Welcome to Inland Empire Health Plan \. Average Interview. according to the FDA-approved indications and the following conditions are met: The procedure and implantation system received FDA premarket approval (PMA) for that system's FDA approved indication. If an alternative drug would be just as effective as the drug you are asking for, and would not cause more side effects or other health problems, we will generally not approve your request for an exception. What is covered? The letter you get from the Independent Review Entity will tell you the dollar amount needed to continue with the appeals process. We will send you a notice with the steps you can take to ask for an exception. If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we get your appeal. 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). Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States. Learn More =====TEXT INFOPANEL. You, your doctor or other prescriber, or your representative can request the Level 2 Appeal. If you decide to ask for a State Hearing by phone, you should be aware that the phone lines are very busy. You have access to a care coordinator. If you would like to switch from our plan to another Medicare Advantage plan simply enroll in the new Medicare Advantage plan. Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience, or retaliation. TTY/TDD users should call 1-800-430-7077. How to obtain an aggregate number of grievances, appeals, and exceptions filed with IEHP DualChoice (HMO D-SNP)? Qualify Based on Your Income edit Edit Content. You wont pay a premium, or pay for doctor visits or other medical care if you go to a provider that works with our health plan. When you choose a PCP, it also determines what hospital and specialist you can use. Treatment for patients with untreated severe aortic stenosis. Diagnostic Tests, X-Rays & Lab Services: $0, Home and Community Based Services (HCBS): $0, Community Based Adult Services (CBAS): $0, Long Term Care that includes custodial care and facility: $0. Yes. CMS has updated Chapter 1, Part 2, Section 90.2 of the Medicare National Coverage Determinations Manual to include NGS testing for Germline (inherited) cancer when specific requirements are met and updated criteria for coverage of Somatic (acquired) cancer. When we send the payment, its the same as saying Yes to your request for a coverage decision. IEHP Undocumented Insurance If the Independent Review Entity says Yes to part or all of what you asked for, we must authorize or give you the drug coverage within 72 hours after we get the decision. Your benefits as a member of our plan include coverage for many prescription drugs. Beneficiaries receiving treatment for implanting a ventricular assist device (VAD), when the following requirements are met and: All other indications for the use of VADs not otherwise listed remain non-covered, except in the context of Category B investigational device exemption clinical trials (42 CFR 405) or as a routine cost in clinical trials defined under section 310.1 of the National Coverage Determinations (NCD) Manual. 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. (Effective: January 18, 2017) If the Independent Review Entity says No to part or all of what you asked for, it means they agree with the Level 1 decision. 2023 Inland Empire Health Plan All Rights Reserved. Providers \. If the Independent Medical Review decision is Yes to part or all of what you asked for, we must provide the service or treatment. To stay a member of IEHP DualChoice, you must qualify again by the last day of the two-month period. If our answer is No to part or all of what you asked for, we will send you a letter. Who is covered: What is covered: Percutaneous Transluminal Angioplasty (PTA) is covered in the below instances in order to improve blood flow through the diseased segment of a vessel in order to dilate lesions of peripheral, renal and coronary arteries. Effective February 15, 2020, CMS will cover FDA approved Vagus Nerve Stimulation (VNS) devices for treatment-resistant depression through Coverage with Evidence Development (CED) in a CMS approved clinical trial in addition to the coverage criteria outlined in the National Coverage Determination Manual. Providers from other groups including patient practitioners, nurses, research personnel, and administrators. You must ask for an appeal within 60 calendar days from the date on the letter we sent to tell you our decision. 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. IEHP DualChoice must end your membership in the plan if any of the following happen: The IEHPDualChoice Privacy Notice describes how medical information about you may be used and disclosed, and how you can get access to this information. 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. A drug is taken off the market. Who is covered? 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). 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 will let you know of this change right away. (SeeChapter 10 oftheIEHP DualChoiceMember Handbookfor information on when your new coverage begins.) 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. Contact: Tel : 04 76 61 52 00 - E-Mail. POLICY: A. Medi-Cal Members do not have any co-payment and must not be charged for such. Yes. A fast coverage decision means we will give you an answer within 24 hours after we get your doctors statement. If your doctor or other prescriber tells us that your health requires a fast coverage decision, we will automatically agree to give you a fast coverage decision, and the letter will tell you that. Click here for more information on Topical Applications of Oxygen. (This is sometimes called prior authorization.), Being required to try a different drug first before we will agree to cover the drug you are asking for. When your doctor recommends services that are not available in our network, you can receive these services by an out-of-network provider. IEHP IEHP DualChoice If the IRE says No to your appeal, it means they agree with our decision not to approve your request. 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. 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. You or someone you name may file a grievance. IEHP DualChoice (HMO D-SNP) has contracts with pharmacies that equals or exceeds CMS requirements for pharmacy access in your area. To learn how to submit a paper claim, please refer to the paper claims process described below. This is called upholding the decision. It is also called turning down your appeal. For more detailed information on each of the NCDs including restrictions and qualifications click on the link after each NCD or call IEHP DualChoice Member Services at (877) 273-IEHP (4347) 8am-8pm (PST), 7 days a week, including holidays, or. What is covered: IEHP Search Results Search for "edi" What is covered: Medi-Cal (the name for Medicaid in California) offers comprehensive coverage, including mental health resources. 711 (TTY), To Enroll with IEHP If we uphold the denial after Redetermination, you have the right to request a Reconsideration. They have a copay of $0. You will not have a gap in your coverage. Notify IEHP if your language needs are not met. Benefits and copayments may change on January 1 of each year. Have a Primary Care Provider who is responsible for coordination of your care. Some households qualify for both. Here are three general rules about drugs that Medicare drug plans will not cover under Part D: For more information refer to Chapter 6 of yourIEHP DualChoice Member Handbook. Orthopedists care for patients with certain bone, joint, or muscle conditions. Welcome to Inland Empire Health Plan \. We will send you a letter within 5 calendar days of receiving your appeal letting you know that we received it. However, your PCP can always use Language Line Services to get help from an interpreter, if needed. (800) 718-4347 (TTY), IEHP DualChoice Member Services IEHP Welcome to Inland Empire Health Plan Both of these processes have been approved by Medicare. Appointment of Representatives Form (PDF), 2023 Drugs Requiring Prior Authorization (PDF). Tier 1 drugs are: generic, brand and biosimilar drugs. IEHP DualChoice Medicare Team at (800) 741-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays, TTY users should call (800) 718-4347. (877) 273-4347 You may be able to order your prescription drugs ahead of time through our network mail order pharmacy service or through a retail network pharmacy that offers an extended supply. 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. This includes getting authorization to see specialists or medical services such as lab tests, x-rays, and/or hospital admittance. 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. There is no deductible for IEHP DualChoice. Get Help from an Independent Government Organization. If we are using the fast deadlines, we will give you our answer within 72 hours after we get your appeal, or sooner if your health requires it. Kids and Teens. Effective June 21, 2019, CMS will cover TAVR under CED when the procedure is related to the treatment of symptomatic aortic stenosis and according to the Food and Drug Administration (FDA) approved indication for use with an approved device, or in clinical studies when criteria are met, in addition to the coverage criteria outlined in the NCD Manual. Click here for more information on Leadless Pacemakers. 1. If you or your family has limited income, Medi-Cal provides health coverage for no or low-cost. Information on this page is current as of October 01, 2022. Your IEHP DualChoice Doctor cannot charge you for covered health care services, except for required co-payments. You can tell Medi-Cal about your complaint. With a provider network of more than 6,000 and a team of more than 2,000 employees, IEHP provides quality, accessible healthcare services to more than 1.2 million members. This is not a complete list. The Level 3 Appeal is handled by an administrative law judge. Or your doctor or other prescriber can tell us on the phone, and then fax or mail a statement. For example, we might decide that a service, item, or drug that you want is not covered or is no longer covered by Medicare or Medi-Cal. Click here for more information onICD Coverage. TTY should call (800) 718-4347. How much time do I have to make an appeal for Part C services? Inland Empire Health Plan Interview Questions (2023) | Glassdoor ii. The clinical study must adhere to all the standards of scientific integrity and relevance to the Medicare population. Please see below for more information. CMS has updated Chapter 1, section 20.19 of the Medicare National Coverage Determinations Manual. If your case is urgent and you qualify for an IMR, the DMHC will review your case and send you a letter within 2 calendar days telling you that you qualify for an IMR. We have 30 days to respond to your request. Complain about IEHP DualChoice, its Providers, or your care. You must choose your PCP from your Provider and Pharmacy Directory. To learn how to submit a paper claim, please refer to the paper claims process described below. If you want the Independent Review Organization to review your case, your appeal request must be in writing. If your problem is about a Medicare service or item, the letter will tell you that we sent your case to the Independent Review Entity for a Level 2 Appeal. You can download a free copy here. (Implementation date: June 27, 2017). The treatment is considered reasonably likely to predict a clinical benefit and is administrated in a randomized controlled trial under an investigational new drug application. This includes: Primary Care Providers (PCPs) are usually linked to certain hospitals. 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. 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. We will let you know of this change right away. See how IEHP's broad range of high-quality programs can help you improve Members' health outcomes. Will my benefits continue during Level 1 appeals? If you need help to fill out the form, IEHP Member Services can assist you. 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. Say Yes to Physical Activity + Control Your Blood Pressure (in Spanish), Topic: Get Energized! 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. You can ask us to reimburse you for IEHP DualChoice's share of the cost. You may also call Health Care Options at 1-800-430-4263 or visit www.healthcareoptions.dhcs.ca.gov. IEHP Special Programs The patient is experiencing a major depressive episode, as measured by a guideline recommended depression scale assessment tool on two visits, within a 45-day span prior to implantation of the VNS device. (Effective: July 2, 2019) You should continue to use our network pharmacies to get your prescriptions filled until your membership in our plan ends. When your PCP thinks that you need specialized treatment or supplies, your PCP will need to get prior authorization (i.e., prior approval) from your Plan and/or medical group. (Effective: January 21, 2020) (in English), Topic: Healthy Eating: Part 2 (in Spanish), Topic: We will show you where you can get a form called an Advance Care Directive, how to fill it out, and why we should have one. If you move out of our service area for more than six months. Topic:Physical Activity (in English), Topic: We will show you where you can get a form called an Advance Care Directive, how to fill it out, and why we should have one. At Level 2, an outside independent organization will review your request and our decision. If you or your doctor disagree with our decision, you can appeal. The Centers of Medicare and Medicaid Services (CMS) will cover transcatheter aortic valve replacement (TAVR) under Coverage with Evidence Development (CED) when specific requirements are met. In the instance where there is not FDA labeling specific to use in an MRI environment, coverage is only provided under specific conditions including the following: Medicare beneficiaries with an Implanted pacemaker (PM), implantable cardioverter defibrillator (ICD), cardiac resynchronization therapy pacemaker (CRT-P), and cardiac resynchronization therapy defibrillator (CRT-D). Apply Renewing Your Benefits Annually To keep your Medi-Cal coverage, youll have to renew once a year on your original sign-up date. The letter will tell you how to make a complaint about our decision to give you a standard decision. What is covered: Manufacturing accounts for 18.3% of the region's value added and provides employment for . CMS has updated Chapter 1, section 160.18 of the Medicare National Coverage Determinations Manual. 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, If your health requires it, ask the Independent Review Entity for a fast appeal.. Roundtrip prices range from $112 - $128, and one-ways to Grenoble start as low as $62. IEHP How to Get Care to part or all of what you asked for, we will make payment to you within 14 calendar days. See Chapters 7 and 9 of the IEHP DualChoice Member Handbookto learn how to ask the plan to pay you back. when beneficiaries are suspected of having white coat hypertension or masked hypertension in addition to the coverage criteria outlined in the, Ambulatory Blood Pressure Monitoring (ABPM), for the diagnosis of hypertension when either there is suspected white coat or masked hypertension. Advance care planning (ACP) involves shared decision making to write down-in an advance care directive-a persons wishes about their future medical care. (Effective: December 15, 2017) (Effective: February 15, 2018) Enrollment in IEHP DualChoice (HMO D-SNP) is dependent on contract renewal.