COMPLIANCE TRAINING DOCUMENTS
Viva Health COVERAGE POLICIES AND CRITERIA
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 (CPT®) 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
COMMERCIAL POLICIES
PHARMACY POLICIES - COMMERCIAL MEMBERS
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.
Forms
Please fax Coverage Determination form(s) to
Viva Health at
205-449-2465 on 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
Please fax Coverage Determination form(s) to
Viva Health at
205-449-2465 on drug(s) that will be filled at a dispensing pharmacy.
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.
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