Care Plans

CARE PLANS

2020 Model of Care

QI - Care Plan Member

QI - Care Plan Cancer

QI - Care Plan Congestive Heart Failure

QI - Care Plan Diabetes

QI - Care Plan High Blood Pressure

QI - Care Plan Stroke

COMPLIANCE TRAINING DOCUMENTS

GENERAL

Provider Compliance Training 2017

Viva Health COVERAGE POLICIES AND CRITERIA

General Statement
Medicare Policies
Commercial Policies
Medical Benefit Drugs

GENERAL STATEMENT

The Viva Health Coverage Policies and Criteria contain Policies approved by Viva. Policies are based upon criteria from the Centers of Medicare & Medicaid Services (CMS), CMS approved drug compendia, or scientific evidence of merit for a particular medication. They represent the medical criteria identified by CMS and by research to be safe and effective. Please refer to the policy disclaimer. The applicable Viva policy is the policy that is in effect at the time of service.

Restrictions and Limitations

Policies DO NOT determine the schedule of benefits. Rather, Policies are used in the process of determining whether a service may be medically necessary and appropriate or investigational.
Payment will not be made for any use of these drugs outside of the criteria without prior authorization. The member may not be billed unless the member explicitly agrees in writing to be responsible for the charges in accordance with the contract/provider manual. Prior authorization will only be given if the provider demonstrates the intended use meets Medicare coverage guidelines.
Policies are interpreted and applied in the sole discretion of the Plan.
Policy application is subject to state and federal laws and specific instructions from Plan Sponsors of self-insured groups.
Policies DO NOT constitute medical advice and DO NOT guarantee any results or outcomes.
Current Procedural Terminology (CPTÂ®) codes and descriptions are the property of the American Medical Association with all rights reserved.

» MEDICARE POLICIES (click to view)

» COMMERCIAL POLICIES (click to view)

LOCAL COVERAGE DETERMINATIONS

MEDICARE POLICIES

COMMERCIAL POLICIES

PHARMACY POLICIES - COMMERCIAL MEMBERS

Commercial Pharmacy Coverage Determination Request Form

Specialty Drug List All unclassified drug codes (such as J3490, J3590, J8999 and J9999) require prior authorization. When requesting authorization for an unclassified drug, please submit the NDC#, Drug Name, and Dosage. Other Specialty Medications not listed on this list may be covered under your medical benefits. If covered, these drugs are subject to the cost-sharing specified in Attachment A and may be subject to Prior Authorization.

Medical Benefit Drugs

Medical Benefit Drug Prior Authorization Form

Medical Preferred Drug Program

Oncology and Support Drug Prior Authorization Reference List

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

Medicare Part D - Coverage Determination Form This form is not required to be used to request a coverage determination for a Medicare Part D member.

Hospice Beneficiary - Medicare Part D Request Form

PHARMACY FORMS - COMMERCIAL

Commercial Pharmacy Coverage Determination Form

OTHER INFORMATION

EFT - Electronic Payment Flyer 2021 EFT Flyer

Request for Reopening vs. Appeal Viva Medicare Pre-Service Requests Only

BEHAVIORAL HEALTH

Applied Behavior Analysis (ABA) Initial and Concurrent Authorization Request Form

Psychological-Neurological Testing Request Form

Transcranial Magnetic Stimulation Authorization Request Form

Electroconvulsive Therapy (ECT) Authorization Request Form

Mental Health Continued Stay Review Fax Form

Mental Health Initial Review Fax Form

Substance Abuse Initial Review Fax Form

Substance Abuse Continued Stay Review Form

Discharge Orders Fax Form

AUTHORIZATION / PRECERTIFICATION FORMS

Medical Benefit Drug Prior Authorization Form

Skilled Nursing Facility (SNF) Precertification Form

Imaging Request Form

Referral Authorization Form

DME Form

Therapy Precertification Form Physical, Speech, and Occupational Therapy

Inpatient/Outpatient Precertification Form

Rehabilitation Precertification Forms Physical, Speech, and Occupational Therapy and Nursing and Wound Care

SNF/Rehab Discharge Documentation

PHARMACY FORMS - MEDICARE

Medicare Part D - Coverage Determination Form This form is not required to be used to request a coverage determination for a Medicare Part D member.

Hospice Beneficiary - Medicare Part D Request Form

PHARMACY FORMS - COMMERCIAL

Commercial Pharmacy Coverage Determination Form

REGIONAL CARE ORGANIZATIONS

Alabama Care Plan Referral Form

Alabama Care Plan Health Home Provider Reference Guide

Health Home Provider Reference Guide

Gulf Coast RCO Referral Form

Care Network of AL Referral Form

Care Network of AL Reference Guide

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.

» Waiver of Liability Statement Form

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.

» Fraud Complaint Form

FORMULARY INFORMATION LIST

LEGAL DOCUMENTS

2020 Viva Medicare Plus, Premier, Prime, and Me Plans Comprehensive Formulary Updated December 2020

2020 Viva Medicare Extra Value Comprehensive Formulary Updated December 2020

2021 Viva Medicare Premier and HH Preferred Plans Comprehensive Formulary

2021 Viva Medicare Extra Value and HH Extra Care Plans Comprehensive Formulary

2021 Viva Medicare Plus, Prime, Me and HH Classic Plans Comprehensive Formulary

PHARMACY POLICIES - GENERAL

High Risk Medications Pocket Guide

PHARMACY POLICIES - MEDICARE PART D

2020 Viva Medicare Plus, Premier, Prime and Me (Non SNP) Prior Authorization Criteria Updated December 2020

2020 Viva Medicare Extra Value (SNP) Prior Authorization Criteria Updated December 2020

2020 Viva Medicare Extra Value (SNP) - Cumulative Changes Updated December 2020

2020 Viva Medicare Plus, Premier, Prime and Me Plans (Non SNP) - Cumulative Changes Updated December 2020

2021 Viva Medicare Premier and Preferred (Non SNP) Prior Authorization Criteria

2021 Viva Medicare Plus, Prime, Me, and Classic (Non SNP) Prior Authorization Criteria

2021Viva Medicare Extra Value and Extra Care (SNP) Prior Authorization Criteria

2021 Viva Medicare Premier and Preferred (Non SNP) Step Therapy Criteria

2021 Viva Medicare Plus, Prime, Me and Classic (Non-SNP) Step Therapy Criteria

2021 Viva Medicare Extra Value and Extra Care (SNP) Step Therapy Criteria

2020 Viva Medicare Plus, Premier, Prime and Me (Non SNP) Step Therapy Criteria Updated April 2020

2020 Viva Medicare Extra Value (SNP) Step Therapy Criteria

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.

PRIOR AUTHORIZATION LIST

MANUALS

Quick Reference Guide Viva Health and Viva Medicare Plans

PROVIDER MANUALS AND GUIDES

LEGAL DOCUMENTS

St. Vincent's East Provider Directory includes St. Vincent's East, St Vincent's Blount, and St. Vincent's St. Clair ONLY

UAB Provider Directory

Medical West Provider Directory

MANUALS

Quick Reference Guide Viva Health and Viva Medicare Plans

Provider Access Matrix 2021

Viva Health/Viva Medicare Provider Manual 2021

Viva Health NPI Compliance Plan

MEDICAL POLICIES - GENERAL

Urine Drug Testing in Pain Management - Policy

Pain Management Referral Policy Medicare

PROVIDER DIRECTORIES

Open Panel Provider Directory

Viva Medicare St. Vincent's Me Provider Directory St. Vincent's Health System Physician Alliance

Viva Medicare Brookwood Baptist Me Provider Directory Brookwood Baptist Health System Physician Alliance

Viva Medicare Southeast Me Provider Directory Southeast Me Provider Directory