists that are currently in practice. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contact renewal. This letter will tell you if the service or item is usually covered by Medicare or Medi-Cal. 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. (Implementation date: June 27, 2017). 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. You must qualify for this benefit. (Effective: June 21, 2019) IEHP Medi-Cal Member Services Concurrent with Intracranial Stent Placement in FDA-Approved Category B IDE Clinical Trials Who is covered: Autologous Platelet-Rich Plasma (PRP) treatment of acute surgical wounds when applied directly to the close incision, or for splitting or open wounds. There may be qualifications or restrictions on the procedures below. Prior to the beneficiarys first lung cancer LDCT screening, the beneficiary must receive a counseling and shared decision-making visit that meets specific criteria. Click here for more information on acupuncture for chronic low back pain coverage. You will usually see your PCP first for most of your routine health care needs. 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. 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. This number requires special telephone equipment. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drugs manufacturer takes a drug off the market, we will take it off the Drug List. 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). 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. Yes. 711 (TTY), To Enroll with IEHP Get a 31-day supply of the drug before the change to the Drug List is made, or. Treatments must be discontinued if the patient is not improving or is regressing. Your benefits as a member of our plan include coverage for many prescription drugs. We take another careful look at all of the information about your coverage request. If the IMR is decided in your favor, we must give you the service or item you requested. This includes: Primary Care Providers (PCPs) are usually linked to certain hospitals. The following criteria must also be met as described in the NCD: Non-Covered Use: You can call (800) MEDICARE (800) 633-4227, 24 hours a day, 7 days a week, TTY (877) 486-2048. Sign up for the free app through our secure Member portal. You will get a letter from us about the change in your eligibility with instructions to correct your eligibility information. For example, you can make a complaint about disability access or language assistance. Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. 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. Click here for more information on chimeric antigen receptor (CAR) T-cell therapy coverage. H8894_DSNP_23_3241532_M. The FDA provides new guidance or there are new clinical guidelines about a drug. A medical group or IPA is a group of physicians, specialists, and other providers of health services that see IEHP Members. The letter you get from the Independent Review Entity will tell you the dollar amount needed to continue with the appeals process. Bringing focus and accountability to our work. If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. 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. They can also answer your questions, give you more information, and offer guidance on what to do. (Implementation Date: January 17, 2022). 2) State Hearing IEHP DualChoice is very similar to your current Cal MediConnect plan. Effective for dates of service on or after December 15, 2017, CMS has updated section 220.6.19 of the National Coverage Determination Manual clarifying there are no nationally covered indications for Positron Emission Tomography NaF-18 (NaF-18 PET). Certain combinations of drugs that could harm you if taken at the same time. It also has care coordinators and care teams to help you manage all your providers and services. Benefits and copayments may change on January 1 of each year. 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).