Winter 2020

Coronavirus Update

As you know, the Novel Coronavirus (COVID-19) outbreak is a concern here in the U.S. The outbreak began in Wuhan City, Hubei Province of China in December, 2019. Over 79,000 cases have been identified in multiple countries including China, Thailand, Japan, Korea, Iran, Europe and the United States. These numbers and information about the virus continue to change on a daily basis and the Centers for Disease Control is monitoring the outbreak closely. Please see below article.
Inside this Issue:
  • Change in Nursing Home Benefit For VillageCareMAX MLTC Members
  • Medlmpact Direct Specialty® FAQs for VillageCareMAX Prescribers and Case Managers
  • Healthcare Effectiveness Data and Information Set (HEDIS®) abstraction
  • Cyber Attack Warnings from NY DOH
  • How to File a Provider Claim Appeal
  • Coronavirus Update
  • Quick Reference Sheet for Providers
Change in Nursing Home Benefit For VillageCareMAX MLTC Members
We wanted to alert members that the state has received approval from the the Centers for Medicare and Medicaid Services (CMS) for the proposed amendment to the State’s Medicaid 1115 waiver that limits the partially capitated Managed Long Term Care (MLTC) plan nursing home benefit to three months for individuals who are designated as long stay residents. Such members would need to be disenrolled from Medicaid managed care and revert to fee-for-service Medicaid after a three-month period. Additionally, individuals entering nursing homes for Medicaid funded long stays would no longer be mandated to enroll into MLTC and would remain in fee-for-service Medicaid. 

This provision was enacted in the 2018-19 State Budget and has been the subject of lengthy negotiations between the State and CMS, with the state submitting the formal waiver amendment request in the Fall of 2018.

While the Department of Health (DOH) has been preparing for the change in anticipation of CMS approval, the requirement to notify MLTC members of benefit changes and other implementation details will likely mean that the shift of existing long-stay residents back to fee-for-service may not begin immediately. 

Please note that this change will impact members of partially capitated MLTC plans only; permanent nursing home members enrolled in Medicaid Advantage Plus (MAP) or participating in Programs of All-Inclusive Care for the Elderly (PACE) will not be affected. We anticipate that short term nursing home stays that are covered by Medicaid will not be impacted- such stays will continue to be covered by managed care or managed long term care plans for their enrollees. This means that while the volume of Medicaid managed care days is likely to decrease for most homes, the need to establish and maintain contract arrangements with plans will continue.  

DOH will likely make a formal announcement shortly and provide additional information and guidance as to the timing and procedures for implementing this change

Our Provider Manual will be updated with these updates of provider requirements.

If you have any questions related to authorization inquiries and claims issues, please contact provider services at (855) 769-2500.
Medlmpact Direct Specialty® FAQs for VillageCareMAX Prescribers and Case Managers

VillageCareMAX Health Plans (VCM) is implementing a new specialty pharmacy network starting
July 15, 2019. Members may now use Medlmpact Direct Specialty® Pharmacy Program for their
specialty pharmacy needs. Medlmpact Direct Specialty® will send referrals, along with the
member's benefit and eligibility information, to an in-network, contracted specialty pharmacy. Our
network pharmacies offer high-touch services to allow access to treatment without placing added
burden on your staff.
Medlmpact Direct Specialty® is a hub that receives and directs specialty referrals to the dispensing
specialty pharmacy on behalf of the plan sponsor. Medlmpact Direct Specialty® also simplifies
limited distribution drug fulfillment by directing referrals to the appropriate pharmacy in advance.
Our pharmacies contact patients each month to start a refill, review adherence and answer
questions. Prescribers may call Medlmpact Direct Specialty® at 1-877-391-1103 (TTY 711).

Healthcare Effectiveness Data and Information Set (HEDIS®) Abstraction
The Healthcare Effectiveness Data and Information Set (HEDIS® ) medical record data abstraction process is fast approaching. VillageCareMAX would like to request your assistance this year in completing this process in the most efficient manner. 
     VillageCareMAX is pleased to announce that it has contracted with Inovalon, Inc. to perform HEDIS® medical record data abstraction on its behalf. It is important for you to know that Inovalon serves VillageCareMAX in a role that is defined and covered by the Health Insurance Portability and Accountability Act (HIPAA). As defined by HIPAA, Inovalon’s role is as a “Business Associate” of “Covered Entities,” and as such, Inovalon is ethically and legally bound to protect, preserve and maintain the confidentiality of any Protected Health Information (PHI) it gleans from clinical records provided by medical practice locations pursuant to its contractual obligations to VillageCareMAX. In this setting, you may be assured that Inovalon will treat your patients’ PHI with the appropriate level of protection and confidentiality.

     The HEDIS® medical record data abstraction process will begin in early February 2019 and proceed through early May. Prior to conducting an on-site review, Inovalon will contact your office to schedule a visit and subsequently distribute information about the scheduled visit to you to explain its data collection process. Inovalon may also request that copies of chart components be sent via mail or fax for off-site review. Please be aware that Inovalon is committed to the protection of all patient information and reminds providers to be diligent in following the specific Inovalon chart copying instructions such that accurate measure level patient information is provided while maintaining a minimum necessary patient information release approach. 

           Your cooperation in extending Inovalon your professional courtesy and prompt attention is very much appreciated. If you have questions or concerns about any portion of this process, please contact me at . We appreciate your assistance in this effort and thank you for partnering with us to improve the health of individuals, families and communities.
Cyber Attack Warnings from NY DOH

As you may be aware, the New York State Department of Health (NYSDOH) recently issued an important alert regarding potential cyber-based attacks . 

We urge your agency to take additional steps to help protect critical infrastructure and information systems to protect patient/member confidential information. Several basic preventive measures include directing your workforce to:
  • screen emails for unknown senders
  • avoid the use of personal email or social media on company equipment and for company business
  • use caution in following email links and opening attachments without authenticating the sender
If you are aware of any potential threats that may impact our members or their information, please contact us immediately.
Thank you for your attention to this critical matter.
How to File a Provider Claim Appeal

If your claim was processed and you disagree with how it was processed, you may submit a written request for review and reconsideration with supporting documentation .   All claim appeals, unless specified otherwise in your contract must be submitted within forty-five (45) days of receipt of a claim determination for MLTC product and within sixty (60) days of receipt of claim determination for Health Advantage & Total Advantage products. 

The following must be included for review and consideration of payment:
  • Claim number
  • Authorization number
  • Member/Participant name
  • VillageCareMax Member ID number
  • Exact date(s) of service (do not give range)
  • Codes billed
  • Units billed
  • Amount billed
  • Reason for appeal (including any supporting documentation to support your appeal)

Examples of information and supporting documentation that should be submitted with written requests for review and reconsideration include :
 • A written statement explaining why you disagree with VillageCareMAX’s claim determination.
 • Provider’s name, address, and telephone number
. • Provider’s identification number
 • A copy of the original claim or corrected claim, if applicable.
 • A copy of the VillageCareMAX EOP.
 • A copy of the EOP from another insurer or carrier (e.g., Medicare), along with supporting medical records to demonstrate medical necessity.
 • Contract rate sheet to support payment rate or fee schedule.
 • Evidence of timely filing:
VillageCareMAX will investigate all written requests for Review and Reconsideration, and issue a written explanation stating that the claim has been either reprocessed or the initial denial has been upheld, within sixty(60) calendar days from the date of receipt of the provider’s request for Review and Reconsideration.

Attention: Correspondence Department at PO Box 21516 Eagan, MN 55121
Coronavirus Disease 2019 (COVID-19) Update

As you know, the Novel Coronavirus (COVID-19) outbreak is a concern here in the U.S. The outbreak began in Wuhan City, Hubei Province of China in December, 2019. Over 79,000 cases have been identified in multiple countries including China, Thailand, Japan, Korea, Iran, Europe and the United States. These numbers and information about the virus continue to change on a daily basis and the Centers for Disease Control is monitoring the outbreak closely. 

While the news media is currently focused on thie global spread of COVID-19, it is equally important to help prevent the spread of Influenza, which has already caused a significant number of deaths here in the U.S. this year. 

Coronaviruses are a large family of viruses, some producing common cold like symptoms and other respiratory symptoms in people. The symptoms noted in the patients in the current outbreak include fever, aches and pains, tiredness, cough and shortness of breath. Some have developed pneumonia. The symptoms may appear 2 to 14 days after exposure to the virus.

Currently the CDC is recommending if anyone develops symptoms or has been in close contact with a patient that is under investigation for exposure to COVID-19, they should see their healthcare provider as soon as possible.

The best way to prevent infection is to avoid being exposed to the virus but everyday preventive action helps prevent the spread of all respiratory viruses. These actions include:

  • Washing your hands often with soap and water for at least 20 seconds or using a hand sanitizer that contains at least 60% alcohol if soap and water are not available.
  • Avoid touching your eyes , nose and mouth with unwashed hands.
  • Avoid close contact with people who are sick.
  • Stay home when you are sick.
  • Cover your cough or sneeze with a tissue then throw the tissue in the trash
  • Clean and disinfect frequently touched objects and surfaces.

There is no specific treatment for COVID-19 but all patients should receive supportive care to help relieve their symptoms. (anti-fever medications, fluids etc.) For more severe symptoms, care to support vital organ functions should be given.
VillageCareMAX Provider Portal
As a reminder, the VillageCareMAX Provider Portal is a quick, convenient and secure way to verify member eligibility, review claim status, verify authorization status and much more.
The portal is available 24 hours a day, 7 days a week and can be accessed by visiting: