2024 - 1st Quarter Provider Bulletin

Special Needs Plan (SNP) Model of Care Training

The Special Needs Plans (SNP) Model of Care (MOC) Training Program is a basic training required by The Centers for Medicare & Medicaid Services (CMS) for all contracted medical Providers and staff.   As per CMS, “the Model of Care is a vital quality improvement tool and integral component for ensuring that the unique needs of each enrollee are identified by the SNP and addressed through the plan's care management practices.

ACTION NEEDED: You are required to complete this training for all SNP Plans.  The purpose of the training is for the provider to support the Special Needs Plan Model of Care while understanding CMS requirements for managing those members.  


Cultural and Linguistic Training

The Culturally and Linguistically Appropriate Services (CLAS) Training Program is a training required by VillageCareMAX (VCMAX) and the Office for Minority Health (OMH) at the U.S Department of Health and Human Services (HHS).  As a VCMAX provider, you are required to complete this training. The purpose of the Program is to communicate with providers the 15 National CLAS Standards broken up into (4) categories: Principal Standard; Governance, Leadership and Workforce; Communication and Language Assistance; and Engagement, Continuous Improvement, and Accountability.

ACTION REQUIRED: Please use the attestation link below to attest to completing this required training on your behalf and or on the behalf of your organization. A receipt of your completed Attestation Form will ensure the VillageCareMAX and provider remain compliant in these requirements by CMS and OMH.


VillageCareMAX – 2024 Plan Products/ Benefit Updates

VillageCareMAX Provider Education Sessions:
VillageCareMAX hosted 3 Provider Education webinars in November to review the changes in 2024 related to NEW plan products, benefit highlights, pharmacy programs, quality initiatives, and more. 

If you would like to view a recorded session, please click the following link, enter your Name and Email Address, and click “Register”, and the webinar will start playing in your window browser: https://attendee.gotowebinar.com/recording/8654411488405697792

If you would like a copy of the handout presented during this session, please send an email to [email protected] and request a copy of the “2024 VillageCareMAX Provider Education Presentation”, and our team will send you the PowerPoint for your records.

VillageCareMAX 2024 Plan Products

Click here to view the 2024 VillageCareMAX Medicare Benefits Portfolio (PDF)

Managed Long-Term Care (MLTC): 
VillageCareMAX MLTC is a Medicaid Managed Care Long-Term Care (MLTC) plan that provides members with long-term care services and supports like personal care, adult day health care and others. This product is for Medicaid eligible individuals.

Medicare Total Advantage (MAP)
VillageCareMAX Medicare Total Advantage Plan (HMO D-SNP) is a Medicare Special Needs Plan that provide benefits designed for individuals with special health care needs as well as long-term care services and supports who are dual eligible for Medicare and Medicaid.

Dual Special Needs Plan (HMO DSNP): 
VillageCareMAX Medicare Health Advantage Plan (HMO D-SNP) is a Medicare Special Needs Plan that provide benefits designed for individuals with special health care needs who are dually eligible for Medicare and Medicaid. Individuals must live in the counties in which VillageCareMAX is licensed to operate.

FLEX Dual Special Needs Plan (HMO DSNP): 
VillageCareMAX Medicare Health Advantage FLEX Plan (HMO D-SNP) is a Medicare Special Needs Plan that provide benefits designed for individuals with special health care needs who are dually eligible for Medicare and Medicaid. Individuals must live in the counties in which VillageCareMAX is licensed to operate. With the FLEX benefit option, members can get even more covered services to fit their dental, vision or hearing needs.

NEW: Medicare Select Advantage Plan (HMO)
•    Effective January 1, 2024, VillageCareMAX will be offering a new plan called VillageCareMAX Medicare Select Advantage Plan.
•    VillageCareMAX created Medicare Select Advantage, a Non-D-SNP Medicare Plan, intended for Medicare members who are Medicare eligible and receive financial full “Extra Help“, also referred to as the Low-Income Subsidy plan (LIS), to pay for Part D benefits.
•    Eligible members are not eligible for Medicaid.
•    This is a $0 premium and deductible plan when the member receives Extra Help. Members pay $0 for primary doctor and preventive visits, and Part D prescription copays are as low as $4.50 for generics and $11.20 for brand medications
•    Providers will need to collect copays and coinsurance from members for Medicare covered services
•    This plan offers members non-Medicare supplemental benefits such as vision, hearing, and dental as well as a fitness program.

Provider Claims Processing and Billing

Electronic Submission of Claims for physical health claims only - Not Applicable for Behavioral Health Claims
Participating Providers may submit electronic claims by using VillageCareMAX's Change Health Care Payer ID/Submitter ID: 26545. Electronic Claims must be submitted in 837I or 837P format. Please refer to the Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA/835) forms in Appendix 3 of the Provider Manual or the following direct links:

•    Change Health Care EFT & ERA Forms for Professional Providers
•    Change Health Care EFT & ERA Forms for Institutional Providers

Claims for authorized services must be submitted to VillageCareMAX generally within ninety (90) days from the date of service, but providers should always review their contracts for specific timely filing timeframes.
All paper claims, correspondence, and Claims Disputes and Appeals should be submitted in writing to: 

ILS - VillageCareMAX 
Provider Services Department
P.O. Box 21516
Eagan, MN 55121

Claims disputes and Appeals must be submitted within forty-five (45) days for MLTC and sixty (60) days for MA and MAP from the date of decision.
For claims-related inquiries, please call Provider Services at 1-855-769-2500
For EFT Inquiry/Status Updates, please contact 855-769-2500 or email [email protected]
For ERA Inquiry/Status Updates, please contact 866-924-4634 or email [email protected]

Required documentation for Hospital Admission approvals, continued stay, and discharge planning 

All VillageCareMAX Hospital partners are encouraged to refer the Documentation Template below prior to submitting any requests for clinical information.  The cheat sheet below outlines all the required clinical information needed for the Utilization Team to determine medical necessity for a member’s inpatient admission, continued stay and the appropriate discharge planning.  Any submissions/requests for clinical information without some of these needed clinical elements may delay the process in receiving a determination. 
VillageCareMAX is committed to our members and you, our providers.   Please collaborate with us and ensure all needed parties on your side are educated on the clinical documentation requirements attached and the importance of timely submissions. 

VillageCareMAX Request for Clinical Information Template

Clinical information is critical for the clinical review process. To evaluate the medical necessity for each member, receiving the most updated, accurate and complete information helps to make the most appropriate determination for our members.

As a result, the following clinical information is needed during an initial admission clinical review. Please note that additional clinical may be required depending upon the member’s clinical scenario:
•    Primary Diagnosis driving the hospital admission.
•    Presentation upon Emergency Department Triage
•    Vital signs including but not limited to: BP, RR, SPO2, HR, Temperature
•    History and Physical
•    Treatment and progress to treatment in Emergency Department
•    Any labs that are abnormal and pertinent to the admission diagnoses or determining the clinical scenario of the member
•    Medications and response to medications including I&Os during hydration therapy
•    Diagnostics including but not limited to CXR, CT, Ultrasound, MRI
•    Treatment plans including consultation notes.

If a LOS review is required, the following clinical information is needed during the review:
•    Vital signs including I&Os
•    Consultation Notes
•    Operative reports
•    Changes in medications
•    Follow up diagnostics, labs and testing
•    Progress to discharge
•    Therapy evaluation notes (OT, ST, PT)
•    Barriers impacting discharge including social determinants of health
•    Potential anticipated discharge to post -acute inpatient placement (e.g., Acute Rehab, Skilled Nursing)
•    Anticipated Durable Medical equipment (DME) needs.
•    Anticipated discharge date

During a discharge planning review, the following clinical information is needed to support the member effectively transitioning to the next level of care or back to the community:
•    Resumption of care activities in the community
•    Any post discharge limitations (e.g., physical, mental, social)
•    Post follow up care needs (e.g., provider, specialist, therapies)
•    Post hospital specialty services (e.g., infusion, home care, wound care, dialysis, enteral new titration for new or existing peg, TPN)
•    Post discharge authorization required to support the members transition back to home and community
In addition to the clinical information required in the above sections, for complex cases such as CHF, COPD, Diabetes, Chest Pain, CKD, the below outlines the specific clinical that should also be received for those specific complex diagnosis.

Chest Pain:
•    Vital Signs Including SPO2 on room air, temperature, ED visit treatment
•    Pain management
•    Response to treatment in ED
•    Cardiac medication interventions including infusions.
•    3 sets of Cardiac enzymes with dates and times
•    CXR, EKG,
•    O2 therapy
•    Cardiology consultation note and intervention recommendations.

•    Vital Signs Including SPO2 on room air, temperature, ED visit treatment
•    Response to treatment in ED
•    Tachypnea
•    Unable to speak in full sentences, labor breathing, Use of accessory muscles, unable to take PO, hunched over position, sitting due to respiratory effort,
•    Arterial blood gas values
•    Bronchodilator and corticosteroid treatment frequency
•    CXR, EKG, CT Scan
•    O2 therapy
•    Antibiotics
•    Specialist consultation and intervention recommendations

•    Vital Signs Including SPO2 on room air, temperature, ED visit treatment
•    Dyspnea, Lung examination
•    Physical assessment for classical CHF symptoms: Edema, S3 auscultation, Jugular vein distention
•    BNP, troponin, Creatinine, Electrolytes, Arterial blood gas values
•    Diuretic treatment,
•    Response to treatment in ED
•    CXR, EKG, CT Scan
•    O2 therapy
•    Antibiotics

•    Vital Signs Including SPO2 on room air, temperature, ED visit treatment
•    Blood glucose, Ketones, Arterial blood gas values , Osmolality
•    Fluid resuscitation and Insulin (oral/Subcutaneous/IV) administration.

•    Vital Signs Including SPO2 on room air, Temp, ED visit treatment
•    Urine output,
•    Labs: Electrolytes, BUN, Creatinine,
•    CXR, EKG, CT Scan
•    Dialysis: Initiation or schedule.
•    IV fluid treatment, Electrolyte replacement, Diuretics


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 help we can close gaps in care, help our members, your patients with barriers to medication and improve our ratings.

Comprehensive Medication Reviews

As year-end is nearing, an annual comprehensive medication review (CMR), whether face to face or through telehealth, is important to complete for all our members to identify medication related problems and reconcile discrepancies. We appreciate your support in assisting our Pharmacy and Quality Department in our effort in improving member health outcome. VillageCareMAX is working closely with MedWatchers, a professional MTM service, to complete CMR calls. Please remind your patients to accept the calls to ensure that they complete their annual CMR calls.


Please refer to our provider website for pharmacy information for 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. The formulary and coverage determination criteria (PA, ST, and QL) is located on our website:

Click here for VillageCareMAX 2024 Formulary

Top Non-Formulary Drugs 2024


Prior Authorizations

The VillageCareMAX Medicare Total Advantage Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from us before you fill your prescriptions. If you don’t get approval, the plan may not cover the drug. 

Link: 2024 List of drugs that require prior authorization

Step Therapy
In some instances, VillageCareMAX Medicare Total Advantage Plan may require you to try certain drugs to treat your 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

Changes in 2024

5 Tier Formulary

•    Tier 1 contains lower costing generic drugs chosen by VillageCareMAX. These drugs have the same active ingredients as their brand-name counterparts and have been in the market for years.
•    Tier 2 consists of medium costing generic drugs. These drugs also contain the same active ingredients as their brand-name counterparts that recently lost their market exclusivity.
•    Tier 3 primarily consists of preferred brand name drugs that do not have generic equivalents available. VillageCareMAX selected these drugs based on their high overall value, considering their safety, efficacy, and cost compared to other brand name drugs on the market. Tier 3 also includes medium-high costing generic drugs.
•    Tier 4 mainly includes non-preferred brand name drugs. It also encompasses high costing generic drugs and highest costing generic drugs, and generics new to market.
•    Tier 5 is composed of all specialty drugs.

Choice 100 Program

VillageCareMAX is pleased to announce a new pharmacy program to assist our members and prescribers with medication adherence for chronic maintenance medication. Members can 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.

Enhanced Supplemental Drug List

In addition to the standard Medicare Part D formulary, the 2024 VillageCareMAX formulary includes 2 enhanced supplemental drugs not traditionally covered under CMS standard formulary.

Specialty Pharmacy Network

MedImpact offers VillageCareMAX participating physicians a direct delivery program to the office setting for a select list of specialty medications. 

Examples include Alzheimer’s Disease injectables like Leqembi (lecanemab) and Aduhelm (Aducanumab), and other specialty injectable medications that require clinical staff administration and/or handling.
Direct delivery to the practice reduces the administrative burden of office staff and eliminates the need to buy and bill. A 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. 

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


Annual Wellness Visits

  • The Medicare Annual Wellness Visit is a valuable opportunity to build strong relationships with patients, identify and document health risks, and complete a number of important preventive care activities.
  • The Medicare Annual Wellness Visit (AWV) is a once-a-year, prevention-focused visit between a patient and a primary care provider. 
  • These visits allow providers and patients to update information about a patient’s health status, set shared goals for the year ahead, and close any gaps in care.


CODE: G0438 CODE: G0439
Eligible after the member has had Medicare Part B for 12 months. Eligible annually after the “Initial Annual Wellness Visit.”

Provider Authorization Quick Reference Guide and Fax #s

The GuidingCare/Altruista Health Provider Authorization Portal is a tool for providers to electronically submit authorizations and receive automated responses and real-time updates. Providers can request authorization for services, follow up on the status, and add supporting documentation.

Authorization Portal link:  vcm.guidingcare.com/AuthorizationPortal/

Authorization Portal Quick Reference Guide link: https://d2mcoh0vajf3v0.cloudfront.net/production/public/files/docs/ForProviders/2023/Prov_Portal_QuickRef_Guide_3-2023.pdf
Provider Quick Reference Guide link: https://d2mcoh0vajf3v0.cloudfront.net/production/public/files/docs/ForProviders/2023/Prov_QuickRef_Guide_3-2023.pdf

To ensure your authorization and related requests are in compliance and handled timely, please fax your request to the following Fax # based on the type of request listed below:

Authorizations for:

Telephone #: 

7 days/week
8am – 8pm

All Fax #s should be used for requests related to authorizations including authorization changes, authorization corrections, authorization modifications, clinical & supporting documentation, and prior authorization forms.
Inpatient Admissions
    Fax #: 
Inpatient admissions; UR requests, Clinical, Discharge Summaries
Outpatient Services    Fax #: 
 Outpatient Services (e.g. Certified Home Health Agency (CHHA), In-Home & Outpatient Physical, Occupational, Speech Therapies (PT/OT/ST) Nursing Services, Home Infusions, etc.) including New & Continuing Service Requests
Personal Care    
 Fax #: 
Licensed Home Care Service Agency (LHCSA) Personal Care Aide (PCA) and Consumer Directed Personal Assistance Services (CDPAS), including Overtime Requests
Long Term Support Services         Fax #: 
Social Adult Day Care (SADC), Adult Day Health Care (ADHC), Personal Emergency Response System (PERS), Home-Delivered & Congregate Meals, and Environmental/Home Modifications
DME (Durable Medical Equipment)         Fax #: 
Requests for all new & existing Durable Medical Equipment (DME)/ Medical Necessity, Prescriptions
SNF (Skilled Nursing Facility) Admissions       Fax #: 
All information regarding Skilled Nursing Facility Admissions, including: Patient Review Instrument (PRI) and Short-Term Rehab Requests, Clinicals, Discharge Summaries, Requests for Continuity of Care, etc.
Part B        Fax #: 
All requests related to authorizations for Part B Drugs, including New & Continuing Service Requests

Grievance and Appeals        
Fax #: 
All requests related to grievance and appeals


Provider Claims Appeals Process

Click here for Provider Claims Appeals Process 

Provider Demographic Change Form

To meet Centers for Medicare & Medicaid Services (CMS) requirements, support claim accuracy and timely reimbursements, and provide our members with up-to-date information, all VillageCareMAX contracted providers are required to submit any demographic changes or provider terminations within 30 days of a known update or termination. 

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

Please click this direct link for the Provider Termination Form (i.e. if  provider is leaving practice, no longer participating under contracted Tax ID, retired, etc.), or click on the Provider Manual on our website at the following link and click on the Appendix 17 link: https://www.villagecaremax.org/provider-manual 

Please submit your provider demographic change form or termination form to your Provider Relations Account Manager or [email protected] to ensure your update or termination request is processed accordingly.

To verify the current information loaded in the VillageCareMAX network, please refer to our Provider Online Search Tool at https://providersearch.villagecaremax.org/ to verify your provider information is up-to-date. 

We sincerely appreciate all your assistance in confirming your provider information is accurate and current in our online search tool/provider directory and you and your organization are meeting access and availability standards (examples below) – your efforts help ensure our members are able to quickly and easily access our participating providers and experience the best quality of care.  

If Member has urgent need to see the doctor, appointment should be within next 24 hours.

If Member is feeling sick but non-urgent, appointment should be within next 48–72 hours.

If Member wants a routine wellness visit, appointment should be within next 4 weeks.

If Member was discharged from hospital 2 days prior, appointment should be within next 5 days.

Modifier 59 Quick Reference Guide

Appropriate Usage Guidelines

Inappropriate Usage Guidelines
• Documentation indicates two separate procedures performed on the same day by the same physician represented by a different session or patient encounter, different procedure or surgery, different site, or separate injury (or area of injury) Code combination not appearing in the NCCI edits 
• Use Modifier 59 with the secondary, additional or lesser procedure of combinations listed in National Correct Coding Initiative (NCCI) edits.  Submission of Evaluation and Management (E/M) Codes 
• Use Modifier 59 when there is no other appropriate modifier.  Submission of weekly radiation therapy management codes (CPT 77427) 
• Use Modifier 59 on the second initial injection procedure code when the IV protocol requires two separate IV sites or when the patient has to come back for a separately identifiable service. The NCCI tables lists the procedure code pair with a modifier indicator of "0" 
  Documentation does not support the separate and distinct status
  Exact same procedure code performed twice on the same day 
  Multiple administration of injections of the same drug
  Multiple surgical procedures via same cite/incision or operative session
  If a valid modifier exists to identify the services





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