If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. The letter will explain why more time is needed. 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. ii. Drugs that may not be safe or appropriate because of your age or gender. Benefits and copayments may change on January 1 of each year. At IEHP, you will find opportunities to take initiative, expand your knowledge and advance your career while working a position that's both challenging and rewarding. 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. Our plan usually cannot cover off-label use. 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. You may also have rights under the Americans with Disability Act. Effective January 21, 2020, CMS will cover acupuncture for chronic low back pain (cLBP) for up to 12 visits in 90 days and an additional 8 sessions for those beneficiaries that demonstrate improvement, in addition to the coverage criteria outlined in the NCD Manual. Beneficiaries that demonstrate limited benefit from amplification. Non-Covered Use: The following uses are considered non-covered: Click here for more information on Blood-Derived Products for Chronic, Non-Healing Wounds coverage. All screenings DNA tests, effective April 28, 2008, through October 8, 2014. IEHP DualChoice. chimeric antigen receptor (CAR) T-cell therapy coverage. Click here to download a free copy of Adobe Acrobat Reader.By clicking on this link, you will be leaving the IEHP DualChoice website. We do a review each time you fill a prescription. What is the Difference Between Hazelnut and Walnut If you are asking us to pay you back for medical care you have already received and paid for yourself, you are not allowed to ask for a fast appeal. You must ask to be disenrolled from IEHP DualChoice. Who 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 other indications of VNS for the treatment of depression are nationally non-covered. If you are admitted to one of these hospitals, a hospitalist may serve as your caregiver as long as you remain in the hospital. We may contact you or your doctor or other prescriber to get more information. 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. Level 2 Appeal for Part D drugs. If we are using the standard deadlines, we must give you our answer within 7 calendar days after we get your appeal, or sooner if your health requires it. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision. Because you get assistance from Medi-Cal, you can end your membership in IEHPDualChoice at any time. ii. Beneficiaries receiving autologous treatment for cancer with T-cell expressing at least one least one chimeric antigen receptor CAR, when all the following requirements are met: The use of non-FDA-approved autologous T-cell expressing at least one CAR is non-covered or when the coverage requirements are not met. To stay a member of IEHP DualChoice, you must qualify again by the last day of the two-month period. Some hospitals have hospitalists who specialize in care for people during their hospital stay. Your PCP should speak your language. 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). 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. A standard coverage decision means we will give you an answer within 72 hours after we get your doctors statement. How to ask for coverage decision coverage decision to get medical, behavioral health, or certain long-term services and supports (CBAS, or NF services). Mail your request for payment together with any bills or receipts to us at this address: IEHPDualChoice A clinical test providing a measurement of the partial pressure of oxygen (PO2) in arterial blood. 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. 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). There are also limited situations where you do not choose to leave, but we are required to end your membership. H8894_DSNP_23_3241532_M. IEHP Welcome to Inland Empire Health Plan Vision Care: $350 limit every year for contact lenses and eyeglasses (frames and lenses). Get a 31-day supply of the drug before the change to the Drug List is made, or. If IEHP DualChoice removes a covered Part D drug or makes any changes in the IEHP DualChoice Formulary, IEHP DualChoice will post the formulary changes on the IEHP DualChoice website and notify the affected Members at least thirty (30) days prior to effective date of the change made on the IEHP DualChoice Formulary. You will be able to get the service or item within 14 calendar days (for a standard coverage decision) or 72 hours (for a fast coverage decision) of when you asked. You may be able to get extra help to pay for your prescription drug premiums and costs. Beneficiaries with Alzheimers Disease (AD) may be covered for treatment when the following conditions (A or B) are met: Click here for more information on Monoclonal Antibodies Directed Against Amyloid for the Treatment of Alzheimers Disease (AD). NOTE: If you ask for a State Hearing because we told you that a service you currently get will be changed or stopped, you have fewer days to submit your request if you want to keep getting that service while your State Hearing is pending. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. The treatment is based upon efficacy from a direct measure of clinical benefit in CMS-approved prospective comparative studies. To make this request, or if you have any concerns about your continuity of care, please call IEHP DualChoice Member Services at 1-877-273-IEHP (4347). Information on procedures for obtaining prior authorization of services, Quality Assurance, disenrollment, and other procedures affecting IEHP DualChoice Members. You can call the California Department of Social Services at (800) 952-5253. The procedure must be performed by an interventional cardiologist or cardiac surgeon.<. You must choose your PCP from your Provider and Pharmacy Directory. Certain combinations of drugs that could harm you if taken at the same time. 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. 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. We will give you our answer sooner if your health requires it. 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. Fax: (909) 890-5877. Be under the direct supervision of a physician. An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. The list can help your provider find a covered drug that might work for you. The reviewer will be someone who did not make the original coverage decision. Breathlessness without cor pulmonale or evidence of hypoxemia; or. (SeeChapter 10 oftheIEHP DualChoiceMember Handbookfor information on when your new coverage begins.) MRI field strength of 1.5 Tesla using Normal Operating Mode, The Implanted pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy defibrillator (CRT-D) system has no fractured, epicardial, or abandoned leads, The facility has implemented a specific checklist. IEHP (Inland Empire Health Plan) is a provider that contains a network of doctors, dentists, pyschs, therapists, and specialists. How to Enroll with IEHP DualChoice (HMO D-SNP), IEHP Texting Program Terms and Conditions. Welcome to Inland Empire Health Plan \ Members \ Medi-Cal California Medical Insurance Requirements; main content TIER3 SUBLAYOUT. Terminal illnesses, unless it affects the patients ability to breathe. (Implementation Date: December 10, 2018). A medical group or IPA is a group of physicians, specialists, and other providers of health services that see IEHP Members. At level 2, an Independent Review Entity will review the decision. If possible, we will answer you right away. Related Resources. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. If we uphold the denial after Redetermination, you have the right to request a Reconsideration. (Effective: January 19, 2021) Call, write, or fax us to make your request. When a provider leaves a network, we will mail you a letter informing you about your new provider. i. When you make an appeal to the Independent Review Entity, we will send them your case file. Rights and Responsibilities Upon Disenrollment, Ending your membership in IEHP DualChoice (HMO D-SNP) may be voluntary (your own choice) or involuntary (not your own choice). Information on this page is current as of October 01, 2022. However, if the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drugs manufacturer removes the drug from the market we will immediately remove the drug from our formulary. Also, someone besides your doctor or other provider can make the appeal for you, but first you must complete an Appointment of Representative Form. Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). Your doctor or other prescriber can fax or mail the statement to us. It also has care coordinators and care teams to help you manage all your providers and services. Initial coverage for patients experiencing conditions not described above can be limited to a prescription shorter than 90 days, or less than the numbers of days indicated on the practitioners prescription. If your problem is urgent and involves an immediate and serious threat to your health, you may bring it immediately to the DMHCs attention.