welcome to for Providers
**COVID-19 Related Alert**
New Guidance Available on Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes.
Nursing homes are now required to report the first week of COVID-19 data to the Centers for Disease Control and Prevention (CDC) beginning May 8 but no later than May 17.
COVID-19 Long-Term Care Facility Guidance
The recommendations include:
- Nursing Homes should immediately ensure that they are complying with all CMS and CDC guidance related to infection control
- CMS/CDC urges State and local leaders to consider the needs of long-term care facilities with respect to supplies of PPE and COVID-19 tests
- Long-term care facilities should immediately implement symptom screening for all staff, residents and visitors – including temperature checks
- Long-term care facilities should ensure all staff are using appropriate PPE when they are interacting with patients and residents, to the extent PPE is available and per CDC guidance on conservation of PPE
- To avoid transmission within long-term care facilities, facilities should use separate staffing teams for COVID-19-positive residents to the best of their ability, and work with State and local leaders to designate separate facilities or units within a facility to separate COVID-19 negative residents from COVID-19 positive residents and individuals with unknown COVID-19 status
Suspending of Utilization Management and Medical Necessity for All Lines of Business
VillageCareMAX (Plan) in an effort to reduce administrative burden on key providers that are serving the populations most impacted by COVID-19, we are waiving prior authorization requirements for medically necessary hospital services, home health services, skilled nursing facilities, inpatient rehabilitation facilities and durable medical equipment and supplies for a period of 90 days commencing March 26, 2020. VillageCareMAX reserves the right to conduct retrospective reviews following the 90 days.
VillageCareMAX will continue to monitor the current environment and suspend/relax additional policies to ensure members have access to care. Updates will be posted on the provider page on the VillageCareMAX website.
Insurers Directed to Suspend Utilization / Medical Necessity Reviews for 90 Days
The New York State Department of Financial Services (DFS) has issued a circular letter directing all New York insurers to suspend a broad array of utilization and medical necessity review activities effective immediately.
The DFS directive requires insurers to suspend:
- Preauthorization requirements for scheduled surgeries or admissions
- Concurrent reviews of inpatient hospital services
- Retrospective reviews for medical necessity of inpatient hospital and emergency services
- Preauthorization requirements for inpatient rehabilitation services in a hospital or skilled nursing facility following a hospital admission
- Preauthorization for home health care services following an inpatient admission
- Notification requirements pertaining to inpatient admissions (Hospitals are still required to make best efforts to notify insurers of hospital admissions for purposes of assisting with discharge planning but will not be penalized financially for failure to notify)
- Audits of hospital claims payments
These activities are suspended for at least 90 days, at which point DFS will determine whether they can be resumed. During this period, insurers will be required to pay claims for hospital inpatient and emergency services without consideration of review for medical necessity or standard preauthorization rules. However, insurers will be permitted to retrospectively review these services for medical necessity once the suspension of retrospective review is lifted and may recoup any overpayments resulting from these reviews.
DFS will also monitor the ability of hospitals to comply with timeframes for claims submission and for insurers to comply with prompt payment rules. Additional guidance may be issued about these requirements.
These suspensions are not currently applicable to Medicare Advantage and self-insured lines of business. However, some insurers are working with self-insured employer accounts to extend suspensions to those lines of business and the American Hospital Association has also requested the Centers for Medicare & Medicaid services to consider similar actions. We will keep you apprised of any additional developments.
Information for Providers
VillageCareMAX fully supports the Patient-Centered Medical Home initiative. Our team collaborates with local community services and the patient’s providers to effectively coordinate medical, behavioral, pharmaceutical, and social and community-based services.
The result is a comprehensive, team-based care plan that anticipates and adapts to the changing needs of each member, striving to keep them secure, independent and living in the comfort of their own home.
As a provider, you want to spend your time taking care of your patients and we’ll take care of the rest.
- Ability to maintain current referral patterns
- Care management team to assist with resource management
- Around-the-clock access to a nurse coordinator for information to facilitate service coordination
Participating Provider Responsibilities
- Check governmental exclusion lists on a monthly basis, including the U.S. Dept. of Health and Human Services Office of the Inspector General (“OIG”) List of Excluded Individuals and Entities and the NY Office of the Medicaid Inspector General (“OMIG”) List of Exclusions to ensure that no employee/staff is excluded from participation in government programs.
- A non-participating provider may file an appeal when VillageCareMAX denies claims payment fully or partially. The appeal must include a signed Waiver of Liability form that waives the non-participating provider’s rights to collect payment from the member. VillageCareMAX cannot start the review of your appeal until the signed form is received. Failure to submit the signed form within the required timeframe will result in dismissal of your appeal. The Waiver of Liability Form can be accessed at the below link:
We’re offering a variety of resources and links designed to meet both your needs and the needs of your patients.
- Request for Prior Authorization form (PDF)
- Winter 2020 Provider Newsletter
- Annual Compliance Requirements
- Notice to Providers on False Claims Policy (PDF)
- Provider Portal
- VillageCareMAX Provider Manual
- Quick Reference Guide For Providers (PDF)
- ICD-10 Transition Frequently Asked Questions (PDF)
- ICD-10 Transition Frequently Asked Questions(PDF)