Please fax Medicare Coverage Determination form(s) to Viva Medicare
on Medicare Part D drug(s) that will be filled at a dispensing pharmacy.
Please fax Commercial Coverage Determination form(s) to Viva Health
for other drug(s) that will be filled at a dispensing pharmacy.
PHARMACY FORMS - MEDICARE
PHARMACY FORMS - COMMERCIAL
AUTHORIZATION / PRE-CERTIFICATION FORMS
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:
Medicare Appeals Coordinator
417 20th Street North, Suite 1100
Birmingham, AL 35203
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.
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.
FORMULARY INFORMATION LIST
PHARMACY POLICIES - GENERAL
PHARMACY POLICIES - MEDICARE PART D
A note on compounding drugs
Compound drugs except when used for medically accepted indications that are supported by citations
in standard reference compendia for the specific route of administration being prescribed. Only
National Drug Codes (NDCs) for FDA approved prescription drug products are covered. Traditional
compounding bulk powders, chemicals, creams, and similar products are not FDA-approved drug products
and are not covered. Compounded products that are copies of commercially available FDA-approved drug
products and drugs coded as OTC (over the counter) are not covered. All compounded prescriptions are
subject to review and those with a total cost exceeding $200 are subject to Prior Approval.
PROVIDER MANUALS AND GUIDES
MEDICAL POLICIES - GENERAL