2024 Policy Updates
ADHC Transportation Benefit Carve Out
The transportation benefit is carved out of the Managed Long-Term Care (MLTC) Plan benefit package effective March 1, 2024. ADHCS now need to bill Medicaid FFS to seek reimbursement and not MLTC or MAP plans.
SDC Transportation and Billing Code Changes
Effective 3/1/2024 Non-Emergency Medical Transportation is no longer covered by MLTC and MAP plan. VillageCareMAX will continue to cover the following Medicare covered transportation services through Sentry.
For SADC programs that provide or subcontract transportation as part of their contract with VillageC-areMAX to-and-from the program, the transportation will be covered by the plan through SADC. ALL PROVIDERS ARE REQUIRED TO USE BILLING CODE A0130 EFFECTIVE 4/1/24.
For SADC programs that DO not provide or subcontract transportation as part of their contract with Vil-lageCareMAX to-and-from the program, the transportation will be covered by Fee for Service Medicaid through MAS.
| Benefit | Prior Auth Required (Yes/No) | Plan Coverage |
| Emergency Ambulance Services (Medicare-covered) Transport to the nearest appropriate facility that can provide care only if they are furnished to a member whose medical condition is such that other means of transportation could endanger the person’s health |
No | MTA Dual (501) MTA Medicare Only (503) MHA (301) MHA Flex (311) MSA (601) |
| Non-Emergency Ambulance Services (Medicare-covered) Medicare covers limited non-emergency ambulances. Non-emergency transportation by ambulance is appropriate if it is documented that the member’s condition is such that other means of transportation could endanger the person’s health and that transportation by ambulance is medically required. |
Yes (via Vendor Eligibility File) | MTA Dual (501) MTA Medicare Only (503) MHA (301) MHA Flex (311) MSA (601) |
| Non-Emergency Transportation (Part C Supplemental Benefit) Plan covers non-emergency transportation services that are not covered by Medicare as a supplemental benefit. Covered benefits include: • Up to (36) one-way trips per year to plan approved locations. • Transportation trips are covered for travel by taxi, van, or ride share services. |
Yes (via Vendor Eligibility File) | MHA (301) MHA Flex (311) |
| Non-Medical Transportation (Part C Supplemental Benefit) Plan covers non-emergency transportation services that are not covered by Medicare as a supplemental benefit. Covered benefits include: • Up to (12) one- way trips (6 round trips) per year for non- medical appointments to plan approved locations. • Transportation trips are covered for travel by taxi, van, or ride share services. |
Yes (via Vendor Eligibility File) | MTA Dual (501) MTA Medicare Only (503) |
Provider Training Coming Soon
Annual Provider Trainings 2024
We are excited to announce Halogen, a new web-based platform, will be used this year to deliver the 2024 required annual provider training for both Model of Care and Cultural Sensitivity Awareness. We anticipate this to happen in June. We urge all providers to also visit our website now to complete this training through below links:
VCMAX Special Needs Plan Model of Care Training Attestation Form (Preview) (office.com)
VCMAX CULTURALLY AND LINGUISTICALLY APPROPRIATE SERVICES TRAINING ATTESTATION (Preview) (office.com)
ACTION NEEDED: To ensure seamless delivery of these mandatory sessions, we kindly request providers to update your email. Please click this direct link for the Provider Demographic Change Form (e.g. changes or additions to: address, phone, fax, email, panel, directory, Tax ID, etc.) or visit our website at https://www.villagecaremax.org/providers/provider-demographic-change-form.
Self-Serve Electronic Tools
VillageCareMax Self-Serve Provider Portals play a pivotal role in streamlining administrative tasks and enhancing efficiency within healthcare systems. Providers can easily access pertinent information, and handle Auth, claim related tasks with ease, ultimately leading to improved patient care and satisfaction. Please take advantage of the link below to access these vital functions and experience the transformative benefits firsthand.
Authorization Provider Portal: Link
Key Function:
- Submit or Withdrawal Prior Auth Requests
- Review Auth Status, Download Results
- Adding Discharge Summary or Any additional information related to that Auth
Claims & Eligibility Portal: Link
Key Function:
- Verify Member’s Eligibility
- Review Claims Status
- Submit Claims Inquiry/Appeals
- Obtain Provider Forms for Different Requests
Care Management: Interdisciplinary Care Team (ICT) Update
Providers, you are a critical part of the Interdisciplinary Care Team (ICT) for our Medicare members!
Our care management team holds interdisciplinary care team meetings with our members, and we encourage you to participate.
During the ICT meeting we discussed the plan of care for our members to ensure they remain safe in their homes and communities by coordinating needed care and services.
Again, we encourage you to participate. Our care managers will reach out to you or your office to invite you.
If you are not able to attend, we ask that you send any clinical staff or navigators you have as a resource supporting your patients. Our members’ care will be better for your participation!
Quality Management
Cologard Member Education
VillagecareMax has partnered with Exact sciences to send Cologuard kits to our members in May of 2024. Cologuard is a one-of-a-kind noninvasive and effective at-home colon cancer screening test that requires no prep and looks for both abnormal DNA and blood in stool. It is for members who are low risk for Colorectal cancer. Please educate and guide members if they reach out to your office regarding receiving the Cologuard kit. You can find out more about how to use Cologuard here,
Link: https://www.cologuard.com/how-to-use-cologuard
HEDIS Measures & Billing Codes
As state and federal governments move toward a quality-driven healthcare industry, HEDIS rates are becoming more important for both health plans and individual providers. State purchasers of healthcare use aggregated HEDIS rates to evaluate health insurance companies' efforts to improve preventive health outreach for members.
Physician-specific scores are also used to measure your practice's preventive care efforts. Your practice's HEDIS score determines your rates for physician incentive programs that pay you an increased premium — for example Pay for Performance or Quality Bonus Funds.
Please see our 2024 HEDIS Reference Guide for billing codes and more details: Link
Physician Network Pharmacy Corner
Medication Adherence Matters
Improving the health of our members and Star Ratings for our Plan Medication adherence measures a member’s adherence to diabetes, hypertension and cholesterol lowering medications, as well as Statin Use in Persons with Diabetes (SUPD). With your collaboration we can close gaps in care and help your patients with barriers to medication, thus improving our star ratings. This is heavily reliant on Doctors, Nurses and Medical personnel alike to ensure current and sufficient prescription refills for all patients.
Formulary
Please refer to our provider website for pharmacy information and a complete list of covered prescription medications (Formulary), which includes the most current information on Step-Therapy (ST), Prior Authorizations (PA) and Quantity limits (QL). It is important to stay updated on the formulary to avoid gaps in care. Please continue below for links to our Formulary list, Prior Authorization request form and our coverage determination inquiry resources.
VillageCareMAX 2024 Formulary Coverage Determination Form
Prior Authorization Request Form Coverage Determination Web Portal
Top Non-Formulary Drugs 2024
Prior Authorizations
The VillageCareMAX Medicare Total Advantage Plan requires Prescribers to get prior authorization for certain drugs. This means that you will need to get approval from us before prescriptions are filled for your patients. If you don’t get approval, the plan may not cover the drug. When completing our PA forms, please be sure to include patient diagnoses and other unsuccessful therapy trials, if applicable.
Link: 2024 List of drugs that require prior authorization
Step Therapy
In some instances, VillageCareMAX Medicare Total Advantage Plan may require our members to try certain drugs to treat their medical condition before we will cover another drug for that same condition. This is called Step Therapy.
Link: 2024 List of drugs that require step therapy
Choice 100 Program
VillageCareMax is pleased to announce a new pharmacy program to assist our members and pre-scribers with medication adherence for chronic maintenance medication. Members may now receive up to a 100-day supply at their local community pharmacy of choice. To assist with this enhancement, the prescriber will receive a fax notification that their patient is eligible for a 100-day supply for targeted medications. In addition, the prescriber will receive a pre-populated form that can be forwarded to the pharmacy. Alternatively, the prescriber can E- Prescribe a new prescription with 100-day supply and 3 refills. This will cover the member and the pharmacy for up to one year of prescription refills.
Group Potential Benefits Members With 100-day supply, there are fewer trips needed to the pharmacy, saving the member time. Members can also improve their medication adherence and disease management. Choice 100-day supply fills have the same copay as Choice 90.
Prescribers Doctors benefit from writing fewer prescriptions and reducing administrative burden for medications that remain unchanged, improved adherence metrics, healthier patients, and enhanced health outcomes.
Specialty Pharmacy Network/Mail Order
MedImpact offers VillageCareMAX participating physicians a direct delivery program to the
office setting for a select list of specialty medications. Direct delivery to the practice reduces the administrative burden of office staff and eliminates the need to buy and bill. A
| Group | Potential Benefits |
| Members | With 100-day supply, there are fewer trips needed to the pharmacy, saving the member time. Members can also improve their medication adherence and disease management. Choice 100-day supply fills have the same copay as Choice 90. |
| Prescribers | Doctors benefit from writing fewer prescriptions and reducing administrative burden for medications that remain unchanged, improved adherence metrics, healthier patients, and enhanced health outcomes |
clinical pharmacist will assist the physician team in shipping the medication just in time for
the members’ medical office appointment. Refills will be managed by the MedImpact team
who will contact your office in advance of all deliveries to ensure the regimen is current and
accurate.
VCM Mail Order Form
For additional information on how to enroll and participate in this program go to:
https://www.medimpact.com or call toll-free at 1-855-873-8739 (TTY dial 711).
Customer Service Hours
Monday-Friday: 7:00 am - 7:00 pm Central Time
Saturday: 8:00 am - 4:00 pm Central Time
Helpful Reminder
Behavioral Health Service Code
FRIENDLY REMINDER: All claims submitted to Carelon for Behavioral Health services must include a valid
rate code to process and pay. Any claims without a valid code will cause claim issues and delays in payment.
For more information regarding claims submissions and eligibility, benefits and claim status please click
here: Beacon Behavioral Health Claim Submission; Beacon Behavioral Health Phone #: (800) 397-1630
Group Potential Benefits
Members With 100-day supply, there are fewer trips needed to the pharmacy, saving
the member time. Members can also improve their medication adherence
and disease management. Choice 100-day supply fills have the same copay
as Choice 90.
Prescribers Doctors benefit from writing fewer prescriptions and reducing administrative
burden for medications that remain unchanged, improved adherence metrics, healthier patients, and
enhanced health outcomes.
Meal Delivery Service Available for Members
Emphasizing the vital role of meals in maintaining health, we're pleased to authorize and offer meal delivery to patients' homes based on their needs.
MLTC and MAP members have unlimited access, while DSNP members (excluding Flex) are covered for
up to 2 meals daily for 4 weeks, totaling 56 meals annually.
Please inform your patients of this valuable resource if necessary, as it can significantly contribute to their
overall health and well-being. Thank you for your dedication to the health of our members!
Provider Authorization Fax #s
For new participating provider enrolling, please remember you can fax prior authorization requests using
the following fax numbers. You may find more provider info here: https://www.villagecaremax.org/provider
