Provider Forms Library

• Provider Change of Information Form
• Using the Provider Change of Information Form  (PDF)
• Facility/Ancillary Provider Change of Information (PDF)
• Provider Participation Guide (PDF)
• Provider Application Request (PDF)—To properly use the Provider Application Request Form, please right-click the link and select “Save link as” to save the file to your device. Then the form can be populated in Acrobat Reader. Do not complete this form in your browser. 
• Supplemental Provider Credentialing Application (PDF)
• MVP Contracted Hospitals (PDF)
• Practitioner Continuity of Care Statement (PDF)
• Provider Leave of Absence Notification (PDF)
• Provider Credentialing Rights (PDF)
• Federal Tax W-9 (PDF)

• Children’s Home and Community Based Service Notification Form (PDF)—For use by Children Home and Community Based Service providers when requesting an initial HCBS service request for children.
• Children’s Home and Community Based Service Authorization and Continuation Form (PDF)—For use by Children Home and Community Based Service providers when requesting a continuation of HCBS service(s) for children.
• Child Health Plus Referral for Home and Community Based Services (HCBS) to HCBS Provider (PDF)—For use by Health Home entity/C-YES when referring CHPlus Members for HCBS Services, intended to be given to HCBS providers to review
• CHPlus Medically Fragile Home and Community Based Services (MF HCBS) Decision Support Model: Ages 0 – 5 HCBS Eligibility Determination Worksheet (PDF)—For use by Health Home entity/C-YES to determine HCBS eligibility for MF HCBS ages 0-5.
• CHPlus Medically Fragile Home and Community Based Services (MF HCBS) Decision Support Model: Ages 6 – 19 HCBS Eligibility Determination Worksheet (PDF)—For use by Health Home entity/C-YES to determine HCBS eligibility for MF ages 6-19. 
• CHPlus Serious Emotional Disturbance Home and Community Based Services (SED HCBS) Decision Support Model: Ages 0 – 5 HCBS Eligibility Determination Worksheet (PDF)—For use by Health Home entity/C-YES to determine HCBS eligibility for SED ages 0-5. 
• CHPlus Serious Emotional Disturbance Home and Community Based Services (SED HCBS) Decision Support Model: Ages 6-19 HCBS Eligibility Determination Worksheet (PDF)—For use by Health Home entity/C-YES to determine HCBS eligibility for SED ages 6-19.  
• Licensed Practitioner of the Healing Arts (LPHA) Attestation Serious Emotional Disturbance (SED) Form for the CHPlus Program (PDF)—For use by LPHA’s when requesting HCBS eligibility Assessment.
• Medically Fragile Target Population Forms (only required if SSI certification or DOH disability Review Team Certification with valid coverage dates is not available):
  • Childhood Medical Disability Report (DOH 5151) (PDF)—For use by child’s doctor to assist in determining Medicaid eligibility based on a disability, after an application for benefits has been filed.
  • Description of Child’s Activities (DOH-5153) (PDF)—For use by Members to assist in determining Medicaid eligibility based on a disability, after an application for benefits has been filed.
  • Disability Questionnaire (DOH 5139) (PDF)—For use by Members when requesting Eligibility assessment from Health Home entity/C-YES. 
  • Questionnaire of School Performance (DOH-5152) (PDF)—For use by the child’s teacher or school administrator to assist in determining Medicaid eligibility based on a disability and physical or mental limitations on a child’s ability, after an application for benefits has been filed.

• EDI Enrollment
• EDI Enrollment Form 835/ERA

Providers may create and submit medical claims online to MVP by accessing TransShuttle . This website is hosted and powered by AXIOM and the services available therein are offered by AXIOM to providers on behalf of MVP Health Care. AXIOM may require that users agree to AXIOM’s site requirements and certain terms of use before accessing AXIOM’s services. Please note an NPI is required to setup an account.  

For questions, contact our EDI Service Department by email or at 1-877-461-4911. 

To learn about claim adjustment requests, review the Summary of CARF Enhancement presentation, which reviews claims adjustment requests that can be submitted and tracked online 

• Claim Adjustment Request
• Dental Claim Adjustment Request
• Risk Adjustment Form
• Authenticated Risk Adjustment Form — Please note, you must be logged in to your MVP Provider Online Account to access this form.

Admissions

Notification of Unplanned, Urgent, or Emergency Room Admission 

Prior Authorizations 

• Prior Authorization Request Form (PDF)
• Prior Authorization Request Form (NY) (Sign-In Required)
• Vermont Uniform Medical Prior Authorization Form (PDF)
• Prior Authorization Request Form for DME/O&P Items & Services (PDF)
• Prior Authorization Request Form for DME/O&P Items and Services (NY) (Sign-In Required)
• Prior Authorization Request Form for Skilled Nursing Facilities & Acute Inpatient Rehabilitation (SNF & AIR) (PDF)

Pharmacy 

Reminder: For a more streamlined review process, log in to your MVP provider online account and submit pharmacy prior authorization forms via Novologix. 

• NYS Medicaid Prior Authorization Request Form for Prescriptions (PDF)
• Prior Authorization Request Form for Medication (PDF)
• Medication (General & Formulary exception) (Sign-in required)

Medicare Part D  

• Hospice — Medicare Part D (PDF)
• Medicare Prescription Drug Coverage Determination Request (Submit Online) 
• Medicare Standard Form (PDF) 

Radiation and Radiation Therapy  

• Information about eligibility and prior authorization can be found at eviCore healthcare. 

• Personal Care Services Time-Tasking Tool (Digital Version) (PDF). If you are using the digital version, please right-click the link and select Save link as to save the file to your device. Do not complete this form in your browser. 
• Personal Care Services Time-Tasking Tool (Print Version) (PDF)
• Considerations for Personal Care Services (PDF) 

• Uniform Clinical Network Provider Training Enrollment Form
• Acknowledgement of Hysterectomy Information (PDF)
• Prior Authorization Request Form for Sterilization and/or Hysterectomy (PDF)
• Sterilization Consent Form (PDF)
• Medicaid Prenatal Registration Form (Rochester) (PDF)

• ABA Authorization Request (PDF)—For requesting authorization for Applied Behavioral Analysis Assessment and Treatment 
• Authorization to Disclose Information (PDF)—For Members to complete if they wish to give MVP permission to discuss their health with another person 
• Substance Use Disorder Two Business Day Notification and Initial Treatment Plan (PDF)—For use by hospitals and facilities when a member is admitted for Inpatient and/or Residential Substance Use Treatment 
• Two-Day Notification and Initial Treatment Plan (PDF) —For use by hospitals and facilities when a child/adolescent, age 0-17, is admitted for Inpatient Mental Health 
• Mental Health Treatment Notification of Admission (PDF)—For use by hospitals and facilities when an adult, age 18+, is admitted for Inpatient Mental Health and for admissions to Mental Health Residential Treatment Centers for members of all ages 
• Behavioral Health Outpatient Treatment Request (PDF)—For use by Providers requesting authorization for outpatient mental health and/or substance use treatment 
• Prior Authorization Request Form Vermont (PDF)—For use by Providers located in VT requesting authorization for mental health and/or substance use treatment 
• Children’s Home and Community Based Service Notification Form (PDF)—For use by Children Home and Community Based Service providers when requesting an initial HCBS service request for children. 
• CORE Overview—Please review the LPHA Recommendation forms and the CORE Provider Service Initiation template under the Resources & Guidance section.

• Primary Care Provider Change or Patient Reassignment Request (PDF)
• Disability Eligibility Determination Form (PDF)
• Member Approval for Appeal Delegation Form (PDF)
• Diabetic Eye Exam Form (PDF)
• Diabetic Eye Exam Form-Spanish (PDF)
• Unclaimed Property Claim Form (PDF)
• New York Health Care Proxy
• Vermont Health Care Proxy 
• Medical Orders for Life Sustaining Treatment (MOLST) (PDF)

• Health Home Adult Enrollment Referral (PDF)
• Health Home Child Enrollment Referral (PDF)

• Disclosure of Ownership-Control (Facilities) (PDF)
• Disclosure of Ownership-Control (Provider Group) (PDF)
• Disclosure of Ownership-Control FAQs (Provider Group) (PDF)
• Unclaimed Property Claim Form (PDF)

Un-cashed Checks? Please visit LongLostMoney’s website to see if MVP has any un-cashed checks in your name, or in the name of your business.