Forms
Please fax Medicare Coverage Determination form(s) to
Viva Medicare at
205-449-2465 on Medicare Part D drug(s) that will be filled at a dispensing pharmacy.
Please fax Commercial Coverage Determination form(s) to
Viva Health at
205-872-0458 for other drug(s) that will be filled at a dispensing pharmacy.
PHARMACY FORMS - MEDICARE
PHARMACY FORMS - COMMERCIAL
AUTHORIZATION / PRECERTIFICATION FORMS
PHARMACY FORMS - MEDICARE
PHARMACY FORMS - COMMERCIAL
REGIONAL CARE ORGANIZATIONS
WAIVER OF LIABILITY
Appeals Process for Non-contracted Medicare Providers
Pursuant to federal regulations governing the Medicare Advantage program, non-contracted providers may request reconsideration (appeal) of a Medicare Advantage plan payment denial determination. To appeal a claim denial, a written request and a completed Waiver of Liability Statement form must be submitted to Viva Medicare within 60 calendar days of the date on the claim denial letter. Please also submit a copy of the original claim, remittance notification showing the denial, and any clinical records and other documentation that will support your argument for reimbursement.
The Centers for Medicare and Medicaid Services (CMS) describes the Medicare appeal process available to non-contracted providers in Section 60.1.1 of Chapter 13 of the Medicare Managed Care Manual, which is titled "Non-Contracted Provider Appeals". Section 60.1.1 of Chapter 13 of the Medicare Managed Care Manual states:
A non-contracted provider, on his or her own behalf, is permitted to file a standard appeal for a denied claim only if the non-contracted provider completes a waiver of liability statement, which provides that the non-contracted provider will not bill the enrollee regardless of the outcome of the appeal.
Click the link below to obtain a copy of the Waiver of Liability Statement form. Please note that the Waiver of Liability Statement form must be completed in its entirety. The Medicare Health Insurance Claim Number (HICN) must be included on the Waiver of Liability Statement form.
Please submit the completed Waiver of Liability Statement and your written appeal request to:
VIVA MEDICARE
Medicare Appeals Coordinator
417 20th Street North, Suite 1100
Birmingham, AL 35203
FAX: (205)933-1239
If you have questions regarding the non-contracted provider appeal process, please contact our Customer Service Department at (205) 558-7474 or 1-800-294-7780.
FRAUD COMPLAINT
If you suspect Medicare fraud or abuse, please click the link below to file your complaint. Your name is not required.
Viva Medicare will protect your anonymity to the fullest extent of the law.
PROVIDER MANUALS AND GUIDES
MEDICAL POLICIES - GENERAL