Prior Authorizations
Learn when MVP prior authorization may be needed, how requests work, and where to find help with medical services, prescriptions, and approvals.
Based on your plan, certain procedures, treatments, or prescription drugs may need approval from MVP before you receive them. This is called a prior authorization. It’s often used when treatment is considered high risk or may have lower cost options. It helps ensure your care is safe, effective, and right for you.
When Do I Need a Prior Authorization?
Below are common examples of services that usually do not require prior authorization, and those that often do. Your exact requirements depend on your MVP plan and your provider’s clinical review.
Common procedures that don’t require prior authorization
- Routine primary care visits
- Most in‑network specialist visits
- Standard lab tests and basic bloodwork
- Basic X‑rays
- Preventive care, such as routine screenings and vaccinations
- Urgent or emergency care
- Most generic medications
- Initial physical therapy evaluations
- Basic diagnostic ultrasound
Common procedures that do require prior authorization
- Advanced imaging, such as MRI, CT, or PET scans
- Non‑emergency hospital or skilled nursing facility admissions
- Durable Medical Equipment like wheelchairs, oxygen equipment, or infusion pumps
- Genetic testing and specialty lab services
- Radiation therapy, including IMRT
- Gender‑affirming surgery, based on clinical review and plan details
- Elective surgeries (including joint, spine, and bariatric procedures)
- Pain‑management procedures, including nerve stimulation therapies and facet joint interventions
- Transplant procedures or transplant evaluations
- Home health services requiring higher levels of care
- Specialty medications or high‑cost prescriptions, including injectables or drugs with safety monitoring needs
These lists are only examples. Your provider will help you understand what applies to your care.
Medical and pharmacy policies
MVP covers hundreds of generic and brand medications. You can search for a specific drug or view your plan’s Formulary on our Prescription Benefits page. You can also consult our Medical Policies or Pharmacy Policies for coverage rules, clinical criteria, and requirements.
How to Get a Prior Authorization
The best way to know if you need a prior authorization is to ask your provider. Usually, they will start the request on your behalf and track it through completion. This process can take time. For that reason, it’s helpful to talk to your provider early.
Providers can find prior authorization forms in the Provider Form Library. For questions, they can contact Provider Services by email, or by fax at 1‑800‑280‑7346.
If you prefer to initiate a prior authorization yourself, call MVP Customer Care at the number on the back of your Member ID Card.
What you can expect
Most members don’t need to take any action beyond working with their provider. If a service or medication needs review, you can expect:
- Your provider to submit the request
- MVP to review clinical information
- A written decision sent to you and your doctor
- Clear next steps if more information is needed or if the request is denied
Finding information about a prior authorization in progress
Your provider is the best source for status updates. They receive requests for more information, approvals, and decisions directly.
If you have questions, call the MVP Customer Care Center at the number on the back of your Member ID card.
If your prior authorization has not yet been approved
If MVP needs more information, we will contact your provider. They may need to share clinical notes or clarify details before MVP can make a decision. Staying in touch with your provider can help prevent delays.
If your request is denied, both you and your provider will receive a written notice. The notice will explain the reason for the decision and your options. Your provider can request a reconsideration or help you file an appeal if needed.