The Provider Manual covers the following Plans:
- VillageCareMAX Managed Long-Term Care (MLTC)
- VillageCareMAX Medicare Health Advantage Plan (HMO D-SNP)
- VillageCareMAX Medicare Health Advantage FLEX Plan (HMO D-SNP)
- VillageCareMAX Medicare Total Advantage Plan (HMO D-SNP)
- VillageCareMAX Medicare Select Advantage Plan (HMO)
Sections
Section 1: Quick Reference Guides
Section 2: VillageCareMAX Overview
Section 3: Enrollment Eligibility Criteria
Section 4: Enrollment Eligibility Verification
Section 5: Covered Benefits
Section 6: Model of Care
Section 7: Participating Provider Responsibilities
Section 8: Appointment Availability Standards
Section 9: Authorization Requirements
Section 10: List of Services that Require Prior Authorization
Section 11: Claims Submission
Section 12: Claims Appeals
Section 13: Adverse Reimbursement Change
Section 14: Medicaid Surplus and NAMI
Section 15: Third Party Insurance
Section 16: Marketing Guidelines
Section 17: Member Confidentiality
Section 18: Member Rights
Section 19: Grievance and Appeals
Section 20: Dispute Resolution
Section 21: Credentialing
Section 22: Participating Provider Audits
Section 23: Termination of Participating Providers
Section 24: Policies and Procedures
Section 25: Quality Management
Section 26: Fraud Waste and Abuse
Section 27: False Claims Act
Section 28: Compliance Requirements
Appendices
Appendices
Appendix 1: VillageCareMAX Lead Form
Appendix 2: Sample Authorization Letter
Appendix 3: Electronic Funds Transfer and Electronic Remittance Advice Forms
Appendix 4: Service Authorization Request Form
Appendix 5: Quality Improvement Program
Appendix 6: Clinical Practice Guidelines
Appendix 7: LHCSA Operational Guidelines
Appendix 8: Provider Information Change Form
Appendix 9: Important Information: CMS -10611 Form – Medicare Outpatient Observation Notice (MOON)
Appendix 10: DME Services that do not require Prior Authorization
Appendix 11: NYS DOH universal billing codes for home care and adult day health care services
Appendix 12: 2019 Medicare Part D Opioid Policies
Appendix 13: Update: NYS Medicaid Program Dental Policy and Procedure Code Manual
Appendix 14: Member Correspondence Grid
Appendix 15: VillageCareMAX Special Needs Plan Model of Care Training
Appendix 16: VillageCareMAX Health and Total Advantage Services do not require Prior Auth
Appendix 17: Participating Provider Termination Form
Appendix 18: VillageCareMAX CLAS Training Attestation
