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Provider Manual

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The Provider Manual covers the following Plans:

  • VillageCareMAX Managed Long-Term Care (MLTC)
  • VillageCareMAX Full Advantage Duals Advantage FIDA Plan (MMP)
  • VillageCareMAX Medicare Health Advantage Plan (HMO-POS SNP)
  • VillageCareMAX Medicare Total Advantage Plan (HMO-POS SNP)

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: Care Management and 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

Section 15: Third Party Insurance

Section 16: Marketing Guidelines

Section 17: Member/Participant Confidentiality

Section 18: Member/Participant Rights and Responsibilities

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 and Abuse

Section 27: False Claims Act

Section 28: Compliance Requirements

 

Appendices

Appendix 1: VillageCareMAX MLTC Referral Form

Appendix 2: Sample Authorization Letter

Appendix 3: Electronic Funds Transfer Form for Providers

Appendix 4: Service Authorization Request Form

Appendix 5: Quality Improvement Program

Appendix 6: Clinical Practice Guidelines

Appendix 7: LCSHA Operational Guidelines

Appendix 8: Provider Information Change Form

Appendix 9: Important Information: CMS -10611 Form – Medicare Outpatient Observation Notice (MOON)

Appendix 10: List of Covered Benefits and Prior Authorization for the VillageCareMAX Full Advantage FIDA Plan

Appendix 11: NYS DOH universal billing codes for home care and adult day health care services

  • Medicare will mail new Medicare cards between April 2018 and April 2019. Your new card will have a new Medicare Number that is unique to you, instead of the SocialSecurity Number. This will help to protect your identity.

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