Opportunities to Grow. For more information on network providers refer to Chapter 1 of the IEHP DualChoice Member Handbook. How long does it take to get a coverage decision coverage decision for Part C services? This includes getting authorization to see specialists or medical services such as lab tests, x-rays, and/or hospital admittance. Certain combinations of drugs that could harm you if taken at the same time. (Implementation Date: March 26, 2019). Is Medi-Cal and IEHP the same thing? You pay no costs for an IMR. (877) 273-4347 We are also one of the largest employers in the region, designated as "Great Place to Work.". Who is covered: Medicare beneficiaries will have their blood-based colorectal cancer screening test covered once every 3 years when ordered by a treating physician and the following conditions are met: (Effective: December 1, 2020) Or you can ask us to cover the drug without limits. After the continuity of care period ends, you will need to use doctors and other providers in the IEHP DualChoice network that are affiliated with your primary care providers medical group, unless we make an agreement with your out-of-network doctor. Cardiologists care for patients with heart conditions. More. Our response will include our reasons for this answer. We do not allow our network providers to bill you for covered services and items. Make recommendations about IEHP DualChoice Members rights and responsibilities policies. B. 2. When you are following these instructions, please note: If we answer no to your appeal and the service or item is usually covered by Medicare, we will automatically send your case to the Independent Review Entity. Disrespect, poor customer service, or other negative behaviors, Timeliness of our actions related to coverage decisions or appeals, You can use our "Member Appeal and Grievance Form." The only amount you should be asked to pay is the copay for service, item, and/or drug categories that require a copay. The organization will send you a letter explaining its decision. Yes. All screenings DNA tests, effective April 28, 2008, through October 8, 2014. My problem is about a Medi-Cal service or item. A care team may include your doctor, a care coordinator, or other health person that you choose. Most recently, as of May 1, 2016, Medi-Cal now covers all low income children under the age of 19, regardless of immigration status. IEHP DualChoice (HMO D-SNP) has a list of Covered Drugs called a Formulary. An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. Who is covered: The PTA is covered under the following conditions: If you move out of our service area for more than six months. We take a careful look at all of the information about your request for coverage of medical care. If we need more information, we may ask you or your doctor for it. iii. If our answer is Yes to part or all of what you asked for, we must give you the coverage within 24 hours after we get your request or your doctors or prescribers statement supporting your request. You can send your complaint to Medicare. You can also visit https://www.hhs.gov/ocr/index.html for more information. Your IEHP DualChoice Doctor cannot charge you for covered health care services, except for required co-payments. You should receive the IMR decision within 7 calendar days of the submission of the completed application. You are never required to pay the balance of any bill. 1. The letter will also explain how you can appeal our decision. Box 997413 How can I make a Level 2 Appeal? To learn how to submit a paper claim, please refer to the paper claims process described below. If we decide to take extra days to make the decision, we will tell you by letter. Effective for claims with dates of service on or after February 10, 2022, CMS will cover, under Medicare Part B, a lung cancer screening counseling and shared decision-making visit. This government program has trained counselors in every state. IEHP Welcome to Inland Empire Health Plan 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. Asymptomatic (no signs or symptoms of lung cancer); Tobacco smoking history of at least 20 pack-years (one pack-year = smoking one pack per day for one year; 1 pack =20 cigarettes); Current smoker or one who has quit smoking within the last 15 years; Receive an order for lung cancer screening with LDCT. 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. If you think your health requires it, you should ask for a fast appeal. If you are asking us to pay you back for a drug you already bought, we must give you our answer within 14 calendar days after we get your appeal. Making an appeal means asking us to review our decision to deny coverage. Read your Medicare Member Drug Coverage Rights. Inland Empire Health Plan - Local Health Plans of California Request and receive appeal data from IEHP DualChoice; Receive notice when an appeal is forwarded to the Independent Review Entity (IRE); Automatic reconsideration by the IRE when IEHP DualChoice upholds its original adverse determination in whole or in part; Administrative Law Judge (ALJ) hearing if the independent review entity upholds the original adverse determination in whole or in part and the remaining amount in controversy is $100 or more; Request Departmental Appeals Board (DAB) review if the ALJ hearing is unfavorable to the Member in whole or in part; Judicial review of the hearing decision if the ALJ hearing and/or DAB review is unfavorable to the Member in whole or in part and the amount remaining in controversy is $1,000 or more; Make a quality of care complaint under the QIO process; Request QIO review of a determination of noncoverage of inpatient hospital care; Request QIO review of a determination of noncoverage in skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities; Request a timely copy of your case file, subject to federal and state law regarding confidentiality of patient information; Challenge local and national Medicare coverage determination. (Effective: April 10, 2017) Click here to learn more about IEHP DualChoice. You can call the DMHC Help Center for help with complaints about Medi-Cal services. 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. You have the right to ask us for a copy of your case file. 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. We must give you our answer within 30 calendar days after we get your appeal. 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. 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? If you wish, you can make your complaint about quality of care to our plan and also to the Quality Improvement Organization. How to Enroll with IEHP DualChoice (HMO D-SNP), IEHP Texting Program Terms and Conditions. The list can help your provider find a covered drug that might work for you. Box 1800 It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. Hepatitis B Virus (HBV) is transmitted by exposure to bodily fluids. Send copies of documents, not originals. Leadless pacemakers are delivered via catheter to the heart, and function similarly to other transvenous single-chamber ventricular pacemakers. 3. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. 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. Our plans PCPs are affiliated with medical groups or Independent Physicians Associations (IPA). We may not tell you before we make this change, but we will send you information about the specific change or changes we made. The California Department of Managed Health Care (DMHC) is responsible for regulating health plans. You can send your complaint to Medicare. If you are not satisfied with the result of the IMR, you can still ask for a State Hearing. Please select one of the following: Primary Care Doctor Specialist Behavioral Health Hospitals We do the right thing by: Placing our Members at the center of our universe. The program is not connected with us or with any insurance company or health plan. You can ask us to reimburse you for IEHP DualChoice's share of the cost. Mail your request for payment together with any bills or receipts to us at this address: IEHPDualChoice The beneficiary is under pre- or post-operative care of a heart team meeting the following: Cardiac Surgeon meeting the requirements listed in the determination. After your application and supporting documents are received from your plan, the IMR decision will be made within 3 calendar days. Medicare beneficiaries who are diagnosed with Symptomatic Peripheral Artery Disease who would benefit from this therapy. 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. Deadlines for standard appeal at Level 2. All the changes are reviewed and approved by a selected group of Providers and Pharmacists that are currently in practice. of the appeals process. ii. Please see below for more information. Information on this page is current as of October 01, 2022. You will be automatically enrolled in IEHP DualChoice and do not need to do anything to keep these services. to part or all of what you asked for, we must approve or give the coverage within 72 hours after we get your request or, if you are asking for an exception, your doctors or prescribers supporting statement. This is called a referral. 2023 Plan Benefits. a. (Effective: April 3, 2017) effort to participate in the health care programs IEHP DualChoice offers you. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.). Medi-Cal provides free or low-cost health coverage to low-income individuals and their families.California has been expanding Medi-Cal to a larger and more diverse group of people. Because you get assistance from Medi-Cal, you can end your membership in IEHPDualChoice at any time. Never wavering in our commitment to our Members, Providers, Partners, and each other. 1. Terminal illnesses, unless it affects the patients ability to breathe. Request a second opinion about a medical condition. For more information see Chapter 9 of your IEHP DualChoice Member Handbook. 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. Limitations, copays, and restrictions may apply. 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. Have advanced heart failure for at least 14 days and are dependent on an intraaortic balloon pump (IABP) or similar temporary mechanical circulatory support for at least 7 days. We will review our coverage decision to see if it is correct. Within 10 days of the mailing date of our notice to you that the adverse benefit determination (Level 1 appeal decision) has been upheld; or. Utilities allowance of $40 for covered utilities. 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). We will send you a notice before we make a change that affects you. When we send the payment, its the same as saying Yes to your request for a coverage decision. 10820 Guilford Road, Suite 202 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 you lie about or withhold information about other insurance you have that provides prescription drug coverage. Submit the required study information to CMS for approval. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). CMS has revised Chapter 1, Section 20.29, Subsection C Topical Application of Oxygen to remove the exclusion of this treatment. Information on this page is current as of October 01, 2022. (Effective: February 19, 2019) Most of these drugs are Part D drugs. There are a few drugs that Medicare Part D does not cover but that Medi-Cal may cover. Unleashing our creativity and courage to improve health & well-being. New to IEHP DualChoice. Beneficiaries who meet the coverage criteria, if determined eligible. By clicking on this link, you will be leaving the IEHP DualChoice website. app today. Inland Empire Health Plan (IEHP) has over 1,234 Doctors, 3,676 Specialists, 724 Pharmacies, 74 Urgent Care, 243 OB/GYNs, 383 Behavioral Health Providers, 40 major Hospitals, and 313 Vision doctors in Riverside and San Bernardino counties. D-SNP Transition. "Coordinating" your services includes checking or consulting with other Plan providers about your care and how it is going. How to obtain an aggregate number of grievances, appeals, and exceptions filed with IEHP DualChoice (HMO D-SNP)? If you disagree with the action, you can file a Level 1 Appeal and ask that we continue your benefits for the service or item. 2020) Credentialing Specialist I Job in Rancho Cucamonga, CA at Inland Empire CMS has updated Chapter 1, section 20.32 of the Medicare National Coverage Determinations Manual. You or your provider can ask for an exception from these changes. Denies, changes, or delays a Medi-Cal service or treatment (not including IHSS) because our plan determines it is not medically necessary. Medicare P4P (909) 890-2054 Monday-Friday, 8am-5pm Medicare P4P IEHP Changing your Primary Care Provider (PCP). The procedure must be performed in a hospital with infrastructure and experience meeting the requirements in this determination. Your doctor or other provider can make the appeal for you. You may contact the DMHC if you need help with a complaint involving an urgent issue or one that involves an immediate and serious threat to your health, you disagree with our plans decision about your complaint, or our plan has not resolved your complaint after 30 calendar days. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Capable of producing standardized plots of BP measurements for 24 hours with daytime and nighttime windows and normal BP bands demarcated; Provided to patients with oral and written instructions, and a test run in the physicians office must be performed; and. 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. To stay a member of IEHP DualChoice, you must qualify again by the last day of the two-month period. The plan's block transfer filing indicated that the termination was the result of conduct by Vantage that resulted in the inappropriate delay, denial or modification of authorizations for services and care provide to IEHP's Medi-Cal managed care enrollees. H5355_CMC_22_2746205Accepted, (Effective: September 27, 2021) You can also have a lawyer act on your behalf. If you dont have the IEHP DualChoice Provider and Pharmacy Directory, you can get a copy from IEHP DualChoice Member Services. The procedure is used with a mitral valve TEER system that has received premarket approval from the FDA. If you decide to make an appeal, it means you are going on to Level 1 of the appeals process. No means the Independent Review Entity agrees with our decision not to approve your request. If the State Hearing decision is No to part or all of what you asked for, it means they agree with the Level 1 decision. The MAC may also approve the use of portable oxygen systems to beneficiaries who are mobile in home and benefit from of this unit alone, or in conjunction to a stationary oxygen system.