To request approval for a service or medication through Viva Health, a provider completes the Viva Health prior authorization form that matches the service type, attaches clinical documentation, and submits it through the provider portal at vivaproviders.com or by fax to the department that handles that plan and service. The utilization management team reviews whether the request meets coverage criteria under the member’s plan and returns a decision to both the provider and the member.
Which Form To Use
Viva Health does not use one universal form. The current versions sit on the provider resources page at vivahealth.com/provider/resources/, grouped by what you are asking the plan to cover:
- Medical Benefit Drug Prior Authorization Form, for drugs administered in a provider’s office, infusion center, or other clinical setting.
- Inpatient/Outpatient Precertification Form, for hospital admissions, surgeries, and outpatient procedures.
- Imaging Request Form, for MRI, CT, and other advanced diagnostic imaging.
- DME Form, for durable medical equipment such as wheelchairs and oxygen supplies.
- Therapy Precertification Form, for physical, speech, and occupational therapy.
- Referral Authorization Form, for out-of-network or specialist services.
A few request types catch providers off guard. All unclassified drug codes (J3490, J3590, J8999, and J9999) require prior authorization regardless of the clinical situation. Compounded prescriptions with a total cost above $200 also require prior approval. Specialty medications not listed on the formulary may still be covered under medical benefits, but they go through prior authorization and plan-specific cost-sharing.
Portal users can start certain prior authorizations directly through vivaproviders.com, which supports automatic approvals for some routine requests and lets you check member eligibility and claims status in the same session.
What To Put on the Form
Every version collects two clusters of information: administrative identifiers and clinical justification. The administrative section is simple but unforgiving. A single transposed digit in a member ID bounces the request back.
Patient and Provider Identifiers
The patient section asks for the member’s full name, Member ID number, and date of birth. The provider section needs the prescriber’s name, NPI number, office phone and fax, and a contact person the review team can reach for follow-up. If a facility will deliver the service, add the facility name, address, phone, and Tax ID.
Clinical Information
Most denials start in the clinical section, so completeness matters more here than anywhere else on the page. You need:
- The diagnosis and ICD-10 code justifying the service.
- The drug name and HCPCS code, plus the NDC when the code is an unclassified one.
- Route, frequency, and quantity of the medication.
- Patient height and weight, which many injectable dosages are verified against.
- A brief clinical rationale, with clinical notes attached. The form directs you to fax it with clinical notes; sending it without them almost guarantees a delay or denial.
- For non-preferred or specialty drugs, each alternative the patient has already tried, with dates and outcomes. Reviewers want evidence that cheaper or standard-of-care options came first.
Mark whether the request is initial, a renewal, or urgent/expedited, and show where the drug will be administered: self-administered at home, in a long-term care or skilled nursing facility, from the provider’s stock (buy and bill), or in the office with the patient supplying the medication. The prescribing physician signs and dates the form.
Where To Send It
Viva Health routes requests to different fax numbers by plan type and service category. Picking the wrong number is one of the easier mistakes to make and one of the slower ones to recover from.
- Medical benefit drug prior authorization: fax (205) 449-7049. Phone inquiries go to 205-933-1201 (option 1) or 1-800-294-7780.
- Medicare Part D drugs filled at a dispensing pharmacy: fax 205-449-2465.
- Commercial plan drugs filled at a dispensing pharmacy: fax 205-872-0458.
The provider portal is the faster channel. It generates a confirmation receipt, which gives you a timestamp if there is ever a dispute about when the request was filed, and it avoids the risk that faxed pages arrive illegible or out of order.
How Long Viva Health Has To Decide
Response times depend on whether the request is standard or urgent, and on the type of plan the member holds.
For employer-sponsored plans governed by ERISA, 29 CFR 2560.503-1 sets the outer limits. A standard pre-service claim must receive a decision within 15 days of receipt. The plan can extend that by another 15 days when circumstances beyond its control require more time, but it must notify you of the extension before the first period expires. If the delay is because your submission was incomplete, you get at least 45 days to supply what is missing.
Urgent care claims run on a much shorter clock. The plan must decide as soon as the medical situation requires, and no later than 72 hours after receiving the request. If information is missing, the plan has to tell you within 24 hours what it needs, and you get at least 48 hours to send it.
If a request is time-sensitive, mark it urgent/expedited on the form and have the clinical notes explain why a delay could harm the patient. A checked “urgent” box without supporting documentation will not always trigger the faster track.
If the Request Is Denied
A denial is not the end of the road. Both an internal appeal and an independent external review are available.
Internal Appeal
You have 180 days from the date of the denial notice to file. Complete the Viva Health Consumer Affairs form from the member resources page and send it to the appropriate address. For Viva Medicare members, appeals go to:
Viva Medicare
Attention: Medicare Member Appeals and Grievances Coordinator
417 20th Street North, Suite 1100
Birmingham, AL 35203
Fax: 205-933-1239
Include anything that strengthens the record: a letter from the treating physician on medical necessity, updated lab results, documentation that alternative treatments failed. Keep originals and send copies. For urgent situations where waiting could seriously jeopardize the patient’s health, request an expedited internal appeal, which must be decided within four business days. That decision can be delivered verbally, with a written notice within 48 hours.
External Review
If the internal appeal upholds the denial, you can request an independent external review. It is available for any denial involving medical judgment, a determination that a treatment is experimental, or a cancellation of coverage. File a written request within four months of the final internal appeal decision.
An independent reviewer with no ties to Viva Health examines the case and issues a binding decision; the insurer is required by law to accept it. Standard external reviews must be completed within 45 days of receipt. Expedited reviews, for urgent medical situations, must be decided within 72 hours or less. The HHS-administered federal process is free. State-run processes may charge up to $25.
Treating Without Authorization
Starting treatment before approval comes back puts the patient at real financial risk. Viva Health’s policy is explicit that payment will not be made for any use outside approved criteria without prior authorization. The provider cannot bill the member for the unauthorized service unless the member agreed in writing, before the service was delivered, to accept financial responsibility.
Emergencies are the main exception. Federal rules and most state laws exempt genuine emergencies from prior authorization, so the insurer must cover stabilization care regardless of whether approval was obtained first. “Emergency” has a clinical definition tied to symptoms a reasonable person would consider life-threatening, not an urgent preference for faster treatment.
When a service was delivered without authorization because of a true emergency or an administrative mix-up, a retrospective review may still be possible. The insurer can evaluate medical necessity after the fact, but approval is not guaranteed, and the burden of proving the service was appropriate shifts entirely to the provider. Getting authorization before treatment is always the safer path.