2025 Important VillageCareMAX News
Feature Story: Dr. JP Gonzalez-Torres, DDS, Dental Director – New York, Liberty Dental Plan
Why Comprehensive Dentistry Is Better for Your Long-Term Health
I often see patients who just want to fix one thing at a time. They ask me, “Why can’t you just do this crown?” or “I want an implant on this tooth.” I understand the urge to fix things right away, but some-times, we need to address other more urgent issues first. I usually tell them, “It’s not in your best interest to focus on the crown or implant just yet, and here’s why….” My goal is to give you comprehensive dental care that not only fixes your immediate problems but also helps you stay healthy in the long run.
As we get older, our dental needs change and become more unique. It is important to think beyond just fixing problems as they come up. That is where comprehensive dentistry comes in. Instead of just focusing on one issue at a time, it takes a broader approach—looking at your overall oral health and planning for the future. There’s no one-size-fits-all solution that will make your mouth healthier. By doing a thorough exam, your primary dentist can spend time talking to you to understand your specific situation—whether it is dealing with missing teeth, dry mouth, or discomfort with dentures—and develop a treatment plan that is exactly right for you. It is all about what works best for your health, comfort, and goals.
Comprehensive dentistry also lets your dentist catch potential problems early, like gum disease or teeth grinding, before they become serious. The result? Fewer dental emergencies and a healthier mouth over time. So, instead of waiting until something goes wrong, your primary dentist can help you focus on pre-venting issues before they start. Regular checkups, cleanings, and routine treatments can help stop things like tooth decay or gum disease before they get out of hand. This can save you from having to deal with bigger, more expensive treatments down the road. Your dentist can also detect early signs of systemic health issues, such as diabetes, by spotting changes in your mouth.
Imagine having a dental team that understands your entire health picture. It is like having a personal cheerleader for your mouth! Instead of hopping from one dentist to another, trying to find the best deal, or dealing with multiple specialists for different issues, I suggest you chat with your primary dentist. They can help you create a plan that makes dental care easier and less stressful. With this plan, you will have fewer visits, and your dentist will get to know you better. They will be able to provide the best care possible over time. Plus, with comprehensive dentistry, your dentist can help you stay healthy and happy for years to come. Why wait for dental emergency? Schedule your next visit with your dentist and discuss how to maintain a healthy smile and feel great for years to come!
New Claims System – effective January 1, 2025
As previously shared over the last month, we would like to remind you the way you work with us – including how you submit claims – has changed effective January 1, 2025, as VillageCareMAX has changed the vendor we use for some operations.
Below is a summary of the resources we have prepared for our providers to highlight these important changes:
• Summary of Changes 2024 vs 2025: Please click this link.
• Quick Reference Guide for Providers: Please click this link.
• Provider Authorization Portal Quick Reference Guide: Please click this link.
• 2025 VillageCareMAX Provider Education Webinar: Please click this link to view a recording of the webinar held in December 2024.
• Availity: Create your free Availity account to submit claims starting January 1st.
o Availity setup guide: Please click this link.
If questions with creating account, please email: [email protected]
If questions after creating account, in Availity Essentials menu bar, click Help & Training > Availity Support to access online support ticketing and online chat or call 1.800.AVAILITY (282.4548).
o Availity Reference Guide Users: Please click this link.
o Availity Reference Guide Administrators: Please click this link.
For any concerns about claims payment please contact our Provider Services Call Center at 855-769-2500. If you have continued questions that are unresolved, please email the VillageCareMAX Provider Relations team at [email protected].
Clinical criteria
To access the clinical criteria that was used to make a determination, please visit the VillageCareMAX website, click on Resources, and select Clinical Criteria Guidelines or access directly at the following link: https://www.villagecaremax.org/providers/transparency
VillageCareMAX uses evidence-based nationally recognized tool InterQual to support clinical decision-making. To review the guidelines utilized for a specific diagnosis or procedure, please access the following link: InterQual® Criteria
*Registration is required to view the guidelines. Accounts are free and available to the public.
Patients should consult their member-specific benefit plan document for information regarding covered benefits. As always, a patient should discuss any medical concerns with their primary care provider.
Annual Wellness Visits
We would like to remind providers of the importance of Preventive Care Exams and Visits for our members. These visits are a key component of preventive care, helping identify potential health risks and supporting the overall well-being of your patients.
Key Points to Remember:
• Annual Wellness Visits (AWVs) are covered by the patient’s benefit plan at no cost to them.
• Annual Wellness Visits are different from Initial Preventative Physical Exams (IPPE).
• There are no prior authorization requirements for AWVs and IPPE, making it easier for patients to access these vital preventive services.
• Procedure Codes for AWVs:
o G0402: Initial preventive physical examination (IPPE) – “Welcome to Medi-care” visit
o G0438: Annual wellness visit, initial visit
o G0439: Annual wellness visit, subsequent visit
• Wellness visits can be performed during a primary care appointment or, in some cases, during a specialty visit (e.g., with a cardiologist, pulmonologist, or endocrinologist).
• Encouraging annual check-ups ensures early detection of potential health issues and helps patients maintain their health.
We value your commitment to providing excellent care and encourage you to promote Annual Wellness Visits as part of your practice.
For additional information about Annual Wellness Visits you can visit the following web-site: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/preventive-services/medicare-wellness-visits.html
What you need to know about CAHPS Survey
The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program is an annual survey to support and promote the assessment of patients’ experiences with health care providers and access to health care services. The CAHPS survey covers topics important to consumers and focuses on quality measures such as the communication skills of Health Plan's Customer Service and ease of access to health care services.
From February to May a random sample of VillageCareMAX Medicare plan members receive the CAHPS survey. Member participation in this survey is voluntary. If members need assistance with completing this survey, Members can contact the survey vendor, Press Ganey. In addition members can receive help from family, friends, providers (including LHCSAs), and community leaders.
How can you impact the CAHPS Survey?
- Maintain access and availability standards
- Offer convenient appointment times
- Immediately schedule follow-up appointments to ensure continuity of care
- Assist members with scheduling appointments with specialists
- Share health records with patients’ other providers to keep everyone informed
- Review the patient’s medical record prior to entering the room. Patients are asked if their doctor knew their medical history
- Use language the patient can understand when reviewing test results and explain how these test results relate to their current health
- Ask patients what their treatment goals are and assess treatment options against those goals
- Ask patients about other doctors and specialists they have seen
- Encourage patients to get a flu vaccine for the flu season
- Review patient medications during office or telehealth visits and emphasize the importance of adhering to these medications.
- Prescribe 90-day or 100-day supplies for chronic medications to assist patients with medication adherence
Providers and Office Staff Can Help Patients Complete Surveys by:
- Reading and explaining the survey questions and answering choices to the patient.
- Entering the patients’ answers onto the survey sheet.
- Placing the completed survey into the envelope and mailing the survey.
Social Care Network (SCN)
Effective January 1, 2025, VillageCareMAX is contracting with the following Social Care Network providers for VillageCareMAX MLTC and MAP members to improve integration across health, behavioral health, and social care.
SCNs will identify Medicaid Members’ unmet social needs, navigate Members to Health-Related Social Needs (HRSN) services, and reimburse HRSN service providers. SCNs include a range of service providers such as Community-Based Organizations (CBOs) and other partners e.g. regional non-profits, health care providers. Organizations in an SCN will use shared data and technology to better integrate social, behavioral, and physical health services and improve Member experience.
| Organization Name | Region | Location | Website |
| Health and Welfare Council of Long Island "HEALI" |
Long Island: Nassau, Suffolk Bronx |
110 Walt Whitman Rd. Suite 101 Huntington Station, NY 11746 |
www.healiny.org |
| Hudson Valley Care Coalition | Hudson Valley: Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster, Westchester | 560 White Plains, Suite 200 Tarrytown NY 10591 |
https://hudsonvalleycare.org/ |
| Public Health Solutions | NY (Manhattan), Queens, Brooklyn (Kings) | 40 Worth St, 4th Fl, New York , NY 10013 |
https://wholeyou.nyc |
| Staten Island Performing Provider System LLC | Richmond (Staten Island) | 1 Edgewater Plaza Suite 700 Staten Island, NY 10305 |
https://statenislandpps.org/social-care-network/ for information. |
| Somos Healthcare Providers, Inc. DBA Somos Community Care | Bronx | 2910 Exterior St, 1st Fl, Bronx, NY 10463 | www.somosscn.org |
Please see the New York State Department of Health website at the following link for more information on SCNs: https://www.health.ny.gov/health_care/medicaid/redesign/sdh/scn/
Public Partnerships LLC (PPL)
PPL was selected as the Statewide Fiscal Intermediary (SFI) vendor, and effective April 1, 2025, will be the only entity authorized to provide fiscal intermediary services for the CDPAP per Social Services Law section 365-f. See the announcement here. Per guidance provided by New York State Department of Health (NYS DOH), Fiscal Intermediaries (FIs) are working with plans to transition members to Public Partnerships LLC (PPL).
NYS DOH Memo: https://www.health.ny.gov/health_care/medicaid/redesign/mrt90/mltc_policy/2024/docs/24-04_memo.pdf
NYS DOH MLTC Policy 24.04: https://www.health.ny.https://d2mcoh0vajf3v0.cloudfront.net/production/public/files/documents/Providers/2025/Q1%20Provider%20Newsletter/NYS%20MLTC%20Policy.pdfgov/health_care/medicaid/redesign/mrt90/2024/docs/mltc_policy_24.04.pdf
Pharmacy Information
TransActRX: New Part D Vaccine Billing Option
Providers can go through TransactRX for Part D drugs such as Shingrx vaccine that are provided at the physician’s office without needing members to go to the pharmacy to get the vaccine for the physician. TransactRX will reimburse for the vaccine and the administration fee, which will improve the ease of vaccination for both the member and physician. We encourage providers who are not signed up with TransactRX to sign up.
Benefits to You and Your Patient:
This online resource will help alleviate the burdensome process of manual billing and reimbursement for vaccine and vaccine administrative services. TransactRx also helps beneficiaries minimize up front, out-of-pocket expenditures for vaccines. Enrollment in TransactRx is available at no cost to you or your patient. Payment for submitted claims will come directly from TransactRx twice a month. You will know at the time of service if your patient has a Medicare Part D benefit and the net reimbursement you will be paid for administering the vaccine. Once enrolled, you will be able to:
Verify members’ eligibility and benefits in real-time, Submit vaccine claims electronically, Receive reimbursement information in real-time.
Enrollment Instructions:
You or your authorized staff member may enroll at http://enroll.mytransactrx.com. This is a one-time process that can be updated at any time. The following information will be required: Tax Identification Number (TIN), National Provider Identifier(s) (NPI), Medicare ID number, Drug Enforcement Administration (DEA) number, State Medical License number, Acceptance of TransactRx Vaccine Manager’s Agreement
For questions on enrollment and claims processing, call TransactRx Vaccine Manager Customer support center at (866) 522-3386. To learn more about TransactRx you are invited to view a web based demonstration. To register for an online, live demonstration please visit: www.transactrx.com.
Coverage Determinations and the Formulary
• Medications that are on the VillageCareMAX formulary are covered under Medicare Part D.
• However, within the formulary, some medications must meet certain clinical criteria before Vil-lageCareMAX will pay for the medication.
• Medications can have coverage determination requirements because of clinical rationale, cost-effectiveness, cheaper available formulary alternatives, or all the above.
• Coverage determination requirements can include prior authorizations, step therapy, quantity limits, and other utilization management limitations.
• A formulary exception request is a separate process that requires a different application.
• Both applications are available on our website at https://villagecaremax.org
Top Non-Formulary Drugs 2025
Pharmacy Resource Guide
Transportation Benefit Notice
As a follow-up communication to the VillageCareMAX Provider Bulletin sent in May 2024, effective 3/1/2024, Non-Emergency Medical Transportation is no longer covered by MLTC and MAP plan(s). VillageCareMAX will continue to cover the following Medicare covered transportation services through our transportation vendor, Sentry.
For Social Adult Day Care (SADC) programs that provide or subcontract transportation as part of their contract with VillageCareMAX to-and-from the program, the transportation requires approval by the plan as per their current contract in order to be covered. For SADC programs that DO NOT provide or subcontract transportation as part of their contract with VillageCareMAX 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) |
Sentry Non-Emergent Ambulance Request
*Please allow VillageCareMAX one business day to process the request once received*
Fax request to 212-402-4468 (hospital) / 978-967-8030 (SNF)
Call request to Customer Service 800-469-6292
Transportation Requests:
• Patient name, plan ID, DOB
• Medical reason for ambulance request
• Date of service
• Pick up address: Name of Hospital & address
• Drop off address: Name of Hospital/SNF & address
• Contact person in the hospital: (nurses' station number)
• Details where the patient is (floor-room):
• Best contact number for patient/aid/family member:
Additional information if known:
• Weight of the patient
• Height of the patient
• Oxygen needed?
• Bariatric stretcher needed?
• Are there steps in the patient's home, if so, how many?
• Is the patient aware of their surroundings?
• Does the patient have access and keys to the drop off location?
• Are they traveling alone?
• Does the patient have a DNR?
HEDIS Corner
Pain Intensity
Overtime Quality Measure: Stable or Improved Pain Intensity.
This measure evaluates whether members maintain or improve their ability to manage or reduce pain intensity over time.
Why it Matters:
Effective pain management enhances quality of life by helping members remain active, engaged, and independent. It also reduces hospitalizations, ER visits, medication overuse, dependency, and related mismanagement, ultimately improving satisfaction for both members and caregivers.
How can Providers Assist our Members?
Ø Comprehensive Pain Evaluation
• Conduct regular pain assessments, monitor symptom changes and trends, and adjust care plans accordingly.
• Differentiate between acute, chronic, and breakthrough pain.
• Identify underlying causes and non-pain-related contributors (e.g., anxiety, depression).
Ø Optimize Medication Management
• Ensure proper use of analgesics, NSAIDs, and neuropathic pain agents.
• Avoid unnecessary opioid prescriptions; use multimodal pain management approaches.
• Monitor for side effects, drug interactions, signs of overuse and adjust based on effectiveness and member response.
Ø Non-Pharmacologic Pain Management Strategies
• Utilize physical therapy and rehabilitation to improve strength and flexibility.
• Utilize Cognitive-behavioral therapy (CBT) for coping with pain perception.
• Explore alternative treatments like acupuncture, massage, and heat/cold therapy for pain relief.
• Encourage the use of assistive devices (e.g., walkers, braces, or ergonomic seating).
Ø Care Coordination & Referral Management
• Collaborate with pain specialists, physical therapists, and palliative care teams.
• Refer members for interventional procedures if needed (e.g., nerve blocks, injections).
• Partner with care managers to ensure access to home-based pain management services.
