Viva Medicare
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PROVIDERS

HealthScript (formerly Smart RxAssist)

Viva Health is working with HelpScript (formerly Smart RxAssist) to assist members with copay assistance programs for provider-administered drugs for certain commercial groups effective January 1, 2025.

What Is HelpScript?

Even with insurance coverage, the out-of-pocket costs for specialty drugs can be significant. HelpScript assists patients find and enroll in pharmaceutical manufacturer copay assistance programs. It is designed to assist patients who are prescribed specific provider-administered specialty drugs. The manufacturer assistance helps to ensure access to these drugs with a significantly reduced copay. This assistance applies only to the cost of the provider administered drug(s). It does not apply towards office visits or other costs associated with the administration of these drugs.

Enrollment is optional for eligible Viva Health members, and participation is voluntary for providers as well. Participants who choose to participate are required to enroll in the HelpScript program. HelpScript Patient Advocates will guide patients through the enrollment process which does not take much time at all. Patient Advocates are also in place to assist physicians as needed.

HelpScript Process

  • If your patient has not yet enrolled in HelpScript, a HelpScript Patient Advocate will reach out via phone. They will answer questions as well as guide the patient through the enrollment process.
  • Patient Advocates may reach out to provider offices as well to obtain any needed documentation for the manufacturer programs.
  • If the service requires a prior authorization, please reach out to obtain that. All PAs will follow current requirements. As always, you will receive notification if the prior authorization is approved.
  • Once patients are enrolled, a Patient Advocate will contact the provider to give additional details on copay assistance claim submission. They will also discuss how the manufacturer funds will be distributed.
  • You will still submit medical claims to Viva Health for primary payment.

For additional questions and answers, click here.

2024 Viva Medicare Special Needs Plan Model of Care (SNP MOC) Provider Training

The Centers for Medicare & Medicaid Services (CMS) requires that Medicare Advantage Organizations provide Special Needs Plan Model of Care (MOC) training to all Medicare providers that care for our valued dual eligible members. The Model of Care serves as the foundation for Viva Medicare’s care management policies and procedures. To remain compliant with CMS guidelines, MOC training must be completed annually by all Medicare providers.

Note: This training is required for Medicare providers, only.
Click here to complete your SNP MOC provider training today!

Diagnosis Coding and Documentation Guide

A reference for our provider partners and coding teams to ensure complete and accurate coding. The guide contains frequently used ICD10 codes, as well as the key factors necessary to document when coding. Click here to view.

Utilization Management Criteria and Policies

The Centers for Medicare & Medicaid Services (CMS) is the government agency that manages Medicare Advantage plans throughout the United States. CMS limits Medicare coverage to items and services that are reasonable and necessary for the diagnosis or treatment of an illness or injury (and within the scope of a Medicare benefit category). They require health plans, like Viva Medicare, to base decisions about covering items, services, or medications on National and Local Coverage Determinations.

National Coverage Determinations (NCD) and Local Coverage Determinations (LCDs) are a general outline of coverage that is in place for all Medicare Advantage health plans. NCDs and LCDs are made through an evidence-based process.

When there are no National or Local Coverage Determination policies available, Viva Medicare is allowed to use other evidenced based, recognized coverage criteria, such as the National Comprehensive Cancer Network , or our vendor InterQual®. For the few services in which no criteria is available through these resources, CMS allows us to create an internal policy, using evidenced-based sources.

Viva Health makes all of these criteria publicly available for anyone who wants to view them. The links to the resources are below:

If you have any questions or need help finding a specific criteria, please call Provider Customer Service at 1-800-294-7780, 8am - 5pm, Monday - Friday.

Real-Time Prescription Benefits

Providers treating Viva Medicare patients can use the real-time prescription benefit tool to see drug coverage information, patient cost, up to five alternatives specific to the patient’s plan, and other restriction such as prior authorizations and quantity limits.

For more information, click the links below.

Resources

Pharmacy Compliance Reminders

Viva Medicare has noted medications being prescribed for conditions that are not covered under Medicare Part D. When we pay a drug claim and later discover the drug is not covered for the specified condition, it results in the following:

  • Viva Medicare is obligated to reverse the claim and refund CMS for the inappropriate payment.
  • The member must pay out of pocket for the drug, causing a negative member/patient experience.

To ensure proper benefit payment under Medicare Part D benefits, please be aware of the Medicare coverage rules for the drugs shown below. Non-covered prescribing of these medications will result in rejection of prescription drug claims.

 

Glucagon-like Peptide 1 (GLP-1) Drugs

GLP-1 drugs are considered a first line treatment for patients diagnosed with Type 2 Diabetes Mellitus with ASCVD (Atherosclerotic Cardiovascular Disease) risk.

GLP-1 drugs:

  • Bydureon BCise®
  • Byetta®
  • Ozempic®
  • Rybelsus®
  • Trulicity®
  • Victoza®
  • Adlyxin®

 

Medicare Part D allows coverage of GLP-1 drugs for Type 2 Diabetes Mellitus treatment.
Metabolic syndrome, obesity, pre-diabetes, and weight loss are not coverable conditions under Medicare Part D.

There are formulations of these drug categories specifically FDA approved for weight loss (Saxenda®/ Wegovy®). If that is the intended use, then prescribe those instead. CMS does not allow coverage of weight loss drugs, and they will reject appropriately under Part D coverage and prevent the compliance concerns discussed above.

EFT Availability

Thank you for your patience as we work to resolve Viva Health's claims and payment disruption from Change Healthcare’s cyber security incident. As an organization, we focus on ensuring access to care and prompt payment for those services. Towards that end, it is important that we have multiple ways for you to transact with us.

Viva Health has partnered with Zelis to resume EFT payments.

In order to receive digital payments with Zelis, please see below:

For New Users:

  • Zelis ePayment Center: Here you can register for electronic funds transfer (EFT) and electronic remittance advice (ERA) services from Viva Health at no cost to you. Electronic payments will begin as soon as your setup is complete. To enroll, please visit https://viva.epayment.center.
  • Upgrade to Zelis ACH+: If you have not already, you can upgrade to ACH+ through the Zelis Payments Network. For a small fee, providers can streamline payments and remittances from an additional 450+ payers through a single portal allowing customization of payment and data preferences, including clearinghouse delivery. Additional electronic options are also available. To enroll, please contact Zelis at 1.855.496.1571.

For Current Zelis Payment Network Users:

  • If you are already part of the Zelis Payments Network and currently receive electronic payments, no action is needed! Your electronic preferences will be honored. Zelis will transfer electronic payments to you for these claims as soon as possible using your preferred payment method of ACH+ or Virtual Credit Card (VCC) under the same terms you have today.

Update on Optum iEDI:

In addition to Zelis, we want to provide an update on the Optum iEDI (Intelligent Electronic Data Interchange) system.

Viva Health now has three services up and running through Optum iEDI:

  1. Claims Submission
  2. Eligibility
  3. Claims Verification Processing

For further questions on Optum iEDI and/or to check your status, please visit the following website: Information on the Change Healthcare Cyber Response - UnitedHealth Group

Thank you for your continued partnership as we work together to care for our members and community.

Medical Preferred Drug Program with Step Therapy

Effective January 1, 2022, Viva Health added a Medical Preferred Drug Program with Step Therapy requirements for our Medicare Advantage members. This program is already in place for our commercial members and applies to drugs administered by medical providers such as doctors and hospitals (not retail pharmacies). Click here for information about the program.

Participating Lab Usage

Viva Health is dedicated to working with you to ensure quality care is provided at the lowest cost possible to our members. We need help from you to continue this effort. According to your provider contract, you should only refer patients to participating providers, including lab services. If you use a non-par lab, look for communication from Viva Health regarding a change in our policy that may negatively impact your fee schedule. Our participating laboratories are listed in this document.

Provider Information Updates

The Consolidated Appropriations Act of 2021 was signed into law on December 27, 2020. Included in this law is the No Surprises Act, part of which protects patients by aiming to improve the accuracy of provider directory information.

This law enacted a new mandate for self-insured group health plans and health insurance issuers that offer group or individual health insurance coverage to establish:

  1. A provider data verification process to ensure accurate provider directories
  2. A response protocol for individuals inquiring about the network status of a provider
  3. A database that is publicly accessible and contains accurate information about their in-network providers and facilities

Viva Health, Inc. has enlisted Quest Analytics’ BetterDoctor services to implement a robust process to assist with meeting these requirements. As a participating provider, you will be prompted to attest to your information every 90 days through BetterDoctor. Notices may come to you via email, fax, direct mail, and/or phone calls to ensure that your practice providers and service locations are listed correctly in Viva Health, Inc. provider directories.

BetterDoctor notices will direct you to the BetterDoctor online portal for attestation to information on file with Viva Health, Inc. Please note that providers with more than one service location may be prompted to attest for each location. Once details are received by BetterDoctor and verified, Viva Health, Inc. directories will be updated with any new information within two business days of receiving the provider updates. Failure to attest to your demographics could lead to the suppression of your practice from our provider directories. PROMPT RESPONSE IS KEY. You will continue to receive prompts throughout the 90-day outreach period until your attestation is completed.

For questions regarding the verification process, please contact BetterDoctor directly at support@betterdoctor.com or call (844) 668-2543, 8:00 AM – 5:00 PM CT.

You may also contact Viva Health Provider Services at 1-800-294-7780, 8:00 AM – 5:00 PM CT, Monday – Friday.

Organizations with more than ten (10) practitioners and/or service locations are invited to participate in BetterDoctor’s streamlined roster solution to complete their quarterly provider data attestations. The roster template includes the minimum provider directory data that must be verified for each of your practice providers every 90 days. For more information on participating in the streamlined roster solution, please contact your Viva Health, Inc. provider representative or email rosters@questanalytics.com to work directly with the roster solutions team at BetterDoctor.

Coordination of Benefits

Viva Health accepts secondary HCFA and UB claims electronically for all Commercial, Medicare, and Drummond lines of business. If you have any questions, please feel free to contact our Provider Customer Service department directly at (205) 558-7474.

No Surprises Act Information

If you are a commercial provider not in Viva Health's network and disagree with a payment you received and it is subject to the No Surprises Act (NSA), you may initiate a 30-business-day open negotiation period to determine the out-of-network rate. Please contact the Viva Health Provider Services Department at vivaparticipation@uabmc.edu. If the negotiation period does not result in an agreement, you may initiate the Federal Independent Dispute Resolution (IDR) process. Please note, patients may not be balance billed for services covered by the NSA.

If you would like to join Viva Health’s network, please contact Viva Health Provider Services at vivaparticipation@uabmc.edu.