IEHP DualChoice, a Medicare Medi-Cal Plan, allows you to get your covered Medicare and Medi-Cal benefits through our plan. Non-Covered Use: The following uses are considered non-covered: Click here for more information on Blood-Derived Products for Chronic, Non-Healing Wounds coverage. Inform your Doctor about your medical condition, and concerns. (Effective: January 21, 2020) (Effective: January 19, 2021) Yes, you and your doctor may give us more information to support your appeal. If you wish, you can make your complaint about quality of care to our plan and also to the Quality Improvement Organization. This is a person who works with you, with our plan, and with your care team to help make a care plan. Welcome to Inland Empire Health Plan \. Get Help from an Independent Government Organization. If you do not choose a PCP when you join IEHPDualChoice, we will choose one for you. For more information on network providers refer to Chapter 1 of the IEHP DualChoice Member Handbook. Some hospitals have hospitalists who specialize in care for people during their hospital stay. Call, write, or fax us to make your request. Treatment of Atherosclerotic Obstructive Lesions You can ask us for a standard appeal or a fast appeal.. If you or your doctor disagree with our decision, you can appeal. 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). If you leave IEHPDualChoice, it may take time before your membership ends and your new Medicare coverage goes into effect. You have a care team that you help put together. You can also call if you want to give us more information about a request for payment you have already sent to us. Click here for more detailed information on PTA coverage. (866) 294-4347 3. After your application and supporting documents are received from your plan, the IMR decision will be made within 3 calendar days. 2023 IEHP DualChoice Member Handbook (PDF), Click here to download a free copy of Adobe Acrobat Reader. You can make the complaint at any time unless it is about a Part D drug. You will be able to get the service or item within 14 calendar days (for a standard coverage decision) or 72 hours (for a fast coverage decision) of when you asked. If you have any other feedback or concerns, or if you feel the plan is not addressing your problem, please call (800) MEDICARE (800) 633-4227). (Implementation date: August 29, 2017 for MAC local edits; January 2, 2018 for MCS shared edits) You can download a free copy by clicking here. You may contact the DMHC if you need help with a complaint involving an urgent issue or one that involves an immediate and serious threat to your health, you disagree with our plans decision about your complaint, or our plan has not resolved your complaint after 30 calendar days. Edit Tab. 1501 Capitol Ave., Average Interview. This allows you to pick the cheapest days to fly if your trip allows flexibility and score cheap flight deals to Grenoble. You can always contact your State Health Insurance Assistance Program (SHIP). And routes with connections may be . Click here for more information on Leadless Pacemakers. Click here for more information on Cochlear Implantation. If you are traveling within the US, but outside of the Plans service area, and you become ill, lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy if you follow all other coverage rules identified within this document and a network pharmacy is not available. IEHP DualChoice 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). You will be notified when this happens. You do not need to do anything further to get this Extra Help. Removing a restriction on our coverage. If the service or item is not covered, or you did not follow all the rules, we will send you a letter telling you we will not pay for the service or item and explaining why. Decide in advance how you want to be cared for in case you have a life-threatening illness or injury. Keep you and your family covered! Fill out the Independent Medical Review/Complaint Form available at: If you have them, attach copies of letters or other documents about the service or item that we denied. (800) 440-4347 IEHP Medi-Cal Member Services (800) 718-4347 (TTY), IEHP DualChoice Member Services Yes. ), and, Are age 21 and older at the time of enrollment, and, Have both Medicare Part A and Medicare Part B, and, Are a full-benefit dual eligible beneficiary and enroll in IEHP DualChoice for your Medicare benefits and Inland Empire Health Plan (IEHP) for your Medi-Cal benefits. "Coordinating" your services includes checking or consulting with other Plan providers about your care and how it is going. What if the Independent Review Entity says No to your Level 2 Appeal? This is called upholding the decision. It is also called turning down your appeal. TTY/TDD users should call 1-800-718-4347. To ensure fairness and prompt handling of your problems, each process has a set of rules, procedures, and deadlines that must be followed by us and by you. There may be qualifications or restrictions on the procedures below. Our plan does not cover urgently needed care or any other care if you receive the care outside of the United States. 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. Careers. Remember, if you get a bill that is more than your copay for covered services and items, you should not pay the bill yourself. 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. You must qualify for this benefit. Interventional echocardiographer meeting the requirements listed in the determination. The DMHC may waive the requirement that you first follow our appeal process in extraordinary and compelling cases. The procedure is used with a mitral valve TEER system that has received premarket approval from the FDA. Unless you change plans, IEHP DualChoice (HMO D-SNP) will provide your Medicare benefits. (Implementation Date: February 19, 2019) Erythrocythemia (increased red blood cells) with a hematocrit greater than 56%. Pay For Performance (P4P) and Proposition 56. H8894_DSNP_23_3241532_M. Our Plans IEHP DualChoice Cal , Health (1 days ago) WebWelcome to Inland Empire Health Plan \ Members \ Medical Benefits & Coverage Of Medi-Cal In California; main content TIER3 SUBLAYOUT. 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. Enrollment in IEHP DualChoice (HMO D-SNP) depends on contract renewal. The letter will tell you how to make a complaint about our decision to give you a standard decision. Covering a Part D drug that is not on our List of Covered Drugs (Formulary). See form below: Deadlines for a fast appeal at Level 2 CMS has updated Chapter 1, Part 1, Section 20.4 of the Medicare National Coverage Determinations Manual providing additional coverage criteria for Implantable Cardiac Defibrillators (ICD) for Ventricular Tachyarrhythmias (VTs). 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. 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. The DMHC may accept your application after 6 months if it determines that circumstances kept you from submitting your application in time. 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 ask for a State Hearing for Medi-Cal covered services and items. Member Login. How do I apply for Medi-Cal: Call the IEHP Enrollment Advisors at (866) 294-4347, Monday - Friday, 8am - 5pm. Who is covered: 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: June 21, 2019) An acute HBV infection could progress and lead to life-threatening complications. If the IMR is decided in your favor, we must give you the service or item you requested. 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 the answer is No, we will send you a letter telling you our reasons for saying No. Information on the page is current as of December 28, 2021 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. An interventional echocardiographer must perform transesophageal echocardiography during the procedure. If you miss the deadline for a good reason, you may still appeal. This means within 24 hours after we get your request. If you make an appeal for reimbursement, we must give you our answer within 60 calendar days after we get your appeal. Your PCP will also help you arrange or coordinate the rest of the covered services you get as a member of our Plan. You can also have your doctor or your representative call us. Share via LinkedIn. Receive information about your rights and responsibilities as an IEHP DualChoice Member.
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