Provider Manual

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The Provider Manual covers the following Plans:

• VillageCareMAX Managed Long-Term Care (MLTC)
• VillageCareMAX Medicare Health Advantage Plan (HMO D-SNP)
• VillageCareMAX Medicare Total Advantage Plan (HMO D-SNP)

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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: Model of Care
• Section 7: Participating Provider Responsibilities
• Section 8: Appointment Service 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: DME Services requiring Prior Authorization
• Appendix 11: NYS DOH universal billing codes for home care and adult day health care services
• Appendix 12: 2019 Medicare Part D Opioid Policies
• Appendix 13: Update: NYS Medicaid Program Dental Policy and Procedure Code Manual