VillageCareMAX Q3 2025 Provider Bulletin – Operational & Compliance Updates

VillageCareMAX 3rd Quarter 2025 Provider Bulletin: Comprehensive Updates 

VillageCareMAX has released its Third Quarter 2025 Provider Bulletin containing critical updates that will impact provider operations, credentialing requirements, and patient care delivery. Network providers should review these changes carefully and take necessary actions to ensure compliance and continuity of care. 

Major Plan Changes Effective January 1, 2026 

The most significant announcement is the discontinuation of the VillageCareMAX Medicare Health Advantage FLEX Plan (HMO D-SNP), effective January 1, 2026. This Dual-Eligible Special Needs Plan served Medicare beneficiaries who also qualify for Medicaid assistance. Providers should: 

• Review their patient rosters to identify FLEX Plan members 
• Prepare for potential member transitions to other VillageCareMAX plans 
• Update billing and office systems to reflect the discontinued plan 
• Communicate with affected patients about coverage changes 
• Verify credentialing status for remaining VillageCareMAX plan offerings 

Streamlined Authorization Process 

VillageCareMAX has significantly reduced authorization timeframes to improve care delivery efficiency. Standard authorization requests must now be processed within seven calendar days, down from the previous 14-day timeframe. 

To ensure timely approvals, providers should: 

• Submit all prior authorization requests through the VillageCareMAX Authorization Portal at vcm.guidingcare.com/AuthorizationPortal 
• Include complete medical records with initial submissions 
• Note that delays in submitting medical documentation may result in automatic service denials 
• Plan ahead for the shortened review period when scheduling procedures or treatments 

Telehealth Services Continue 

VillageCareMAX continues to cover and actively encourage the use of telehealth services. Providers are urged to utilize telehealth visits for medication adherence monitoring and assessing member needs before scheduling in-office appointments. This approach can improve access to care while reducing unnecessary office visits. 

Updated Claims Submission Requirements 

To ensure accurate and timely claims processing, VillageCareMAX has clarified submission procedures: 

Electronic Claims: 

• Must be submitted through the Availity clearinghouse (apps.availity.com) 
• Use VillageCareMAX Payer ID: 26545 
• Required format: 837I (institutional) or 837P (professional) 

Paper Claims: 

• Mail to: VillageCareMAX Claims, PO Box 3238, Scranton, PA 18505 
• Claims submitted to other addresses may experience delays or processing issues 

Claims Disputes and Appeals: 

• Mail to the same Scranton address or fax to (855) 864-7385 

Timely Filing: Claims for authorized services must generally be submitted within 90 days from the date of service, though providers should always verify specific timeframes in their individual contracts. 

Electronic Payment Options: 

• Enroll for Electronic Funds Transfer (EFT) by completing the form at villagecaremax.org/eft 
• Enroll for Electronic Remittance Advice (ERA) through the Availity portal 
• Contact Provider Services at 855-769-2500 for payment concerns 

Mandatory Training Requirements - Action Required 

All VillageCareMAX network providers must complete two essential training programs for 2025: 

SNP MOC Training (Special Needs Plan Model of Care): This training ensures providers understand the specialized care coordination and management requirements for serving Special Needs Plan members. Providers must complete the training and submit the attestation form. 

CLAS Training (Culturally and Linguistically Appropriate Services): This program reinforces the importance of delivering culturally sensitive and linguistically appropriate care to VillageCareMAX's diverse member population. 

Action Required: If you have not completed these trainings or have not submitted attestations after completion, do so immediately. Both trainings and attestation forms are available at villagecaremax.org/providers#clas. Failure to complete these requirements may impact your ability to continue providing care to VillageCareMAX members. 

Provider Demographic Updates - Immediate Action Needed 

Accurate provider information is essential for member access and effective communication. Providers must: 

1. Review Current Information: Check your listing in the online provider directory at providersearch.villagecaremax.org 
2. Submit Updates Promptly: All demographic changes must be submitted at least 30 days before the effective date 

For Directly Credentialed Providers: 

• Use the Provider Demographic Change Form at villagecaremax.org/providerupdates 
• Or complete the form in Appendix 8 of the Provider Manual and email to providerrelations@villagecare.org 
• Include updates to addresses, phone numbers, fax, email, panel status, directory visibility, specialty designations, or any other demographic information 

For Delegated Organizations: 

• Submit updates via the VillageCareMAX delegated roster template to your assigned Provider Relations Account Manager 
• Contact providerrelations@villagecare.org to confirm your Account Manager's contact information 

Access and Availability Standards Reminder 

VillageCareMAX requires all participating providers to maintain strict appointment availability standards: 

• Urgent PCP Services: Within 24 hours of member request 
• Non-urgent "Sick" Visits: Within 48-72 hours of request, as clinically indicated 
• Routine Preventive Care: Within four weeks of request 
• Post-Discharge Follow-up: Within seven days of inpatient discharge 

Failure to meet these standards may impact network participation status and member satisfaction scores. 

Critical Pharmacy Update - Effective January 1, 2026 

A significant change is coming to Continuous Glucose Monitor (CGM) coverage: 

Coverage Transition: CGMs will move from Medicare Part B coverage to Part D coverage for MAP, DSNP, and MAPD members effective January 1, 2026. 

Preferred Formulary Products: 

• Freestyle Libre 
• Dexcom 

New Prescription Requirements: 

• All CGM prescriptions must be e-prescribed to the member's local pharmacy for Part D coverage 
• Paper prescriptions or durable medical equipment orders will no longer be appropriate for these devices 

Non-Formulary CGM Requests: If a patient requires a CGM other than Freestyle Libre or Dexcom, providers must: 

• Contact MedImpact Prior Authorization line at 1-888-807-6806 
• Press option #3 for Providers 
• Submit clinical justification for the non-formulary product 

This change aligns with CMS regulations and may affect how providers prescribe and monitor diabetes management devices. 

Additional Resources 

Providers should regularly consult the following resources: 

• Provider Manual: villagecaremax.org/provider-manual (updated regularly) 
• Quick Reference Guides: Available under "For Providers" > "Provider Resources" > "Quick Reference Guides" 
• Provider Services Call Center: 855-769-2500 
• Provider Inquiry Webform: villagecaremax.org/providersupport 

Conclusion 

The Third Quarter 2025 bulletin contains several time-sensitive action items and important operational changes. Providers should prioritize completing mandatory trainings, updating demographic information, and preparing for the January 2026 changes to plan offerings and pharmacy coverage. Maintaining compliance with these requirements ensures continued network participation and optimal care delivery for VillageCareMAX members. 

For questions about any of these updates, contact VillageCareMAX Provider Relations at providerrelations@villagecare.org or call Provider Services at 855-769-2500. 

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