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Vivida HealthNew Provider Orientation

Provider Relations 2018/2019


Welcome to the Vivida Health provider network! As a participant in Vivida’s network, you have the opportunity to make Vivida beneficial for both you and the members you serve. Vivida knows providers are essential in delivering high-quality, cost-effective medical services to Medicaid recipients. Through enhanced local community and provider relationships Vivida stands alongside you in our commitment to our members:

Vivida Health connects you with the care and community servicesyou need. We are local doctors helping you and your family stay

healthy so you can focus on what’s truly important:each other.

Vivida is dedicated to earning your trust and confidence. We are looking forward to working with you to provide the best service and care possible to Vivida members.

Plan Overview


Provider Service Network (PSN)Benefits to Physicians and Providers

Local Care Managers and Clinical Performance Improvement Experts Actionable patient data and physicians reports

Clinical Support

Timely and accurate claims payment and credentialing Local physician-approved policies and prior authorization lists to reduce abrasion

Service Focused

Enhanced compensation through reimbursement and incentive design Insightful information to manage performance

Redesigned Compensation

Local Physician representation involved in making clinical decisions customized to community and patient needs

Local Decision Making


Continuity of Care

Sufficient and accurate provider networks

Prompt and accurate payments to providers

Provide quality healthcare to Florida Medicaid members

MMA Implementation Goals


Region 8

o Sarasota, Lee, Collier, Charlotte, Desoto, Hendry, Glades

Go live Date : 01/01/2019

MMA Service Areas


Providers should continue to render healthcare services during the transition period- 60 days after the

implementation date

Providers should bill claims to the health plan to which the MMA member is assigned

Vivida will cover the continued course of treatment without authorization and without regard to participation

status during the transition period

For non-participating providers, Vivida will pay claims at the rate previously paid by the member’s prior health

plan for the first 30 days

Care may continue after the transition period with prior authorization.

Continuity of Care (COC)

Region Implementation Date Transition Period End Date8 01/01/19 02/28/19


Covered ServicesCovered Services under Vivida include, but are not limited to:• Durable medical equipment (DME), including prosthetic and orthotic devices and disposal medical supplies;• EPSDT screening and special services;• End stage renal dialysis services;• Family planning clinic services in accordance with federal, state, and case law;• Home health services; • Hospice services;• Independent laboratory services;• Inpatient hospital services;• Intensive case management;• Medical detoxification;• Medical services, including those provided by physicians, advanced registered nurse practitioners, physician assistants, and

FQHCs/ primary care centers and rural health clinics;• Organ transplant services not considered investigational by the FDA;• Other laboratory and x-ray services;• Outpatient hospital services;• Pharmacy;• Podiatry services;• Preventive health services, including those currently provided in public health departments, FQHCs/primary care centers, and

rural health clinics;• Specialized Case Management Services for members with Complex, Chronic Illnesses (includes adult and child targeted case

management);• Targeted Case Management;• Transportation to covered services, including emergency and non-emergency ambulance and other stretcher services; and• Urgent and emergency care services.


Vendor/SubcontractorService Provider Telephone Hours

Behavioral Health Beacon Health Options 888-710-2316 (toll free)711 TTY800-370-1116 (fax)

24 hours/7 days/weekwww.beaconhealthoptions.com (website)

Nurse Advice Line Health Dialog 844-865-7920 (toll free)800-499-7033 (fax)

24 hours/7 days/[email protected] (email) www.healthdialog.com website)

Laboratory Services Quest Diagnostics 866-697-8378 (toll free) https://www.questdiagnostics.com/home.html

Transportation (Non-emergent)

OneCall 877-848-5993844-418-0531 (fax)

24 hours/7 days/weekwww.onecallhealth.com/members (website)[email protected] (email)

Over-the-Counter-Supplies OTCHS (CVS) 833-331-1571 (toll free) 877-672-2688 TTY866-682-6733 (fax)

https://vivida.otchs.com/ (website)

DME/HH/Infusion Pharmacy Coastal Care Services, Inc. 855-481-0505 (toll free)855-481-0606 (fax)

24 hours/7 days/week www.ccsi.care/providers/ (website)

http://web.ccsi.care (provider portal)

Vision iCare Health Solutions 855-373-7627 (toll free)305-675-8195 (fax)

[email protected] (email)www.myicarehealth.com (website)


Claims

Vivida encourages all providers to submit claims electronically. For those interested in electronic claim filing, contact your EDI software vendor or the Change Healthcare (formerly Emdeon) Provider Support Line at (800) 845-6592 to arrange transmission.

Vivida Electronic Payer ID: 45488

For paper claims, please submit to Vivida at the following address:Vivida Health

PO BOX 211251Eagan, MN 55121


Balance Billing

As a Vivida participating provider, your office is responsible for verifying eligibility and obtaining approval for services that require authorization (refer to the PA Guide).

Participating providers shall accept Vivida payments as payment in full for covered services. Providers may never bill any enrolled member for any covered benefit, except for copayments and deductibles if applicable.

If a denied claim occurs, provider shall look solely to Vivida for compensation for services rendered.


Timely Filing Requirements

Original claims must be submitted to Vivida within 180 calendar days from the date of service or date of discharge (inpatient) or the timeframe specified in the provider agreement for services rendered or compensable services rendered.

Resubmission of previously processed claims with corrections and/or requests for adjustments must be submitted within ninety (90) days of notification of payment or denial.

Claims originally rejected for missing or invalid data elements must be corrected and resubmitted within the timeframe identified in the provider agreement. Rejected claims are not registered as received in the claims processing system.


Corrected Claims

Corrected claims can be sent electronically. All corrected claims should have the corrected claim indicator (a 7) on the claim and the original claim number that you are correcting.

Claims originally denied for missing/invalid information for inappropriate coding should be submitted as corrected claims. Inaddition to writing “corrected” on the claim, the corrected information should be circled so that it can be identified.

Claims originally denied for additional information should be sent as a resubmitted claim. In addition to writing “resubmitted” on the claim, the additional/new information should be attached.

Corrected and resubmitted paper claims are scanned during reprocessing. Please use blue or black ink only, and refrain from using red ink, white out, and/or highlighting that could affect the legibility of the scanned claim.

Corrected/Resubmitted paper claims should be sent to:

Vivida Health PO BOX 211251 Eagan, MN 55121


Electronic Funds Transfer (EFT)

Vivida is working with InstaMed to deliver claim payments via electronic remittance advice (ERA) and electronic funds transfer (EFT). ERA/EFT is a convenient, paperless and secure way to receive claim payments. The below information is needed for Online Registration includes:• Tax ID• Email Address • Legal Business Name • Business Address/Phone • Principal Name (primary decision maker) • Billing NPI Number • Bank Name • Bank Routing Number

To register for free InstaMed Payer Payments, visit www.instamed.com/eraeft.


Expanded Benefits (Medical)

Services Description Coverage Prior AuthorizationAcupuncture Acupuncture therapy for management of

chronic pain. Covered as medically necessary Prior authorization required

Chiropractic Chiropractic manipulation therapy for the treatment of chronic pain

Visits beyond the allowed 24 annually (e.g. weekly visits deemed medically necessary)

Prior authorization required for visits beyond the allowed 24 visits

Vaccine – Influenza Influenza vaccine One (1) per member per year Age 21 and over

No prior authorization required

Vaccine – Shingles (Varicella – Zoster) Shingles Vaccine One (1) per year with prior authorization Age 21 and over

Prior authorization required for members ages 21-49 due to limited risk factors

No prior authorization required for members ages 50 and older

Vaccine – Pneumonia (Pneumococcal) Pneumonia vaccine Unlimited with prior authorization Age 21 and over

Prior authorization required for members ages 21-64 due to limited risk factors

No prior authorization required for members ages 65 and older

Newborn Circumcision Services related to newborn circumcision One per Life No prior authorization required


Expanded Benefits (Behavioral Health)

Services Description Coverage Prior Authorization

Behavioral Health Risk assessment and interpretation Unlimited beyond 3 assessments as based on medical necessity

Up to 3 without prior authorization

Behavioral Health Substance abuse/ intensive outpatient treatment for pregnant women

3 hours/day, 3 days/week, 9-hours/week; pregnant women for the duration of pregnancy, up to 6 months post-partum

Prior authorization required

Behavioral Health Computerized Cognitive Behavioral Analysis

Unlimited No prior authorization required


Expanded Benefits (Adult Services)Services Description Coverage Prior Authorization

Occupational Therapy Initial evaluation, reevaluation and treatment

OT Eval - Mod Complexity OT Re-evaluation OT Treatment Visit

The initial evaluation does not require prior authorization. Subsequent visits do require prior authorization.

Physical Therapy

.

Initial evaluation, reevaluation and treatment

PT Eval - Mod Complexity PT Re-evaluation PT Treatment Visit

The initial evaluation does not require prior authorization. Subsequent visits do require prior authorization

Respiratory Therapy Initial evaluation, reevaluation and treatment

Initial Eval / Re-evalRT Visit - Daily

The initial evaluation does not require prior authorization. Subsequent visits do require prior authorization.

Vision Services Initial evaluation, reevaluation and treatment

Vision Exam – One per year Frames – One per year Contact Lenses – 6-month Supply with prescription


Prenatal / Perinatal Services

Breast pump rental, additional pregnancy related services

Hospital Grade Breast Pump - Up to 1 per year rental Breast Pump - 1 every 2 years, rental Antepartum Management - Low Risk - 14 Visits High Risk - 18 visits Postpartum Care - 3 visits w/in 90 days delivery

Prior authorization required for Hospital Grade Breast Pump. Other Services do not require prior authorization


Expanded Benefits (Adult Services)Services Description Coverage Prior Authorization

Hearing Services Initial evaluation, reevaluation and treatment

Hearing Aids Prior authorization required

Speech Therapy Initial evaluation, reevaluation and treatment

Speech Therapy Eval / Re-eval – 1 per year Oral and OP Swallow Eval – 1 per year Speech Therapy Visit – up to 7 visits per week (30 minutes each) Augmentative and alternative communication (AAC) Initial Eval– 1 per year AAC Re-eval – 1 per year AAC Fitting, Adjustment and Training Visit – 3 visits within 90 days of delivery

Initial Evaluation does not require prior authorization. Other services require prior

authorization

Primary Care Services Office visits, visits in a nursing facility Office / Outpatient Visits - Unlimited Nursing Facility Care - Unlimited Preventative Visits (18-39, 40-64, 65 and over) - Unlimited



Transportation

Vivida Health offers its members access to non-emergency transportation through OneCall.

To make an appointment for a transportation service, contact OneCall 24 hours/ 7 days per week as follows:

Telephone: 877-340-9491Fax: 844-418-0531Email: [email protected]


Immunizations

Vaccines for Children Program (VFC)• Covers members from birth to age 18• Medikids are not eligible for VFC• Providers must participate in the VFC Program• Providers must maintain adequate vaccine supplies

MMA Plan• Covers the cost of the admin for members eligible for VFC• Covers the cost of the vaccine and the admin for members age 19-20• Covers the cost of the vaccine and the admin for Medikids

o Providers should no longer direct claims to Medicaid state plan for Medikids vaccineso Providers should not use VFC stock for Medikids

***Expanded Benefits• Vaccines for Pneumonia (Pneumococcal), Shingles (Varicella – Zoster), and Influenza are covered for Vivida members

21 and over. o Pneumonia is covered as a core service for members birth through age 20


Preferred Drug List (PDL)

Vivida will adopt the AHCA Medicaid PDL and provide coverage for all drugs and dosage forms listed therein.

Refer to the PDL document for the most current list of preferred drugs: http://ahca.myflorida.com/medicaid/Prescribed_Drug/pharm_thera/fmpdl.shtml.

The PDL is arranged in order by therapeutic classification. To locate a specific drug or therapeutic class, use the search feature available in Adobe Acrobat Reader (keyboard shortcut: CTRL+F). The PDL will also tell you if there are any certain age limits or clinical prior authorization (PA) requirements.

Vivida will not reimburse for prescriptions for early refills, duplicate therapy, or excessively high dosages for members.


Preferred Drug List (PDL)Prior Authorization (PA) is necessary for some medications to establish medical necessity, and to ensure eligibility for coverage per State and/or Federal regulations. This may be due to specific Food and Drug Administration (FDA) indications, the potential for misuse or overuse, safety limitations, or cost- benefit justifications.

PA is required for medications that are:• Outside the recommended age, dose, or gender limits;• Drugs not listed on the PDL;• Drugs listed on the PDL but still require Prior Authorization;• Brand name drugs when a generic exists;• Duplication in therapy (i.e. another drug currently used within the same class);• New to the market and not yet reviewed by AHCA’s P&T Committee• Prescribed for off-label use or outside of certain diseases or specialties; or• Most self-injectable and infusion medications (including chemotherapy).

Providers may request an exception to Vivida’s PDL either verbally or in writing. For written requests, providers should complete a Prior Authorization Request Form that includes pertinent member medical history and information. A Prior Authorization Request Form may be accessed on Vivida’s website at www.vividahealth.com.

To submit an oral request, call 844-716-5385 to speak with a pharmacy specialist.


Over-the-Counter (OTC) Medications

OTC items listed on the PDL require a valid prescription.

Examples of OTC items listed on the PDL include:• Antihistamines• Enteric coated aspirin• Insulin• Topical antifungals• Ibuprofen• Permethrin• Meclizine• H-2 receptor antagonists

CVS is the supplier for OTC Medications and Supplies. Coverage is subject to change.


Provider Handbook

The Provider Handbook explains the policies, procedures and requirements of delivering healthcare services to Vivida members including your responsibilities as a participating provider. It is a guide to answer questions about member benefits, claim submissions, and many other issues.

The Provider Handbook is available online at www.VividaHealth.com.

Providers may request printed copies of the Provider Handbook, at no cost, by contacting Provider Services at 844-243-5175.

Updates to this Provider Handbook will be posted on Vivida’s website on a periodic basis.


Provider Directory

Vivida providers may access a copy of the Provider Directory online at www.VividaHealth.com

Providers may request a printed copy of the Provider Directory by contacting Provider Services at 844-243-5175.


Member Identification Card

ID cards contain the following information:•Member’s name and date of birth;

•PCP group name and telephone number;• Vivida Health identification number;

• Vivida Health contact information; and


Verifying Member Eligibility

Participating providers are responsible for verifying member eligibility before providing services as eligibility may vary per month.

Providers may verify eligibility using the following methods:• Online – Log into www.VividaHealth.com• IVR Automated System at 844-243-5175• Customer Service- 844-243-5175


Member Rights and ResponsibilitiesThe rights of our members include, without limitation, the right to:

• Receive information on available treatment options and alternatives, in a manner appropriate to the member’s condition and ability to understand;

• Be treated with courtesy and respect, with appreciation of his or her dignity, and with protection of privacy;• Receive a prompt and reasonable response to questions and requests; • Know who is providing medical services and who is responsible for his or her care; • Know what patient support services are available, including if an interpreter is available if the patient does not speak English; • Know what rules and regulations apply to his or her conduct; • Be given, by the health care provider, information such as diagnosis, planned course of treatment, alternatives, risks, and prognosis; • To participate in the decision-making process about their health care;• Discuss medically necessary treatment options regardless of cost or insurance coverage; • Refuse any treatment, except as otherwise provided by law;• Be given full information and necessary counseling on the availability of known financial resources for care;• Receive, prior to treatment, a reasonable estimate of charges for medical care; • Receive a copy of an understandable itemized bill and, if requested, to have the charges explained; • Receive medical treatment or accommodations, regardless of race, national origin, religion, handicap, or source of payment; • Receive treatment for any emergency medical condition that will deteriorate from failure to provide treatment; • Know if medical treatment is for purposes of experimental research and to give his or her consent or refusal to participate in such

research; • Express complaints or file an appeal regarding the care received or the health plan services;• Be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation, as specified in other

Federal regulations on the use of restraints and seclusion; and• Request and receive a copy of his or her medical records, and request that they be amended or corrected. Right to make

recommendations regarding the member Rights policy.


Member Rights and Responsibilities

The responsibilities of Vivida’s members include the responsibility to:

• Give the health care provider accurate information about present complaints, past illnesses, hospitalizations, medications, and any other information about his or her health;

• Participate in developing a mutually agreed upon treatment goals, to the degree possible;• Report unexpected changes in his or her condition to the health care provider; • Report to the health care provider whether he or she understands a planned course of action and

what is expected of him or her; • Follow the treatment plan recommended by the health care provider;• Keep appointments and, when unable to do so, notify the health care provider or facility; • Be responsible for his or her actions if treatment is refused or if the patient does not follow the health

care provider’s instructions; • Ensure financial responsibilities are carried out; and • Follow health care facility conduct rules and regulations.


Prior Authorization (PA) GuideVivida participating providers are required to obtain prior authorizations from the Plan’s UM department for inpatient services, specified outpatient services, specialty drugs and home health/DME/Home Infusion. Failure to submit a request for authorization may result in a denial of payment for the related rendered services.

The UM department is available Monday through Friday from 8:00 a.m. to 7:00 p.m., except holidays, Eastern Standard Time (EST).

Providers should request prior authorizations via fax using the Vivida Universal PA Form available on our website at: https://vividahealth.com/en/providers/prior-authorization/ or submitted via our Web Portal.


Prior Authorization (PA) Guide

Providing complete information allows for timely processing by the Prior Authorization Department.

The following information is generally requested for all authorizations.

• Member name• Member identification number• Provider ID and NPI number or name of the treating physician• Facility ID and NPI number or name where services will be rendered (when appropriate)• Provider and/or facility fax number• Date(s) of service• Diagnosis and diagnostic codes• CPT codes• Any relevant clinical information to support medical necessity of request

The Prior Authorization (PA) Guides including specialty drugs are available on our website, at: https://vividahealth.com/en/providers/prior-authorization/


Referral Requirements

Referrals from PCP are required prior to members receiving services from most specialty care providers/providers (see provider handbook for list of exceptions)

PCP referrals can only be made to participating specialists

Prior approval by UM is not required for referrals to participating providers, but a referral must be noted in the member’s medical record

Referrals for consultation, diagnostic studies and treatment are valid for six (6) months unless otherwise specified by the member’s PCP

The PCP may also designate a visit limit if it is preferred for any specialty referral.


Provider NotificationsIt is important for Vivida to keep its provider network information up-to-date. Up-to-date provider information allows Vivida to accurately generate provider directories, process claims and communicate with its network of providers.

Providers must notify Vivida in writing at least 60 days in advance when possible of changes, such as:• Change in practice ownership or Federal TAX ID number• Practice name change• A change in practice address, phone or fax numbers• Change in practice office hours• New office site location• Primary Care Providers (PCP) only: If your practice is open or closed to new patients

The provider data change form can be found at https://vividahealth.com/en/providers/forms-claims-information/

Provider must notify Vivida immediately if any of the following actions occur:• Provider’s business license to practice in any state is suspended, surrendered, revoked, terminated, or subject to terms of probation or other restrictions• Provider is the subject of any criminal investigation or proceeding• Provider is convicted for crimes involving moral turpitude or felonies• Provider is named in any civil claim, or any criminal investigation or proceeding• Provider becomes incapacitated such that the incapacity may interfere with member care for 24 hours• Provider’s professional or general liability insurance is reduced or canceled• Any other action or occurrence which affects the provider’s ability to carry out its duties under the provider contract agreement

Send changes via: email at [email protected] or fax: 888-396-1226


Outreach and Marketing

Providers may:• Announce new or continuing affiliations through general advertising (e.g., radio, television, websites).• Make new affiliation announcements within the first thirty (30) days of the new provider agreement.• Make one announcement to members of a new affiliation that names only the Managed Care Plan when such

announcement is conveyed through direct mail, email, or phone.• Additional direct mail and/or email communications from providers to their members regarding affiliations must include a

list of all Managed Care Plans with which the provider has agreements.Providers may not:• Offer marketing/appointment forms.• Make phone calls or direct, urge, or attempt to persuade potential members to enroll in the Managed Care Plan based

on financial or any other interests of the provider.• Mail marketing materials on behalf of the Managed Care Plan• Offer anything of value to persuade potential members to select them as their provider or to enroll in a particular

Managed Care Plan.• Accept compensation directly or indirectly from the Managed Care Plan for marketing activities.


PCP Responsibilities• Maintaining continuity of the member's health care;• Exercising primary responsibilities for arranging and coordinating the delivery of medically-necessary health care services to

members;• Making referrals for specialty care and other medically necessary services, both in and out of network, if such services are not

available within Vivida's network;• Maintaining a current medical record for the member, including documentation of all PCP and specialty care services, including

periodic preventive and well-care services, and providing appropriate and timely reminders to members when services are due;• Discussing Advance Medical Directives with all members as appropriate. • Providing primary and preventative care, recommending or arranging for all necessary preventive health care, and adhering to

the EPSDT periodicity schedule and the Vaccines For Children (VFC) immunization schedule for each Vivida member younger than twenty-one (21) years of age. Documenting all care rendered in a complete and accurate medical record that meets AHCA specifications;

• Screening and evaluation procedures for the detection and treatment of, or referral for, any known or suspected behavioral health problems;

• Arranging and referring members when clinically appropriate to behavioral health providers;• Providing periodic physical examinations as outlined in the Preventive Health Guidelines;• Providing routine injections and immunizations;• Providing or arranging 24-hours a day, seven days a week access to medical care. For additional information, see Section 4.0 –

Office Standards;• Arranging and/or providing necessary inpatient medical care at participating hospitals; • Providing health education and information.• Manage the care of assigned Vivida members and to direct the members to specialty care services when necessary.


PCP Assignment, Changes, and Dismissals Members have the right to choose their PCP. If a member or his/her designated representative does not choose a PCP, one will be assigned using the following considerations:• Reasonable proximity to the member’s home• member’s last PCP, if known• member’s covered family members, in an effort to keep family together• member’s age

PCP Assignment

Member's may change their PCP at any time with the change being effective no later than the beginning of the month after the request for the change.

PCP Changes

A PCP may find it necessary to dismiss a member from his/her practice due to non-compliance with recommended treatment plan, or unruly and disorderly conduct (must ensure conduct is not related to mental health status). PCPs are encouraged to counsel members prior to dismissal from the practice and allow sufficient time for the conduct to improve. If the dismissal is necessary, PCPs must immediately notify both the member and Vivida of the dismissal and continue treating the member for a minimum of 60 days following the notification for non-complaint members, and 30 days (emergency care only) for disruptive and disorderly members.

PCP Dismissals


Well Child Visit

A Child Health Check-Up (CHCUP) is a comprehensive, preventive health screening service. CHCUPs are performed according to a periodicity schedule that ensures children have a health screening on a routine basis. In addition, a child may receive a CHCUP whenever it is medically necessary or requested by the child or the child’s parent or caregiver.

The purpose of the CHCUP Program is to provide the following services to children from birth through age 20: • Comprehensive, preventive, well child care on a regularly scheduled basis; • Identification and correction of medical conditions before the conditions become serious and disabling; and • An entry into the health care system and access to a medical home

Providers must report the most current and appropriate diagnosis code (ICD-10) to the highest level of specificity that supports medical necessity, as appropriate for this visit.


Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)

EPSDT is a federally mandated Medicaid program developed to ensure that the Medicaid population younger than the age of 21 ismonitored for preventable and treatable conditions which, if undetected, could result in serious medical conditions and/or costly medical care.

Vivida must track the progress of all members younger than the age of 21 and perform outreach as needed to encourage members to obtain EPSDT health screens according to the AAP Guidelines for screening intervals.

Once a condition is detected, treatment may be considered under EPSDT Special/Expanded Services if it is not a current covered benefit under Medicaid, and if medical necessity is established.

PCPs who see children younger than the age of twenty-one (21) are required to conduct EPSDT screenings and complete all EPSDT billing requirements.

To complete an EPSDT preventive health screen:• Verify member’s eligibility either at www.vividahealth.com, reference the PCP monthly panel list, or contact the EPSDT team at

844-243-5175.• Once eligibility is verified, inform the parent/guardian that the visit will be an EPSDT screening; and• Have the parent or legal guardian sign a consent form authorizing the provider to perform screening tests or other assessment

procedures pertaining to EPSDT preventive health screens.• To receive reimbursement, all EPSDT services must be submitted as part of the standard electronic (837) or paper (CMS-1500)

claims submission process.


Timely Access StandardsProviders must adhere to the following appointment scheduling standards to assure timely access to medical care as required AHCA. Compliance with these standards will be audited by periodic on-site review of provider offices and chart sampling.

Appointment Type Access StandardPCPs – Adult and Pediatric Well Care Visit Within thirty (30) calendar days PCPs – Urgent Within forty-eight (48) hours PCPs –Sick Visit

Specialist – non-urgent

Ancillary Service – diagnosis/treatment of injury, illness, or other health condition

Within one (1) week

Within sixty (60) calendar days

Within fourteen (14) calendar days

Behavioral Health – Routine visits

Behavioral Health – post discharge from Inpatient setting

Behavioral Health – Initial outpatient behavioral health treatment

Within thirty (30) calendar days

Within seven (7) calendar days post discharge

Within fourteen (14) calendar days

Behavioral Health-Urgent

Behavioral Health – Sick Visit

Within ninety-six (96) hours

Within one (1) week

Emergency Providers Immediately; twenty-four (24) hours a day, seven (7) days a week and without prior authorization

Emergency Providers Immediately; twenty-four (24) hours a day, seven (7) days a week and without prior authorization

Behavioral Health Non-Life-Threatening Emergency Within six (6) hours


Obstetrical Care & Family Planning

• Pregnancy Notification• Healthy Start Requirements• Obstetrical Delivery• Newborn Care• Postpartum Care• Family Planning Services• Hysterectomies, Sterilizations, and Termination of Pregnancies


Pregnancy Notification

Providers must complete the Pregnancy Notification Form for any member that is identified as pregnant within five (5) business days of any patient visit and testing where pregnancy is confirmed (or determination of Vivida's member eligibility, whichever is later) and submit it to the Pregnancy Care Program via fax or via secure email to:

Pregnancy Notification Form found at: https://vividahealth.com/en/providers/forms-claims-information/Pregnancy Care Program Fax: 888-518-5333 Pregnancy Care Program Email: [email protected]

The form serves as initial notification of a member’s pregnancy to Vivida. Prompt submission from the provider allows us to enroll our members in the Pregnancy Care Program as early as possible.

It is the responsibility of the provider to confirm receipt of the Pregnancy Notification Form by the Pregnancy Care Program if the provider assumes care of the member from another provider.


Disease Management

The Health and Disease Management department offers many programs that assist providers and members in the management of the members’ care, including programs relating to:

• Chronic Respiratory Disease Management (including asthma and COPD)• Congestive Heart Failure (CHF) Disease Management• Diabetes Disease Management• Early and Periodic, Screening, Diagnosis and Treatment (EPSDT)• Mommy Steps Perinatal Program• Obesity

The Health and Disease Management department is available from 8:00 a.m. to 5:00 p.m. EST Monday through Friday.


Medicaid Physician Incentive Program (MPIP)

• Vivida will implement the Agency’s MMA Physician Incentive Program (MPIP) effective 01/01/2019. • As a new plan, Vivida will rely on the Agency’s Qualified Provider List to ensure providers in its network

that have qualified for MPIP historically, continue to receive enhanced reimbursement for services provided to Vivida members.

• Contract amendments will not be required from providers for participation in the MPIP. Vivida will notify providers of their qualification status, in writing, and begin issuing the enhanced payments as of the effective date of qualification. When qualification status is known at the time of contracting, Vivida will utilize its MPIP contract template, which includes MPIP rates on Exhibit 1.

• All identified providers, regardless of qualification status, will receive a quarterly scorecard showing their progress toward achieving or maintaining qualified provider status


Medicaid Physician Incentive Program (MPIP)

Primary Care Physicians• PCMHProviders that have qualified with another plan based on PCMH accreditation will be deemed qualified for MPIP effective 01/01/2019. Enhanced payments for these providers will commence on 01/01/2019.

• Panel Size and HEDIS

Providers that have qualified with another plan using the Agency’s AP program, based on panel size and HEDIS measures, will be considered qualified for MPIP effective 01/01/2019 pending confirmation of panel size with Vivida.

Enhanced payments for these providers will commence on 5/1/19, retroactive to 01/01/2019, after members have made plan and PCP changes during the 120-day change period, and Vivida can apply panel size criteria.

Any claims received from qualified providers with >50 members for dates of service January 1, 2019– April 30, 2019 will be adjusted to pay at the appropriate Medicare rate.

Ob-Gyn

Ob-Gyns that have qualified with another plan utilizing the Agency’s AP program will be deemed qualified for MPIP effective 01/01/2019.

Enhanced payments for these providers will commence on 01/01/2019.

Pediatric Specialists

All pediatric specialists, regardless of board certification, contracted with Vivida, will be deemed qualified effective 01/01/2019.

Enhanced payments for these providers will commence on 01/01/2019.


In Lieu of Services

State Medicaid Plan Service Vivida's In Lieu of ServiceInpatient psychiatric hospital care Crisis stabilization units and Class III and Class IV freestanding psychiatric hospitals

Inpatient detoxification hospital care Detoxification or addictions receiving facilities licensed under s. 397, F.S.Inpatient psychiatric hospital care Partial hospitalization services in a hospitalEmergency behavioral health care Mobile crisis assessment and intervention for members in the community

Inpatient detoxification hospital care Ambulatory detoxification servicesPsychosocial Rehabilitation Services Self-Help/Peer Services

Clubhouse services Drop-in CenterPsychological Testing Services Infant Mental Health Pre and Post Testing Services

Therapeutic Group Care Services or Statewide Inpatient Psychiatric Program Services Community-Based Wrap-Around Services

Inpatient psychiatric hospital care Respite Care ServicesOffice-based therapy and/or TBOS Community Outreach Services

Office-based therapy In Home CounselingOffice-based therapy and/or TBOS Family Training and Counseling

Therapeutic Group Care Services or Statewide Inpatient Psychiatric Program Services Behavioral Health Services - Child WelfareInpatient detoxification hospital care Substance Abuse Intensive Outpatient Program (IOP)Inpatient detoxification hospital care Substance Abuse Short-term Residential Treatment (SRT)Inpatient psychiatric hospital care Mental Health Partial Hospitalization Program (PHP)

Vivida covers services and settings that are in lieu of covered services under the Agency’s state plan. These services are referred to as “in-lieu of services”. members have a choice to receive the Medicaid covered services as available under the state plan, or the in lieu of service. Providers may utilize in lieu of services as appropriate for the member’s

treatment plan, subject to medical necessity and authorization guidelines. Vivida contracts with Beacon Health Options for the delivery of behavioral health services to its members. Beacon Health Options provides assistance to its behavioral health providers to ensure coordination of in lieu of services and other covered services based on member-specific

needs.The following in lieu of services are available to Vivida's members.


TelemedicineVivida is pleased to provide Telemedicine to our members.

The following items for services provided through telemedicine include:

• A brief explanation of the use of telemedicine in each progress note;

• Documentation of telemedicine equipment used for the particular Covered Services provided;

• A signed statement from the member or the member’s representative indicating their choice to receive services through telemedicine. This statement may be for a set period of treatment or a one-time visit, as applicable to the service(s) provided; and

• A review of telemedicine should be included in Vivida's fraud and abuse detection activities.


Translation Services

Members may receive interpreter services at no cost when necessary to access covered services. Interpreter services available include verbal translation and sign language for the hearing impaired.

Providers should assist in the coordination of interpreter services for members by contacting Vivida Member Services at 844-243-5131.


Case Management

Case Management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive healthcare needs through communication and available resources to promote quality cost-effective outcomes.

Members who may benefit from case management are those with ongoing complex medical needs or those at risk for an avoidable adverse outcome/event.

Providers, as well as members and other interested parties, may request Case Management services. Providers may contact the Rapid Response department at 844-243-5131 from 8 a.m. to 7 p.m. EST to make a case management referral or by completing the Care Coordination Request Form available online at www.vividahealth.com.

If you would like to speak with the Case Manager once he or she is assigned, notify the Rapid Response coordinator when you make a Case Management request. Participation in Case Management is voluntary, and the member has the right to decline any or all parts of the program.


Targeted Case Management

Vivida Health follows the Agency’s Targeted Case Management Coverage Policy, Fee Schedule and service maximums for children enrolled in the Early Steps Program or receiving medical foster care:

Targeted Case Management services (TCM) include: • Conducting an assessment of the recipient’s medical, social, and functional status and identifying the recipient’s service needs; • Working with the recipient and his/her natural support system to develop, promote, and coordinate the service plan; • Referring, coordinating or arranging for service delivery from the individual’s chosen provider(s) to ensure access to services;• Reviewing and reassessing the individual’s functional status and service needs; • Following up to determine that the recipient’s planned services have been received and are effective in meeting the recipient’s

needs; • Monitoring to ensure access to quality and the delivery of services identified in the plan of care; • Preparing and maintaining case record documentation to include service plans, forms, reports, narratives, and other documents,

as appropriate in assisting with access to care; and • Explaining to the recipient information regarding the importance of following prescribed treatment or helping with understanding

the condition and how to cope with the condition

No authorization required for participating, or non participating providers for TCM

TCM providers may file claims using Vivida’s standard claims submission process outlined in this document and in the Provider Handbook posted on Vivida’s website


Early Intervention ServicesVivida follows the Agency’s Early Intervention Services Coverage Policy, Fee Schedule and service maximums for all related services. These services include::

• Up to three screenings per year, per recipient, to identify the presence of a developmental disability • One initial evaluation (maximum of eight units) per lifetime, per recipient when conducted by a multidisciplinary

team • Up to three follow-up evaluations (maximum of 24 units) per year, per recipient • Up to two individual or EIS sessions per week (maximum of four units per day) per recipient that includes the

following: o Supporting family or caregiver in learning new strategies to enhance a recipient’s development and

participation in the natural activities and routines of everyday lifeo Training parents to implement intervention strategies to minimize potential adverse effects and maximize

healthy developmento Group sessions must include two or more recipients

• No authorization required for participating, or non participating providers for EIS

Vivida may cover additional services and supports identified during an evaluation through a different service benefit• Additional covered services may require authorization as defined in Vivida’s Prior Authorization guidelines

EIS providers may file claims using Vivida’s standard claims submission process outlined in this document and in the Provider Handbook posted on Vivida’s website


Medical Foster CareVivida follows the Agency’s Medical Foster Care Services Coverage Policy, Fee Schedule and service maximums for all related services. These services include:

• 365/366 days of MFC services per year, per recipient, in accordance with the applicable Florida Medicaid fee schedule, or as specified in this policy, including the following:o Assisting with ADLs and IADLso Coordination of care:o Arranging for the provision of primary medical care and support services needed to safely maintain the recipient in a community-based setting (e.g.,

durable medical equipment and supplies)o Ensuring access to, and coordination with, an accredited educational program for each recipient that complies with the requirements of the Florida

Board of Educationo Facilitating opportunities for the recipient to participate in a range of age-appropriate indoor and outdoor recreational and leisure activities, including

activities for nights and weekends based on group and individual interests and developmental needso Scheduling medical appointmentso Health care management and monitoringo Medication monitoring and administrationo Monitoring vital signso Participating in and coordinating all educational activities for the recipiento Providing transportation to all scheduled appointments and activitieso Provision of skilled interventions to the extent the services are medically necessary and the MFC provider has the requisite training to perform the

necessary tasko Leave Days – up to 15 days during a 90n day period for hospitalization or therapeutic visits

• No authorization required for participating or non participating providers for medical foster care services• Vivida will cover up to 30 days of MFC provided by a substitute MFC provider per year, per recipient

Medical Foster Care providers may file claims using Vivida’s standard claims submission process outlined in this document and in the Provider Handbook posted on Vivida’s website


Grievances & AppealsVivida has dedicated staff to assist providers with the resolution of filed complaints.

Provider may file a complaint by:• Phone: 844-824-8766 option 1 (complaints and grievances); option 2 (appeals); option 3 (State Fair Hearing questions)• Fax: 888-879-9557• Email: [email protected]• Mail: Vivida Health

Attn: Grievance & Appeals Department6630 Orion Drive, Ste 203Fort Myers, FL 33912

Non- Claim related issues:• Vivida shall allow providers forty-five (45) days to file a written Complaint. • Within three (3) business days of receipt of a Complaint, notify the provider (verbally or in writing) that the Complaint has been received and the expected date of resolution; • Thoroughly investigate each provider Complaint using applicable statutory regulatory, contractual, and provider agreement provisions; collect all pertinent facts from all

parties; and apply applicable plan written procedures; • Provide written notice of the status to the provider every fifteen (15) days thereafter; and • Resolve all Complaints within ninety (90) days of receipt and provide written notice of the disposition and the basis of the resolution to the provider within three (3) business

days of resolution.

Claim related issues:• Allow providers ninety days (90) from the date of the final determination for the primary payer to file a written Complaint for claims issues; • Within three (3) business days of receipt of a claim Complaint, notify the provider (verbally or in writing) that the Complaint has been received and the expected date of

resolution; • Within fifteen (15) days of receipt of a claim Complaint, provide written notice of the status of the Complaint to the Agency and to the provider. For claims issues that require

additional time to research, Vivida must submit a written request to the Agency within three (3) business days of receipt of the Complaint that includes:

o An explanation for the need of an extension; and o The expected time needed beyond the fifteen (15) days for research and response. o Approval is contingent upon Agency review. o Vivida must provide written notice of the status to the provider every fifteen (15) days thereafter; and

• In accordance with 641.3155, F.S., resolve all claims Complaints within sixty (60) days of receipt and provide written notice of the disposition and the basis of the resolution to the provider within three (3) business days of resolution.


Web Portal Tools

Member Eligibility

Verify effective dates

Verify member demographics

Authorizations

Request authorizations

Check status of

authorizations

Claims

Submit claims

Check claim status


Fraud & Abuse Providers are required to cooperate with the investigation of suspected fraud and abuse. Vivida is committed to working with federal and state regulatory and law enforcement agencies to help prevent and detect fraud, and to recover funds paid for fraudulent claims.

Fraud means an intentional deception or misrepresentation made by a health care provider or a Medicaid recipient with the knowledge that the deception could result in some unauthorized benefit to him or herself or some other person. It includes any act that constitutes fraud under federal or state law related to Medicaid. (42 CFR §§ 455.2)

Abuse means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary cost to the Medicaid program. (42 CFR §§ 455.2)


Examples of Fraud & Abuse

• Concealing ownership or associations in a related company,• Paying a “kickback” in exchange for a referral for medical services or

equipment,• Using false credentials such as diplomas, licenses or certifications, or• Ordering tests or prescriptions that the patient does not need• Balance billing members• Use of a medical identification card by someone other than the

person identified on the card• Participating in schemes that involve collusion between a provider

and a member, such as diverting controlled substance medications for street sales


Report Fraud & Abuse

Providers are required to cooperate with the investigation of suspected fraud and abuse.If you suspect fraud or abuse by a Vivida member or provider, it is your responsibility to

immediately report this by calling one of the telephone numbers listed below:• Vivida Compliance Hotline: 888-695-1476 Code: VHP

• Medicaid Fraud Hotline: 888-419-3456• Vivida Compliance Fax : xxxx

• Vivida Compliance Email Address: www.mycompliancereport.com Code: VHP


Suspected Child or Adult Abuse or Neglect

Cases of suspected child or adult abuse or neglect might be uncovered during examinations.

Child abuse is the infliction of injury, sexual abuse, unreasonable confinement, intimidation, or punishment that results in physical pain or injury, including mental injury.

To report suspected abuse, neglect, or exploitation of children or vulnerable adults, Providers should call the Florida AbuseHotline at 1-800-96-ABUSE (1-800-962-2873) (TDD 1-800-453-5145) twenty-four (24) hours a day, seven (7) days a week. If a provider sees a child or vulnerable adult in immediate danger, he/she should call 911.

Human Trafficking is defined as the transporting, soliciting, recruiting, harboring, providing, or obtaining another person for transport for the purposes of forced labor, domestic servitude, or sexual exploitation using force, fraud and/or coercion.

If you believe you have identified a victim of Human Trafficking or suspect an adult is a victim of human trafficking, pleasevisit the National Human Trafficking Resource Center, or call 1-888-373-7888.


Cultural CompetencyCultural competence in health care is defined as the ability of providers and organizations to understand and integrate these factors into the delivery and structure of the healthcare system. The goal of culturally competent health care services is to provide the highest quality of care to every patient, regardless of race, ethnicity, cultural background, English proficiency or literacy.

Some common strategies for improving the patient-provider interaction and institutionalizing changes in the health care system include:

• Provide interpreter services• Recruit and retain minority staff• Provide training to increase cultural awareness, knowledge, and skills• Coordinate with traditional healers• Use community health workers• Incorporate culture-specific attitudes and values into health promotion tools• Include family and community members in health care decision making• Locate clinics in geographic areas that are easily accessible for certain populations• Expand hours of operation• Provide linguistic competency that extends beyond the clinical encounter to the appointment desk, advice

lines, medical billing, and other written materials


Join Vivida Health’s Provider Network

Non-participating providers who are interested in joining Vivida Health’s provider network should contact Provider Services at 844-243-5175 or [email protected]


6630 Orion Dr.

Fort Myers, FL 33912

vivida health - provider orientation · welcome to the vivida health provider network! as a...

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