a clinical indication for germline (inherited) testing for hereditary breast or ovarian cancer and; a risk factor for germline (inherited) breast or ovarian cancer and; not been previously tested with the same germline test using NGS for the same germline genetic content. This is a person who works with you, with our plan, and with your care team to help make a care plan. Who is covered: IEHP offers a competitive salary and stellar benefit package . An interventional echocardiographer must perform transesophageal echocardiography during the procedure.>. If the service or item you paid for is covered and you followed all the rules, we will send you the payment for our share of the cost of the service or item within 60 calendar days after we get your request. If we uphold the denial after Redetermination, you have the right to request a Reconsideration. For example, good reasons for missing the deadline would be if you have a serious illness that kept you from contacting us or if we gave you incorrect or incomplete information about the deadline for requesting an appeal. You, your representative, or your provider asks us to let you keep using your current provider. IEHP DualChoice You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. The letter will tell you how to do this. Previously, HBV screening and re-screening was only covered for pregnant women. We must complete the described action(s) within 30 calendar days of the date we received a copy of the decision. 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. Livanta is not connect with our plan. Changing your Primary Care Provider (PCP). The person you name would be your representative. You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. 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. To stay a member of IEHP DualChoice, you must qualify again by the last day of the two-month period. They all work together to provide the care you need. For example, this means that your care team makes sure: Your doctors know about all the medicines you take so they can make sure youre taking the right medicines and can reduce any side effects you may have from the medicines. You can send your complaint to Medicare. Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. (888) 244-4347 your medical care and prescription drugs through our plan. 2. The phone number for the Office of the Ombudsman is 1-888-452-8609. (If possible, please call IEHP DualChoice Member Services before you leave the service area so we can help arrange for you to have maintenance dialysis while you are away.). If your Level 2 Appeal was an Independent Medical Review, the Department of Managed Health Care will send you a letter explaining its decision. The removal of these elements eliminates an important source of complications associated with traditional pacing systems while providing similar benefits. =========== TABBED SINGLE CONTENT GENERAL. Note: You can only make this request for services of Durable Medical Equipment (DME), transportation, or other ancillary services not included in our plan. Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). More . If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we get your appeal. Patients must maintain a stable medication regimen for at least four weeks before device implantation. However, if you ask for more time, or if we need to gather more information, we can take up to 14 more calendar days. All Medicare covered services, doctors, hospitals, labs, and x-rays, You will have access to a Provider network that includes many of the same Providers as your current plan, Coordination of the services you get now or that you might need, Personal history of sustained VT or cardiac arrest due to Ventricular Fibrillation (VF), Prior Myocardial Infarction (MI) and measured Left Ventricular Ejection Fraction (LVEF) less than or equal to .03, Severe, ischemic, dilated cardiomyopathy without history of sustained VT or cardiac arrest due to VF, and have New York Heart Association (NYHA) Class II or III heart failure with a LVEF less than or equal to 35%, Severe, non-ischemic, dilated cardiomyopathy without history of cardiac arrest or sustained VT, NYHA Class II or II heart failure, LVEF less than or equal for 35%, and utilization of optimal medical therapy for at a minimum of three (3) months, Documented, familial or genetic disorders with a high risk of life-threating tachyarrhythmias, but not limited to long QT syndrome or hypertrophic cardiomyopathy, Existing ICD requiring replacement due to battery life, Elective Replacement Indicator (ERI), or malfunction, The procedure is performed in a Clinical Laboratory Improvement Act (CLIA)-certified laboratory. 1. To learn how to submit a paper claim, please refer to the paper claims process described below. If the IMR is decided in your favor, we must give you the service or item you requested. If you are unable to get a covered drug in a timely manner within our service area because there are no network pharmacies within a reasonable driving distance that provide 24-hour service. For more information visit the. If your Level 2 Appeal went to the Medicare Independent Review Entity, it will send you a letter explaining its decision. 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. Generally, IEHP DualChoice (HMO D-SNP) will cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. Governing Board. You should receive the IMR decision within 7 calendar days of the submission of the completed application. Medicare beneficiaries who are diagnosed with Symptomatic Peripheral Artery Disease who would benefit from this therapy. Are a United States citizen or are lawfully present in the United States. There are two ways you can asked to be disenrolled: To disenroll, please call Health Care Options (HCO) at 1-844-580-7272, 8am - 6pm (PST), Monday - Friday. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. Effective January 19, 2021, CMS has determined that blood-based biomarker tests are an appropriate colorectal cancer screening test, once every 3 years for Medicare beneficiaries when certain requirements are met. Or you can ask us to cover the drug without limits. 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. There are also limited situations where you do not choose to leave, but we are required to end your membership. Beneficiaries must be managed by a team of medical professionals meeting the minimum requirements in the National Coverage Determination Manual. The procedure must be performed in a hospital with infrastructure and experience meeting the requirements in this determination. All screenings DNA tests, effective April 28, 2008, through October 8, 2014. Denies, changes, or delays a Medi-Cal service or treatment (not including IHSS) because our plan determines it is not medically necessary. Receive Member informing materials in alternative formats, including Braille, large print, and audio. 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. There are over 700 pharmacies in the IEHP DualChoice network. This is called upholding the decision. It is also called turning down your appeal.. When can you end your membership in our plan? (Effective: January 19, 2021) For more information, call IEHP DualChoice Member Services or read the IEHP DualChoice Member Handbook. VNS is non-covered for the treatment of TRD when furnished outside of a CMS-approved CED study. A care coordinator is a person who is trained to help you manage the care you need. Terminal illnesses, unless it affects the patients ability to breathe. If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals). This form is for IEHP DualChoice as well as other IEHP programs. Also, its possible that your PCP might leave our plans network of providers and you would have to find a new PCP. 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. You have the right to choose someone to represent you during your appeal or grievance process and for your grievancesand appeals to be reviewed as quickly as possible and be told how long it will take. At Level 2, an Independent Review Entity will review our decision. TTY users should call 1-800-718-4347. (Effective: April 13, 2021) You have access to a care coordinator. Whether you call or write, you should contact IEHP DualChoice Member Services right away. If your Level 2 Appeal was a State Hearing, you may ask for a rehearing within 30 days after you receive the decision. 1. Sometimes, a new and cheaper drug comes along that works as well as a drug on the Drug List now. The reviewer will be someone who did not make the original decision. 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. The form gives the other person permission to act for you. 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; 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. Yes. If you do not agree with our decision, you can make an appeal. (SeeChapter 10 oftheIEHP DualChoiceMember Handbookfor information on when your new coverage begins.) Click here to download a free copy of Adobe Acrobat Reader.By clicking on this link, you will be leaving the IEHP DualChoice website. 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. Or you can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. Our plan usually cannot cover off-label use. Effective for dates of service on or after December 1, 2020, CMS has updated section 20.9.1 of the National Coverage Determination Manual to cover ventricular assist devices (VADs) when received at facilities credentialed by a CMS approved organization and when specific requirements are met. Make necessary appointments for routine and sick care, and inform your Doctor when you are unable to make a scheduled appointment. Interventional Cardiologist meeting the requirements listed in the determination. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contact renewal. Change the coverage rules or limits for the brand name drug. In most cases you have 120 days to ask for a State Hearing after the Your Hearing Rights notice is mailed to you. The phone number is (888) 452-8609. 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. It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. Sacramento, CA 95899-7413. 3. H8894_DSNP_23_3879734_M Pending Accepted. If you put your complaint in writing, we will respond to your complaint in writing. Be treated with respect and courtesy. TTY users should call 1-877-486-2048. You can get the form at. You do not need to do anything further to get this Extra Help. IEHP DualChoice (HMO D-SNP) is a HMO Plan with a Medicare contract. How much time do I have to make an appeal for Part C services? Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. You can ask for an Independent Medical Review (IMR) from the Help Center at the California Department of Managed Health Care (DMHC). We check to see if we were following all the rules when we said No to your request. Drugs that may not be safe or appropriate because of your age or gender. Who is covered: The PTA is covered under the following conditions: TTY users should call 1-800-718-4347. The letter will tell you how to make a complaint about our decision to give you a standard decision. They have a copay of $0. If you want someone to act for you who is not already authorized by the Court or under State law, then you and that person must sign and date a statement that gives the person legal permission to be your representative. 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. Make recommendations about IEHP DualChoice Members rights and responsibilities policies. This service will be covered when the Ambulatory Blood Pressure Monitoring (ABPM) is used for the diagnosis of hypertension when either there is suspected white coat or masked hypertension and the following conditions are met: Coverage of other indications for ABPM is at the discretion of the Medicare Administrative Contractors. iv. You can call SHIP at 1-800-434-0222. Previously, PILD for LSS was covered for beneficiaries enrolled only in a CMS-approved prospective, randomized, controlled clinical trial (RCT) under the Coverage with Evidence Development (CED) paradigm. If we decide to change or stop coverage for a service or item that was previously approved, we will send you a notice before taking the action. An appeal is a formal way of asking us to review our decision and change it if you think we made a mistake. Hepatitis B Virus (HBV) is transmitted by exposure to bodily fluids. Send us your request for payment, along with your bill and documentation of any payment you have made. This letter will tell you that if your doctor asks for the fast coverage decision, we will automatically give a fast coverage decision. 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. 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. Medicare Prescription Drug Determination Request Form (for use by enrollees and providers). You ask us if a drug is covered for you (for example, when your drug is on the plans Formulary but we require you to get approval from us before we will cover it for you). 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). 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. We do the right thing by: Placing our Members at the center of our universe. These forms are also available on the CMS website: Receive services without regard to race, ethnicity, national origin, religion, sex, age, mental or physical disability or medical condition, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), disability, genetic information, or source of payment. You may use the following form to submit an appeal: Can someone else make the appeal for me? You are not responsible for Medicare costs except for Part D copays. You can change your Doctor by calling IEHP DualChoice Member Services. 8am - 8pm (PST), 7 days a week, including holidays, TTY: (800) 718-4347. Your benefits as a member of our plan include coverage for many prescription drugs. According to IEHP, 99.4 percent of enrollees retained the same primary care physicians. If you would like to switch from our plan to another Medicare Advantage plan simply enroll in the new Medicare Advantage plan. (Effective: June 21, 2019) 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. (You cannot get a fast coverage decision if you are asking us to pay you back for a drug you have already bought.). Your enrollment in your new plan will also begin on this day. What is covered? 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. There are two ways to make a Level 2 appeal for Medi-Cal services and items: 1) Independent Medical Review or 2) State Hearing.
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