Provider Manual
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)
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