C. Beneficiarys diagnosis meets one of the following defined groups below: An IMR is a review of your case by doctors who are not part of our plan. The Centers of Medicare and Medicaid Services (CMS) will cover Ambulatory Blood Pressure Monitoring (ABPM) when specific requirements are met. i. 3. Prior to the beneficiarys first lung cancer LDCT screening, the beneficiary must receive a counseling and shared decision-making visit that meets specific criteria. chimeric antigen receptor (CAR) T-cell therapy coverage. (Effective: July 2, 2019) You or your provider must show documentation of an existing relationship and agree to certain terms when you make the request. TTY users should call (800) 718-4347. Complex Care Management; Medi-Cal Demographic Updates . You will not have a gap in your coverage. Infected individuals may develop symptoms such as nausea, anorexia, fatigue, fever, and abdominal pain, or may be asymptomatic. Will not pay for emergency or urgent Medi-Cal services that you already received. 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. 2. This is not a complete list. To learn how to submit a paper claim, please refer to the paper claims process described below. Who is covered: Beneficiaries receiving treatment for chronic non-healing diabetic wounds for a duration of 20 weeks, when prepared by a device cleared by the Food and Drug Administration (FDA) for the management of exuding (bleeding, oozing, seeping, etc.) IEHP DualChoice. You can file a grievance. 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. P.O. If the State Hearing decision is Yes to part or all of what you asked for, we must comply with the decision. 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. Including bus pass. If you are having a problem with your care, you can call the Office of Ombudsman at 1-888-452-8609for help. 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. IEHP: "Inland Empire Health Plan (IEHP) is a not-for-profit Medi-Cal and Medicare health plan headquartered in Rancho Cucamonga, California. When you are discharged from the hospital, you will return to your PCP for your health care needs. Breathlessness without cor pulmonale or evidence of hypoxemia; or. After your application and supporting documents are received from your plan, the IMR decision will be made within 30 calendar days. Pulmonary hypertension or cor pulmonale (high blood pressure in pulmonary arteries), determined by the measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVFL; or, 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. See Chapters 7 and 9 of the IEHP DualChoice Member Handbookto learn how to ask the plan to pay you back. Has not resolved your Level 1 Appeal on a Medi-Cal service within 30 calendar days for a standard appeal or 72 hours for a fast appeal. If we do not meet this deadline, we will send your request on to Level 2 of the appeals process. All other indications for colorectal cancer screening not otherwise specified in the Social Security Act, regulations, or the above remain nationally non-covered. A Cal MediConnect Plan is an organization made up of Doctors, Hospitals, Pharmacies, Providers of long-term services and supports, Behavioral Health Providers, and other Providers. However, your PCP can always use Language Line Services to get help from an interpreter, if needed. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more days (44 days total) to answer your complaint. Effective for dates of service on or after January 19, 2021, CMS has updated section 20.33 of the National Coverage Determination Manual to cover Transcatheter Edge-to-Edge Repair (TEER) for Mitral Valve Regurgitation when specific requirements are met. IEHP DualChoice, a Medicare Medi-Cal Plan, allows you to get your covered Medicare and Medi-Cal benefits through our plan. 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. The letter will also explain how you can appeal our decision. (This is sometimes called step therapy.). Typically, our Formulary includes more than one drug for treating a particular condition. You must ask for an appeal within 60 calendar days from the date on the letter we sent to tell you our decision. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. You should not pay the bill yourself. Medicare beneficiaries who meet either of the following criteria: Click here for more information on HBV Screenings. Never wavering in our commitment to our Members, Providers, Partners, and each other. At any time, you can call IEHP DualChoice Member Services to get up-to-date information about changes in the pharmacy network. Your PCP, along with the medical group or IPA, provides your medical care. ii. 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. Please call or write to IEHP DualChoice Member Services. You can call (800) MEDICARE (800) 633-4227, 24 hours a day, 7 days a week, TTY (877) 486-2048. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. If the Independent Review Entity approves a request to pay you back for a drug you already bought, we will send payment to you within 30 calendar days after we get the decision. If your doctor says that you need a fast coverage decision, we will automatically give you one. Medicare beneficiaries may be covered with an affirmative Coverage Determination. Read Will my benefits continue during Level 2 appeals in Chapter 9 of the Member Handbook for more information. Click here for more information on Topical Applications of Oxygen. Yes. The PCP you choose can only admit you to certain hospitals. We must give you our answer within 14 calendar days after we get your request. Use of other PET radiopharmaceutical tracers for cancer may be covered at the discretion of local Medicare Administrative Contractors (MACs), when used in accordance to their Food and Drug Administration (FDA) approval indications. effort to participate in the health care programs IEHP DualChoice offers you. We will contact the provider directly and take care of the problem. Please be sure to contact IEHP DualChoice Member Services if you have any questions. All the changes are reviewed and approved by a selected group of Providers and Pharmacists that are currently in practice. An interventional echocardiographer must perform transesophageal echocardiography during the procedure.>. These forms are also available on the CMS website: Medicare Prescription Drug Determination Request Form (for use by enrollees and providers), Deadlines for a standard coverage decision about a drug you have not yet received, If our answer is Yes 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. The English walnut has a soft and thin shell that makes it easy to crack, while the black walnut has a tougher shell, one of the hardest of all the nuts. Who is covered: The PTA is covered under the following conditions: Your PCP will send a referral to your plan or medical group. What is covered: Beneficiaries receiving autologous treatment for cancer with T-cell expressing at least one. Who is covered: The Help Center cannot return any documents. If we extended the time needed to make our coverage decision, we will provide the coverage by the end of that extended period. If you miss the deadline for a good reason, you may still appeal. Live in our service area (incarcerated individuals are not considered living in the geographic service area even if they are physically located in it. How long does it take to get a coverage decision coverage decision for Part C services? What is covered? If you let someone else use your membership card to get medical care. You can ask for a State Hearing for Medi-Cal covered services and items. The Office of the Ombudsman. You may also ask for an appeal by calling IEHP DualChoice Member Services at 1-877-273-IEHP (4347), 8am 8pm (PST), 7 days a week, including holidays. 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. This statement will also explain how you can appeal our decision. (Effective: January 19, 2021) IEHP DualChoice is very similar to your current Cal MediConnect plan. VNS is non-covered for the treatment of TRD when furnished outside of a CMS-approved CED study. What Prescription Drugs Does IEHP DualChoice Cover? Patients must maintain a stable medication regimen for at least four weeks before device implantation. Our plan cannot cover a drug purchased outside the United States and its territories. A Level 1 Appeal is the first appeal to our plan. All physicians participating in the procedure must have device-specific training by the manufacturer of the device. Your provider will also know about this change. The call is free. TTY users should call 1-877-486-2048. (Effective: January 1, 2022) We will see if the service or item you paid for is a covered service or item, and we will check to see if you followed all the rules for using your coverage. 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. 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. If your problem is about a Medi-Cal service or item, you can file a Level 2 Appeal yourself. IEHP DualChoice also provides information to the Centers for Medicare and Medicaid Services (CMS) regarding its quality assurance measures according to the guidelines specified by CMS. If you are asking for a standard appeal, you can make your appeal by sending a request in writing. If you have a fast complaint, it means we will give you an answer within 24 hours. 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." TTY/TDD users should call 1-800-718-4347. IEHP DualChoice Cal MediConnect (Medicare-Medicaid Plan) is changing to IEHP DualChoice (HMO D-SNP) on January 1, 2023. The following criteria must also be met as described in the NCD: Non-Covered Use: Information on this page is current as of October 01, 2022 Livanta is not connect with our plan. The clinical research study must meet the standards of scientific integrity and relevance to the Medicare population described in this determination. 2. All screenings DNA tests, effective April 28, 2008, through October 8, 2014. Mail your request for payment together with any bills or receipts to us at this address: IEHPDualChoice Choose a PCP that is within 10 miles or 15 minutes of your home. IEHP DualChoice. Rancho Cucamonga, CA 91729-4259. (Effective: January 19, 2021) Then you can: Again, if a drug is suddenly recalled because its been found to be unsafe or for other reasons, the plan will immediately remove the drug from the Formulary.