PROVIDERS

2024 Viva Medicare Special Needs Plan Model of Care (SNP MOC) Provider Training

The Centers for Medicare & Medicaid Services (CMS) requires that Medicare Advantage Organizations provide Special Needs Plan Model of Care (MOC) training to all Medicare providers that care for our valued dual eligible members. The Model of Care serves as the foundation for Viva Medicare’s care management policies and procedures. To remain compliant with CMS guidelines, MOC training must be completed annually by all Medicare providers.

Note: This training is required for Medicare providers, only.
Click here to complete your SNP MOC provider training today!

Viva Health's 2024 Acute/Post-Acute Retrospective Review Notification

Viva Health is committed to providing access to high quality, medically necessary health care services and building a collaborative partnership with providers in our network. In 2024, Viva Health will continue to ensure timely and appropriate access to medically necessary care for your patients and our members.

These notifications serve as notice of changes to Viva Health's policies and procedures regarding acute and post-acute care reviews for inpatient stays for Medicare members and provider appeals for claims related to Medicare and commercial members. These changes are effective January 1, 2024. To view the notifications, see below.

Acute Retrospective Review Notification & FAQs

Post-Acute Retrospective Review Notification & FAQs

Utilization Management Criteria and Policies

The Centers for Medicare & Medicaid Services (CMS) is the government agency that manages Medicare Advantage plans throughout the United States. CMS limits Medicare coverage to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). They require health plans, like Viva Medicare, to base decisions about covering items, services, or medications on National and Local Coverage Determinations.

National Coverage Determinations (NCD) and Local Coverage Determinations (LCDs) are a general outline of coverage that is in place for all Medicare Advantage health plans. NCDs and LCDs are made through an evidence-based process.

When there are no National or Local Coverage Determination policies available, Viva Medicare is allowed to use other evidenced based, recognized coverage criteria, such as the National Comprehensive Cancer Network , or our vendor InterQual®. For the few services in which no criteria is available through these resources, CMS allows us to create an internal policy, using evidenced-based sources.

Viva Health makes all of these criteria publicly available for anyone who wants to view them. The links to the resources are below:

If you have any questions or need help finding a specific criteria, please call Provider Customer Service at 1-800-294-7780, 8am - 5pm, Monday - Friday.

Applied Behavioral Analysis (ABA) Prior Authorizations

ATTENTION: Viva Health will no longer provide retrospective authorizations for Applied Behavioral Analysis (ABA) therapy for Viva Health members.

Effective 09/01/2022, Viva Health will require a prior authorization for Applied Behavioral Analysis (ABA) therapy for Viva Health Members. Initial prior authorization requests can be obtained via phone or fax. For more information click here.

Real-Time Prescription Benefits

Providers treating Viva Medicare patients can use the real-time prescription benefit tool to see drug coverage information, patient cost, up to five alternatives specific to the patient’s plan, and other restriction such as prior authorizations and quantity limits.

For more information, click the links below.

Resources

Pharmacy Compliance Reminders

Viva Medicare has noted medications being prescribed for conditions that are not covered under Medicare Part D. When we pay a drug claim and later discover the drug is not covered for the specified condition, it results in the following:

  • Viva Medicare is obligated to reverse the claim and refund CMS for the inappropriate payment.
  • The member must pay out of pocket for the drug, causing a negative member/patient experience.

To ensure proper benefit payment under Medicare Part D benefits, please be aware of the Medicare coverage rules for the drugs shown below. Non-covered prescribing of these medications will result in rejection of prescription drug claims.

 

Glucagon-like Peptide 1 (GLP-1) Drugs

GLP-1 drugs are considered a first line treatment for patients diagnosed with Type 2 Diabetes Mellitus with ASCVD (Atherosclerotic Cardiovascular Disease) risk.

GLP-1 drugs:

  • Bydureon BCise®
  • Byetta®
  • Ozempic®
  • Rybelsus®
  • Trulicity®
  • Victoza®
  • Adlyxin®

 

Medicare Part D allows coverage of GLP-1 drugs for Type 2 Diabetes Mellitus treatment.
Metabolic syndrome, obesity, pre-diabetes, and weight loss are not coverable conditions under Medicare Part D.

There are formulations of these drug categories specifically FDA approved for weight loss (Saxenda®/ Wegovy®). If that is the intended use, then prescribe those instead. CMS does not allow coverage of weight loss drugs, and they will reject appropriately under Part D coverage and prevent the compliance concerns discussed above.

EFT Availability

Viva Health has selected Change Healthcare (formerly Emdeon) as its electronic payment and remittance reporting provider. Change Healthcare ePayment replaces paper-based claims payments with electronic (EFT) payments that are directly deposited into your bank account. To learn more about this service and how you can sign up, download this [PDF] document.

Change Healthcare (formerly Emdeon) is Viva Health's electronic payment and remittance administrator. There is no fee to use Change Healthcare (formerly Emdeon) ePayment. Enrollment is simple and free.

By enrolling with Change Healthcare, you can accelerate your reimbursement cycle, eliminate paper based claims payments, sorting mail, and making trips to the bank. In addition to receiving payments electronically, Change Healthcare ePayment users can search, view, and print electronic remittance advices (ERAs).

To get started, medical providers can enroll through Payer Enrollment Services by visiting https://payerenrollservices.com or by calling 1-800-956-5190. Dental providers can enroll by visiting https://dental.changehealthcare.com or by calling 1-888-255-7293. NOTE: If you have signed up for EFT, please expect a return email from Change Healthcare verifying your bank account information. Please respond accordingly.

Medical Preferred Drug Program with Step Therapy

Effective January 1, 2022, Viva Health added a Medical Preferred Drug Program with Step Therapy requirements for our Medicare Advantage members. This program is already in place for our commercial members and applies to drugs administered by medical providers such as doctors and hospitals (not retail pharmacies). Click here for information about the program.

Pain Management Referrals Removed

Effective 7/1/20 Viva Medicare members will no longer be required to have a Primary Care Physician referral in order to see a Pain Management physician. Here is an updated copy of our 2020 Provider Reference Guide listing the services that require a prior authorization. Click here to view.

Participating Lab Usage

Viva Health is dedicated to working with you to ensure quality care is provided at the lowest cost possible to our members. We need help from you to continue this effort. According to your provider contract, you should only refer patients to participating providers, including lab services. If you use a non-par lab, look for communication from Viva Health regarding a change in our policy that may negatively impact your fee schedule. Our participating laboratories are listed in this document.

Provider Network Information

Recent changes to section 100.4 of the Medicare Marketing Guidelines now require Health Plans to contact network providers quarterly to verify the information listed in the Health Plan's provider directory.

You should have received a letter from us with the information we have on record for you.

If you have any changes, please email vivaproviderservices@uabmc.edu or call Viva Health Customer Service at (205) 558-7474 or 800-294-7780. We will then update your information on our website.

Coordination of Benefits Update

Viva Health is proud to announce secondary HCFA and UB claims can now be filed electronically for all Commercial, Medicare, and Drummond lines of business. If you have any questions, please feel free to contact our Provider Customer Service department directly at (205) 558-7474.

No Surprises Act Information

If you are a commercial provider not in Viva Health's network and disagree with a payment you received and it is subject to the No Surprises Act (NSA), you may initiate a 30-business-day open negotiation period to determine the out-of-network rate. Please contact the Viva Health Provider Services Department at vivaparticipation@uabmc.edu. If the negotiation period does not result in an agreement, you may initiate the Federal Independent Dispute Resolution (IDR) process. Please note, patients may not be balance billed for services covered by the NSA.

If you would like to join Viva Health’s network, please contact Viva Health Provider Services at vivaparticipation@uabmc.edu.