(800) 718-4347 (TTY), IEHP 24-Hour Nurse Advice Line (for IEHP Members only) This form is for IEHP DualChoice as well as other IEHP programs. If you disagree with a coverage decision we have made, you can appeal our decision. ii. The reviewer will be someone who did not make the original decision. New to IEHP DualChoice. PCPs are usually linked to certain hospitals and specialists. Make recommendations about IEHP DualChoice Members rights and responsibilities policies. (Implementation Date: July 5, 2022). Beneficiaries not meeting all the criteria for cochlear implants are deemed not eligible for Medicare coverage except for FDA-approved clinical trials as described in the NCD. POLICY: A. Medi-Cal Members do not have any co-payment and must not be charged for such. Health Care Coverage. 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. How to Enroll with IEHP DualChoice (HMO D-SNP), IEHP Texting Program Terms and Conditions. If you decide to ask for a State Hearing by phone, you should be aware that the phone lines are very busy. Box 1800 Click here for more information on acupuncture for chronic low back pain coverage. You can contact the Office of the Ombudsman for assistance. (800) 720-4347 (TTY). This means that once you apply using CoveredCA.com, you'll find out which program you qualify for. Please note: If your pharmacy tells you that your prescription cannot be filled, you will get a notice explaining how to contact us to ask for a coverage determination. IEHP DualChoice (HMO D-SNP) has a process in place to identify and reduce medication errors. IEHP DualChoice, a Medicare Medi-Cal Plan, allows you to get your covered Medicare and Medi-Cal benefits through our plan. TTY users should call (800) 537-7697. IEHP - How to Get Care : Welcome to Inland Empire Health Plan \. Our service area includes all of Riverside and San Bernardino counties. Generally, you must receive all routine care from plan providers and network pharmacies to access their prescription drug benefits, except in non-routine circumstances, quantity limitations and restrictions may apply. Treatments must be discontinued if the patient is not improving or is regressing. You can get a fast coverage decision coverage decision only if you are asking for coverage for care or an item you have not yet received. Information on this page is current as of October 01, 2022 Health (4 days ago) WebIEHP Smart Care App allows IEHP Members to manage their health account online, including changing their primary care doctor, checking their eligibility, updating their contact information, https://play.google.com/store/apps/details?id=com.iehp, Health (3 days ago) WebWhen someone enrolls in a health insurance plan during open enrollment but after Jan. 1, 2014, will the effective date be Jan. 1, or is it subject to the actual , https://www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/Medi-Cal_CovCA_FAQ.aspx, Health (Just Now) WebWhen you buy health insurance the total cost of coverage is made up of two costs: the premium you pay each month PLUS the cost sharing you pay out-of-pocket for the , https://www.state.nj.us/dobi/division_insurance/ihcseh/whichindividualplanbest/whichplanbest2019.pdf, Health (2 days ago) WebNJ Protect applications with documentation may be sent via FAX to: AmeriHealth: 609-662-2566. In these situations, please check first with IEHP DualChoice Member Services to see if there is a network pharmacy nearby. If you have a fast complaint, it means we will give you an answer within 24 hours. This is not a complete list. This government program has trained counselors in every state. Who is covered? If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize the medical care coverage within 72 hours or give you the service or item within 14 calendar days from the date we receive the IREs decision. 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. Click here for more information on Positron Emission Tomography NaF-18 (NaF-18 PET) to Identify Bone Metastasis of Cancer coverage. You, your doctor or other prescriber, or your representative can request the Level 2 Appeal. Usually, your prescription drugs are only covered if they are filled at a network pharmacy including through our mail-order pharmacy services. The phone number for the Office for Civil Rights is (800) 368-1019. Hybrid remote in Rancho Cucamonga, CA 91730 +1 location. Previous Next ===== TABBED , https://ww2.iehp.org/en/members/medical-benefits-and-services, Health (2 days ago) WebThe Inland Empire Health Plan (IEHP) provides low-income and working-class individuals and families with access to health services through the Medi-Cal program. Topic:Eating Well(in English), Topic: Things to Avoid During Pregnancy (in Spanish), Topic: The Big Day- Labor & Birth (in English), Topic: Healthy Eating: Part 1 (in Spanish), A program for persons with disabilities. If we need more information, we may ask you or your doctor for it. (Effective: December 15, 2017) The letter will also tell how you can file a fast appeal about our decision to give you a fast coverage decision instead of the fast coverage decision you requested. The list can help your provider find a covered drug that might work for you. We will not rest until our communities enjoy Optimal care and Vibrant Health. b. To learn how to submit a paper claim, please refer to the paper claims process described below. Non-Covered Use: You can call (800) MEDICARE (800) 633-4227, 24 hours a day, 7 days a week, TTY (877) 486-2048. We cannot pay for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency. The removal of these elements eliminates an important source of complications associated with traditional pacing systems while providing similar benefits. Screening computed tomographic colonography (CTC), effective May 12, 2009. All physicians participating in the procedure must have device-specific training by the manufacturer of the device. 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. Asking for a fast coverage decision coverage decision: Here are the rules for asking for a fast coverage decision coverage decision: You must meet the following two requirements to get a fast coverage decision coverage decision: If the coverage decision is Yes, when will I get the service or item? The clinical study must adhere to all the standards of scientific integrity and relevance to the Medicare population. For example, you can make a complaint about disability access or language assistance. 8am - 8pm (PST), 7 days a week, including holidays, TTY: (800) 718-4347. Members \. If you dont have the IEHP DualChoice Provider and Pharmacy Directory, you can get a copy from IEHP DualChoice Member Services. (Effective: May 25, 2017) Horizon: 973-274-2226. MediCal Long-Term Services and Supports. 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). If we are using the standard deadlines, we must give you our answer within 72 hours after we get your request or, if you are asking for an exception, after we get your doctors or prescribers supporting statement. Concurrent with Carotid Stent Placement in Patients at High Risk for Carotid Endarterectomy (CEA) 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 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. Routine womens health care, which includes breast exams, screening mammograms (X-rays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider. Use the IEHP Medicare Prescription Drug Coverage Determination Form for a prior authorization. We are also one of the largest employers in the region. If you decide to make an appeal, it means you are going on to Level 1 of the appeals process. Medicare beneficiaries in need of a pacemaker who are participating in an approved clinical study. C. Beneficiarys diagnosis meets one of the following defined groups below: H8894_DSNP_23_3879734_M Accepted. All of our Doctors offices and service providers have the form or we can mail one to you. This will give you time to talk to your doctor or other prescriber. Will my benefits continue during Level 1 appeals? Also, its possible that your PCP might leave our plans network of providers and you would have to find a new PCP. Click here for information on Next Generation Sequencing coverage. The time of need is indicated when the presumption of oxygen therapy within the home setting will improve the patients condition. When you choose your PCP, you are also choosing the affiliated medical group. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. When we say existing relationship, it means that you saw an out-of-network provider at least once for a non-emergency visit during the 12 months before the date of your initial enrollment in our plan. 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). During these events, supplemental oxygen is provided during exercise, if the use of oxygen improves the hypoxemia that was demonstrated during exercise when the patient was breathing room air. Who is covered: The PTA is covered under the following conditions: This section is about asking for coverage decisions and making appeals with problems related to your benefits and coverage. Information on this page is current as of October 01, 2022. Transportation: $0. When that happens, we may remove the current drug, but your cost for the new drug will stay the same or will be lower. If you want to change plans, call IEHP DualChoice Member Services. Medicare beneficiaries with LSS who are participating in an approved clinical study. You may also have rights under the Americans with Disability Act. How can I make a Level 2 Appeal? There are many kinds of specialists. Your PCP should speak your language. The form gives the other person permission to act for you. As COVID-19 becomes less of a threat, California will restart yearly Medicaid eligibility reviews using available information to decide if you or your family member (s) still . Or, if you havent paid for the service or item yet, we will send the payment directly to the provider. Other Qualifications. CMS has issued a National Coverage Determination (NCD) which expands coverage to include leadless pacemakers when procedures are performed in CMS-approved Coverage with Evidence Development (CED) studies. You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Text size: 100% A + A A -. Make necessary appointments for routine and sick care, and inform your Doctor when you are unable to make a scheduled appointment. You have a right to appeal or ask for Formulary exception if you disagree with the information provided by the pharmacist. CMS has updated Chapter 1, section 30.3.3 of the Medicare National Coverage Determinations Manual. (800) 720-4347 (TTY). Calls to this number are free. Or you can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. As an IEHP DualChoice (HMO D-SNP) Member, you have the right to: As an IEHP DualChoice Member, you have the responsibility to: For more information on Member Rights and Responsibilities refer to Chapter 8 of your IEHP DualChoice Member Handbook. Arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88%, tested during functional performance of the patient or a formal exercise, Notify IEHP if your language needs are not met. Try to choose a PCP that can admit you to the hospital you want within 30 miles or 45 minutes of your home. (Implementation Date: October 5, 2020). If you prefer, you can make your complaint about the quality of care you received directly to this organization (without making the complaint to our plan). Mail or fax your forms and any attachments to: You may complete the "Request for State Hearing" on the back of the notice of action. (800) 718-4347 (TTY), IEHP DualChoice Member Services 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. Careers. Effective for dates of service on or after August 7, 2019, CMS covers autologous treatment for cancer with T-cell expressing at least one chimeric antigen receptor (CAR) when administered at healthcare facilities enrolled in the Food and Drug Administrations (FDA) Risk Evaluation and Mitigation Strategies (REMS) and when specific requirements are met. P.O. disease); An additional 8 sessions will be covered for those patients demonstrating an improvement. For certain drugs, you or your provider need to get approval from the plan before we will agree to cover the drug for you. Information is also below. The care team helps coordinate the services you need. Learn more here, including how to apply. When will I hear about a standard appeal decision for Part C services? After your coverage begins with IEHP DualChoice, you must receive medical services and prescription drug services in the IEHP DualChoice network. (Implementation Date: February 27, 2023). You can make the complaint at any time unless it is about a Part D drug. Beneficiaries that demonstrate limited benefit from amplification. We take another careful look at all of the information about your coverage request. This is not a complete list. They can also answer your questions, give you more information, and offer guidance on what to do. Providers from other groups including patient practitioners, nurses, research personnel, and administrators. Beneficiaries receiving autologous treatment for cancer with T-cell expressing at least one. During this time, you must continue to get your medical care and prescription drugs through our plan. To learn how to submit a paper claim, please refer to the paper claims process described below. When you are outside the service area and cannot get care from a network provider, our plan will cover urgently needed care that you get from any provider. Medi-Cal offers free or low-cost health coverage for California residents . It also has care coordinators and care teams to help you manage all your providers and services. 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. Apply Renewing Your Benefits Annually To keep your Medi-Cal coverage, youll have to renew once a year on your original sign-up date. Be treated with respect and courtesy. 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. You may also contact the local Office for Civil Rights office at: U.S. Department of Health and Human Services. Annapolis Junction, Maryland 20701. Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plans service area. (Implementation date: June 27, 2017). Information on the page is current as of March 2, 2023 IEHP DualChoice is very similar to your current Cal MediConnect plan. What is covered: Information on this page is current as of October 01, 2022. 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. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. Effective for claims with dates of service on or after 01/18/17, Medicare will cover leadless pacemakers under CED when procedures are performed in CMS-approved studies. of the appeals process. If you have a standard appeal at Level 2, the Independent Review Entity must give you an answer to your Level 2 Appeal within 7 calendar days after it gets your appeal. Click here for more information on Cochlear Implantation. either recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer and; has not been previously tested with the same test using NGS for the same cancer genetic content and; has decided to seek further cancer treatment (e.g., therapeutic chemotherapy). Unless you change plans, IEHP DualChoice (HMO D-SNP) will provide your Medicare benefits. 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; An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision. The Inland Empire Health Plan (IEHP) provides low-income and working-class individuals and families with access to health services through the Medi-Cal program. Medicare beneficiaries who are diagnosed with Symptomatic Peripheral Artery Disease who would benefit from this therapy. Your PCP, along with the medical group or IPA, provides your medical care. How long does it take to get a coverage decision coverage decision for Part C services? To find the name, address, and phone number of the Quality Improvement Organization in your state, lookin Chapter 2 of your. app today. We are always available to help you. What is covered: The Help Center cannot return any documents. 1. Rancho Cucamonga, CA 91729-1800. How will I find out about the decision? If you are asking for a standard appeal, you can make your appeal by sending a request in writing. If you ask for a fast coverage decision, without your doctors support, we will decide if you get a fast coverage decision. You will get a letter from us about the change in your eligibility with instructions to correct your eligibility information. We will not rest until our communities enjoy Optimal Care and Vibrant Health. You can call IEHP DualChoice Member Services at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Typically, our Formulary includes more than one drug for treating a particular condition. Pay For Performance (P4P) and Proposition 56. Click here for more information on Transcatheter Edge-to-Edge Repair [TEER] for Mitral Valve Regurgitation coverage . Your membership will usually end on the first day of the month after we receive your request to change plans. Your PCP will send a referral to your plan or medical group. chimeric antigen receptor (CAR) T-cell therapy coverage. Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). If your Level 2 Appeal was a State Hearing, you may ask for a rehearing within 30 days after you receive the decision. If we do not give you an answer within 30 calendar days or by the end of the extra days (if we took them), we will automatically send your case to Level 2 of the appeals process if your problem is about a Medicare service or item. If we tell you after our review that the service or item is not covered, your case can go to a Level 2 Appeal. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Or, if you are asking for an exception, 24 hours after we get your doctors or prescribers statement supporting your request. With this app, you or a designated person with Power of Attorney can access your advance health care directives at any time from a home computer or smartphone. How will you find out if your drugs coverage has been changed? This page provides you information on what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug. Advance care planning (ACP) involves shared decision making to write down-in an advance care directive-a persons wishes about their future medical care. Click here to download a free copy of Adobe Acrobat Reader.By clicking on this link, you will be leaving the IEHP DualChoice website. wounds affecting the skin. There may be qualifications or restrictions on the procedures below. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. Who is covered: TTY/TDD (800) 718-4347. For inpatient hospital patients, the time of need is within 2 days of discharge. This service will be covered only for beneficiaries diagnosed with chronic Lower Back Pain (cLBP) when the following conditions are met: All types of acupuncture including dry needling for any condition other than cLBP are non-covered by Medicare. If you want a fast appeal, you may make your appeal in writing or you may call us. 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. Per the recommendation of the United States Preventive Services Task Force (USPSTF), CMS has issued a National Coverage Determination (NCD) which expands coverage to include screening for HBV infection. When a provider leaves a network, we will mail you a letter informing you about your new provider. Send copies of documents, not originals. We will send you your ID Card with your PCPs information. 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. If you miss this deadline and have a good reason for missing it, we may give you more time to make you appeal. The Centers of Medicare and Medicaid Services (CMS) will cover acupuncture for chronic low back pain (cLBP) when specific requirements are met. An interventional echocardiographer must perform transesophageal echocardiography during the procedure.>. (Effective: February 10, 2022) The screen test must have all the following: Food and Drug Administration (FDA) market authorization with an indication for colorectal cancer screening; and. 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. What is covered: Topic: A program for persons with disabilities. The phone number for the Office for Civil Rights is (800) 368-1019. Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal. For more information on Grievances see Chapter 9 of your IEHP DualChoice Member Handbook. The procedure must be performed by an interventional cardiologist or cardiac surgeon.<. P.O. What if you are outside the plans service area when you have an urgent need for care? Read through the list of changes, and click "Report a , https://www.healthcare.gov/apply-and-enroll/change-after-enrolling/, Health (2 days ago) WebThe Inland Empire Health Plan (IEHP) provides low-income and working-class individuals and families with access to health services through the Medi-Cal program. To stay a member of IEHP DualChoice, you must qualify again by the last day of the two-month period. Visit KeepMediCalCoverage.org for more details. (800) 718-4347 (TTY), IEHP DualChoice Member Services You can make a complaint to the Department of Health and Human Services Office for Civil Rights if you think you have not been treated fairly.
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