MVP Health Care® (MVP) continues to monitor the COVID-19 situation carefully and is taking proactive measures to protect the health and safety of MVP members, employees, providers, and our community. We are working in accordance with the guidelines provided by the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and with both New York and Vermont state departments overseeing the needs of the communities we serve.

MVP is committed to keeping providers up to date regarding changing guidelines and policies. Below is a summary of changes made during this State of Emergency.

Please note, MVP is abiding by guidance put forth by all regulating bodies and will provide coverage accordingly. As regulatory dates change, so will the dates associated with MVP coverage outlined below. To receive updates as they are announced, contact your MVP Professional Relations representative to receive email updates. MVP will email or fax updates to providers and will update this page accordingly.

On July 2, 2021 MVP announced changes to member cost-share effective August 1, 2021. Please review these changes by going to the Provider FastFax page and selecting fax number 30.

• Summary of Codes for Use During State of Emergency

  	Commercial	Medicaid	Medicare	Notes
  COVID-19 Diagnostic Testing	U0001 U0002 U0003 U0004 U0005 86318 86328 86408 86409 86413 86769 87426 87428 87631 87635 87636 87637 87811 87426 87428 0202U 0223U 0224U 0225U 0226U 0240U 0241U   ICD-10 Codes: R05 R06.02 R50.9	U0001 U0002 U0003 U0004 U0005 86318 86328 86408 86409 86413 86769 87426 87428 87631 87635 87636 87637 87811 87426 87428 0202U 0223U 0224U 0225U 0226U 0240U 0241U	U0001 U0002 U0003 U0004 U0005 86318 86328 86408 86409 86413 86769 87426 87428 87631 87635 87636 87637 87811 87426 87428 0202U 0223U 0224U 0225U 0226U 0240U 0241U   Office, ER, UCC: ICD-10 codes (1st position): Z03.818 Z03.828	No cost-share to the member
  COVID-19 Antibody Testing	86328 86769	86328 86769	86328 86769	No cost-share to the member
  COVID-19 Treatment	U07.1 J12.82 M35.81 M35.89	U07.1 J12.82 M35.81 M35.89	U07.1 J12.82 M35.81 M35.89	No cost-share to the New York members for treatment between 4/1/2020 through 6/30/21 No cost-share for Vermont members for treatment through 7/1/2021 Self-funded employer groups have the option to offer treatment coverage to their employees with no member cost share.
  Telemedicine Visits	Submit appropriate E/M or CPT code (for example 99212 or 99213) POS as appropriate; GT/95 modifiers Ensure only services that can be reasonably provided via telemedicine are billed	Submit appropriate E/M or CPT code (for example 99212 or 99213)POS as appropriate; GT/95 modifiers	99201-99215 POS as appropriate; GT/95 modifiers E-Visits MD, DO, NP, CNM bill: 99421-99423 All others bill: G2061-G2063 View a summary of Medicare Telemedicine Services.	Effective 3/13/2020, no cost-share to Member during SOE Existing provider/patient relationship not necessary Included in any applicable Member benefit visit limitations VT Variation – billing as outlined can be done for visits performed visually or telephonically.
  TeleMental Health Visits	Submit appropriate E/M or CPT code POS as appropriate; GT/95 modifiers May bill for ABA covered services (covered in a Commercial Member’s Subscriber Contract) for in-person visits as a TeleMental Health visit at no cost-share to the Member	Submit appropriate E/M or CPT code POS as appropriate; GT/95 modifiers OMH/OASAS Licensed Facilities: Ensure OMH attestation is on file with OMH	Submit appropriate contracted codes POS as appropriate; GT/95 modifiers E-Visits MD, DO, NP, CNM bill: 99421-99423 Providers who do not bill E/M: G2061-G2063 View a summary of Medicare Telemedicine Services.	Effective 3/13/2020, no cost-share to Member during SOE Telemental health visits may be provided as telephonic or video visits
  Telephonic	99441 99442 99443 POS as appropriate Physician, NP, PA & Licensed CNM Virtual Check-in: G2012 G2010	99441 99442 99443 POS as appropriate Physician, NP, PA & Licensed CNM	87631 87635 U0001 U0002 U0003 U0004 Virtual Check-in: G2012 G2010	As of 3/13/2020, telephone-only codes covered at no cost-share to the Member Reimbursement is based whenever possible on rates in provider agreement Existing provider/patient relationship not necessary

  MVP reserves the right to review all claims after the State of Emergency has been lifted to determine if proper coding was billed.

  
  

• COVID-19 Diagnostic & Antibody Testing

  Diagnostic Testing

  In compliance with state and federal regulations, MVP does not apply a cost-share to visits for testing for COVID-19 when deemed medically necessary, including any fees associated with an in-network office, Emergency Department (ED), or Urgent Care Center (UCC) or an out-of-network ED, or UCC Provider for the purpose of getting tested for COVID-19. Medicare MSA plan Members must meet their deductible for cost-share to be waived.

  The following CPT codes should be used for COVID-19 testing:

  CPT Code	Description
  U0001	Reported for coronavirus testing using the Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel.
  U0002	Reported for validated non-CDC laboratory tests for SARS-CoV-2/2019-nCoV (COVID-19).
  U0003	Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, making use of high throughput technologies as described by cms-2020-01-r
  U0004	2019-ncov coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc, making use of high throughput technologies as described by cms-2020-01-r
  U0005	Infection agent detection by nucleic acid (DNA OR RNA); Sever acute respiratory syndrome coronavirus 2 (SARS-COV-2) (coronavirus disease [COVID-19]), amplified probe technique
  86318	Immunoassay for infection agent antibody(ies), qualitative or semiquantitative, single step method (e.g., reagent strip)
  86328	Immunoassay for infections agent antibody(ies), qualitative or semiquantitative, single step method (e.g., reagent strip); sever acute respiratory syndrome coronavirus 2 (SARS-COV-2)
  86408	Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) (coronavirus disease [COVID-19]); Screen
  86409	Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) (coronavirus disease [COVID-19]); Titer
  86413	Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) (coronavirus disease [COVID-19]); Antibody, quantitative
  86769	Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) (coronavirus disease [COVID-19]);
  87426	Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative;
  87428	Infectious agent antigen detection by immunoassay technique, (eg, enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative;
  87631	Infectious Agent Detection By Nucleic Acid; Respiratory Virus, Reverse Transcription And Amp Probe Tech, 3-5 Targets
  87635	Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]), amplified probe technique
  87636	Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) (coronavirus disease [COVID-19]) and influenza virus types A and B, multiplex amplified probe technique
  87637	Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-COV-2(coronavirus disease [COVID-19]) and influenza virus types A and B, and respiratory syncytial virus, multiplex amplified probe technique
  87811	Infectious agent antigen detection by immunoassay with direct optical (i.e., visual) observation; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19])
  87426	Infectious agent antigen detection by immunoassay technique, (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (e.g., SARS-CoV, SARS-CoV-2 [COVID-19])
  87428	Infectious agent antigen detection by immunoassay technique, (e.g., enzyme immunoassay [EIA], enzyme-linked immunosorbent assay [ELISA], fluorescence immunoassay [FIA], immunochemiluminometric assay [IMCA]) qualitative or semiquantitative; severe acute respiratory syndrome coronavirus (e.g., SARS-CoV, SARS-CoV-2 [COVID-19]) and influenza virus types A and B
  0202U	Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome corona
  0223U	Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome corona
  0224U	Antibody, severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) (coronavirus disease [COVID-19]), includes titer(s), when performed
  0225U	Infectious disease (bacterial or viral respiratory tract infection) pathogen-specific DNO or RNA, 21 targets, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
  0226U	Surrogate viral neutralization test (SVNT), severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) (coronavirus disease [COVID-19]), ELISA, plasma, serum
  0240U	Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 3 targets (severe acute respiratory syndrome coronavirus 2 [SARS-COV-2], influenza A, influenza
  0241U	Infectious disease (viral respiratory tract infection), pathogen-specific RNA, 4 targets (severe acute respiratory syndrome coronavirus 2 [SARS-COV-2], influenza A, influenza

   

  Claims billed with the following ICD-10 codes in the first position for office, ED, or UCC visits that are for the primary purpose of testing will not apply a cost-share:

  • Z20.828

  In addition, effective 3/13/2020, the following codes will be covered at no cost-share for commercial members:

  • R05
  • R06.02
  • R50.9

  MVP has updated diagnosis codes that waive cost share for visits for diagnostic testing. Effective January 1, 2021, diagnosis codes Z20.822 and Z86.16 waive Member cost share. Effective May 1, 2021 diagnosis code Z11.59 will no longer waive cost share but will still be covered. The following diagnosis codes will waive cost share for Members who have a visit for diagnostic testing:

  Diagnosis Code	Description
  Z20.828	Contact with and exposure to other viral communicable diseases
  R05	Cough
  R06.02	Shortness of breath
  R50.9	Fever, unspecified
  Z20.822	Contact with and (suspected) exposure to COVID-19
  Z86.16	Personal history of COVID-19

   

  Specimen Handling

  MVP will cover specimen handling, 99001, and C9803 with Member cost-share waived when billed with the following diagnosis codes in any position:

  Diagnosis Code	Description
  Z03.818	Encounter for observation for suspected exposure to other biologic agents ruled out
  Z20.828	Contact with and exposure to other viral communicable diseases
  R05	Cough
  R06.02	Shortness of breath
  R50.9	Fever, unspecified
  Z20.822	Contact with and (suspected) exposure to COVID-19
  Z86.16	Personal history of COVID-19

   

  New HCPCS Lab Code

  Effective for dates of service January 1, 2021 and after, in order to receive the higher payment from CMS during the Public Health Emergency, the new HCPCS code U0005 must be used to signify that the laboratory is effectively turning around their high throughput test (i.e., they were “completed within two calendar days of the specimen being collected, meaning, the results of the test[s were] finalized and ready for release”). This code should be submitted along with U0003 or U0004.

  Pre-op Testing

  Pre-op COVID-19 diagnostic testing is covered for all Members with no cost share. MVP will not reimburse separately for diagnostic pre-op testing for MVP commercial and Medicaid Members as it will be considered global to the surgery, as are all other pre-op tests. Providers billing for MVP Medicare Members will be reimbursed based on CMS Guidelines.

  COVID-19 Antibody Testing

  Only a small number of the serologic assays to identify antibodies to SARS-CoV-2are officially approved by the FDA. Providers are strongly encouraged to only use the tests officially approved by the FDA. Information about the tests is found on the FDA’s website.

  If performed, use the following codes to ensure member cost-share is waived*:

  CPT Code	Description
  86328	Immunoassay for infectious agent antibody(ies), qualitative or semiquantitative, single step method (eg, reagent strip); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (COVID-19)
  86769	Antibody; severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (COVID-19)

   

  Providers should be aware of the following when ordering serologic assays for COVID-19:

  • Serologic tests should not be used as the sole basis to diagnose or exclude SARS-CoV-2 infection.
  • Negative results do not rule out SARS-CoV-2 infection, particularly in those who have been in contact with the virus.
  • Positive results may be due to past or present infection with non-SARS-CoV-2 coronavirus strains, such as coronavirus strains seen with the common cold.
  • Testing will not provide any information on a person’s immunity or risk of re-infection, but rather just that someone has been exposed.

  In addition, the following lab codes will also be covered at no cost-share to the member:

  CPT Code	Description
  87631	Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets
  87635	Infectious agent detection by nucleic acid (DNA or RNA); severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (COVID-19), amplified probe technique
  U0001	Reported for coronavirus testing using the Centers for Disease Control and Prevention (CDC) 2019 Novel Coronavirus Real Time RT-PCR Diagnostic Test Panel.
  U0002	Reported for validated non-CDC laboratory tests for SARS-CoV-2/2019-nCoV (COVID-19).

   

  *Medicare MSA plan members must meet their deductible in order for the cost-share to be waived.

  
  

• COVID-19 Treatment

  Treatment

  MVP has extended the Member cost-share waiver for COVID-19 treatment costs for any site of service, including inpatient hospitalizations and emergency room visits, for New York fully insured health plans and Medicare health plans through 7/31/2021. Medicare MSA Members must first meet their deductible to achieve $0 cost-share. The Member cost-share waiver for Vermont fully insured health plans has been extended through 3/1/2022. Self-funded employer groups have the option to waive COVID-19 treatment costs for their plan participants.

  Please note, MVP is abiding by guidance put forth by all regulating bodies and will provide coverage accordingly. As regulatory dates change, so will the dates associated with MVP coverage

  To ensure Member cost-share is waived for applicable Members as described above, use the following codes for the treatment of COVID-19:

  Diagnosis Code	Description
  U07.1	2019-nCoV acute respiratory disease
  J12.82	Pneumonia due to coronavirus disease 2019
  M35.81	Multisystem inflammatory syndrome
  M35.89	Other specified systemic involvement of connective tissue

   

  In addition, in Vermont, MVP will waive member cost-share for applicable members for dates of service from 3/13/2020 through 3/31/2020 when the following code is billed:

  Diagnosis Code	Description
  B97.29	Other coronavirus as the cause of diseases classified elsewhere

   

  For COVID-19 treatment performed 4/1/2020 or after, bill U07.1 as the primary diagnosis on the claim except:

  • For obstetrics patients as indicated in Section I.C.15.s. for COVID-19 in pregnancy, childbirth, and the puerperium.
  • For a COVID-19 infection that progresses to sepsis, see Section I.C.1.d. Sepsis, Severe Sepsis, and Septic Shock.
  • For a pneumonia case confirmed as due to COVID-19, assign codes U07.1 and J12.89 (other viral pneumonia).
  • For a patient with acute bronchitis confirmed as due to COVID-19, assign codes U07.1, and J20.8 (acute bronchitis due to other specified organisms).
  • For acute respiratory distress syndrome (ARDS) due to COVID-19, assign codes U07.1 and J80 (acute respiratory distress syndrome).

  For more information, consult the CDC Coding and Reporting Guidelines.

  Monoclonal Antibodies COVID-19 Billing Guidance

  The FDA has issued Emergency Use Authorization (EUA) for the following investigational monoclonal antibody treatment for COVID-19:

  • Casirivimab and imdevimab
  • Bamlanivimab
  • Bamlanivimab and etesevimab

  The EUA allows any of these three treatments to be administered to non-hospitalized adults and pediatric patients (12 years of age and older weighing at least 40kg) with confirmed COVID-19 infection, who are experiencing mild to moderate symptoms, and are at high risk for progressing to severe symptoms and hospitalization. For purposes of the EUA Casirivimab and imdevimab must be administered together by intravenous (IV) infusion.

  Allocation and distribution of the treatments are determined by the U.S. Department of Health and Human Services, Office of the Assistant Secretary of Preparedness and Response (HHS/ASPR).

  MVP will reimburse for the administration of the treatments listed above at no cost share to MVP Medicaid Managed Care and commercial Members when the codes below are submitted. MVP will not provide payment for the monoclonal antibody products that health care providers receive for free, as will be the case upon the product’s initial availability in response to the COVID-19 public health emergency.

  • M0239 (intravenous infusion, bamlanivimab-xxxx, includes infusion and post administration monitoring)
  • M0243 (intravenous infusion, casirivimab and imdevimab, includes infusion and post administration monitoring)
  • M0245 (intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring

  Providers should bill Medicare Fee-for-Service (FFS) directly for the monoclonal antibody products and administration of these products to MVP Members enrolled in Medicare Advantage. Reimbursement submitted to MVP for these Members will be denied.

  
  

• COVID-19 Vaccines

  MVP covers approved COVID-19 vaccines at no cost-share to Members in all plans.

   
  Medicare Members

  Effective January 1, 2022, MVP Health Care® (MVP) will reimburse Participating Providers and out-of-network providers for the cost of COVID-19 vaccines and their administration, as well as antibody treatment, to MVP Members enrolled in Medicare Advantage in 2022. Providers should no longer submit claims to Medicare Fee-for-Service.

   
  New York Commercial and Medicaid Members

  When COVID-19 vaccine doses are provided by the government without charge, only bill for the vaccine administration. MVP will reimburse Providers for the administration of the vaccine when the following codes are used:

  CPT Code	Description
  0001A	Pfizer-BioNtech Immunization Administration, first dose
  0002A	Pfizer-BioNtech Immunization Administration, second dose
  0003A	Pfizer-BioNtech Immunization Administration, third dose
  0004A	Pfizer-BioNtech Immunization Administration, booster dose
  0011A	Moderna Immunization Administration, first dose
  0012A	Moderna Immunization Administration, second dose
  0013A	Moderna Immunization Administration, third dose
  0031A	Janssen (Johnson & Johnson) Immunization Administration, first dose
  0034A	Janssen (Johnson & Johnson) Immunization Administration, booster dose
  0051A	Pfizer-BioNTech Immunization Administration, preservative free, first dose
  0052A	Pfizer-BioNTech Immunization Administration, preservative free, second dose
  0053A	Pfizer-BioNTech Immunization Administration, preservative free, third dose
  0054A	Pfizer-BioNTech Immunization Administration, preservative free, booster dose

   

  New York Providers should not include the vaccine codes (91300, 91301, and 91303) on the claim when the vaccines are free.

  Vaccine codes should not be included on claims when the vaccines are free of charge:

  CPT Code	Description
  91300	Pfizer-BioNtech vaccine
  91301	Moderna vaccine
  91303	Janssen (Johnson & Johnson) vaccine
  91305	Pfizer-BioNTech, preservative free

   

  Antibody Treatment Codes

  CPT Code	Description
  M0240	Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring, subsequent repeat doses
  M0241	Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring in the home or residence, this includes a beneficiary’s home that has been made provider-based to the hospital during the COVID-19 public health emergency, subsequent repeat doses
  M0243	Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring
  M0244	Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the COVID-19 public health emergency
  M0245	intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring
  M0246	Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the COVID-19 public health emergency
  M0247	Intravenous infusion, sotrovimab, includes infusion and post administration monitoring
  M0248	Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary’s home that has been made provider-based to the hospital during the COVID-19 public health emergency
  M0249	Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, first dose
  M0250	Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, second dose
  Q0240	Injection, casirivimab and imdevimab, 600 mg
  Q0243	Injection, casirivimab and imdevimab, 2400 mg
  Q0244	Injection, casirivimab and imdevimab, 1200 mg
  Q0245	Injection, bamlanivimab and etesevimab, 2100 mg
  Q0247	Injection, sotrovimab, 500 mg
  Q0249	Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, 1 mg

  Note: Codes M0249-50 and Q0249 should be used for inpatient only.

   
  Vermont Only

  MVP Commercial Members

  In addition to the vaccine administration code, Vermont Providers must also include the vaccine code— billed with a $0.00 or $0.01 charge on the claim. COVID-19 vaccines are not considered state-supplied; therefore, providers should not use the SL modifier.

  Administration Code	Short Description	Vaccine Code	Effective Date
  0001A	Pfizer vaccine – 1st dose	91300	12/11/2020
  0002A	Pfizer vaccine – 2nd dose	91300	12/11/2020
  0003A	Pfizer vaccine – 3rd dose	91300	8/12/2021
  0004A*	Pfizer vaccine – Booster	91300	9/22/2021
  0011A	Moderna vaccine – 1st dose	91301	12/18/2020
  0012A	Moderna vaccine – 2nd dose	91301	12/18/2020
  0013A	Moderna vaccine – 3rd dose	91301	8/12/2021
  0031A	Janssen/Johnson & Johnson vaccine – 1st dose	91303	2/27/2021
  0034A*	Janssen/Johnson & Johnson vaccine – Booster	91303	10/20/2021
  0051A	Pfizer ready-to-use vaccine – 1st dose	91305	9/22/2021
  0052A	Pfizer ready-to-use vaccine – 2nd dose	91305	9/22/2021
  0053A	Pfizer ready-to-use vaccine – 3rd dose	91305	9/22/2021
  0054A*	Pfizer ready-to-use vaccine – Booster	91305	9/22/2021
  0064A*	Moderna lower dose vaccine – Booster	91306	10/20/2021
  0071A	Pfizer Pediatric vaccine – 1st dose	91307	10/29/2021
  0072A	Pfizer Pediatric vaccine – 2nd dose	91307	10/29/2021

  *CDC guidance regarding eligibility for a booster dose is available for review at cdc.gov/coronavirus/2019-ncov/vaccines/booster-shot.html.

  Following AMA and CMS guidance, the administration code must match the manufacturer code of the vaccine provided at the encounter. The Vaccine Administration (Vermont Only) Payment Policy will be updated with these additional codes. To review the current policy, visit mvphealthcare.com/policies and select Payment Policies, Effective January 1, 2022, then select Vaccine Administration (Vermont Only).

   
  MVP Medicare Advantage Plan Members

  As of January 1, 2022, COVID-19 vaccine administration claims for MVP Medicare Advantage Plan Members should be submitted to MVP. Providers should not include the vaccine codes on the claim, when COVID-19 vaccine doses are provided by the government at no charge and should only bill for the vaccine administration.

  
  

• Telemedicine

  MVP is covering all telemedicine services at no cost-share to the Member during the declared State of Emergency.

  Providers should submit claims for Covered Services as outlined below in order for the Member cost-share to be waived:

  • Submit the appropriate Evaluation & Management (E/M) or CPT code (for example 99212 or 99213)
  • Submit the claim with the appropriate place of services (POS) code that would have been reported had the services been furnished in person.
  • Claim modifiers “95” or “GT” should be appended as appropriate on each claim that represents a service delivered via Telemedicine.
    • 95 modifier – Synchronous telemedicine service rendered via real-time interactive audio and video telecommunication system.
    • GT modifier – Via interactive audio and video telecommunication systems.

  Providers do not have to have an existing patient relationship with a Member to be reimbursed for telephone triage services and health care services delivered through telemedicine or audio-only telephone.

  While we encourage Providers to bill consistent with an office visit – and understand that certain services can be time consuming and complex even when provided virtually – such services should be coded at a level of care appropriate for provision through a telephonic mechanism and Providers should maintain documentation in the medical record for the level of care billed.

  Telemedicine visits will be included in any applicable Member benefit visit limitations.

  Telemedicine Platforms

  The Office for Civil Rights (OCR) at the Department of Health and Human Services (HHS) will exercise its enforcement discretion and will not impose penalties for noncompliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telemedicine during the COVID-19 State of Emergency. Providers who want to use audio or video communication technology to provide telemedicine during the State of Emergency can use any non-public facing remote communication product that is available to communicate with patients.

  • Examples of Acceptable Platforms (non-public facing): Apple FaceTime, Google G Suite Hangouts Meet, Skype for Business
  • Examples of Unacceptable Platforms (public facing): Facebook Live, Twitch, TikTok

  Store and Forward

  In Vermont, MVP is covering Store and Forward technology when the below code, or any other appropriate procedure code, is billed, along with modifier GQ:

  CPT Code	Description
  G2010	Remote evaluation of recorded video and/or images submitted by the patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.

  Reimbursement is based on contractual agreement.

  
  

• TeleMental Health

  Effective 3/13/2020, during the duration of the State of Emergency, Behavioral Health Providers, including qualified practitioners and services Providers, may deliver Covered Services via TeleMental Health, including telephonic services at no cost-share to the Member.

  Providers should submit the appropriate E/M or CPT code along with the POS code that would have been reported had the services been furnished in person and use claim modifiers “95” or “GT” on each claim that represents a service delivered via TeleMental Health.

  • 95 modifier – Synchronous telemedicine service rendered via real-time interactive audio and video telecommunication system.
  • GT modifier – Via interactive audio and video telecommunication systems.

  Providers in OMH/OASAS Licensed Facilities or Designated Programs should work with the NYS Office of Mental Health (OMH) to ensure the required attestation is on file with OMH. Access the Self-Attestation of Compliance to Offer TeleMental Health Services form.

  Behavioral Health Providers may bill for Applied Behavioral Analysis (ABA) Covered Services which would otherwise be covered in a Commercial Member’s Subscriber Contract for in-person visits as a TeleMental Health visit at no cost-share to the Member.

  
  

• Telephone Visits

  Vermont Commercial Members

  As of 3/13/2020, MVP is covering telephone-only codes as a telemedicine visit at no cost-share to members in Vermont. Providers will be reimbursed same as in person visits, rates based on their Provider Agreement.

  Providers should submit claims for telephone only visits as telemedicine visits for Covered Services as outlined below in order for the Member cost-share to be waived:

  • Submit the appropriate Evaluation & Management (E/M) or CPT code (for example 99212 or 99213)
  • Submit the claim with the POS code that would have been reported had the services been furnished in person
  • Claim modifiers “95” or “GT” should be appended as appropriate on each claim that represents a service delivered via Telemedicine.
    • 95 modifier – Synchronous telemedicine service rendered via real-time interactive audio and video telecommunication system.
    • GT modifier – Via interactive audio and video telecommunication systems.

  Providers do not have to have an existing patient relationship with a Member to be reimbursed for telephone triage services and health care services delivered through telemedicine or audio-only telephone.

  While we encourage Providers to bill consistent with an office visit – and understand that certain services can be time consuming and complex even when provided virtually – such services should be coded at a level of care appropriate for provision through a telephonic mechanism and Providers should maintain documentation in the medical record for the level of care billed.

  In addition, MVP will also cover the following telephonic codes. These will be covered at no cost-share to the member during the declared State of Emergency.

  CPT Code	Description
  99441	Telephone evaluation and management service; 5-10 minutes of medical discussion
  99442	Telephone evaluation and management service; 11-20 minutes of medical discussion
  99443	Telephone evaluation and management service; 21-30 minutes of medical discussion

  New York Commercial Members

  Virtual Check-In

  Providers should bill the following G codes for all Commercial members when conducting visits via telephone. These will be covered at no cost-share* to members during the declared State of Emergency.

  CPT Code	Description
  G2012	Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management [E/M] services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
  G2010	Remote evaluation of recorded video and/or images submitted by the patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.

  The codes below may also be used for telephonic visits with Commercial members. These will be covered at no cost-share* to the member during the declared State of Emergency.

  CPT Code	Description
  99441	Telephone evaluation and management service; 5-10 minutes of medical discussion
  99442	Telephone evaluation and management service; 11-20 minutes of medical discussion
  99443	Telephone evaluation and management service; 21-30 minutes of medical discussion

  Self-funded members should consult directly with their employer to see if their employer is waiving cost-share for telemedicine or telephone visits.

  New York Medicaid Members

  The codes below should be used for telephonic visits with Medicaid members. These will be covered at no cost-share to the member during the declared State of Emergency.

  CPT Code	Description
  99441	Telephone evaluation and management service; 5-10 minutes of medical discussion
  99442	Telephone evaluation and management service; 11-20 minutes of medical discussion
  99443	Telephone evaluation and management service; 21-30 minutes of medical discussion

  
  

• Medicare Specific Information

  Effective 3/1/2020, MVP is following the payment rules published in the Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency, Interim Final Rule with Comment (IFC).

  COVID-19 Testing Coding

  See coding section above.

  Telemedicine for Medicare Members

  During the current State of Emergency related to COVID-19, telemedicine visits for Medicare Members will be paid at the same rate as if the visit was in person. 1. Effective 3/13/2020, telemedicine visits billed with codes 99201-99215 with the POS code that would have been reported had the services been furnished in person, and the appropriate appended modifier, “95” or “GT”, will be reimbursed at no cost-share to the Member. This applies to all services (E/M, Mental Health Counseling, and preventive services) that would have otherwise been face-to-face.

  The following modifications have been made for the duration of the declared State of Emergency:

  • Location restrictions on Originating Sites: Medicare Members can be in their home for the telemedicine visit.
  • Providers may conduct telemedicine visits with a Member that is not already established (new patients).

  Providers must use an interactive audio and video telecommunications system that permits real-time communication between the Provider (“Distant Site”) and the Member (“Originating Site”). When it is possible for Covered Services to be furnished via telemedicine, MVP will pay for such services. Such services should be coded at a level of care appropriate for provision through a telemedicine mechanism. Providers should maintain documentation in the medical record for the level of care billed. MVP may request additional documentation to review and confirm such level of care.

  The following new codes should be used for telephone visits with Medicare Members to ensure cost-share is waived:

  CPT Code	Description
  98966	Telephone assessment and management service by a non-physician, 5-10 min
  98967	Telephone assessment and management service by a non-physician, 11-20 min
  98968	Telephone assessment and management service by a non-physician, 21-30 min
  99441	Telephone assessment and management service by a physician, 5-10 min
  99442	Telephone assessment and management service by a physician, 11-20 min
  99443	Telephone assessment and management service by a physician, 21-30 min
  G0071	Payment for communication technology-based services for 5 minutes or more of a virtual -non-face-to-face communication between a rural health clinic -RHC or federally qualified health center-FQHC

  More information about the Interim Final Rule can be accessed here.

  Virtual Check-In

  Consistent with CMS guidance, Providers should bill the following G codes for all Medicare Members when conducting visits via telephone. These are the only codes that may be used for Medicare Members and will be covered at no cost-share to Members during the declared State of Emergency. Claims should include the appropriate place of service code and modifiers should be appended per appropriate coding guidelines.

  CPT Code	Description
  G2012	Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report E/M services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
  G2010	Remote evaluation of recorded video and/or images submitted by the patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.

  Medicare E-Visits

  Medicare Part B pays for E-visits, or patient-initiated online E/M conducted via a patient portal. Providers who may independently bill Medicare for E/M visits (for instance, physicians and nurse practitioners) can bill the following codes:

  CPT Code	Description
  99421	Online digital E/M service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes
  99422	Online digital E/M service, for an established patient, for up to 7 days cumulative time during the 7 days; 11– 20 minutes
  99423	Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes

   

  Clinicians who may not independently bill for E/M visits (examples include but are not limited to: physical therapists, occupational therapists, speech language pathologists, clinical psychologists) may provide E-visits and bill the following codes:

  CPT Code	Description
  G2061	Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the 7 days; 5–10 minutes
  G2062	Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11–20 minutes
  G2063	Qualified non-physician qualified healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes

  Claims should include the appropriate place of service code and modifiers should be appended per appropriate coding guidelines.

  View a summary of Medicare Telemedicine Services.

  
  

• Prior Authorizations

  All Lines of Business

  MVP has suspended prior authorization requirements for all lines of business for:

  • Inpatient surgery and inpatient admissions to any hospital
  • Post-acute care services after discharge from any inpatient stay (including prior authorization requirements administered by naviHealth)
  • All Radiation Therapy and High-Tech Radiology (MRI’s, MRA’s, CT’s, Nuclear Cardiology and PET Scans) managed by eviCore*
  • All musculoskeletal codes managed by Magellan*/NIA

  *As of 6/2/2020, Magellan and eviCore are accepting requests to obtain prior authorizations for dates of service 6/19/2020 and beyond. Pre authorization is not required for dates of service from 3/20/2020 through 6/18/2020.

  Commercial Fully Insured, Self-Funded Plans, and Medicaid

  MVP will continue to perform prior authorization review for all other services, including:

  • Outpatient elective procedures, in-office procedures, durable medical equipment, and physician administered drugs
  • Use of out-of-network and out-of-state providers for provider office, ambulatory surgical and outpatient facility care

  Medicare Advantage

  MVP will continue to perform prior authorization review for all other in-network services, including:

  • Outpatient elective procedures, in-office procedures, durable medical equipment, and physician administered drugs

  
  

• Utilization Management

  Acute Care Facilities

  All Lines of Business
  As is standard business practice, services performed in an urgent care facility or an emergency room do not require prior authorization.

  MVP is suspending the following:

  • Admission and concurrent review requirements for acute care facility admissions
  • Performing retrospective review upon receipt of a claim for an Acute Inpatient admission not previously notified

  After June 18, 2020, MVP reserves the right to retrospectively review all admissions that occurred during this 90-day timeframe regardless of notification to MVP. MVP reserves the right to retrospectively audit any inpatient claim approvals made from March 20 – June 18, 2020.

  Post-Acute Care Services

  Skilled Nursing and IP Rehabilitation Facilities
  All Lines of Business
  MVP has suspended prior authorization for transfers to Skilled Nursing and Rehabilitation Facilities. It is encouraged that Skilled Nursing and Acute Inpatient Rehabilitation Facilities continue to notify MVP (for Medicare Advantage Members continue to notify naviHealth) within 48 hours of admission.

  • MVP will waive the 3-day hospital stay rule, if it exists, for all lines of business.
  • It is preferred that members continue to be directed to participating facilities. MVP and naviHealth will not reject admissions to non-participating facilities
    • To find participating rehabilitation facilities and skilled nursing facilities, visit mvphealthcare.com/searchproviders. After you enter a zip code and choose the member’s plan type, click Search All, then type in “rehabilitation” or “skilled nursing”. You can use the filters to adjust the distance and other preferred attributes.
    • o If you need assistance navigating the Provider Search tool, or would like a list provided to you, contact the MVP Customer Care Center for Provider Services at
      1-800-684-9286.
  • If you need assistance with discharge planning, please contact your assigned MVP UM representative.
  • It is expected that transfers are medically necessary. MVP and naviHealth will perform concurrent review during member stays at skilled nursing and rehabilitation facilities. All Adverse Determination adjudication will follow all applicable NYS DFS rules for 90-day extension of timeframe for appeals.
  • Medicare Advantage Members
    • If a skilled nursing facility considers care no longer medically necessary, naviHealth should be notified prior to issuing a Notice of Medical Non-Coverage (NOMNC).

  After June 18, 2020, MVP reserves the right to retrospectively review all skilled nursing or acute inpatient rehabilitation facility admissions that occurred during this 90-day timeframe regardless of notification to MVP.

  Home Care Services
  Medicare Advantage
  MVP has suspended the prior authorization for home care services for Medicare Advantage members.

  • Home Health Agencies may continue to evaluate members home health needs without prior authorization.
  • It is encouraged that Home Health Agencies continue to provide minimal demographic information at start of care
    • Name of Agency
    • Name of Patient
    • Date of Birth
    • Member Number
    • Member Address
    • Ordering Physician Name
    • Diagnosis
    • Start of Care or Resumption of Care Date (if following a readmission)
  • If the agency determines that they need more than 10 visits, it is encouraged that you submit additional visits and supply naviHealth with the complete OASIS, 485, and last two visit notes for each discipline requested.

  After June 18, 2020, MVP reserves the right to retrospectively review all home health care that occurred during this 90-day timeframe regardless of notification to MVP.

  Commercial and Medicaid
  As always, prior authorization is not required for home health care services.

  Admission Requirements for Behavioral Health

  All Lines of Business

  MVP has modified the admission requirements for inpatient mental health, mental health residential, inpatient substance use detoxification, inpatient substance use rehabilitation, and substance use residential for 90 Days.

  Providers should notify MVP within two business days of the admission to the above levels of care. Concurrent reviews are suspended for all services mentioned above. MVP will continue to assist in coordinating care and discharge planning throughout the member’s stay.

  MVP clinicians will contact facilities for periodic consultations. These consultations are not for Utilization Review purposes, but rather for coordination of care regarding the member’s treatment and discharge plans. MVP is also offering assistance as needed during these consultations to remove any barriers there may be related to post discharge care.

  When the member is discharged, the provider should notify MVP of the discharge date along with the discharge plan within 24 hours of discharge. This includes members leaving against medical advice (AMA).

  As a reminder, Partial Hospitalization and Continued Day Treatment no longer requires prior authorization as of March 17, 2020.

  After June 18, 2020, MVP reserves the right to retrospectively review all admissions that occurred during this 90-day timeframe regardless of notification to MVP.

  
  

• Personal Protective Equipment (PPE)

  The New York State Department of Financial Services (DFS) recently released a Circular Letter reminding health plans that New York State Participating Providers cannot charge patients additional fees, beyond their standard cost-share for covered services, for personal protective equipment (PPE). To access the DFS Circular Letter, click on the link below. If your practice charged Non-Medicare MVP Members for PPE, you must fill out the PPE Survey.

  • PPE Survey
  • DFS Circular Letter

  
  

• Prescriptions / Pharmacy

  MVP members are now able to obtain an early refill on a 30-day supply of maintenance medications at an in-network pharmacy, regardless of whether the state the member resides in has called a state of emergency. Medicaid members who are quarantined or whose provider suggests self-quarantine may contact CVS to request a 90-day supply of maintenance medications during the COVID crisis. MVP Medicare members may request a 90-day supply of medications at an in-network pharmacy. Members should speak with their pharmacist to enter the applicable emergency supply override code into their dispensing systems to trigger the early refill override.

  Members with a mail-order benefit taking maintenance medications should be encouraged to take advantage of the ability to receive a 90-day supply of medication through the CVS Caremark Mail Order pharmacy and mailed directly to their home. Some retail pharmacies will also mail prescriptions to a home address; members should be encouraged to please ask their pharmacist if this is an option.

  Controlled substances and specialty medications will be exempt from this override process. Please remember that most specialty medications may be obtained from the CVS Specialty Pharmacy, which mails prescriptions to a member’s home already.

   
  MVP Pharmacy Billing for COVID-19 Testing (PDF)

  
  

• Physical Therapists, Occupational Therapists, and Speech Therapists

  Physical therapists (PT), occupational therapists (OT), and speech therapists (ST) may render telemedicine services to MVP commercial and Medicaid members in New York and Vermont. Certified Athletic Trainers may render telemedicine services to commercial members in Vermont.

  During the declared State of Emergency, MVP will reimburse for PT, OT, and ST services for initial and subsequent visits for new and existing patients. PT, OT, and ST providers may not perform telemedicine visits telephonically. Providers should only bill within their scope of practice and should not bill for physical manipulation if they are not physically manipulating the patient. All visits will count toward a members’ annual allotment of visits.

  Claims submitted with standard CPT codes and the appropriate place of service will be paid with no cost-share for Medicaid and commercial members. In addition, either modifier 95 or GT should be appended to the claim as appropriate.

  See the Telemedicine section for more information.

  
  

• Gia Health Care Services

  Beginning January 1, 2021, MVP will launch Gia^℠ to help connect members to the right care, right away. myERnow will be retired and MVP members should be redirected to Gia or “start with Gia” for their health care needs.

  Gia will be available for free on New York and Vermont fully insured plans, Medicaid, and most Medicare plans. Self-funded employers can elect to offer Gia. Medicare MVP SmartFund MSA, MVP RxCare, and Child Health Plus members are not eligible for Gia services.

  Gia includes access to telemedicine services, including 24/7 urgent and emergency care, psychiatry, behavioral health, and more, and referrals to in-person care from nearby doctors, specialists, labs, pharmacies, and other providers.

  Gia telemedicine is not the same as a member using their current doctors’ telehealth platform or offering. If an MVP member makes a telehealth appointment or has a telehealth visit with his/her own doctor, and not through Gia, co-pays or a cost-share will apply per plan details.

  
  

• Nurse Practitioners, Physician Assistants, Special Assistants, and Certified Registered Nurse Anesthetists

  During the State of Emergency:

  • Nurse practitioners will be able to practice without a written practice agreement or collaborative relationship with a doctor or hospital.
  • Physician assistants and specialist assistants can provide medical services without oversight from a supervising physician.
  • Certified registered nurse anesthetists are permitted to administer anesthesia without the supervision of a physician.

  
  

• Additional Resources

  Federal Agency Resources

  • HHS COVID-19 Updates
  • CMS Current Emergencies
  • SAMHSA COVID-19 Resources and Information
  • CDC COVID-19 Guidance
  • FDA COVID-19 Information
  • Resources for Ordering & Administering COVID-19 Vaccine (PDF)
  • COVID-19 Vaccine Quick Reference Guide for Healthcare Professionals (PDF)

  State Agency Resources

  • NYS DFS COVID-19 Industry Guidance
  • NYS DOH COVID-19 Guidance for Medicaid Providers
  • NYS Office of Mental Health COVID-19 Updates
  • NYS Office of Addiction Services and Supports COVID-19 Updates
  • Vermont DOH COVID-19 Guidance for Health Care Professionals
  • Physicians ToolKit Letter (PDF)