If the coverage decision is No, how will I find out? After your application and supporting documents are received from your plan, the IMR decision will be made within 3 calendar days. If our answer is No to part or all of what you asked for, we will send you a letter that explains why we said No. You can file a grievance online. You should provide all requested information such as your full name, address, telephone number, the name of the plan or county that took the action against you, the aid program(s) involved, and a detailed reason why you want a hearing. (Implementation Date: February 19, 2019) You must apply for an IMR within 6 months after we send you a written decision about your appeal. The procedure must be performed in a hospital with infrastructure and experience meeting the requirements in this determination. If we say no to part or all of your Level 1 Appeal, we will send you a letter. But if you do pay the bill, you can get a refund if you followed the rules for getting services and items. Effective for dates of service on or after January 1, 2022, CMS has updated section 180.1 of the National Coverage Determination Manual to cover three hours of administration during one year of Medical Nutrition Therapy (MNT) in patients with a diagnosis of renal disease or diabetes, as defined in 42 CFR 410.130. Effective for claims with dates of service on or after 12/07/16, Medicare will cover PILD under CED for beneficiaries with LSS when provided in an approved clinical study. Your care team may include yourself, your caregiver, doctors, nurses, counselors, or other health professionals. An integrated health plan for people with both Medicare and Medi-Cal. If the plan says No at Level 1, what happens next? When your complaint is about quality of care. IEHP - MediCal Long-Term Services and Supports : Welcome to Inland Empire Health Plan \. How to Enroll with IEHP DualChoice (HMO D-SNP), IEHP Texting Program Terms and Conditions. TTY should call (800) 718-4347. Yes. Decide in advance how you want to be cared for in case you have a life-threatening illness or injury. If the Food and Drug Administration (FDA) says a drug you are taking is not safe or the drugs manufacturer takes a drug off the market, we will take it off the Drug List. Box 997413 You can call SHIP at 1-800-434-0222. 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. Whether you call or write, you should contact IEHP DualChoice Member Services right away. You can ask us to reimburse you for our share of the cost by submitting a claim form. If you are admitted to one of these hospitals, a hospitalist may serve as your caregiver as long as you remain in the hospital. Until your membership ends, you are still a member of our plan. A Level 1 Appeal is the first appeal to our plan. 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. Make necessary appointments for routine and sick care, and inform your Doctor when you are unable to make a scheduled appointment. If you are under a Doctors care for an acute condition, serious chronic condition, pregnancy, terminal illness, newborn care, or a scheduled surgery, you may ask to continue seeing your current Doctor. (800) 718-4347 (TTY), IEHP 24-Hour Nurse Advice Line (for IEHP Members only) Receive information about IEHP DualChoice, its programs and services, its Doctors, Providers, health care facilities, and your drug coverage and costs, which you can understand. 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, You can call IEHP DualChoice at (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. Our state has an organization called Livanta Beneficiary & Family Centered Care (BFCC) Quality Improvement Organization (QIO). Here are two ways to get information directly from Medicare: By clicking on this link, you will be leaving the IEHP DualChoice website. We may stop any aid paid pending you are receiving. The organization will send you a letter explaining its decision. Contact: Tel : 04 76 61 52 00 - E-Mail. 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. 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. These reviews are especially important for members who have more than one provider who prescribes their drugs. See below for a brief description of each NCD. IEHP DualChoice network providers are required to comply with minimum standards for pharmacy practices as established by the State of California. (Effective: February 15, 2018) If we decide that your health does not meet the requirements for a fast coverage decision, we will send you a letter. You can call us at: (877) 273-IEHP (4347), 8am-8pm (PST), 7 days a week, including holidays. CMS reviews studies to determine if they meet the criteria listed in Section 160.18 of the National Coverage Determination Manual. IEHP DualChoice (HMO D-SNP) has contracts with pharmacies that equals or exceeds CMS requirements for pharmacy access in your area. TTY users should call 1-800-718-4347 or email us at msdirectories@iehp.org How does IEHP confirm your doctor and hospital facts? If your problem is about a Medi-Cal service or item, you will need to file a Level 2 Appeal yourself. CMS has updated Chapter 1, Part 1, Section 20.7 of the Medicare National Coverage Determinations Manual providing additional information regarding PTA. To see if you qualify for getting extra help, you can contact: Do you need help getting the care you need? Box 4259 You cannot ask for an exception to the copayment or coinsurance amount we require you to pay for the drug. Department of Health Care Services If you would like to switch from our plan to Original Medicare but you have not selected a separate Medicare prescription drug plan. This is called prior authorization. Sometimes the requirement for getting approval in advance helps guide appropriate use of certain drugs. You, your representative, or your doctor (or other prescriber) can do this. 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. Open Solicitations - RFP's and Bids. 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. Autologous Platelet-Rich Plasma (PRP) treatment of acute surgical wounds when applied directly to the close incision, or for splitting or open wounds. All of our Doctors offices and service providers have the form or we can mail one to you. (Implementation Date: June 16, 2020). Deadlines for standard appeal at Level 2. What if the Independent Review Entity says No to your Level 2 Appeal? Please see below for more information. Your IEHP DualChoice Doctor cannot charge you for covered health care services, except for required co-payments. Our plan cannot cover a drug purchased outside the United States and its territories. No more than 20 acupuncture treatments may be administered annually. If you are not satisfied with the result of the IMR, you can still ask for a State Hearing. Effective for dates of service on or after December 15, 2017, CMS has updated section 220.6.19 of the National Coverage Determination Manual clarifying there are no nationally covered indications for Positron Emission Tomography NaF-18 (NaF-18 PET). Your membership will usually end on the first day of the month after we receive your request to change plans. Copy Page Link. 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. Complain about IEHP DualChoice, its Providers, or your care. The letter will also explain how you can appeal our decision. Your provider will also know about this change. If your health requires it, ask us to give you a fast coverage decision Who is covered? Changing plans after you're enrolled | HealthCare.gov D-SNP Transition. You, your doctor or other prescriber, or your representative can request the Level 2 Appeal. 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. What is covered? Information on the page is current as of March 2, 2023 If you decide to go on to a Level 2 Appeal, the Independent Review Entity (IRE) will review our decision. Health Care Coverage | Riverside County Department of Public Social If you wish, you and your doctor or other prescriber may give us additional information to support your appeal. Contact us promptly call IEHP DualChoice at (877) 273-IEHP (4347), 8am - 8pm, 7 days a week, including holidays.TTY users should call 1-800-718-4347. All the changes are reviewed and approved by a selected group of Providers and Pharmacists that are currently in practice. 2023 IEHP DualChoice Provider and Pharmacy Directory (PDF), http://www.dmhc.ca.gov/FileaComplaint/SubmitanIndependentMedicalReviewComplaintForm.aspx, Request for Medicare Prescription Drug Coverage Determination (PDF). It is very important to get a referral (approval in advance) from your PCP before you see a Plan specialist or certain other providers. Dependent edema (gravity related swelling due to excess fluid) suggesting congestive heart failure; or, The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists. If we are using the fast deadlines, we must give you our answer within 24 hours.