PROVIDERS

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 only 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, contact Change Healthcare: Phone: 1.866.506.2830 Fax: 615.238.9615 Online: www.changehealthcare.com Mail: Attention – Electronic Payment Service Enrollment P.O. Box 148850 Nashville, TN 37214 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 is adding 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.