MVP Process Updates

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