2023 - 2nd Quarter Provider Bulletin

Diabetes Awareness: How Primary Care Providers Can Educate Their Patients

There has been an increase in members utilizing emergency services for high or low Blood Glucose (BG) levels that can be safely managed at home. Many members are unaware of how to truly manage their blood sugars. In fact, they're unsure of what their readings even mean. Educating (and re-educating) members on treating their BGs at home is extremely important in preventing unnecessary emergency department visits and hospital admissions:

  • Help members identify a healthy range for their glucose readings.
  • Highlight the effects that water consumption and exercise have on decreasing blood sugar.
  • For insulin users, encourage additional insulin use at times of hyperglycemia (as specified by the provider).
  • Ensure members have glucose tablets at home or adequate food sources on hand to raise blood sugar (hypoglycemia) from the "comfort of their couch." 


Teaching members how to identify signs and symptoms of both hyper and hypoglycemia can be helpful in recognizing the need for treatment sooner rather than later, especially if they are unable to check their glucose levels at that time.

It may be beneficial to create a "protocol" with these members and/or share generalized documentation to remind them of what to do during hyperglycemic or hypoglycemic episodes. Often, these members can treat their sugar safely without having to utilize emergency services. 

Identify polypharmacy members and work with them on medication reconciliation and proper usage (and storage) of medications. Sometimes, numerous medications can lead to confusion. Working to reduce the number of medications (oral or injectable) can cut down on confusion and increase compliance over time.

At the very least, encouraging members to call their primary care office to receive further instruction when their BG is outside of range can be helpful in managing these members at home.

Physician Highlight:
Dr. Mohamed Aniff, MD, Medical Director for Emerest Health IPA

Dr. Mohammad Aniff is the Medical Director for Emerest Connect, where he designs clinical programs that provide quality care to vulnerable patients in New York City. His expertise in internal medicine and geriatrics, with over 15 years of experience, allows him to specialize in developing programs for older adults. Before joining Emerest, Dr. Aniff served as Chief Medical Officer, leading large IPA and PCP groups to adopt value-based care in their practices.
Dr. Aniff is proud to work for Emerest because he is part of a highly talented and dedicated team that provides 24/7 patient care. Through collaboration with assigned PCPs for each patient, Emerest manages the most complex patients in their panel, leading to better outcomes by reducing avoidable hospitalizations, improving quality metrics, and increasing patient satisfaction. As a result of these efforts, Emerest has successfully reduced hospitalization rates for providers by 22% and provided relief for loneliness (88%), depression (86%), and pain (83%).

"At Emerest Connect, we are honored to partner with organizations such as VillageCareMAX to enrich member lives through remote patient management," says Dr. Aniff. "We care not only for our patient's physical health but also their mental and behavioral well-being."

Behavioral Health (BH) Claims Submission to Carelon

Primary Care Provider (PCP) appropriate screenings, when applicable:PCPs may bill Carelon with code G0444 (the Medicare-approved code for annual depression screening) or if assessing using the PHQ-9 questionnaire, please proceed using CPT® code 96127 (brief emotional/behavioral assessment), as applicable in conjunction with diagnosis code Z13. 13 (screening for depression). 

Reminder: Effective January 1, 2023, VillageCareMAX Behavioral Health benefits are administered by Carelon Behavioral Health (formerly known as Beacon Health Options) for MAP and DSNP programs.

  • All Utilization Management (UM), Care Management (CM), Provider Relations (PR), claims processing, and call center operations related to behavioral health are managed by Carelon. 
  • Any providers who wish to provide behavioral health services to VillageCareMAX members must participate with Carelon for VillageCareMAX. 
  • Any claims relating to covered behavioral health services must be submitted to Carelon for payment.


Important Information for Carelon Behavioral Health:

For more information regarding claim submissions and eligibility, benefits, and claim status, please click here:  https://s21151.pcdn.co/wp-content/uploads/2.18.22-Availity-Transition_Updated-Provider-FAQ_FINAL.pdf

Pharmacy Corner - MedImpact

The VillageCare Specialty Pharmacy program is managed under MedImpact Direct Specialty (Birdi) and delivers specialty medications to your location of choice. 

Pharmacy Network 

This program helps deliver specialty medications to providers to treat patients’ complex medical conditions, including but not limited to immune deficiency, rheumatoid arthritis, and osteoporosis.

Specialty medication coverage is based on the member’s benefit. Prior authorization approval may still apply to specific specialty medications.

By obtaining these medications from these preferred specialty pharmacies. Providers will benefit from:

  • No upfront acquisition cost
  • Convenient delivery of medication to location of choice: provider office/site of practice/patients home
  • Coordination of refills
  • Compliance with nationally recognized guidelines and standards


The network of pharmacies provides clinical services for you and your patients and deliver to the location of choice. The pharmacies will contact the patients each month to start a refill, review adherence and answer questions. For each therapy, the network pharmacies provide:

 Information to improve patient outcomes:                                

  • Patient education
  • Managing side effects
  • Lab reviews
  • Coordination with doctor’s appointment
  • Outreach calls to help patients with therapy
  • Quality checks


Click here for the MedImpact Direct Specialty Referral Form 

Call MedImpact Direct Specialty 1-877-391-1103 8am-8pm EST

Provider Appeals/Dispute Process

Health care providers can use the VillageCareMAX dispute and appeal process if they do not agree with a claim or utilization review decision

Product Lines Offered by VillageCareMAX:

  • MLTC - Managed Long-Term Care Plan
  • DSNP - Medicare Health Advantage Plan
  • DSNP - Medicare Health Advantage FLEX Plan
  • MAP - Medicare Total Advantage Plan


Claim Appeals: 
Provider does not agree with claim determination (denial)

Payment Dispute: 
Provider does not agree with the amount of payment

Reconsideration of a Claim: 
At times, a provider may be dissatisfied with a decision made by VillageCareMAX regarding a claim determination. Some of the common denials and reasons for reconsideration include incorrectly processed or denied claim, incorrect paid amount, or failure to obtain prior authorization. Providers who are dissatisfied with a claim determination made by VillageCareMAX must submit a written request for review and reconsideration with all supporting documentation to VillageCareMAX within forty-five (45) calendar days of receipt of a claim determination for MLTC and within sixty (60) calendar days of receipt of a claim determination for Health Advantage and Total Advantage.

In-Network/Out-of-Network Provider Claim Appeals/Payment Disputes must be in writing and should be sent to: 
ILS – VillageCareMAX
Provider Services Department 
P.O. Box 21516 

In-Network Providers
May submit requests via provider portal 24 hours a day, 7 days a week

Information Include In Request for Reconsideration/Appeal: 

  • A written statement explaining why you disagree with VillageCareMAX’s claim determination
  • Provider’s name, address, and telephone number
  • Provider’s identification number
  • Member’s name and VillageCareMAX identification number
  • Date(s) of service
  • VillageCareMAX claim number
  • A copy of the original claim or corrected claim, if applicable
  • A copy of the VillageCareMAX EOP
  • A copy of the EOP from another insurer or carrier (e.g.) Medicare, along with supporting medical records to demonstrate medical necessity
  • Contract rate sheet to support payment rate or fee schedule
  • Evidence of eligibility verification
  • Evidence that initial claim was submitted on time


VillageCareMAX will investigate all written requests for Review and Reconsideration, and issue a written explanation stating that the claim has been either reprocessed or the initial denial has been upheld, generally within sixty (60) calendar days from the date of receipt of the provider’s request for Review and Reconsideration.

If a provider submits a request for review and reconsideration after the forty- five (45) calendar day time frame for MLTC or the sixty (60) calendar time frame for Health Advantage, Health Advantage FLEX and Total Advantage, the request is deemed ineligible and will be dismissed.  

Network Management Team Contact Info

Click the following link to access the VIllageCareMAX Provider Manual and Quick Reference Guides on the VillageCareMAX website: https://www.villagecaremax.org/provider-manual/
Please refer to below grid for your account manager’s contact info, and if any questions or you need to confirm who your account manager is, please contact our team at [email protected]

Provider Relations Account Manager Contact Info:

Peter Siyi Xie Community-Based Providers, IPAs, Groups [email protected]
Jinyu "Andrea" Lin  Community-Based Providers, IPAs, Groups [email protected]
David Godoy Community-Based Providers, IPAs, Groups [email protected]
Yarha Frederique Community-Based Providers, IPAs, Groups [email protected]
Alexis Ortiz Community-Based Providers, IPAs, Groups [email protected]
Sergio Ferguson Hospital-Based Providers in Queens and Manhattan [email protected]
Orlando Santos Hospital-Based Providers in Queens and Manhattan [email protected]
Reina Peguero Ancillaries (Labs, Meals, SNFs, etc.) & Single Case Agreements [email protected]
Nancy Martinez LHCSAs, Fiscal Intermedaries (FIs)/CDPAPs, CHHAs, Social Adult Day Cares (SADCs) [email protected]
Tameka Robinson LHCSAs, Fiscal Intermedaries (FIs)/CDPAPs, CHHAs, Social Adult Day Cares (SADCs) [email protected]

Provider Demographic Updates:
Please refer to our Provider Online Search Tool  to verify that your provider information is up-to-date.  If any changes needed, please fill out the update form at link (https://d2mcoh0vajf3v0.cloudfront.net/production/public/files/docs/ForProviders/2023/Provider%20Manual/FINAL_VCM%20Provider%20Manual_20221220.pdf#page=165) and submit to your Account Manager at the email addresses above.

Preparing for the End of the Public Health Emergency (PHE)


CMS developed Frequently Asked Questions (FAQ) to help prepare for the expiration of the COVID-19 PHE and are relevant for all CMS programs; including, Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and private insurance.

Please see below for some key takeaways from the FAQs. (see FAQs for additional information)

  • Based on current COVID-19 trends, the Department of Health and Human Services (HHS) is planning for the federal Public Health Emergency for COVID-19 (PHE) declared by the Secretary of the Department of Health and Human Services (Secretary) under Section 319 of the Public Health Service (PHS) Act to expire at the end of the day on May 11, 2023.
  • The PHE for COVID-19 declared by the Secretary under section 319 of the PHS Act is not the same as the COVID-19 National Emergency declared by President Trump in 2020, which ended when President Biden signed H.J.Res.7.
  • People with Medicare coverage will continue to have access to COVID-19 vaccinations without out-of-pocket costs after the end of the PHE.
  • Under the Medicare Part B preventive vaccine benefit, CMS will continue to pay approximately $40 per dose for administering COVID-19 vaccines through the end of the calendar year in which the Secretary ends the Emergency Use Authorization (EUA) declaration for drugs and biologicals with respect to COVID-19. 
  • Medicare will continue to pay an additional amount of about $36 in addition to regular administration fees for the administration of COVID-19 vaccines at home when the PHE ends.
  • Beginning on July 1, 2023, SNFs will be responsible for billing for vaccines furnished to SNF patients in a Part A stay.
  • For individuals enrolled in a MA plan, the plans must cover treatments that Traditional Medicare covers, but they may require the individual to see a provider who is in the MA plan’s network and may have different cost sharing than Traditional Medicare.
  • For certain DME supplies and ongoing rental items provided during the PHE, CMS allowed certain flexibilities and has not enforced certain NCD and LCD requirements.


CMS resources for the expiration of the COVID-19 PHE:


Risk Adjustment Coding Corner

A Medicare Annual Wellness Visit (AWV) is an opportunity to promote quality, proactive, cost-effective care
Who can perform an AWV: A physician, PA, NP, certified clinical nurse specialist or a medical professional under the direct supervision of a physician (including health educators, registered dietitians and other licensed practitioners) can perform AWVs
AWV documentation
Document all diagnoses and conditions to accurately reflect severity of illness and risk of high-cost care to the appropriate specificity

AWV coding 
An ICD-10 Z code is the first diagnosis code to list for wellness exams to ensure that member financial responsibility is $0

  • Z00.00 — encounter for general adult medical examination without abnormal findings
  • Z00.01 — encounter for general adult medical examination with abnormal findings


The CPT® codes used to report AWV services are:*


  • G0402 —  Welcome to Medicare visit
  • G0438 — initial visit**
  • G0439 — subsequent visit (no lifetime limits)
  • G0468 — FQHC distinction for billing an AWV visit 


Click here to view Annual Wellness Visits Guidelines (PDF)

 **Additional services ordered during an AWV may be applied toward the patient’s deductible and/or be subject to coinsurance. Before performing additional services, discuss them
with the patient to verify that the patient understands their financial responsibilities
More information
 . https://www.medicare.gov/coverage/yearly-wellness-visits
 *CPT® is a registered trademark of the American Medical Association

How to Code Social Determinants of Health Care

Social Determinants of Health or (SDoH) Z- codes are the codes ranging from Z55-Z65 which are the ICD-10-CM encounter reason codes used to document SDOH data (e.g., housing, food insecurity, transportation, etc.) They are also Risk Adjustable. Below are tips on how to appropriately code and capture Z codes for Social Determinants of Health.

Step 1. Collect SDOH Data Any member of a person's care team can collect SDOH data during any encounter. • Includes providers, social workers, community health workers, case managers, patient navigators, and nurses. • Can be collected at intake through health risk assessments, screening tools, person-provider interaction, and individual self-reporting.

Step 2. Data are recorded in a person's paper or electronic health record (EHR). • SDOH data may be documented in the problem or diagnosis list, patient or client history, or provider notes. • Care teams may collect more detailed SDOH data than current Z codes allow. These data should be retained. • Efforts are ongoing to close Z code gaps and standardize SDOH data

Step 3. Map SDOH Data to Z Codes Assistance is available from the ICD-10-CM Official Guidelines for Coding and Reporting.1 • Coding, billing, and EHR systems help coders assign standardized codes (e.g., Z codes). • Coders can assign SDOH Z codes based on self-reported data and/or information documented by any member of the care team if their documentation is included in the official medical record.

Step 4. Use SDOH Z Code Data analysis can help improve quality, care coordination, and experience of care• Identify individuals’ social risk factors and unmet needs. • Inform health care and services, follow-up, and discharge planning. • Trigger referrals to social services that meet individuals' needs. • Track referrals between providers and social service organizations

Step 5. Report SDOH Z Code Data Findings. SDOH data can be added to key reports for executive leadership and Boards of Directors to inform value-based care opportunities. • Findings can be shared with social service organizations, providers, health plans, and consumer/patient advisory boards to identify unmet needs. • A can be used to identify opportunities for advancing health equity.

Reference points:


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