Until your membership ends, you are still a member of our plan. The Help Center cannot return any documents. If this happens, you will have to switch to another provider who is part of our 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). 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. If you are admitted to one of these hospitals, a hospitalist may serve as your caregiver as long as you remain in the hospital. If you let someone else use your membership card to get medical care. (Effective: February 19, 2019) Certain combinations of drugs that could harm you if taken at the same time. We serve 1.5 million residents of Riverside and San Bernardino counties through government-sponsored programs including Medi-Cal (families, adults, seniors and people with disabilities) and Cal MediConnect. Click here for more information on Positron Emission Tomography NaF-18 (NaF-18 PET) to Identify Bone Metastasis of Cancer coverage. If we uphold the denial after Redetermination, you have the right to request a Reconsideration. If our answer is Yes to part or all of what you asked for, we must authorize or provide the coverage within 72 hours after we get your appeal. For the treatment of symptomatic moderate to severe mitral regurgitation (MR) when the patient still has symptoms, despite stable doses of maximally tolerated guideline directed medical therapy (GDMT) and cardiac resynchronization therapy, when appropriate and the following are met: Treatment is a Food and Drug Administration (FDA) approved indication. (Implementation Date: June 16, 2020). Here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy: We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgently needed care. To start your appeal, you, your doctor or other provider, or your representative must contact us. If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your supply of the drug before you leave. If we tell you after our review that the service or item is not covered, your case can go to a Level 2 Appeal. If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. What if the Independent Review Entity says No to your Level 2 Appeal? This service will be covered when the TAVR is used, for the treatment of symptomatic aortic valve stenosis. (Implementation Date: July 27, 2021) If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. If you do not qualify by the end of the two-month period, youll de disenrolled by IEHP DualChoice. Medi-Cal through Kaiser Permanente in California Please call or write to IEHP DualChoice Member Services. Or your doctor or other prescriber can tell us on the phone, and then fax or mail a statement. 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. You can call the California Department of Social Services at (800) 952-5253. Including bus pass. 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 our answer is No to part or all of what you asked for, we will send you a letter. Be prepared for important health decisions If the IMR is decided in your favor, we must give you the service or item you requested. 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. Current or lifetime history of psychotic features in any MDE; Current or lifetime history of schizophrenia or schizoaffective disorder; Current or lifetime history of any other psychotic disorder; Current or lifetime history of rapid cycling bipolar disorder; Current secondary diagnosis of delirium, dementia, amnesia, or other cognitive disorder; Treatment with another investigational device or investigational drugs. 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. By clicking on this link, you will be leaving the IEHP DualChoice website. The therapy is used for a medically accepted indication, which is defined as used for either and FDA approved indication according to the label of that product, or the use is supported in one or more CMS approved compendia. For example: We may make other changes that affect the drugs you take. Also, its possible that your PCP might leave our plans network of providers and you would have to find a new PCP. Please select one of the following: Primary Care Doctor Specialist Behavioral Health Hospitals The services of SHIP counselors are free. Walnuts grow in U.S. Department of Agriculture plant hardiness zones 4 through 9, and hickories can be . If you have a fast complaint, it means we will give you an answer within 24 hours. Click here for more information on Topical Applications of Oxygen. Yes. (800) 440-4347 Effective on January 1, 2023, CMS has updated section 210.3 of the NCD Manual that provides coverage for colorectal cancer (CRC) screening tests under Medicare Part B. 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. Please see below for more information. If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. At Level 2, an Independent Review Entity will review your appeal. We have arranged for these providers to deliver covered services to members in our plan. If your health requires it, ask for a fast appeal, Our plan will review your appeal and give you our decision. 504 Plan Defined The 504 Plan is a plan developed to ensure that a child who has a disability 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. They mostly grow wild across central and eastern parts of the country. What is covered: You, your representative, or your provider asks us to let you keep using your current provider. i. (Implementation Date: October 3, 2022) After your application and supporting documents are received from your plan, the IMR decision will be made within 3 calendar days. 3. 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. i. We will generally cover a drug on the plans Formulary as long as you follow the other coverage rules explained in Chapter 6 of the IEHP DualChoice Member Handbookand the drug is medically necessary, meaning reasonable and necessary for treatment of your injury or illness. The State or Medicare may disenroll you if you are determined no longer eligible to the program. We will tell you about any change in the coverage for your drug for next year. The list can help your provider find a covered drug that might work for you. If your change request is received byIEHP by the 25th of the month, the change will be effective the first of the following month; if your change request is received byIEHP after the 25th of the month, the change will be effective the first day of the subsequent month (for some providers, you may need a referral from your PCP). The list must meet requirements set by Medicare. If the Independent Medical Review decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. We add a generic drug that is not new to the market and: Replace a brand name drug currently on the Drug List or. The PCP you choose can only admit you to certain hospitals. We do the right thing by: Placing our Members at the center of our universe. (Effective: February 10, 2022) Follow the appeals process. Unleashing our creativity and courage to improve health & well-being. If you decide to go on to a Level 2 Appeal, the Independent Review Entity (IRE) will review our decision. (Effective: April 3, 2017) To speak with a care coordinator, please call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. 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. Important things to know about asking for exceptions. This additional time will allow you to correct your eligibility information if you believe that you are still eligible. Heart failure cardiologist with experience treating patients with advanced heart failure. 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). Send us your request for payment, along with your bill and documentation of any payment you have made. (This is called upholding the decision. It is also called turning down your appeal.) The letter you get will explain additional appeal rights you may have. 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. We will tell you in advance about these other changes to the Drug List. IEHP DualChoice will honor authorizations for services already approved for you. We also review our records on a regular basis. Information on the page is current as of March 2, 2023 PO2 may be performed by the treating practitioner or by a qualified provider or supplier of laboratory services. Emergency services from network providers or from out-of-network providers. The Independent Review Entity is an independent organization that is hired by Medicare. Sign up for the free app through our secure Member portal. The NCR serves as a liaison for matters involving the contract between IEHP and both Network and Non-Network Providers. If we need more information, we may ask you or your doctor for it. You have access to a care coordinator. B. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). TTY users should call 1-800-718-4347. (Implementation Date: July 22, 2020). You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. The FDA provides new guidance or there are new clinical guidelines about a drug. When can you end your membership in our plan? We take another careful look at all of the information about your coverage request. (Implementation date: October 2, 2017 for design and coding; January 1, 2018 for testing and implementation) If we agree to make an exception and cover a drug that is not on the Formulary, you will need to pay the cost-sharing amount that applies to drug. b. Topical Application of Oxygen for Chronic Wound Care. Here are a few examples: You will usually see your PCP first for most of your routine healthcare needs such as physical checkups, immunization, etc. This includes: Primary Care Providers (PCPs) are usually linked to certain hospitals. It is not connected with this plan and it is not a government agency. You can still get a State Hearing. Interventional echocardiographer meeting the requirements listed in the determination. The letter will explain why more time is needed. The call is free. The benefit information is a brief summary, not a complete description of benefits. Receive Member informing materials in alternative formats, including Braille, large print, and audio. In most cases, you must start your appeal at Level 1. Ask us for a copy by calling Member Services at (877) 273-IEHP (4347). CMS has added a new section, Section 220.2, to Chapter 1, Part 4 of the Medicare National Coverage Determinations Manual entitled Magnetic Resonance Imaging (MRI). When you choose a PCP, it also determines what hospital and specialist you can use. The time of need is indicated when the presumption of oxygen therapy within the home setting will improve the patients condition. The device must be approved by the Food and Drug Administration (FDA) for this purpose; OR. Your PCP will send a referral to your plan or medical group. You can tell Medicare about your complaint. This is asking for a coverage determination about payment. 2023 Plan Benefits. Our plans Part D drug coverage cannot cover a drug that would be covered under Medicare Part A or Part B. Effective for dates of service on or after January 27, 2020, CMS has determined that NGS, as a diagnostic laboratory test, is reasonable and necessary and covered nationally for patients with germline (inherited) cancer when performed in a CLIA-certified laboratory, when ordered by a treating physician and when specific requirements are met. 2. We are always available to help you. (800) 718-4347 (TTY), IEHP DualChoice Member Services (Effective: April 13, 2021) (800) 720-4347 (TTY). You can also have a lawyer act on your behalf. CMS has revised Chapter 1, Section 20.29, Subsection C Topical Application of Oxygen to remove the exclusion of this treatment. Click here for more information on MRI Coverage. and hickory trees (Carya spp.) Request a second opinion about a medical condition. The clinical research study must critically evaluate each patient's quality of life pre- and post-TAVR for a minimum of 1 year, but must also address other various questions. The following link will take you to the Centers for Medicaid and Medicare Services website, where you can look through the CMS Best Available Evidence Policy using the following link: CMS Best Available Evidence Policy. Angina pectoris (chest pain) in the absence of hypoxemia; or. If you wish, you can make your complaint about quality of care to our plan and also to the Quality Improvement Organization. Make recommendations about IEHP DualChoice Members rights and responsibilities policies. What is covered? Medicare beneficiaries who are diagnosed with Symptomatic Peripheral Artery Disease who would benefit from this therapy. If we do not agree with some or all of your complaint or dont take responsibility for the problem you are complaining about, we will let you know. This is called prior authorization. Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. Beneficiaries that demonstrate limited benefit from amplification. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. If the answer is No, we will send you a letter telling you our reasons for saying No. To be a Member of IEHP DualChoice, you must keep your eligibility with Medi-Cal and Medicare.
