2025 Important VillageCareMAX News
VillageCareMAX Plan Offerings Update:
Effective January 1, 2026, the VillageCareMAX Medicare Health Advantage FLEX Plan (HMO D-SNP) is no longer offered.
Click here to view the VillageCareMAX Medicare Health Advantage Plan (HMO D-SNP) 2026 plan offerings.
Telehealth:
As a reminder, VillageCareMAX continues to cover telehealth services and encourages providers to utilize telehealth visits prior to in-office scheduled appointments for medication adherence and ensuring members at home have their needs met.
Authorization Timeframes:
For standard authorization requests, the timeframe has shortened from 14 calendars days to seven (7) calendar days.
As a reminder, the preferred and quickest method of submitting prior authorization requests and submitting medical records is via the VillageCareMAX Authorization Portal at https://vcm.guidingcare.com/AuthorizationPortal/.
Please note, delays in receiving medical records may result in denial of services.
Claims Submissions:
In order to ensure claims are processed timely, please:
• Submit all physical health claims through the Availity clearinghouse (https://apps.availity.com)
• Use VillageCareMAX Payer ID: 26545
• Electronic Claims must be submitted in 837I or 837P format
For Paper Claims Submission, please mail original and corrected claims to:
VillageCareMAX Claims
PO Box 3238
Scranton, PA 18505
For Claims Disputes and Appeals, please mail to:
VillageCareMAX Claims
PO Box 3238
Scranton, PA 18505
Fax to (855) 864-7385
Paper Claims or correspondence submitted to any other address may result in issues or delays.
Timely Filing: Claims for authorized services must be submitted to VillageCareMAX generally with-in 90 days from the date of service, but providers should always review their contracts for specific timely filing timeframes.
Electronic Funds Transfer (EFT) Enrollment & Changes:
Complete the EFT form on our website at https://www.villagecaremax.org/eft and submit the completed forms and required documents to [email protected]
Electronic Remittance Advice (ERA):
Enroll for ERA through the Availity portal https://apps.availity.com
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 submit your inquiry via our provider inquiry webform here: https://www.villagecaremax.org/providersupport.
Provider Manual and Quick Reference Guides:
• Please review the latest Provider Manual posted on the VillageCareMAX website at the following direct link: https://www.villagecaremax.org/provider-manual
• Please review the latest VillageCareMAX Provider Quick Reference Guides posted on the VillageCareMAX website by visiting https://www.villagecaremax.org/, click “For Providers”, “Provider Resources”, and “Quick Reference Guides”.
Provider Trainings
Annual Provider MOC and CLAS Trainings
As a crucial part of our commitment to delivering the highest standard of care, we want to reinforce the importance of completing the mandatory SNP MOC (Special Needs Plan Model of Care) and CLAS (Culturally and Linguistically Appropriate Services) Training Programs.
ACTION NEEDED: If you have not yet completed these essential trainings for 2025, or if you have completed the trainings but have not yet submitted the attestations, please do so as soon as possible.
Please click the links below to review the trainings and attest to you and/or your organization’s completion. It is imperative that every provider fulfills these requirements to continue offering culturally sensitive and effective care to our members.
Please visit our website now to complete this training: https://www.villagecaremax.org/providers#clas
SNP MOC Training: Click here for the MOC training.
SNP MOC Attestation: Click here to attest to taking the MOC training.
CLAS Training: Click here for the CLAS training.
CLAS Attestation: Click here to attest to taking the CLAS training.
Provider Demographic Updates
ACTION NEEDED: To ensure provider information is listed correctly in our provider directory, and to ensure seamless delivery of provider communications and mandatory training:
1) Please review your demographic information currently published in our online search tool (https://providersearch.villagecaremax.org/), and if any updates are needed, please submit your updates to VillageCareMAX at least 30 days prior to the date of add, update, or termination.
2) If you are a directly credentialed provider:
a. Please submit all provider demographic updates (e.g. new or terminated addresses, phone, fax, email, panel, directory status, specialty, etc.) via the Provider Demographic Change Form here: https://www.villagecaremax.org/providerupdates
b. Or fill out the demographic update form located in Appendix 8 of our Provider Manual here and submit to [email protected]: https://www.villagecaremax.org/provider-manual
3) If your organization is delegated for credentialing:
a. Please submit all provider demographic updates via VillageCareMAX delegated roster template to your Provider Relations Account Manager.
b. To confirm or request your Provider Relations Account Manager contact info, please reach out to [email protected].
Access & Availability Standards:
Reminder: Participating Providers shall provide services to members/participants in accordance with the standards outlined below:
1. Urgent services (PCPs): within 24 hours of request.
2. Non-urgent “sick” visit: within 48 to 72 hours of request, as clinically indicated.
3. Routine non-urgent, preventive appointment: within four (4) weeks of request.
4. Inpatient Discharge: within seven (7) days of inpatient discharge.
Pharmacy
Reminder
As a reminder, effective 1/1/2026 the Continuous Glucose Monitors will be moving from Part B coverage to Part D for the MAP, DSNP and MAPD members. The preferred formulary CGMS are Freestyle Libre and Dexcom. New prescriptions must be eprescribe to your patients, our members local pharmacy to be covered. In the event your patient, our member needs a CGM other than these formulary products, you need to contact the MedImpact Prior Authorization line at 1-888-807-6806 and press option #3 for Providers.
