2023 - 3rd Quarter Provider Bulletin

Special Needs Plan (SNP) Model of Care Training

The Special Needs Plans (SNP) Model of Care Training Program is a basic training required by The Centers for Medicare & Medicaid Services (CMS) for all contracted medical Providers and staff.   As per CMS, “the Model of Care is a vital quality improvement tool and integral component for ensuring that the unique needs of each enrollee are identified by the SNP and addressed through the plan's care management practices.”  

ACTION REQUIRED: Please use the attestation link below to attest to completing this required training on your behalf and or on the behalf of your Organization no later than December 31, 2023. A receipt of your completed Attestation Form will ensure the VillageCareMAX and provider remain compliant in these requirements by CMS and OMH.

Cultural and Linguistic Training

The Culturally and Linguistically Appropriate Services (CLAS) Training Program is a training required by VillageCareMAX and the Office for Minority Health (OMH) at the U.S Department of Health and Human Services (HHS).  As a VillageCareMAX provider, you are required to complete this training. The purpose of the Program is to communicate with providers the 15 National CLAS Standards broken up into (4) categories: Principal Standard; Governance, Leadership and Workforce; Communication and Language Assistance; and Engagement, Continuous Improvement, and Accountability. 

ACTION REQUIRED: Please use the attestation link below to attest to completing this required training on your behalf and or on the behalf of your Organization no later than December 31, 2023. A receipt of your completed Attestation Form will ensure the VillageCareMAX and provider remain compliant in these requirements by CMS and OMH.

Provider Demographic Change Form

To meet Centers for Medicare & Medicaid Services (CMS) requirements, support claim accuracy and timely reimbursements, and provide our members with up-to-date information, all 

ACTION NEEDED: VillageCareMAX contracted providers are required to submit any demographic changes within 30 days of an update. Please click this direct link for the provider demographic change form, or visit our website.

Please refer to our Provider Online Search Tool to verify your provider information is up-to-date. 

Physician Network Pharmacy Corner

October 2023 
Medication Adherence Matters
Improving the health of our members and Star Ratings for our Plan

Medication adherence measures a member’s adherence to diabetes, hypertension and cholesterol lowering medications, as well as Statin Use in Persons with Diabetes (SUPD). With your help we can close gaps in care, help our members, your patients with barriers to medication and improve our ratings.

Comprehensive Medication Reviews
As year-end is nearing, an annual comprehensive medication review (CMR), whether face to face or through telehealth, is important to complete for all our members to identify medication related problems and reconcile discrepancies. We appreciate your support in assisting our Pharmacy and Quality Department in our effort in improving member health outcome. VillageCareMAX is working closely with SinfoniaRX, a professional MTM service, to complete CMR calls. Please remind your patients to accept the calls to ensure that they complete their annual CMR calls.

Please refer to our provider website for pharmacy information for a complete list of covered prescription medications (formulary) which includes the most current information on Step-Therapy (ST), Prior Authorizations (PA) and Quantity limits (QL). It is important to stay updated on the formulary to avoid gaps in care.
VillageCareMAX 2023 Formulary

Choice 100 Program
VillageCareMAX is pleased to announce a new pharmacy program to assist our members and prescribers with medication adherence for chronic maintenance medication. Members can now receive up to a 100-day supply at their local community pharmacy of choice. To assist with this enhancement, the prescriber will receive a fax notification that their patient is eligible for a 100-day supply for targeted medications. In addition, the prescriber will receive a pre-populated form that can be forwarded to the pharmacy. Alternatively, the prescriber can E-Prescribe a new prescription with 100-day supply and 3 refills. This will cover the member and the pharmacy for up to one year of prescription refills.


Group Potential Benefits
Members With 100-day supply, there are fewer trips needed to the pharmacy, saving the member time. Members can also improve their medication adherence and disease management. Choice 100-day supply fills have the same copay as Choice 90.
Prescribers Doctors benefit from writing fewer prescriptions and reducing administrative burden for medications that remain unchanged, improved adherence metrics, healthier patients, and enhanced health outcomes.

Enhanced Supplemental Drug List

In addition to the standard Medicare Part D formulary, the 2024 VillageCareMAX formulary includes 2 enhanced supplemental drugs not traditionally covered under CMS standard formulary.

Enhanced Supplemental Drug List

Category Drug Drug Name Route Dose
Cough medication Benzonatate Oral 100mg, 200mg
Erectile Dysfunction med Sildenafil Citrate Oral 25mg, 50mg, 100mg

Health Outcomes Survey (HOS) Information



The Survey asks members about Physical Activity, Falls and Bladder Continence. Be sure to discuss these important topics with your patients:

  • Discuss physical activity with your patients:
  • Including activities appropriate for them based on their medical conditions. 
  • VillageCareMAX offers the Silver & Fit Healthy Aging and Exercise Program:
  • Offers flexible fitness options that support physical activity, well-being, and healthy aging.
  • Gym membership at a participating fitness center or YMCA.
  • Home Fitness Kits, Customized Workout Plans.
  • Access videos for on-demand home exercises, including Chair Yoga and Chair Tai Chi.
  • To enroll members can contact Customer Service at 877.427.4788 and an agent will assist them or go online at www.SilverandFit.com.


Assess your patients for risk of falling:

  • Assess polypharmacy and side effects of medications.
  • Encourage patients to have their eyes checked.
  • Ask patients about incontinence and discuss ways to manage incontinence.
  • Assess foot problems and discuss appropriate footwear.

Discuss bladder continence and ways to manage bladder incontinence.



Physician Highlight:

Dr. Binu Kuriakose, MD, Medical Director for Essen Urgent Care

Dr. Binu Kuriakose, MD is the Medical Director for Essen Urgent Care. 

Under Dr. Binu Kuriakose’s leadership, Essen Urgent Care helps support local health care providers by preventing hospitalizations and avoidable emergency department visits for their patients. 

Utilizing a combination of both on-site Urgent Care (UC) visits as well as telehealth visits via our UC on Demand, Essen Urgent Cares treats both acute as well as uncontrolled, chronic conditions. 

In addition, Essen Urgent Care offers same day walk-in or telehealth appointment, same day X-ray imaging at several locations, shorter wait times than the Emergency Department, close follow-up within 2-3 days after an Urgent Care visit to ensure patient is clinically improving, and timely referrals to Essen specialists to expedite care.

Modifier 59 Quick Reference Guide:


Appropriate Usage Guidelines Inappropriate Usage Guidelines
Documentation indicates two separate procedures performed on the same day by the same physician represented by a different session or patient encounter, different procedure or surgery, different site, or separate injury (or area of injury) Code combination not appearing in the NCCI edits 
Use Modifier 59 with the secondary, additional or lesser procedure of combinations listed in National Correct Coding Initiative (NCCI) edits.  Submission of Evaluation and Management (E/M) Codes 
Use Modifier 59 when there is no other appropriate modifier. 
Submission of weekly radiation therapy management codes (CPT 77427) 
Use Modifier 59 on the second initial injection procedure code when the IV protocol requires two separate IV sites or when the patient has to come back for a separately identifiable service. The NCCI tables lists the procedure code pair with a modifier indicator of "0" 
  Documentation does not support the separate and distinct status 
  Exact same procedure code performed twice on the same day 
  Multiple administration of injections of the same drug
  Multiple surgical procedures via same cite/incision or operative session  
  If a valid modifier exists to identify the services




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