Frequently Asked Questions

Below are just a few frequently asked questions about Viva Health group coverage. Please review your plan documents for more information.

Please click on a question to expand the answer.

Viva Health communicates with members in several different ways – you pick what works best for you!

Each family or individual member receives an ID card in the mail upon enrollment and periodically thereafter if information changes. Your Certificate of Coverage and other Viva Health plan materials are available on this site.

In addition, for most plans, when we pay a claim we send you an Explanation of Benefits (EOB) that tells you what was billed, what Viva Health paid, and how much you owe. If you prefer to receive your EOBs electronically, you can access them from the Viva Health member portal at You can log into the portal to get your EOBs electronically or request or print a new ID card.

Our website also offers valuable health plan and wellness information.

If you or your spouse give birth to or adopt a child, you have 30 days (or 31, depending on your employer) from the date of birth, adoption, or placement for adoption to add that child to your health insurance coverage. Check your Viva Health Certificate of Coverage or with your employer to determine whether your plan allows 30 or 31 days.

Remember: only your children are eligible for coverage. The children of your dependent children are not eligible for coverage under your plan unless you or your spouse is the child's court-appointed, legal guardian.

To add a new baby or child to your plan, contact your employer.

Viva Health plans cover many preventive services such as mammograms, flu shots, and routine eye exams. For a description of covered preventive services, visit

If you are on a "non-grandfathered" plan that covers preventive services at 100%, your annual wellness visit, including an annual well woman visit, is covered at 100% with no cost-sharing. However, if you get other services during this visit that are not preventive, your doctor's office may charge you cost-sharing.

For example, if you present with flu-like symptoms during your wellness visit and are tested and treated for the flu, you will likely owe cost-sharing for that office visit because you received non-preventive services.

If you leave an inpatient facility, outpatient facility, or an emergency department against medical advice after being admitted, you will be responsible for the full cost of that admission.

For example, if you are admitted to the emergency department but leave against medical advice for any reason before the hospital discharges you, you may be responsible for 100% of that bill. This most commonly occurs when people seek care in the emergency department for non-emergency conditions and walk out before they are discharged due to a long wait to be treated. One way to avoid this situation is to only go to the emergency department when you believe it is a true emergency.

If your condition is not a true emergency, you can visit or call your Primary Care Physician (PCP) or go to an urgent care center. In addition, if your plan offers Teladoc, you can reach a physician 24/7/365 by calling 1-800-TELADOC or on the web at to discuss your symptoms. Viva Health also has an on-call nurse available through Viva Health Customer Service after hours to assist you in accessing care when you have an urgent medical condition.

If you have a complaint about the care you are receiving in a facility, please call Viva Health Customer Service.

As a Viva Health member, you agree to get your health care from doctors, hospitals, and other medical providers who have a contract with us. We call these providers "network providers" or "participating providers."

The only services covered by an out-of-network provider when you are not in the Viva Health service area are emergency services and urgently needed care to treat an unforeseen injury or illness.

If you are unsure if your condition is an emergency or requires urgently needed care, contact your PCP or the physician on-call if after hours. Viva Health also has an on-call nurse available after hours by calling Customer Service to assist if you cannot reach your PCP's office.

Always call Viva Health within 24 hours or as soon as reasonably possible after you receive emergency services.

If you are 65 or older and your employer has fewer than 20 employees, you should strongly consider signing up for Medicare. Group coverage sponsored by employers with fewer than 20 employees pays secondary for members 65 and older.

This means if you do not take Medicare when you're eligible, it will be like having very little coverage. The same is true if you are under 65 and disabled and have coverage in a plan sponsored by an employer with fewer than 100 employees. Also, if you are 65 or older and covered by a retiree plan, Medicare is the primary payor, and our payment amounts will assume Medicare paid its share first even if you are not enrolled in Medicare.

If you have any questions regarding coordinating coverage between Medicare and your group coverage, please contact Viva Health Customer Service.

Some members have coverage under multiple private plans, such as individual, student, and employer-based coverage. Many times, for example, it is through both their employer and their spouse's employer. This can lead to confusion for members in terms of which carrier is primary (pays benefits first).

Here are four rules, in terms of priority, for knowing which plan is primary:

  1. The plan with no coordination of benefits provision or non-duplication coverage exclusion is always primary. All Viva Health plans have a coordination of benefits provision.
  2. The plan that covers a member as a subscriber (policyholder) is primary.
  3. The plan of the parent whose birthday comes first in the calendar year is primary with respect to coverage for enrolled dependent children. There are additional rules for divorced or separated parents. See your Certificate of Coverage (COC) or call Customer Service for more information.
  4. Finally, if none of the rules above determine the order of benefits, the plan that has covered you the longest is primary.

Sometimes when you need care, your doctor may not be available to treat you but another doctor in the same practice can see you. Usually, that other doctor is also in our network, but not always. If that doctor is not in our network, you will need to check with their office to see if the non-contracted doctor will accept Viva Health's payment rate as payment in full once you have paid your applicable cost-sharing. If they will not, you will be responsible for your normal cost sharing plus any difference between our payment and what the out of network doctor charges.

Emergency room services, observation services, outpatient surgeries, lab tests, x-rays or any other hospital services are considered to be outpatient unless the physician has written an order for admission to the hospital as an inpatient. If you are admitted for outpatient observation, your outpatient cost sharing applies even if an overnight stay is required.

Like all health plans, Viva Health does not cover every service a health care provider may recommend.

To be covered, services must be medically necessary, included in your Certificate of Coverage, and not in the listing of Plan exclusions. Some services also require a referral from your PCP or Prior Authorization from Viva Health to be Covered Services.

The fact that a medical provider performs or prescribes a service or that a service is the only available treatment for a particular medical condition does not mean the service is a Covered Service. Viva Health does not under any circumstances make treatment decisions. Viva Health only makes administrative decisions about the benefits covered under the Plan for payment purposes. Your financial or family situation, the distance you live from a hospital or other facility or any other non-medical factor is not considered. The Participating Provider is responsible for the quality of care a Member receives and Viva Health is not liable for any act or omission of a Participating Provider.

If you are experiencing a problem with your coverage, such as a disagreement over how your cost-sharing was applied or if a service was denied, please contact our Customer Service department. If our representatives are unable to resolve the issue to your satisfaction you can always file a complaint verbally or in writing. All of our plans have an established procedure for filing a complaint or grievance. Copies of this procedure can be found in your Certificate of Coverage or Summary Plan Description.