Published October 2023

MVP Provider Policies and Payment Policies includes revisions on operational procedures, plan type offerings, and clinical programs. The policies are designed to serve as a reference tool for Providers and facilities. The following policies have been updated, with an effective date of October 1, 2023, and are posted at mvphealthcare.com/policies.

Below is a listing of the specific policies that have been updated and are effective October 1, 2023.

MVP Provider Policies

• Claims
• Credentialing
• Inpatient and Outpatient Services

MVP Payment Policies

• Applied Behavior Analysis Services
• Article 28 Split Billing
• Audiology Services
• Contrast Materials
• Diagnosis Matching Edits
• Elective Delivery for Providers and Facilities
• Evaluation and Management
• Eye Wear Coverage
• Implantable Devices
• Laboratory Services
• Mental Health and Substance Use Disorder
• Modifier Policy for Physician
• Observation Status for Facility and Provider
• Personal Care/Consumer Directed Personal Assistance Services - Service Units Billing
• Preoperative Lab Testing
• Preventive Health Care
• Radiology
• Radiopharmaceuticals
• Robotic and Computer Assisted Surgery
• Surgical Supplies
• Unlisted CPT Code
• Urgent Care
• Virtual Check-ins and Interpersonal

Published October 2023

MVP offers a variety of classes and workshops at all activity levels. We recognize that your patients may need extra support these days, and we encourage you to make them aware of the many virtual classes and workshops available from MVP.

Featured virtual classes and workshops that may be of interest to your patients

• Pelvic Floor Health: Every Thursday through November 16, 12-12:30 pm
• Tai Chi for Health and Fall Prevention:Every Friday through November 17, 9:30-10:30 am

The Living Well programs listed above are only a sampling of the many offerings from MVP. Access our complete calendar by visiting mvphealthcare.com/calendar and selecting Living Well. Please encourage your patients to participate throughout the year.

Published July 2023

MVP Provider Policies and Payment Policies includes revisions on operational procedures, plan type offerings, and clinical programs. The policies are designed to serve as a reference tool for Providers and facilities. The following policies have been updated, with an effective date of July 1, 2023, and are posted at mvphealthcare.com/policies.

• Behavioral Health
• Claims
• Credentialing
• New York State Government Programs
• Quality Programs
• Utilization and Case Management
• MVP Payment Policies

Published July 2023

Helping your patients to understand the benefits

Patient engagement and education are crucial to their understanding of consent options and the impact of their choices when they decline or decide to enroll in a regional Health Information Exchange (HIE). Meaningful consent occurs when patients make an informed decision. It is important that members understand that when they go to an emergency department, urgent care, or a new doctor’s office, the caregivers need to know current and past health conditions, prior medical tests and results, any medications prescribed, medication allergies or side effects, and any/all other specialists on a patient’s health care team. If they are unable to provide these details, it is reassuring to know that a care team can have instant access to this health information if they have signed a consent to become enrolled in a regional HIE.

The benefits of accurate, up-to-date information include:

• Reduced risk of medical mistakes
• Less chance of drug interactions
• Fewer repeated tests and duplicate charges
• Easier second opinions
• Physicians can send and receive referrals and share test results and other information that can help improve the coordination of your care
• Helping your care team to make informed decisions when placing orders for tests and treatment

Additional benefits to patients:

• An HIE allows for secure sharing of health record with other Providers for the best coordination of care
• State and county public health officials can see patient records in situations like the COVID-19 pandemic, when they are helping manage large health events
• Health information is private and secure. Providers who access your medical record must report to the HIE whose records they have accessed and why. That way, you know your information has been handled properly and your privacy has been protected
• Patients can view their medical records or those for whom they are a parent, legal guardian, or designated caregiver
• Patients can share records with doctors outside the region or with facilities not connected to the HIE, like VA hospitals
• Enrollment can be rescinded at any time

Please be sure to talk to your patients about the importance of enrolling in a Health Information Exchange. If you have questions, please contact MVP at hedisquality@mvphealthcare.com.

Published April 2023

MVP provides a Code of Ethics and Business Conduct Summary as part of its commitment to conducting business with integrity and in accordance with all federal, state, and local laws. This summary provides MVP’s Participating Providers, vendors, and delegated entities (Contractors) with a formal statement of MVP’s commitment to the standards and rules of ethical business conduct. All MVP Contractors are expected to comply with the standards as highlighted below. Contractors may access MVP’s full Code of Ethics and Business Conduct by visiting mvphealthcare.com/providers then select Reference Library, then Learn about MVP Policies.

Protecting confidential and proprietary information

It is of paramount importance that MVP’s Member and proprietary information be always protected. Access to proprietary and Member information should only be granted on a need-to-know basis and great care should be taken to prevent unauthorized uses and disclosures. MVP’s Contractors are contractually obligated to protect Member and proprietary information.

Complying with the anti-kickback statute

As a Government Programs Contractor, MVP is subject to the federal anti-kickback laws. The anti-kickback laws prohibit MVP, its employees, and Contractors from offering or paying remuneration in exchange for the referral of Government Programs business.

Reviewing the federal and state exclusion, preclusion, and identification databases

MVP and its Government Programs Contractors are required to review the applicable federal and/or state exclusion, preclusion, and identification databases. These database reviews must be conducted to determine whether potential and current employees, Contractors and vendors are excluded or precluded from participation in federal and state sponsored health care programs. The federal and state databases are maintained by the Centers for Medicare and Medicaid Services (CMS), the Department of Health and Human Services (HHS), the Office of Inspector General (OIG), the General Services Administration (GSA), the New York State Office of Medicaid Inspector General (OMIG), the Social Security Administration Death Master File (SSADMF), and the National Plan and Provider Enumeration System (NPPES).

Prohibiting the acceptance of gifts

MVP prohibits employees from accepting or soliciting gifts of any kind from MVP’s current or prospectivevendors, suppliers, Providers, or customers that are designed to influence business decisions.

Detecting and preventing fraud, waste, and abuse (FWA)

MVP has policies and processes in place to detect and prevent fraud, waste, and abuse (FWA). These policies outline MVP’s compliance with the False Claims Act and other applicable FWA laws and regulations. These laws and regulations prohibit MVP and its Contractors from knowingly presenting or causing to present a false claim or record to the federal government, the State Medicaid program, or an agent of these entities for payment or approval. Contractors may access MVP’s policy for Detecting and Preventing FWA by visiting mvphealthcare.com/providers then select Reference Library , thenselect Learn about MVP Policies . MVP’s Special Investigations Unit (SIU) is instrumental in managing the program to detect, correct and prevent FWA committed by Providers, Members, subcontractors, vendors, and employees. The SIU maintains a toll-free, 24-hour hotline, 1-877-835-5687 , where suspected fraud, waste, and abuse issues can be reported directly by internal and external sources.

Providing compliance training, FWA training, and HIPAA training

To prevent and detect FWA, all MVP’s Contractors that support its Medicare plansand who are first tier, downstream, or related (FDRs) entities are required to provide general compliance training and FWA training to their employees, subcontractors, and downstream entities upon hire, annually, and as changes are implemented. CMS provides a Medicare Parts C and D FWA and general compliance training program. This online program is available through the CMS Medicare Learning Network at cms.gov.

Entities who have met the FWA certification requirements through enrollment into Parts A or B of the Medicare Program or through accreditation as a supplier of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) are deemed to have met the FWA training requirement. However, these entities must provide general compliance training.

MVP’s Contractors that support its Medicaid plansare also required to provide general compliance and FWA training to their employees, subcontractors, and downstream entities upon hire, annually, and as changes are implemented.

In addition, Contractors who handle MVP Protected Health Information are required toprovide HIPAA Privacy, Security, and Breach Prevention trainings to their employees.

Reporting suspected violations

MVP provides an Ethics & Integrity Hotline for reporting suspected violations of the Code or of its legal requirements. The Ethics & Integrity Hotline - 1-888-357-2687 - is available for employees, vendors, and Contractors to report suspected violations anonymously. Reports of suspected fraud, waste, and abuse may also be reported anonymously by contacting the Ethics and Integrity Hotline. EthicsPoint manages MVP’s confidential reporting system and receives calls made to the Hotline. EthicsPointtriages reports in a secure manner to MVP’s Compliance Office. The Compliance Office promptly and thoroughly investigates all allegations of violations. All MVP Contractors are required to report actual or suspected non-compliance and FWA that impacts MVP using the hotlines referenced above. Contractors are protected from intimidation and retaliation for good faith participation in MVP’s Compliance Program.

Published April 2023

MVP Provider Policies and Payment Policies includes revisions on operational procedures, plan type offerings, and clinical programs. The policies are designed to serve as a reference tool for Providers and facilities. The following policies have been updated, with an effective date of April 1, 2023, and are posted at mvphealthcare.com/policies.

PROVIDER POLICY UPDATES EFFECTIVE April 1, 2023

• Appeals
• Pharmacy Benefits
• New York State Government Programs
• Provider Responsibilities

PAYMENT POLICY UPDATES EFFECTIVE April1, 2023

• After Hours
• Allergy Testing and Serum Preparation Claims
• Arthroscopic, Endoscopic, and other Non Gastro Intestinal Scope Procedures
• Audiology
• Consistency of Denials
• Default Pricing
• Durable Medical Equipment
• Evaluation & Management (E & M)
• Interpreter
• JW and JZ Modifiers
• Laboratory
• Mental Health and Substance Use Disorder
• Multiple Surgery - VT Only
• NDC Policy
• NP/PA & Mid-Level Policy
• Preventive Payment Policy
• Radiology
• Telehealth
• Transitional Care

Published January 2023

MVP Provider Policies and Payment Policies includes revisions on operational procedures, plan type offerings, and clinical programs. The policies are designed to serve as a reference tool for Providers and facilities. The following policies have been updated, with an effective date of January 1, 2023, and are posted at mvphealthcare.com/policies

PROVIDER POLICY UPDATES EFFECTIVE January 1, 2023

• Appeals Process
• Behavioral Health
• Claims
• Credentialing
• New York State Government Programs
• Quality Improvement 
• Utilization and Case Management

PAYMENT POLICY UPDATES EFFECTIVE January 1, 2023

• Audio Only VT
• Breast Reconstruction (new policy)
• COVID-19 Lab Testing
• Durable Medical Equipment
• Elective Delivery for Provider and Facilities
• Locum Tenens
• NDC Policy
• Occupational Therapy
• Physical Therapy
• Speech Therapy
• Telehealth
• Telemental Health Services
• Vaccine Administration VT Only

Published January 2023

This Notice applies to Members of health plans offered by the following MVP operating subsidiaries: MVP Health Plan, Inc. (except for Medicare Advantage products), MVP Health Services Corp., and MVP Health Insurance Company.

The New York State Department of Financial Services recommends that providers print and post this notice in their office. The PDF notice is available for download in both English and Spanish. Visit mvphealthcare.com/notices, then select Legal Notices/Reports.

Insurance Law § 2612 states that if any person covered by an insurance policy issued to another person who is the policyholder or if any person covered under a group policy delivers to the insurer that issued the policy, a valid order of protection against the policyholder or other person, then the insurer is prohibited for the duration of the order from disclosing to the policyholder or other person the address and phone number of the insured, or of any person or entity providing covered services to the insured. The regulation governs confidentiality protocols for domestic violence victims and endangered individuals.

To make a request, the requestor should contact the MVP Customer Care Center at the address or phone number indicated in this notice.

The requestor must provide the MVP Customer Care Center with an alternative address, phone number, or another method of contact, and may be required to provide the MVP Customer Care Center with a valid order of protection.

To revoke a request, the requestor should submit a sworn statement to the address indicated on the contact information in this notice. To contact the New York State Domestic Violence and Sexual Violence Hotline, call 1-800-942-6906.

Published January 2023

MVP is excited to announce that we have received our CAQH® Committee on Operating Rules for Information Exchange (CORE®) Certification Seal, demonstrating our commitment to streamlining electronic health care administrative data exchange.


MVP applied for CORE Certification status because we support CORE’s mission, collaborative industry approach, and administrative simplification objectives. MVP is one of only a small number of plans in the country that has achieved this certification.


CAQH, a nonprofit alliance of health plans and trade associations, launched CORE to promote health plan-provider interoperability and improve Provider access to administrative information.


The mission of CORE is to accelerate the transformation of business processes in health care through collaboration, innovation, and a commitment to ensuring value across stakeholders.


Achieving the CORE Certification Seal reinforces MVP’s dedication to exchange electronic administrative data in compliance with the CORE rules. CAQH currently awards a CORE-certification Seal to health plans that complete the Phase I, Phase II, and Phase III certification processes. The Phase III Seal indicates that the MVP is certified as operating in compliance with Phase I, Phase II and Phase III rules.


Phase III of the CAQH CORE Operating rules is specific to Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA). MVP provides EFT & ERA through PaySpan®. This service is provided at no cost to Providers and allows online enrollment, saving you time and ensuring faster payments.


PaySpan can be contacted by calling 877-331-7154 extension 1, or by email at providersupport@payspanhealth.com.

Published January 2023

Reduced Coinsurance for Related Procedures Begins January 1, 2023

Currently, planned colorectal cancer screening tests are free. However, if you add a procedure in the same clinical encounter because of the colorectal cancer screening, the patient pays a coinsurance.

Beginning January 1, 2023, CMS will gradually reduce coinsurance for procedures performed for Medicare Members:

• In connection with a colorectal cancer screening test 
• As a result of a screening test 
• In the same clinical encounter as the screening test

The reduced coinsurance applies regardless of the code you bill.

For dates of service in CYs: 

• 2023–2026, coinsurance is 15%
• 2027–2029, coinsurance is 10%
• Beginning 2030, no coinsurance

Learn more about Phasing and Coinsurance at CMS.com.

Published October 2022

Effective October 1, 2022, MVP will no longer print and mail explanations of payment or capitation summaries with paper remittances. Electronic versions of your payment summaries will be available for download and printing, only from the Payspan website.

If you do not have a Payspan account

To register, please visit payspanhealth.com. A Registration Code and PIN are required to create a Payspan health account. This information can be found on your latest MVP paper remittances, or you can obtain from Payspan by phone or email noted below.

If you have a Payspan account

If you have a Payspan account, you can activate service for your MVP payment summaries:

1. Access your current Payspan account at payspanhealth.com
2. Login and select Your Payments
3. Select Manage Reg Codes
4. Select Add New Reg Code (far right of screen)
5. Enter required fields on the Add Registration Code screen

Once completed, you will have access to payment summaries and MVP Member details from your Payspan dashboard. To view, select Research Payments, hover over View Remit, and choose Download CSV to export.

Save time and ensure secure payment

This is the perfect time to register for Electronic Funds Transfer (EFT) payments, a service provided at no cost to you, saving you time and ensuring faster and secure payments. If you wish to receive EFT payments, have your bank account and routing numbers ready when registering for a Payspan health account.
If you need additional assistance, please visit payspanhealth.com or contact Provider Support via email at providersupport@payspanhealth.com or by phone at 877-331-7154, Option 1.

This change in process is part of MVP’s commitment to going green and eliminating unnecessary printing and mailing. We appreciate your efforts in supporting this goal.

Published October 2022

Exclusionary Database Monitoring is a critical tool for ensuring compliance, program integrity, and patient safety for your patients. MVP is obligated to confirm our Medicaid Provider Network has the appropriate policies and procedures in place regarding exclusionary databases and required annual training for all practitioners, employees, and staff.

Why this action is important

• Practices must monitor state and federal exclusion lists to verify that an employee or provider is in good standing
• Providers or employees not in good standing cannot receive money for state and federal healthcare programs In Sections 1128 and 1156 of the Social Security Act, the U.S. Department of Health & Human Services (HHS) Office of Inspector General prohibits healthcare organizations from contracting with excluded or sanctioned individuals or entities.

Published October 2022

MVP Provider Policies and Payment Policies includes revisions on operational procedures, plan type offerings, and clinical programs. The policies are designed to serve as a reference tool for Providers and facilities. The following policies have been updated, with an effective date of October 1, 2022, and are posted at  mvphealthcare.com/policies.

PROVIDER POLICY UPDATES EFFECTIVE OCTOBER 1, 2022

• Credentialing
• MVP Plan Type Information
• Provider Responsibilities

PAYMENT POLICY UPDATES EFFECTIVE OCTOBER 1, 2022

• Article 28 Split Billing
• Contrast Materials
• Diagnosis Matching Edits
• Durable Medical Equipment
• Evaluation & Management
• Eyewear
• Modifier Policy
• Observation Policy
• Personal Care/Consumer Directed Personal Assistance
• Physical Therapy
• Preoperative Testing
• Preventive Health Care
• Radiopharmaceuticals
• Robotic and Computer Assisted Surgery
• Surgical Supplies
• Telehealth
• Unlisted CPT Code
• Urgent Care
• Virtual Check-ins

Published October 2022

To continuously improve your experience while navigating the MVP website and to ensure you can find the information, tools, and resources you need to be successful, the Quality Programs page for Providers has been redesigned and now, also includes the Provider Quality Improvement Manual (PQIM) directly on this page. The Quality Programs page for Providers is now a one-stop resource hub to find:

• MVP’s Current Quality Programs and Initiatives
• Quality Improvement Clinical Guidelines and Supporting Resources
• HEDIS Provider Tip Sheets and HEDIS Compliance Resources
• Guidance for Granting MVP Remote Access to EMRs
• Best Practices for Submitting Medical Records

The PQIM had also been redesigned for a better user-experience; Providers and office staff can now use the built-in Document Finder to search for all PQIM resources including Clinical Guidelines, Supporting Tools for Clinicians, Useful Information for Members, and Related Links. No more clicking your way through multiples pages and sub-pages to find important clinical guidelines, screening tools, condition-specific brochures, and more!

Check out the new Quality Programs page today, visit mvphealthcare.com/providers and select Quality Programs.

Published July 2022

As part of the MVP commitment to the accreditation standards of the National Committee for Quality Assurances (NCQA) and to comply with state and federal government regulations and mandates, MVP publishes regulatory and compliance content on mvphealthcare.com. Annual Notices include upgrades regarding Member’s Rights and Responsibilities, Member Complaint and Appeal Process, MVP’s Privacy Notice, Confidentiality and Privacy Policies Protection of Oral, Written, and Electronic Protected Health Information, HIPAA reminder about faxes, Medical Management Decisions, Pharmacy Benefit Management, Utilization Management Criteria, Practitioner Appeals, MVP Non-Compliance Policy, Utilization Management Criteria, Practitioner Appeals, MVP Non-Compliance Policy, Utilization Management Processes, Out-of-Network Requests, Transition of Care for Members of Practitioner leaving the MVP Provider Network, Transition of Care for New MVP Members, Transition of Pediatrics to Adult Care, Specialist as a Primary Care Physician, Emergency Services, New Technology assessment, MVP Medical Record Standards and Guidelines, Nondiscrimination in Health Care Delivery, Advance Directives, The MVP Quality Improvement Program, Invitation to Join the MVP Quality Improvement Program, Practitioner Credentialing and Recredentialing Process, Provisional Credentialing Requirements for New York State Physicians, Report Suspected Insurance Fraud/Abuse, Self-Treatment and Treatment of Immediate Family Member, MVP Meets Members’ Cultural and Linguistic Needs, and the MVP Participating Provider Directory. To view the 2022 Provider Annual Notices, visit mvphealthcare.com, then select Notice of Privacy Practices and Compliance and then select Legal Notices/Reports.

Published July 2022

MVP Provider Policies and Payment Policies includes revisions on operational procedures, plan type offerings, and clinical programs. The policies are designed to serve as a reference tool for Providers and facilities. The following policies have been updated, with an effective date of July 1, 2022, and are posted at mvphealthcare.com/policies.

PROVIDER POLICY UPDATES EFFECTIVE July 1, 2022

• Appeals Process
• Behavioral Health
• Claims
• Credentialing
• New York State Government Programs
• Quality Improvement
• Utilization and Case Management

PAYMENT POLICY UPDATES EFFECTIVE July 1, 2022

• Audio-Only (VT Only)
• COVID-19 Lab Testing
• Durable Medical Equipment
• Elective Delivery for Provider and Facilities
• Locum Tenens
• Mid-Level Providers
• Multiple Surgery (VT Only)
• National Drug Code (NDC)
• Occupational Therapy (OT)
• Physical Therapy (PT)
• Preventive Health Care
• Radiology
• Speech Therapy (ST)
• Telehealth
• Telemental Health Services
• Transitional Care Management
• Vaccine Administration (VT Only)
• Viscosupplementation of the Knee: Non-Coverage for Medicaid Manage Care(MMC) Plans (New Policy)

Published July 2022

The Social Determinants of Health Data Journey to Better Outcomes

Social Determinants of Health (SDOH) are the conditions in the environments where people are born, live, learn, work, and play. “Z Codes” can be used to help pinpoint specific conditions that have an impact on the health and wellness of your patients.SDOH-related Z codes ranging from Z55-Z65 are theICD-10-CM encounter reason codes used to document SDOHdata. Using SDOH Z codes can help to improve the quality of health care for your patients. For more information on how to use Z codes, visit cms.gov/files/document/zcodes-infographic.pdf.

Published July 2022

To ensure prior authorization requests for prescriptions are received and reviewed in a timely manner, MVP is asking all offices that utilize “memory buttons” to save fax numbers to verify that the numbers are accurate. Below, please find the two forms that should be utilized for prescription requests and the appropriate fax numbers where they should be returned to MVP. 

The two forms are:

• NYS Medicaid Prior Authorization Request Form For Prescriptions
• Fax completed form to 1-800-376-6373
• Prior Authorization Request For Prescriptions
• For Medicare Advantage Plan Members, fax the completed form to 1-800-401-0915
• For all other MVP Members, fax the completed form to 1-800-376-6373

The forms can be accessed at mvphealthcare.com/Providers, then select Forms, then Prior Authorization, then select the appropriate form under the Pharmacy section.

Published July 2022

Collaborating with you

MVP offers dedicated Case Management programs to MVP Members living with multiple or chronic health concerns, both physical and behavioral. Drawing on the combined strength of our registered nurses, respiratory therapists, social workers, registered dietitians, and other health care professionals, MVP offers a highly focused, integrated approach that promotes quality, cost effective health care. As part of our business agreement, representatives of the MVP Case Management team will at times need to contact your practice to obtain health information and/or request information regarding our Members. The information requested is HIPAA-compliant and helps ensure a collaborative partnership between MVP and your office to give your patients – our Members, the best possible care. We appreciate your timely response to requests from our team.

Published July 2022

In accordance with the New York State Circular letter No. 4, MVP has updated its policy regarding the Prevention of Colorectal Cancer. The updated policy can be reviewed at mvphealthcare.com/policies then select Payment Policies, Effective July 1, 2022.

To read theInsurance Circular Letter No. 4 (2022), visitny.gov.

Published April 2022

MVP places great importance on information security to protect against internal and external threats. Our cybersecurity strategy prioritizes detection, analysis, and incident response to cyber threats, vulnerability management, and resilience against cyber incidents. MVP continuously strives to meet and exceed the industry’s information security best practices and applies controls to protect our Provider partners and our Members. As a strategic partner, we want to remind you of some basic questions to ask yourself before clicking on emails that come from an unknown source:

• Do you recognize the sender’s email address?
• If you know the sender, were you expecting this email?
• Does the message contain poor spelling or grammar?
• Does the message ask for personal information?
• Does the offer seem too good to be true?
• Did you initiate the action?
• Are you being asked to send money? 
• Does the message make unrealistic threats? 
• Does the message appear to be from a government agency like the IRS?
• Does anything look off?

Please be sure to remind your staff to ask themselves these questions and to stay vigilant against cyberattacks.

Published April 2022

Authorization to Disclose Information

MVP strives to create the best experience for our Members, your patients. Collaboration between providers can make a positive impact on their overall health by helping to close communication gaps, identify potential health issues before they arise, and provide more comprehensive care. MVP encourages providers to work with their patients to sign releases of information to offer a more integrative approach to treatment. MVP Case Managers (CMs) help to coordinate care by educating Members on completing an Authorization to Disclose Information Form (PDF).

Published April 2022

MVP Participating Providers must ensure that there is 24/7 coverage for Members. PCPs may use a back-up call service, provided that a physician is always available to back up the call service. PCPs agree that, in the case of an absence, they will arrange for patient care to be delivered by another provider and ensure the covering provider participates with MVP. If arrangements are made with a non-participating physician, it is the responsibility of the participating physician to ensure that the non-participating physician will: 

• Accept MVP’s fee as full payment for services delivered to MVP Member patients 
• Accept the MVP peer-review procedures 
• Seek payment only from MVP for covered services provided to Members and at no time bill or otherwise seek compensation for covered services from MVP Members, except for the applicable co-payments 
• Comply with MVP utilization management and quality improvement procedures 

Note: Providers who are not contracted for Government Program lines of business are considered non-participating for Government Program plan types (Medicaid Managed Care, HARP, and Child Health Plus). When submitting the insurance claim to MVP, the covering provider should indicate “covering for Dr. ‘X’” in box 19 of the CMS-1500 claim form.

Published April 2022

MVP provides this Code of Ethics and Business Conduct Summary as part of its commitment to conducting business with integrity and in accordance with all federal, state, and local laws. This summary provides MVP’s network Providers, vendors, and delegated entities (Contractors) with a formal statement of MVP’s commitment to the standards and rules of ethical business conduct. All MVP Contractors are expected to comply with the standards as highlighted below. View MVP’s Corporate Code of Ethics and Business Conduct (PDF).

Protecting Confidential and Proprietary Information

It is of paramount importance that MVP’s Member and proprietary information be always protected. Access to proprietary and Member information should only be granted on a need-to-know basis and great care should be taken to prevent unauthorized uses and disclosures. MVP’s Contractors are contractually obligated to protect Member and proprietary information.

Complying with the Anti-Kickback Statute

As a Government Programs Contractor, MVP is subject to the federal anti-kickback laws. The anti-kickback laws prohibit MVP, its employees, and Contractors from offering or paying remuneration in exchange for the referral of Government Programs business.

Reviewing the Federal and State Exclusion, Preclusion, and Identification Databases

MVP and its Government Programs Contractors are required to review the applicable federal and/or state exclusion, preclusion, and identification databases. These database reviews must be conducted to determine whether potential and current employees, Contractors, and vendors are excluded or precluded from participation in federal and state sponsored health care programs. The federal and state databases are maintained by the Centers for Medicare and Medicaid Services (CMS), the Department of Health and Human Services (HHS), the Office of Inspector General (OIG), the General Services Administration (GSA), the New York State Office of Medicaid Inspector General (OMIG), the Social Security Administration Death Master File (SSADMF) and the National Plan and Provider Enumeration System (NPPES). 

Prohibiting the Acceptance of Gifts

MVP prohibits employees from accepting or soliciting gifts of any kind from MVP’s current or prospective vendors, suppliers, providers, or customers that are designed to influence business decisions.

Detecting and Preventing Fraud, Waste, and Abuse (FWA)

MVP has policies and processes in place to detect and prevent fraud, waste, and abuse (FWA). These policies outline MVP’s compliance with the False Claims Act and other applicable FWA laws and regulations. These laws and regulations prohibit MVP and its Contractors from knowingly presenting or causing to present a false claim or record to the federal government, the State Medicaid program, or an agent of these entities for payment or approval. View MVP’s policy for Detecting and Preventing Fraud, Waste and Abuse (PDF). MVP’s Special Investigations Unit (SIU) is instrumental in managing the program to detect, correct, and prevent FWA committed by providers, Members, subcontractors, vendors, and employees. The SIU maintains a toll-free, 24-hour hotline, 1-877-835-5687, where suspected fraud, waste, and abuse issues can be reported directly by internal and external sources.

Providing Compliance Training, Fraud, Waste,and Abuse (FWA) Training and HIPAA Training 

To prevent and detect FWA, all MVP’s Contractors that support its Medicare products and who are first tier, downstream, or related entities (FDRs) are required to provide general compliance training and FWA training to their employees, subcontractors, and downstream entities upon hire, annually, and as changes are implemented. The Centers for Medicare and Medicaid Services (CMS) provides a Medicare Parts C and D FWA and general compliance training program. This online program is available through the CMS Medicare Learning Network. Entities who have met the FWA certification requirements through enrollment into Parts A or B of the Medicare Program or through accreditation as a supplier of DMEPOS are deemed to have met the FWA training requirement. However, these entities must provide general compliance training. MVP’s Contractors that support its Medicaid products are also required to provide general compliance and FWA training to their employees, subcontractors, and downstream entities upon hire, annually and as changes are implemented. In addition, Contractors who handle MVP Protected Health Information are required to provide HIPAA Privacy, Security, and Breach Prevention trainings to their employees.

Reporting Suspected Violations

MVP provides an Ethics and Integrity Hotline for reporting suspected violations of the Code or of its legal requirements. The Ethics and Integrity Hotline – 1-888-357-2687 – is available for employees, vendors, and Contractors to report suspected violations anonymously. Reports of suspected fraud, waste, and abuse may also be reported anonymously by contacting the Ethics and Integrity Hotline. EthicsPoint manages MVP’s confidential reporting system and receives calls made to the Hotline. EthicsPoint triages reports in a secure manner to MVP’s Compliance Office. The Compliance Office promptly and thoroughly investigates all allegations of violations. All MVP Contractors are required to report actual or suspected non-compliance and FWA that impacts MVP using the hotlines referenced above. Contractors are protected from intimidation and retaliation for good faith participation in MVP’s Compliance Program.

Published April 2022

MVP Provider Policies and Payment Policies includes revisions on operational procedures, plan type offerings, and clinical programs. The policies are designed to serve as a reference tool for Providers and facilities. The following policies have been updated, with an effective date of April 1, 2022, and are posted at mvphealthcare.com/policies.

Provider Policy Updates Effective April 1, 2022

• Behavioral Health Policy
• Claims
• Contacting MVP
• Provider Responsibilities

Payment Policy Updates Effective April 1, 2022

• After-Hours
• Allergy Testing and Serum Preparation Claims
• Audiology Services
• Arthroscopic, Endoscopic, and other Non-Gastrointestinal Scope Procedures
• Consistency of Denials
• Default Pricing
• Home Infusion
• Interpreter Services
• Infusion Policy
• JW Modifier
• Laboratory Services
• Mental Health and Substance Use Disorder
• Mid-Level Payment Policy
• Multiple Surgery – VT Only
• NDC Policy
• Preventive Payment Policy
• Radiology
• Transitional Care Management
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Published April 2022

Follow-up Care After Emergency Department Visits

According to the US National Institutes of Health, 50% of all hospital admissions are a direct result of Emergency Department (ED) visits. Timely followup care with the patient after an ED visit may be the key to reducing return ED visits as well as improving overall population health outcomes.

Behavioral Health ED Visits

For ED visits due to a Behavioral Health event, such as mental illness, alcohol dependence, or substance use disorders, studies have demonstrated the benefits of timely follow-up care such as decreased suicidal ideation, reduced ED readmissions, and improved medication adherence¹. Furthermore, the American Medical Association has found that follow-up care for people with Behavioral Health conditions not only lead to fewer repeat ED visits, but also improved physical and mental function, and increased compliance with follow-up instructions.

Implementing Best Practices for Follow-Up Care

Reach out to your patients to schedule a follow-up appointment as soon as you are notified of their ED visit. Utilize your health information exchange (HIE) to gain more information on ED discharges or collaborate with hospital ED’s to obtain data exchange reports on your patients seen in the ED for better care coordination. If available, offer your patients options for telemedicine services for follow-up care, including:

• Telephone visits
• Telehealth visits
• Online Assessment (e-visits or virtual check-ins)

Providers can improve the transition of care by connecting Members with appropriate Behavioral Health care providers in their area or working with Members to sign information sharing agreements that facilitate integrated health care between providers. For more information on follow-up care after ED visits for Behavioral Health events, view MVP’s HEDIS Provider Reference Guides.

MVP Behavioral Health Care Program

MVP’s Behavioral Health care program connects Members to licensed Behavioral Health clinicians who are available for support calls, to help improve their daily quality of life, and to help them better understand their Behavioral Health condition. If you are treating MVP Members who may benefit from this program, refer them to MVP Case Management at 1-866-942-7966, Monday–Friday 8:30 am–5 pm.

¹Source: Psychiatry Online: ps.psychiatryonline.org/ doi/10.1176/appi.ps.201500104