We know that you are busy, and having access to the latest Virginia health care tools and information is critical in today’s fast paced healthcare environment. So Virginia Premier decided to create an area dedicated to providing quick and easy access to the latest Virginia Premier provider communications and tools.
The Provider Manual is one of the many tools that Virginia Premier has available to make doing business with us easier. The Provider Manuals contain CompleteCare’s policies and processes on topics such as Member Benefits and Covered Services, Claims and Electronic Payments, Medical Management, Pharmacy Guidelines and much more.
Looking for the latest Virginia health care news and updates from Virginia Premier? The Provider Newsletter is just one of the ways we regularly communicate changes, updates and reminders to the provider network.

2015

We’re here for you! CompleteCare is building free online training modules and a library of literature to help give our providers the best possible resources to care for your patients.

CompleteCare Training

Annual Provider Training

If you would like to attend an in-person training, our schedule can be found under the Education Meetings tab.

If you are looking for our “Nuts and Bolts” training, that can be found here.

If you have any questions about our training options, please contact us.

Some of the topics we offer training on:

  • Cultural Competency
  • Practice Accessibility
  • Patient Safety
  • Disability Literacy
  • And many more great topics!
Looking for answers to your questions? CompleteCare has created a FAQ page with some of the most commonly asked questions from our providers.

Eligibility and Enrollment

Q: Who is eligible for Virginia Premier CompleteCare?

Eligible individuals include those who:

  • Are 21 and older
  • Are enrolled in full Medicare and full Medicaid
  • Live in designated regions of Virginia serviced under the Commonwealth Coordinated Plan
Q: Is participation in Virginia Premier CompleteCare voluntary?

Yes, plan participation is completely voluntary. Members may decide not to join by opting out or withdraw from the program at any time and return to original Medicare and Medicaid coverage.

Q: How are members enrolled with a Virginia Premier CompleteCare?

Eligible members received a letter in 2014 which provides a phone number to call to sign up. A trained professional with Maximus, the enrollment broker hired by the State of Virginia, guides beneficiaries through the enrollment process. Individual health plans cannot enroll or dis-enroll beneficiaries directly.

Q: Do I need to check member eligibility?

Each new member enrolled with Virginia Premier CompleteCare will receive an individual member identification card. It is important to remember that a member’s eligibility could change on a month-to-month basis. Consequently, you should verify your patient’s eligibility each time they present for services. Providers can check member eligibility through several methods:

Q: Can my office staff and providers encourage members to select one plan over another?

No, this type of activity is prohibited by CMS. Providers are expected to remain neutral and should not encourage or sway members towards one plan or another. A provider may assist a beneficiary in an objective assessment of his/her needs and potential options to meet those needs. However providers should encourage members to call the plan’s enrollment broker, Maximus for assistance is selecting a plan.

Benefits and Covered Services

Q: What are the benefits for a potential enrollee to enroll with one of the Commonwealth Coordinated plans?
  • One ID card for members
  • One toll free phone number for 24 hours/7 days a week assistance
  • A unified appeals process
  • Person-centered service coordination/case management
Q: What are the covered services to members enrolled Virginia Premier CompleteCare?

Benefits include all Medicare (part A, B and D) benefits and Medicaid benefits, including EDCD waiver services, nursing facility services and transportation.

Q: What types of Long Term Support Services are covered for the members enrolled in Virginia Premier CompleteCare?

Members have access to the following Long Term Support services, however all services must be pre-authorized.

  • Adult Day services
  • Respite Care
  • Personal Care services
  • Transition Coordination
  • Personal Emergency Response services
  • Transition Services
Q: Are there guidelines regarding out-of-network referrals for Virginia Premier CompleteCare members?

Referrals to non-participating specialists are permitted only if the required specialty service is not available through the Virginia Premier Health Plan network and the service is pre-authorized by the Plan. Out-of-plan referrals should be documented in the POC (Plan of Care) and agreed to by all ICT members.

Q: What if any benefits are carved out from this plan?

The following services are carved out:

  • Case Management Services for participants of auxiliary grants
  • Targeted case management for individuals with intellectual disabilities
  • Community mental retardation services
Q: Can enrollees see providers who are out of network?

Yes, the plan must allow enrollees to maintain their current providers (including out-of-network providers) for 180 days from enrollment for new enrollees or for 30 days if the enrollee is switching from another CCC plan. However, after that period the plan must authorize any request to see an out-of-network provider.

Billing and Claims

Do I need to submit a claim to both Virginia Premier and Medicaid in order to get paid?

No providers only need to submit claims directly to Virginia Premier. One of the benefits of the Commonwealth Coordinated Care program is that providers receive a blended reimbursement from contracted health plans so there is no need to send claims to a secondary payer. When an individual is enrolled in Virginia Premier CompleteCare, he/or she is no longer enrolled in traditional Medicare or Medicaid fee-for-service.

Do members enrolled in Virginia Premier CompleteCare have co-pays or cost sharing?

No, as part of this program, there is no cost-sharing. Providers cannot collect co-payments, coinsurance, deductibles or any other amount for services covered under this plan. The contract you have with Virginia Premier clearly stipulates that you cannot balance bill members enrolled with the dual eligible plan.

Are there are special requirements for how I bill services rendered to Virginia Premier CompleteCare members?

No, providers are expected to follow Medicare and Medicaid billing guidelines unless otherwise noted in the Virginia Premier CompleteCare Provider Manual.

What is the timely filing period for participating Virginia Premier CompleteCare providers?

Providers should follow the timely filing as indicated on their contract, but in general providers have 180 days to file claims to Virginia Premier CompleteCare.

Grievances and Appeals

How do members appeal a decision made by the plan?

An enrollee or a provider acting on behalf of an Enrollee and with the Enrollee’s written consent may appeal the plan’s decision to deny, terminate, suspend, or reduce services. An enrollee or provider action on behalf of an enrollee and with the enrollee’s consent may also appeal the plan’s delay in providing or arranging for a Covered Service. Virginia Premier has 30 days from receipt to resolve all initial appeals and seventy-two (72) hours or as expeditiously as the enrollee’s condition requires for appeals qualifying as expedited appeals.

Provider Participation

Why must I complete training to participate with Virginia Premier CompleteCare?

As required by the 3 Way Contract with CMS and DMAS, Virginia Premier must provide initial and annual Model of Care training for our provider network. This requirement keeps everyone informed about the care management structure. Providers must satisfy this requirement by completing the course provided in our learning management system.

I am a Virginia Premier CompleteCare PCP, what are my responsibilities?

In addition to managing the members overall health and well-being you will:

  • Develop, maintain and monitor Plan of Care (POC) for the member
  • Actively participate as a member of the Interdisciplinary Care Team (ICT)
  • Provide information to member’s regarding LTSS services
  • Perform an initial health assessment for new members assigned to their panel to begin establishing the physician-patient relationship
  • Direct provision or coordination of all healthcare services for the member to include 24-hour coverage
  • Generate referrals to in-network specialist when services cannot be performed by the PCP
  • Contact Virginia Premier CompleteCare to obtain necessary prior authorization for designated services (e.g. out of network referrals, specified diagnostic tests)
  • Freely communicate with patients about their treatment, regardless of benefit coverage limitations
Interested in the opportunity to interact with your local Provider Services team and other providers in your area? Then attend one of Virginia Premier’s quarterly Provider Education Meetings that are held throughout our various service areas. These meetings are intended to give providers and their staff the opportunity to exchange ideas and suggestions with Virginia Premier staff while also receiving the latest news and updates. Please RSVP to the contact provided under the location that you wish to attend.

 

Regional Contacts


Central Virginia:

Nicole Williams at 800.727-7536 ext. 55118 or email: nicole.williams@vapremier.com
Taylor Fink at 800.727.7536 ext. 55456 or email: taylor.fink@vapremier.com
A.J. Binga at 800.727.7536 ext. 55263 or email: anthony.binga@vapremier.com

Roanoke

Contact to Attend:
Tammy English at 888.338.4579 ext. 55817 tammy.english@vapremier.com
Katrina Evans at 888.338.4579 ext. 55883 or email: katrina.evans@vapremier.com
Rebecca Frango at 888.338.4579 ext. 55876 or email: rebecca.frango@vapremier.com

Tidewater

Contact to Attend:
Dana Wilson at 800-828-7989, ext 55504 or email: Dana.wilson@vapremier.com
Constance Ferguson, 800.828.7989 ext. 55590 or email: Constance.ferguson@vapremier.com
Rashard Grier at 888.828.7989 ext. 55501 or email: Rashard.grier@vapremier.com

Western Va

Roger Young at 540.607.7312 or email: roger.young@vapremier.com

South West Virginia

Robin Murray at 888.338.4579 ext. 55626 or email: Robin.murray@vapremier.com
Spencer Huddleston at 888.338.4579 ext. 55667 or email: rhuddleston@vapremier.com

Northern Virginia

Tanya Labrador at 804.998.0548 or email: tanya.labrador@vapremier.com