2026 Important VillageCareMAX News
Medicaid Managed Care Program Updates:
Per NYS DOH Medicaid Managed Care Program Update on 3/12/2026, providers will need to register with eMedNY as paper applications will no longer be accepted moving forward. Please see below for guidance from NYS DOH:
Modernization of Provider Enrollment Process:
- The provider enrollment process continues to move toward full implementation of the online Medicaid Provider Services Portal (PSP) later this year, with the next release anticipated early this spring.
- Please encourage network practitioners to register for an NY.gov Business Account so they can easily complete enrollment updates and revalidation requirements when needed.
- A NY.gov Business Account is required to access the PSP. Please review the link below for instruc-tions on how to create an account:
- https://www.emedny.org/PSP/#psm=step1
- It is anticipated that paper applications will no longer be accepted before the end of the year, so it is imperative that providers prepare.
Medicaid Primary Care LISTSERV:
- The newly launched eMedNY Medicaid Primary Care LISTSERV® enables subscribers to instantly receive:
o NYS Patient Centered Medical Home (PCMH) Program updates.
o Announcements about upcoming webinars and Medicaid primary care related information.
o Notice of fee schedule updates.
o Billing related notifications.
o The LISTSERV supplements the Medicaid Update newsletter and PCMH Billing Manual.
o Communications will be archived on the eMedNY website.
o To subscribe, visit the eMedNY LISTSERV webpage and select “Primary Care” under Over-view
Category.
o Enter email address at the bottom of the webpage.
Please direct questions to [email protected]
CMS RADV Audits
CMS is intensifying audits for PY 2018-2024 to confirm that all risk-adjusted diagnoses are supported in the medical record. CMS intends to audit a new payment year every 3 months and intends to publish a calendar soon. VillageCareMAX will share the calendar when received.
Key Compliance Requirements
Record Retrieval: Medical records from encounters that include risk adjusted diagnosis selected for audit will be retrieved from the reporting office/facility by VillageCareMAX and submitted to CMS for auditing of clinical documentation and signature requirements.
Signature Standards:
- * Medical Records must be signed by the rendering provider within 180 days of the encounter.
o If the record is not signed by the rendering provider within the 180-day window, a signed attestation is required to confirm the diagnosis during audit.
o Signatures from anyone other than the service rendering provider are not permissible.
o Signatures must clearly display the provider’s name, credentials, and the date the record was
signed.
o 10-Year Retention: While DOH requires providers to retain medical records for 6 years, CMS
requires Medicare Managed Care providers to retain medical records for 10 years.
Resources:
- CMS.gov Press Release: CMS Rolls Out Aggressive Strategy To Enhance and Accelerate Medicare Advantage Audits
- Medicare Learning Network: Medical Record Retention and Media Format for Medical Records
Action Item: Please ensure all clinical documentation for the 2018–2024 period is complete and meets the signature requirements above to prevent audit findings.
Important Reminders for Authorizations and Claims
Authorization Timeframes:
For standard authorization requests, the timeframe is 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/Au-thorizationPortal/.
Please click this link to view the Authorization Portal Quick Reference Guide. Or access the latest version by visiting the VillageCareMAX website at https://www.villagecaremax.org/ click “For Providers”, “Provider Resources”, “Quick Reference Guides”, and “Provider Authorization Portal Quick Reference Guide”.
Registration for this portal is self-service. Registrations are approved by Applications team usually within 24–48 hours. Users will receive an acknowledgement email to complete the registration process and log in.
Please note, delays in receiving medical records may result in denial of services.
Claims Submissions:
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 within 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 after calling Provider Services, please submit an inquiry to the Provider Relations Team, and include date of call, reference number, and name of representative: 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”.
2026 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: The 2026 Trainings are now available on our website as of May 5, 2026. If you have not yet completed these essential training courses for 2026, 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 cul-turally 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 2026 MOC training
SNP MOC Attestation: Click here to attest to taking the 2026 MOC training
CLAS Training: Click here for the 2026 CLAS training.
CLAS Attestation: Click here to attest to taking the 2026 CLAS training.
Provider Demographic Updates
ACTION NEEDED: To ensure provider information is listed correctly in our provider directory for our members, and to ensure seamless delivery of provider communications and mandatory training:
1) Please review your demographic information currently published in our online search tool at https://providersearch.villagecaremax.org/. Please submit demographic updates to VillageCareMAX at least 30 days prior to the date of add, up-date, or termination.
2) If you are a directly credentialed provider:
a. Please submit all provider demographic updates via the Provider Demographic Change Form here: https://www.villagecaremax.org/providerupdates
3) If your organization is delegated for credentialing:
a. Please submit provider demographic updates via delegated roster template to your Provider Relations Account Manager on a monthly basis.
b. To confirm or request your Provider Relations Account Manager contact in-fo, 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.
Understanding the VillageCareMAX & Outcomes Medication Adherence Program:
VillageCareMAX partners with Outcomes, a trusted clinical pharmacy support organization, to help members stay safe and consistent with their medications. Through this partnership, local pharma-cists reach out to members for brief check-ins, answer questions, help with refills, provide educa-tion, and monitor adherence to important medications throughout the year. The goal is to prevent medication-related problems, make treatment easier to follow, and support better health outcomes.
1. What is Outcomes?
• Outcomes is a health care partner that works with licensed pharmacists to help members get the most out of their medications.
• They provide Medication Therapy Management (MTM) services, which include:
o Checking in on how medications are being taken.
o Helping with new medications.
o Supporting refills.
o Providing education on conditions and medications.
• Their goal is to prevent medication-related problems, improve safety, and ensure members stay on track with their treatment.
2. What is the relationship between VillageCareMAX and Outcomes?
• VillageCareMAX partners with Outcomes to provide certain pharmacy-based support ser-vices to our members.
• Outcomes uses a secure system and a network of “Approved Providers”—primarily com-munity pharmacists—to carry out these services on our behalf.
• VillageCareMAX sends membership and prescription claim data to Outcomes so they can identify which members need support and help pharmacists deliver the right interventions.
• Outcomes is an operational partner—not a replacement for VillageCareMAX. They help us ensure members stay healthy, adhere to medications, and reduce medication issues.
3. Purpose of the Adherence Program
• The program helps ensure members take certain medications regularly and safely.
• Staying adherent improves health outcomes and reduces risk of complications.
• Pharmacists receive alerts to check in with members who may be falling behind.
4. How It Works
• Outcomes’ system identifies members who are taking key long-term medications.
• Pharmacists will reach out to:
o Check if the member has the medication.
o Make sure they understand how to take it.
o Answer questions or resolve any issues.
o Help with refills or switching to 90-day supplies if appropriate.
• The pharmacist documents each “interaction in the Outcomes system.
5. Why Members Might Receive a Call
• If a member appears to be late refilling a prescription, a pharmacist may contact them to prevent a lapse.
• This may involve a quick phone call, a discussion during a pharmacy visit, or coordination with their prescriber.
6. What Members Need to Know
• There is no cost to the member for these adherence support services.
• Participation helps avoid gaps in medication therapy, which can lead to health complications.
• All communication is confidential and part of their VillageCareMAX benefit.
Frequently Asked Questions:
1. If a member asks, “Why is a pharmacist calling me?”
VillageCareMAX partners with Outcomes to help ensure members take their medica-tions safely and consistently. Pharmacists may call if they notice you might need a re-fill or haven’t picked up a medication.
2. If they ask whether their doctor is involved
Yes, pharmacists can communicate with a member’s doctor if something needs to be adjusted, refilled, or clarified.
3. If they ask whether this is a telemarketing call
No. This is a clinical outreach related to your health and medication safety, provided through VillageCareMAX.
VillageCare at 46 & Ten
