2021 PROVIDER MANUAL Toll-Free: 1-800-294-7780 Hours: Mon - Fri, 8 a.m. - 5 p.m. | Visit us online at www.vivahealth.com Last Updated 01/2021 Property of VIVA HEALTH® Property of VIVA HEALTH | 2021 Provider Manual 1 Table of Contents Important Contact Information ................................................................................................................................ 1 Introduction to VIVA HEALTH........................................................................................................................................ 3 VIVA HEALTH Product Descriptions and Benefit Plans ............................................................................................... 4 VIVA HEALTH Provider Portal: Internet Access to VIVA HEALTH................................................................................... 6 VIVA HEALTH’s Accessibility Standard ......................................................................................................................... 7 VIVA HEALTH’s Practice Site Visit Standard ................................................................................................................. 8 Your Role in Improving Member Satisfaction .......................................................................................................... 9 Access Standards ..................................................................................................................................................... 9 Cultural Competency .............................................................................................................................................. 9 Respect for Members’ Privacy .................................................................................................................................. 9 Communication .................................................................................................................................................... 10 Prevention of Discrimination ................................................................................................................................ 10 Access to Medical Records ...................................................................................................................................... 11 Proper Billing Practices ......................................................................................................................................... 11 The Role of the Primary Care Physician .................................................................................................................. 12 Responsibilities of the Primary Care Physician ...................................................................................................... 13 VIVA HEALTH Referral Form ........................................................................................................................................ 14 Responsibilities of the Specialist.............................................................................................................................. 15 Responsibilities of the Hospital ............................................................................................................................... 17 Hospital Inpatient Prior Authorization ................................................................................................................. 18 Procedures Requiring Prior Authorization from VIVA HEALTH .............................................................................. 19 Extended Referrals ............................................................................................................................................... 20 Inpatient Outpatient Precertification Form ............................................................................................................ 23 Procedures That Do Not Require Prior Authorization ..........................................................................................24 Diabetic Supplies: Update for 2019 .......................................................................................................................... 25 Services Covered Under the Global Delivery Fee .................................................................................................... 25 Ambulatory Surgical Authorization Guidelines ................................................................................................... 26 Ambulatory Surgical Procedures that Are Not Covered ....................................................................................... 27 Emergency Services .................................................................................................................................................... 28 VIVA HEALTH Medical Management ........................................................................................................................... 29 VIVA HEALTH’S Quality Improvement Program ........................................................................................................32 Information Needed to Assure Timely Claims Payment ........................................................................................ 36 Filing Claims when Capitated ................................................................................................................................ 36 Electronic Claim Filing ......................................................................................................................................... 37 Electronic Funds Transfer (EFT) .......................................................................................................................... 37 Claims Information for Dental Providers ............................................................................................................... 38 Unique Billing Situations ...................................................................................................................................... 38 Fee Schedule Changes ............................................................................................................................................ 41 Appealing Denied Claims .......................................................................................................................................41 VIVA HEALTH’S Provider Credentialing/ Recredentialing and Provider Sanctioning ............................................ 42 Accessing Mental Health/ Substance Abuse ........................................................................................................... 45 Table of Contents VIVA HEALTH Pharmacy Information ......................................................................................................................... 46 Member’s Rights and Responsibilities .................................................................................................................... 49 VIVA HEALTH’S Complaint Procedure ......................................................................................................................... 50 VIVA MEDICARE Information (Medicare Members) Introduction to VIVA MEDICARE .................................................................................................................................. 54 VIVA HEALTH Medicare Advantage Plans ................................................................................................................... 58 Things to Know About VIVA MEDICARE Provider Systems ....................................................................................... 59 Open/Closed Provider System Matrix ..................................................................................................................... 60 Plans Offered by VIVA MEDICARE in 2021 ...................................................................................................................61 VIVA MEDICARE Plus ............................................................................................................................................. 61 VIVA MEDICARE Premier ....................................................................................................................................... 61 VIVA MEDICARE Prime .......................................................................................................................................... 62 VIVA MEDICARE Select ........................................................................................................................................... 62 VIVA MEDICARE Me .............................................................................................................................................. 63 VIVA MEDICARE Classic, Preffered, and Extra Care ................................................................................................. 64 VIVA MEDICARE Extra Value ................................................................................................................................. 65 Provider Responsibilities .......................................................................................................................................... 66 Patient Communication ........................................................................................................................................ 66 Treatment Plans 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