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MVP Health Care 2022 Payment Policies (partial)
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Collection of MVP Health Care payment and reimbursement policy guidelines governing billing, coding, and reimbursement rules for various services (e.g., after-hours, allergy testing, E&M) for providers submitting claims to MVP Health Care.
Policy Summary
PayerMVP Health Care
PolicyMVP Health Care 2022 Payment Policies (partial)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateDec 1, 2021
Last ReviewDec 1, 2021
Next Review DateN/A
Key ActionProviders must check member eligibility, the Member Benefits Display, and MVP Utilization Management Guides to determine if prior authorization is required.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
~30+individual policy topics referenced in table of contents
4095165 first-year units per claim
16095165 first-year units per year
1E&M per day limit
CoveredElectroconvulsive Therapy
Sept 1, 2021Document last reviewed
Coverage Criteria and Policy Positions
After-Hours Billing Rules
After-hours services billing rules
Allergy Testing Coverage
Allergy testing and serum preparation reimbursement limits
MVP reimburses for allergy testing and serum preparation but requires the number of units/tests be specified on the claim and applies calendar-year and per-claim limits as listed below.
95165 limits: CPT 95165 (supervision of preparation/provision of antigens): number of units/doses must be specified on the claim; first year reimbursement limited to 40 units per claim and 160 units per calendar year; subsequent years limited to 30 units per claim and 120 units per calendar year.
95004 limit: CPT 95004 (percutaneous allergy tests): number of tests must be specified on the claim; reimbursement limited to 80 units per calendar year.
95024 limit: CPT 95024 (intracutaneous immediate type tests): reimbursement limited to 40 units per calendar year.
95028 limit: CPT 95028 (intracutaneous delayed type tests): number of tests must be specified on the claim; reimbursement limited to 30 units per calendar year.
E&M Coverage and Medical Necessity
Evaluation and Management (E&M) coverage stance
MVP will reimburse medically necessary E&M services in accordance with AMA/CPT and CMS documentation guidance; documentation may be requested to verify that services meet medical necessity criteria.
Medical necessity definition: MVP adopts AMA and CMS definitions of medical necessity and applies MVP's specific five criteria: services appropriate/consistent with diagnosis; not primarily for convenience; required for direct care; provided in accordance with generally accepted practice and supporting evidence; provided in a safe, appropriate and cost‑effective setting.
E&M coverage and bundling rules
Rules for reimbursement, bundling, and exceptions for E&M and related services.
When the primary reason for the visit is preventive, claims are reimbursed per state/federal regulations and many same-day office procedures are not reimbursed separately (see preventive visit exclusions).
Sexual assault/forensic exams are reimbursed per NY Office of Victims Services mandate with no member cost share where applicable.
MVP allows only one E&M CPT code per day per physician group per specialty; preventive visits disallow many specified same-day procedures.
E&M during a global surgical period is not separately reimbursed unless a significant unrelated problem arises; Modifier 24 must be appended for unrelated post‑operative E&M.
Diabetes education codes (e.g., 98960) are reimbursed when billed alone but will deny as bundled when billed with E&M office visit codes (e.g., 99211-99215).
Osteopathic manipulation codes are not reimbursed unless the provider's contract specifies an exception.
The first prenatal E&M visit is global to OB delivery charges; antepartum codes require indication of number of prenatal visits for reimbursement.
When two inpatient physician E&M codes are billed on the same date for the same/related condition by the same provider, the second will be denied.
E&M codes billed as urgent care are not reimbursed when billed with well child care, routine diagnoses, or routine services such as immunizations.
COVERAGE CRITERIA
Coverage positions and billing rules summarized from the present document chunks.
After-hours codes: 99050 reimbursed without review unless submitted with preventive visit codes 99381-99397; after‑hours range 99051-99060 are governed by MVP After‑Hours Payment Policy.
Urgent care: E/M codes billed as urgent care (99201-99499) are not reimbursed when billed with well child care, routine diagnoses, or routine services such as immunizations.
Consultations: MVP follows CMS guidance and does not reimburse consultation codes (99241-99245, 99251-99255); providers should bill appropriate E/M codes instead.
Initial hospital/observation visits: Initial hospital visit codes (99221-99223) should be used for hospital initial visits; AI modifier when provider is admitting/attending; one visit per provider per day per condition; codes are timed/component‑based per CPT.
Scope procedures multiple-procedure reimbursement: When multiple arthroscopic/endoscopic procedures within same code family occur on the same date, the highest RVU procedure is reimbursed and secondary procedures are reduced per Medicare methodology; applies to all product lines.
Split billing recognition: MVP recognizes split billing only for Article 28 providers participating with Medicare and/or Medicaid/Child Health Plus; Commercial/ASO/Exchange products are not eligible.
Split billing and Audiology coverage rules
Rules governing split billing and its applicability to MVP products and billing practice.
Split billing (separate professional and technical charges) is recognized only when the billing entity meets Article 28 requirements (or equivalent); under split billing one bill may be generated which combines components per Article 28 rules.
MVP Commercial, ASO and Exchange products are not eligible for split billing arrangements.
When billing under split billing, the hospital incurs expenses for employed providers and receives technical reimbursement; provider claims must use a facility place of service (e.g., POS 22) instead of non‑facility POS.
Procedure codes on MVP's In‑Office Only list are not reimbursed under split billing unless authorization is obtained; if authorized, reimbursement may be allowed for Medicare and Medicaid products.
Payment policies are not guarantees of payment; providers must check member eligibility and prior authorization requirements via MVP resources.
Audio-only and Behavioral Health Coverage Criteria
Audio-only reimbursement and behavioral health coverage rules
MVP covers audio-only telephone services in Vermont and will reimburse telephone-only codes and in-person E/M codes when provided via audio-only means (use POS 99 and modifier V3 for in‑person codes delivered audio‑only as specified).
Behavioral health providers will not be reimbursed for CPT codes 99441-99443; behavioral health providers will be reimbursed for contract‑specified in‑person codes when delivered audio‑only except 99441-99443.
Reimbursement for audio-only services is paid at 75% of the medical providers' physician fee schedule.
Behavioral health and SUD reimbursement rules apply across Medicaid (including HARP), Essential, Commercial, and Medicare Advantage lines of business per member benefit and provider agreement; providers should follow contract terms and MVP behavioral health billing guidance.
Behavioral health coverage summary
Coverage and provider eligibility
Electroconvulsive therapy is reimbursable when provided by psychiatrists.
Psychological and neuropsychological testing is reimbursable when performed by licensed physicians, doctorate-level psychologists, and qualified technicians.
Behavioral health outpatient E&M claims are expected to use appropriate outpatient E&M CPT codes; MVP will reimburse psychiatrists and psychiatric nurse practitioners per their agreements.
Medically necessary inpatient behavioral health care is covered.
Partial hospitalization requires direct physician supervision and an individualized treatment plan; services must be essential for treatment.
Medically necessary outpatient diagnostic and treatment services by listed behavioral health provider types (physicians, psychiatrists, clinical psychologists, social workers, psychiatric nurse specialists, nurse practitioners, licensed professional counselors, physician assistants) are covered, subject to contractual and program rules.
Medicare variation: Services from professional Licensed Mental Health Counselors (LMHC) are not covered for Medicare.
Medicaid/HARP program variation: NYSDOH expanded MH and SUD services and effective Jan 1, 2020 eligible adults in MVP's HARP are managed by MVP; billing must follow NYS DOH Medicaid/HARP billing manuals.
Billing and coding criteria
Billing, rates, and allowable service combinations
Ambulatory behavioral health services (including ACT, clinics, day treatment, partial hospitalization, PROS) are reimbursed using APG or other government rates established by OMH; APG‑paid claims are not subject to lesser‑of billed charges or provider fee schedule reductions.
CPEP claims must follow OMH billing guidance; CPEP Extended Observation bed bills use rate code 4049. HCBS and HARP claims must follow DOH billing guidance and are submitted per Medicaid/HARP rules.
Children's HCBS services may only be billed for members under age 21 eligible for waiver services and must follow the NYS Children's Health and Behavioral Health Billing and Coding Manual.
Electronic institutional claims must be submitted using the 837i form; Medicaid FFS rate code must be entered in the claim header as value code '24' followed by the four‑digit rate code; valid procedure codes, modifiers, and units are required.
Crosswalks and appendices provide coding combinations for HCBS and ambulatory behavioral health services (per diem/HCPCS/modifiers) to indicate government‑rate claims.
Only certain combinations of HCBS and State Plan services are allowed within an individual's treatment plan; a grid of allowable combinations is provided and must be followed.
Allowable billing combinations (select examples)
Allowable billing combinations between Children's Behavioral Health/CFTSS, OMH/OASAS State Plan services and HCBS are specified; many pairings are allowed ('Yes'), some are not ('No') or not applicable ('.' or '-').
Example pairings (select): Other Licensed Practitioner (OLP) with OMH Clinic = Yes; OLP with OMH PROS = No; CPST with OMH ACT = No; PSR with OMH Partial Hospital = Yes.
Telepsychiatry in OMH Clinics
Telepsychiatry reimbursement for OMH-authorized clinics
Telepsychiatry services provided by clinics authorized by NYS OMH are reimbursed at the government APG rate when the clinic has OMH approval to offer telepsychiatry (14 NYCRR Part 599.17).
HCBS utilization thresholds, Non-Medical Transportation, and Children's BH service expansion
HCBS and related service caps and children's services expansion
Adult HCBS utilization thresholds apply per recipient per calendar year: Tier 1 group limit $8,000 with a 25% corridor to $10,000; overall HCBS cap $16,000 with a 25% corridor to $20,000; crisis respite limits separate (7 days per episode, 21 days per year).
Non‑Medical Transportation for non‑HCBS trips is capped at $2,000 per participant per year; BH HCBS trips and public transportation are excluded from this cap.
Children's BH services (CFTSS/BH‑HCBS) were expanded (e.g., OLP, PSR, CPST, FPSS) and Youth Peer Support and Crisis Intervention became available as of Jan 1, 2020; billing must follow NYS manuals and program guidance.
Vermont supervised billing and exclusions
Vermont supervised billing policy
In Vermont, services furnished by a Qualified Non‑Licensed Psychotherapist are reimbursable when provided under the direct supervision of a Qualified Licensed Psychotherapist; MVP Medicare Advantage products are excluded from this policy.
Billing instructions: list supervising clinician NPI/taxonomy in Box 24J and supervising provider name/degree in Box 31 of CMS‑1500; append modifier HO (Master's level) or HP (Doctorate level) as appropriate for supervised billing claims.
Services performed by non‑licensed providers who are not actively working toward licensure, or services for MVP Medicare members delivered by non‑licensed providers, are not reimbursable.
Authorization and contrast reimbursement criteria
Coverage and reimbursement rules for contrast materials and authorizations
When MVP Utilization Management Guides require prior authorization for a service, that authorization applies to all technical, professional, global and facility claims for the service; services provided without required authorization will be denied administratively.
Contrast materials (ionic and listed HCPCS codes) are considered inclusive to the primary contrast‑enhanced examination; MVP will deny separate claims for contrast materials for Commercial, Exchange, and Medicaid products.
Providers must verify member eligibility and check Member Benefits Display and Utilization Management Guides for authorization and benefit details; lack of authorization may lead to administrative denials.
Coverage criteria for COVID-19 testing
Coverage is provided when testing is medically appropriate for diagnosis and treatment; tests ordered solely for pandemic control, re-opening, or asymptomatic screening for administrative reasons are not covered.
COVID‑19 diagnostic (viral/antigen) and antibody testing are covered when medically appropriate for diagnosis and treatment of the individual member.
Testing ordered solely for pandemic control, re‑opening, employer/school/government requirements, travel, or at the member's request solely to self‑assess immune status is not covered.
Claims submitted with administrative/screening diagnosis codes (examples listed in the policy) will be denied; services are subject to post‑payment review and audit; MVP will cover testing when required by law or regulation but providers/members may be liable for denied claims per product rules.
Nutritional counseling and DSME coverage criteria
Reimbursement and limitations for nutritional counseling and DSME services:
Nutritional counseling is reimbursable when medically necessary for chronic diseases where dietary adjustment has a therapeutic role; services must be prescribed by a physician or qualified non‑physician practitioner and furnished by recognized providers (licensed nutritionist, registered dietitian, or other qualified licensed health professionals trained in nutrition).
Diabetic self‑management education (DSME) is medically necessary when the member has a diabetes diagnosis and services are prescribed by an appropriate practitioner and provided by a licensed healthcare professional who is a certified diabetes educator (CDE).
DSME documentation should include assessment of education needs, individualized self‑management goals, education/intervention provided, and evaluation of attainment.
Nutritional counseling & diabetic management coverage criteria
Reimbursement and exclusions
Nutritional counseling is not reimbursed for commercial diet plans, gym memberships, holistic therapy, services offered by health resorts/recreational programs/camps/outdoor programs, skill/relaxation/lifestyle programs, supplemental fasting, or treatment by a physical therapist for weight loss.
Extensive specific ICD‑10 diagnosis lists for diabetes subtypes and gestational/other diabetes are provided for use with nutritional counseling and diabetic management services (appendix and code lists referenced).
Coding reference
This section is an informational code list for billing and reimbursement; it does not itself state coverage rules beyond listing diagnosis codes.
Extensive ICD‑10 code lists for diabetes (E08, E09, E10, E11, E13 series) and related complications are enumerated for use with nutritional counseling and diabetic management billing; these code lists are informational and referenced in the appendix.
Diagnosis matching and medical necessity criteria
Coverage is contingent on submitting the correct diagnosis consistent with applicable Medicare LCDs/NCDs; specific procedure groups have associated diagnosis matching edits and denial rules.
Claims must include the correct diagnosis per the applicable Medicare Local Coverage Determination (LCD) or National Coverage Determination (NCD) or will be denied for medical necessity.
Transthoracic echocardiography codes (93303-93308, 93350-93352) require LCD‑consistent diagnoses; MVP requires the correct diagnosis or the claim will be denied; pediatric cardiology specialty is excluded from the edit.
Facet procedures: Facet joint injections and radiofrequency neurotomy codes (64490-64495, 64625, 64633-64636) require LCD‑consistent diagnoses or will be denied for medical necessity.
NCS/EMG: Nerve conduction studies and EMG codes (listed group) require submission of the correct diagnosis per the referenced Medicare LCD or the claim will be denied for medical necessity.
Corneal pachymetry (76514) requires a correct diagnosis consistent with the referenced Medicare LCD or the claim will be denied for medical necessity.
Coverage conditional on diagnosis and authoritative guidance
Coverage is conditional on submission of appropriate diagnosis codes consistent with referenced authoritative guidance (Medicare LCDs, specialty societies, or USPSTF/AAFP where indicated).
NCS/EMG requirement: Nerve conduction studies and EMG: submit the correct diagnosis per the referenced Medicare LCD (Document ID/L35098 or equivalent); claim will be paid if diagnosis matches the LCD or denied for medical necessity if not.
Corneal pachymetry requirement: Corneal pachymetry (76514): submit the correct diagnosis per the referenced Medicare LCD (Document ID L33630) or claim will be denied for medical necessity.
Visual fields requirement: Visual fields testing codes (92081-92083): submit the correct diagnosis per the referenced LCD (Document ID L33574) or claim will be denied for medical necessity.
Thyroid testing: TSH and related thyroid tests: submit correct diagnosis per referenced NCD/LCD (National Coverage Determination Publication ID #100-3 and Novitas LCDs) or claim will be denied for medical necessity.
Appendix contains reimbursable diagnosis codes for the listed laboratory services; providers should use the appendix codes when billing.
Coding Guidance and Code Lists
Selected CPT/HCPCS and guidance referencedmixedCovered
| 99051 | After-hours office/service; bill with E&M; not separately reimbursed |
| 99053 | Service(s) provided between 10:00 pm and 8:00 am at 24-hour facility; bill with E&M; not separately reimbursed |
| 99056 | Office service provided out of the office at patient's request; bill with E&M; not separately reimbursed |
| 99058 | Emergency basis in office disrupting scheduled services; bill with E&M; not separately reimbursed |
| 99060 | Emergency basis out of office disrupting scheduled services; bill with E&M; not separately reimbursed |
| 95165 | Supervision of preparation/provision of antigens for immunotherapy; units must be specified; first year/annual limits apply |
| 95004 | Percutaneous allergy tests; number must be specified; calendar year limit applies |
| 95024 | Intracutaneous immediate type tests; calendar year limit applies |
| 95028 | Intracutaneous delayed type tests; number must be specified; calendar year limit applies |
| E&M (CMS 1995/1997 and CMS 2021 guidance) | Medically necessary E&M services per CMS and AMA definitions; documentation may be requested |
Routine screening/lab proceduresCPTNot Covered
| G0102 | Manual rectal neoplasm screening |
| 36415 | Collection of venous blood by venipuncture |
| 36416 | Collection of capillary blood specimen |
| 99000 | Lab specimen handling services |
| 99001 | Lab specimen handling services |
| Q0091 | Collection of pap smear specimen |
| 92567 | Tympanometry (impedance testing) |
| 94760 | Pulse oximetry |
| 94761 | Pulse oximetry |
Immunization administration requires diagnosis Z23CPTCovered
Key E/M and related procedure code guidanceCPTCovered
| 99050 | After-Hours Code; reimbursed without review unless submitted with preventative visit codes 99381-99397. |
| 99051-99060 | E&M After-Hour Procedures; refer to MVP After-Hours Payment Policy. |
| 99201-99499 | E/M billed as urgent care; not reimbursed when billed with Well Child Care, Routine Diagnoses, or Routine Services such as Immunizations. |
| 99241-99245, 99251-99255 | Consultation codes; MVP follows CMS guidelines and does not reimburse consultations. |
| 99221-99223 | Initial hospital visit; rules on AI modifier, one visit per provider per day, documentation/time requirements. |
| 99291-99292 | Critical care codes; require >=30 minutes for 99291 and specific increment rules for 99292 multiples. |
Procedures excluded from critical care time / separately reimbursedCPTCovered
| 93561-93562 | Cardiac output interpretation; time does NOT count toward critical care and cannot be billed separately by the critical care physician. |
| 94760-94762 | Pulse oximetry; time does NOT count toward critical care and cannot be billed separately by the critical care physician. |
| 71045-71046 | Chest x-rays professional component; time does NOT count toward critical care and cannot be billed separately by critical care physician. |
| 99090 | Data interpretation services; time does NOT count toward critical care and cannot be billed separately by critical care physician. |
| 92950, 31500, 36555-36556, 36680, 32551, 33210, 93010 | Specific procedures (CPR, intubation, central line, intraosseous, thoracostomy, temporary pacemaker, ECG interpretation) reimbursed separately from critical care services. |
Scope procedures multiple-procedure reimbursementmixedCovered
| various arthroscopic/endoscopic CPT families | When multiple procedures in same code family on same date, highest RVU procedure reimbursed per provider fee schedule; secondary procedures reduced per Medicare methodology. |
Audiology billing rules and specific codesmixedCovered
| 99201-99499 | E&M CPT codes not billable by audiologists |
| 69209, 69210 | Cerumen removal codes not billable by audiologists; included in diagnostic test RVU |
| G0268 | Physician removal of impacted cerumen on same day as diagnostic test |
| 92620, 92621, 92626, 92627, 92640 | Timed audiology codes with specific time designations |
Telephone E/M and 15-minute coding guidanceCPTCovered
| 99441 | Telephone E/M service; 5-10 minutes of medical discussion |
| 99442 | Telephone E/M service; 11-20 minutes of medical discussion |
| 99443 | Telephone E/M service; 21-30 minutes of medical discussion |
Required coding elements and modifiersCPT | Modifier | mixed
| E&M codes (outpatient) | Appropriate outpatient Evaluation & Management CPT codes from the E&M range expected on claims |
| Modifier list (AF, AH, AJ, HE, ... US) | Modifiers used for HARPs and Mainstream BH Carve-in with definitions (e.g., AF = Specialty physician, AH = Clinical psychologist, etc.) |
Claims and rate codingHCPCS | mixed
| Rate codes (four-digit) | Medicaid fee-for-service rate codes must be entered as value code '24' followed by the four-digit rate code in claim header |
| 837i | Electronic institutional claim form required for certain behavioral health claims |
Vermont supervised billing form and modifier requirementsCPTCovered
| Box 24j | List NPI and taxonomy of supervising licensed clinician on CMS 1500 |
| Box 31 | List name and degree/title of supervising provider on CMS 1500 |
| HO | Modifier for supervised billing when unlicensed practitioner is Master's level |
| HP | Modifier for supervised billing when unlicensed practitioner is Doctorate level |
Contrast material HCPCS codesHCPCSNot Covered
| A9579 | Injection, gadolinium-based MRI contrast agent, per ml |
| Q9951 | Low osmolar contrast material, 400+ mg/ml iodine concentration, per ml |
| Q9965 | Low osmolar contrast material, 200-299 mg/ml iodine concentration, per ml |
| Q9966 | Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml |
| Q9967 | Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml |
| Q9958 | High osmolar contrast material, up to 149 mg/ml iodine concentration, per ml |
| Q9959 | High osmolar contrast material, 150-199 mg/ml iodine concentration, per ml |
| Q9960 | High osmolar contrast material, 200-249 mg/ml iodine concentration, per ml |
| Q9961 | High osmolar contrast material, 250-299 mg/ml iodine concentration, per ml |
| Q9962 | High osmolar contrast material, 300-349 mg/ml iodine concentration, per ml |
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COVID-19-related diagnosis coding guidanceICD-10
| Z02.0, Z02.1, Z02.4, Z02.5, Z02.79, Z02.89 | Diagnosis codes that will be denied when submitted for COVID-19 testing (administrative/examination reasons). |
| Z03.818, Z76, Z01.89, Z13.9, Z71.89, Z71.82, R68.89, B34.9, E55.9, Z03.89, E03.9, Z56.5, Z00.00, K21.9, E11.9, R10.9, N23 | Examples of diagnosis codes listed as non-reimbursable/inappropriate for COVID-19 testing. |
| N39.0, R73.03, M54.5, E78.2, R07.89, K62.89, N89.8, M25.50, Z20.818, R42, Z09, K80.00, R07.9, N93.9, K29.00, I24.9, O24.419, E78.5, E16.2, J11.1, Z29.9, Z119 | Additional diagnosis codes provided as examples of inappropriate diagnoses for COVID-19 testing. |
Reimbursable nutritional counseling codesCPT | HCPCSCovered
| 97802 | Medical nutritional therapy; initial assessment and intervention, individual, each 15 minutes |
| 97803 | Re-assessment and intervention, individual, each 15 minutes |
| 97804 | Group (2 or more), each 30 minutes |
| G0270 | Medical nutritional therapy; re-assessment and subsequent intervention following second referral in same year, individual, each 15 minutes |
| G0271 | Medical nutritional therapy; re-assessment and subsequent interventions following second referral in same year, group, each 30 minutes |
Diabetes-related ICD-10 codes for nutritional counselingICD-10Covered
| E08.* | Diabetes mellitus due to underlying condition and complications (multiple specific codes listed) |
| E09.* | Drug or chemical induced diabetes mellitus and complications (multiple specific codes listed) |
| E10.* | Type 1 diabetes mellitus and complications (multiple specific codes listed) |
| E11.* | Type 2 diabetes mellitus and complications (multiple specific codes listed) |
| E13.* | Other specified diabetes mellitus (multiple specific codes listed) |
Type 2 diabetes mellitus codesICD-10Covered
| E11.* | Type 2 diabetes mellitus and many specific complication codes listed |
Other specified diabetes mellitus codesICD-10Covered
| E13.* | Other specified diabetes mellitus codes and complications |
Diabetes due to underlying condition / drug-inducedICD-10Covered
| E08.*, E09.* | Diabetes due to underlying condition (E08) and drug/chemical induced (E09) codes enumerated |
E08 series (diabetes due to underlying condition)ICD-10Covered
| E08.40 | Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified |
| E08.41 | Diabetes mellitus due to underlying condition with diabetic mononeuropathy |
E09 series (drug/chemical induced diabetes)ICD-10Covered
| E09.00 | Drug or chemical induced Diabetes mellitus with hyperosmolarity without NKHHC |
| E09.3513 | Drug or chemical induced Diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateral |
E10/E11 series (Type 1 and Type 2 diabetes)ICD-10Covered
| E10.21 | Type 1 Diabetes mellitus with diabetic nephropathy |
| E11.3211 | Type 2 Diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eye |
E13 series (other specified diabetes)ICD-10Covered
| E13.00 | Other specified Diabetes mellitus with hyperosmolarity without NKHHC |
Transthoracic echocardiographyCPTCovered
| 93303-93308, 93350-93352 | Transthoracic echocardiography groups and related local coverage rules |
Facet proceduresCPTCovered
| 64490-64495, 64625, 64633-64636 | Facet joint injections, medial branch blocks, and radiofrequency neurotomy procedure codes |
Corneal pachymetryCPTCovered
| 76514 | Ophthalmic ultrasound; corneal pachymetry |
Corneal PachymetryCPT
| 76514 | Ophthalmic ultrasound; corneal pachymetry |
Sedimentation Rate (ESR)CPT
| 85652 | Erythrocyte sedimentation rate; automated |
Folic AcidCPT
| 82746 | Assay of Folic Acid Serum |
Vitamin B12CPT
| 82607 | Cyanocobalamin (Vitamin B12) |
FSHCPT
| 83001 | Follicle Stimulating Hormone |
Quick Coding Limits and Key Values
95165 — First year limits
95165 — first year per claim limit40 units per claim; 160 units per calendar year
Claim requirementNumber of units/doses must be specified on the claim
Applicable codeCPT 95165 — supervision of preparation/provision of antigens for immunotherapy
95165 — Subsequent years limits
95165 — subsequent years per claim limit30 units per claim; 120 units per calendar year
Claim requirementNumber of units/doses must be specified on the claim
Applicable codeCPT 95165 — subsequent year dosing limits apply after first year
95004 limit
95004 — calendar year limitReimbursement limited to 80 units per calendar year
Claim requirementNumber of tests must be specified on the claim
Applicable codeCPT 95004 — percutaneous allergy tests (scratch, puncture, prick)
95024 limit
95024 — calendar year limitReimbursement limited to 40 units per calendar year
Applicable codeCPT 95024 — intracutaneous (intradermal) immediate type tests
NotesUsed with allergenic extracts; includes test interpretation and report
95028 limit
95028 — calendar year limitReimbursement limited to 30 units per calendar year
Claim requirementNumber of tests must be specified on the claim
Applicable codeCPT 95028 — intracutaneous delayed type tests (including reading)
E&M per day limit
E&M per day limitOne E&M CPT code per day per physician group per specialty
Preventive visit interactionPreventive medicine visits may block reimbursement for many same-day office procedures — see member benefits
Codes referencedApplicable to E/M CPT range (e.g., 99202-99215 and preventive codes 99381-99397)
Critical care time thresholds (99291/99292)
Critical care minimum99291 requires at least 30 minutes of critical care time to be billed
Incremental rules30–74 min = 99291 once; 75–104 = 99291 + 99292 x1; 105–134 = 99291 + 99292 x2; continuing in ~30‑minute increments
Time countingCritical care time is time directly related to patient care (bedside or elsewhere), billed per calendar day; certain procedures and family discussions do not count toward critical care time
Timed code time threshold
Timed code billing thresholdA timed code is billed only if testing meets at least 51% of the time designated in the code descriptor
Application exampleApplies to audiology timed CPT codes (e.g., 92620, 92621, 92626, 92627, 92640)
Time components excludedNon-test activities (counseling, goal setting, remediation evaluation) should not be counted toward timed test time
15-minute code unit rules (examples)
1 unit time range (15-minute codes)1 unit = 8 minutes to < 23 minutes
2 unit time range2 units = 23 minutes to < 38 minutes
3 unit time range3 units = 38 minutes to < 53 minutes
15-minute unit time ranges
Unit 18 minutes to < 23 minutes
Unit 223 minutes to < 38 minutes
Unit 338 minutes to < 53 minutes
Claim minimum data elements
Required claim formElectronic institutional claims: use the 837i form
Medicaid FFS rate code entryEnter rate code as value code '24' followed immediately by the four-digit rate code in the claim header
Other minimum elementsValid procedure codes, procedure code modifiers (as needed), and units of service
Adult HCBS utilization thresholds
Adult HCBS Tier and overall capsTier 1 group limit $8,000 per recipient per calendar year (25% corridor to $10,000); overall HCBS cap $16,000 per year (25% corridor to $20,000)
Crisis respite limitsCrisis respite limited to 7 days per episode and 21 days per year (separate from Tier caps)
Non-Medical Transportation exclusionBH HCBS trips and public transportation are not subject to the $2,000 non‑medical transportation cap
Non-Medical Transportation cap
Non-Medical Transportation cap$2,000 per participant per year for non-HCBS trips
ScopeApplies to trips to/from non-HCBS destinations related to goals in Plan of Care
ExclusionsTrips to/from BH HCBS and trips using public transportation are not subject to this cap
Coding guidance source
Primary coding guidanceFollow CDC ICD-10-CM Official Coding Guidelines when selecting diagnosis codes
Procedure code setsUse applicable CPT and HCPCS code lists published by AMA and CMS
LCD/NCD referencesUse Medicare Coverage Database (LCD/NCD) for diagnosis matching and authoritative guidance
Diagnosis restriction for nutritional counseling
Diagnosis restriction (Medicare MSA)Codes 97802-97804 and G0270-G0271 are limited to specified ICD-10 diagnoses for Medicare MSA plans only
Other plansAll other plans have no diagnosis code restrictions for these nutritional counseling codes
Reimbursable codesCPT/HCPCS codes 97802, 97803, 97804, G0270, G0271 are considered reimbursable for nutritional counseling/medical nutrition therapy
Laterality and detail
Laterality and macular edema variantsMany diabetes-related codes include right/left/bilateral eye designations and macular edema variants (e.g., E09.3211–E11.3513 series)
Implication for billingUse the specific laterality/edema code that matches the clinical documentation to ensure correct claim processing
ExamplesE10.3311 (Type 1, moderate NPDR with ME, right eye); E11.3511 (Type 2, proliferative DR with ME, right eye)
LCD requirement
LCD diagnosis requirementClaims must include diagnoses consistent with the referenced Medicare Local Coverage Determination or the claim will be denied for medical necessity
Where to find LCDsRefer to the specific LCD document IDs cited in the policy (e.g., L35098, L33630, L33574, L37535) or the Medicare Coverage Database
ExamplesVitamin D assays, NCS/EMG, corneal pachymetry, transthoracic echocardiography all require LCD-consistent diagnoses
Provider Actions, Authorization & Documentation
Prior Authorization
Verify eligibility and check UM guides before services
Providers must check member eligibility and the Member Benefits Display and review MVP's Utilization Management Guides and the Benefit Interpretation Manual (accessible at mvphealthcare.com) to determine whether prior authorization is required; payment policies are not a guarantee of payment.
Prior Authorization
Check eligibility and UM guides for authorization
Providers must check member eligibility and the Member Benefits Display and review MVP's Utilization Management Guides and the Benefit Interpretation Manual (available via mvphealthcare.com) to determine if prior authorization is required; payment policies do not guarantee payment.
Prior Authorization
Confirm eligibility and prior‑auth rules using MVP resources
Providers must verify member eligibility via the Member Benefits Display and consult MVP's Utilization Management Guides and the Benefit Interpretation Manual (sign in at mvphealthcare.com) to determine whether prior authorization is required; policy statements are not guarantees of payment.
Documentation Required
Follow MVP After‑Hours policy for 99050–99060
Refer to the MVP After‑Hours Payment Policy and your contractual agreement to determine applicability and billing rules for codes 99051–99060 and 99050.
- 99051–99060: refer to MVP After‑Hours Payment Policy for guidelines
- 99050: reimbursed without review unless submitted with preventive visit codes 99381–99397; check contract
Prior Authorization
Verify eligibility and UM guides for prior authorization
Providers must check member eligibility and review MVP's Utilization Management Guides and Benefit Interpretation Manual (via mvphealthcare.com) to determine if prior authorization is required; payment policies are not a guarantee of payment.
Prior Authorization
Obtain authorization for In‑Office Only codes under split billing
Procedure codes on MVP's In‑Office Only list are not reimbursed under a split‑billing arrangement unless an authorization is obtained; if authorized, reimbursement may be allowed for Medicare and Medicaid products.
- Split billing ineligible for Commercial/ASO/Exchange products (see split billing rules)
- When billing split arrangement, submit provider claims with facility POS (e.g., POS 22)
Prior Authorization
Check eligibility, Member Benefits Display and UM guides
Providers must check member eligibility and consult the Member Benefits Display, MVP's Utilization Management Guides, and the Benefit Interpretation Manual (sign in at mvphealthcare.com) to determine whether prior authorization is required; policies do not guarantee payment.
Note
Inpatient care: ensure medical necessity
Medically necessary inpatient care is covered by MVP.
Documentation Required
Comply with supervision and treatment‑plan requirements for partial/outpatient care
Partial hospitalization must be provided under direct physician supervision pursuant to an individualized treatment plan; medically necessary outpatient diagnostic and treatment services by listed behavioral health providers are covered.
- Partial hospitalization: direct physician supervision and individualized treatment plan required
- Outpatient services: covered when medically necessary and delivered by listed provider types
Prior Authorization
Confirm authorization requirements via eligibility and UM guides
Providers must check member eligibility and review MVP's Utilization Management Guides and the Benefit Interpretation Manual (via mvphealthcare.com) to determine if prior authorization is required; payment policies are not guarantees of payment.
Denial Risk
Authorization required — missing authorization triggers administrative denial
When an authorization is required per MVP's Utilization Management Guides and is not obtained, all technical, professional, global and/or facility claims for that service will be denied administratively; providers must check eligibility, Member Benefits Display, and consult the UM Guides and Benefit Interpretation Manual for clinical guidance.
- Authorization requirement applies to all technical/professional/global/facility claims for the service
- Failure to obtain required authorization results in administrative denial (applies to outpatient surgical services and radiology code set)
Prior Authorization
Verify eligibility and UM guides for authorization determination
Providers must check member eligibility and refer to the Member Benefits Display and MVP's Utilization Management Guides to determine if prior authorization is required.
Prior Authorization
Check eligibility and UM guides to determine prior‑auth need
Providers must check member eligibility and the Member Benefits Display and review MVP's Utilization Management Guides to determine if prior authorization is required; payment policies are not guarantees of payment.
Documentation Required
Use listed ICD‑10 codes for nutritional counseling
ICD‑10 diagnosis codes associated with nutritional counseling (many E08–E13 and related codes) are listed and must be used when billing for nutritional counseling services.
Documentation Required
Reference E08.* codes for diabetes due to underlying conditions
Section lists ICD‑10 codes for diabetes due to an underlying condition and associated complications — use these codes when appropriate for diabetic management and nutritional counseling.
Documentation Required
Reference E09.* drug/chemical‑induced diabetes codes
Section provides ICD‑10 codes for drug‑ or chemical‑induced diabetes and related complications; use these when applicable for diabetic management and billing.
Documentation Required
Use E10/E11/E13 codes for Type 1/Type 2/other diabetes
Sections list Type 1, Type 2, and other specified diabetes ICD‑10 codes (E10, E11, E13) including complication and laterality variants for use in billing and medical necessity determinations.
Prior Authorization
Verify eligibility and UM guides before submitting claims
Participating providers must check member eligibility, refer to the Member Benefits Display, and review MVP's Utilization Management Guides to determine if prior authorization is required; policy guidance is not a guarantee of payment.
Denial Risk
Submit LCD‑consistent diagnosis or claim will be denied
MVP requires the correct diagnosis be submitted with the claim in accordance with the applicable Medicare Local Coverage Determination (LCD); failure to submit the LCD‑consistent diagnosis will result in claim denial for medical necessity.
- Transthoracic echocardiography codes require LCD‑consistent diagnoses; pediatric cardiology specialty is excluded from the edit
Denial Risk
NCS/EMG: include LCD‑required diagnosis or expect denial
Submit the correct diagnosis with NCS/EMG claims in accordance with the referenced Medicare Local Coverage Determination; claims lacking the LCD‑consistent diagnosis will be denied for medical necessity.
Denial Risk
Corneal pachymetry claims require LCD‑consistent diagnosis
Submit the correct diagnosis with corneal pachymetry (76514) claims in accordance with the referenced Medicare Local Coverage Determination; incorrect diagnoses will result in denial for medical necessity.
Denial Risk
Visual fields testing requires LCD‑consistent diagnosis
Submit the correct diagnosis with visual fields testing (92081–92083) claims in accordance with the referenced Medicare Local Coverage Determination; failure to do so will result in denial for medical necessity.
Denial Risk
Vitamin D testing: include LCD‑required diagnosis or risk denial
Submit the correct diagnosis code per the referenced Medicare LCD for Vitamin D assays (82306, 82652); claims without the LCD‑consistent diagnosis will be denied for medical necessity.
- Refer to Document ID/LCD referenced for appropriate diagnoses
Definitions and Terminology
Medical Necessity
MVP Medical Necessity definitionHealth care services necessary to prevent, diagnose, correct or cure conditions causing acute suffering, endangering life, or interfering with normal activity; recommended by treating provider and meet MVP criteria including appropriateness, not for convenience, required for direct care, consistent with standards and cost‑effective setting
CMS definitionMedical necessity is the overarching criterion for payment and documentation should support the level of service reported; do not bill higher level when lower level warranted
AMA definitionServices a prudent physician would provide in accordance with generally accepted standards of medical practice
After-Hours
Normal business hoursMVP defines normal business hours as 8:00 am - 6:00 pm
After-hours billing ruleAfter-hours codes (e.g., 99051, 99053, 99056, 99058, 99060) must be billed with an E&M code and are considered inclusive to the E&M; not separately reimbursed for Commercial and Medicare products
ReferenceRefer to MVP After-Hours Payment Policy for applicability of codes 99051-99060 and 99050
Medically Necessary / Medical Necessity
MVP definition of 'Medically Necessary'Services necessary to prevent, diagnose, correct or cure conditions, recommended by treating provider and meeting MVP criteria (appropriateness, not for convenience, required for direct care, consistent with standards, and provided in a safe, cost‑effective setting)
DocumentationMedical records may be requested to verify documentation and accuracy of billed services
Guidance followedMVP follows AMA CPT definitions and CMS 1995/1997 and 2021 E&M documentation/guidelines
New Patient
New patient definitionA new patient has not received any professional services from the same provider or another provider of the same specialty within the same group (same tax ID) in the past three years
ImplicationAffects selection of initial vs established patient E/M codes
SourceAMA definition followed by MVP
Significant E&M Service
Significant E&M Service — definitionA significant service warrants at minimum an expanded problem focused examination; routine reassurance/monitoring/refills are not significant
Examples excludedReassurance, medication refills, routine monitoring, minor problem‑focused visits
ImplicationDetermines when an additional E&M is billable during a visit or procedure
Critically ill
Critically ill — definitionA critical illness or injury that acutely impairs one or more vital organ systems indicating high probability of imminent or life‑threatening deterioration (examples: CNS, circulatory, shock, renal, hepatic, metabolic, respiratory failure)
ImplicationDetermines applicability of critical care codes (99291/99292)
DocumentationTime spent and activities must be documented in the medical record
Critical care time
Critical care time countingTime directly related to patient care (bedside or elsewhere), need not be continuous, billed per calendar day; excludes time spent performing certain procedures and some family discussions
Counting detailsIncludes bedside care, reviewing tests, staff discussions; must be immediately available to patient
ExclusionsTime for listed procedures does not count toward critical care time and may be billed separately
Split Billing
Split Billing — definitionA billing structure with two separate charges: professional (physician) and technical (facility) reimbursement
Professional componentPayments to physician/provider group for interpretation and provider services
Technical componentPayments to facility for non‑professional services (labs, imaging, E/M in facility)
Professional
Professional — definitionBillable services provided by a physician (consultation, interpretation of imaging/labs); payment made to provider group
ExamplesPhysician interpretation, consultations, pro fees
Relation to split billingProfessional component billed separately when split billing applies
Technical
Technical — definitionBillable services provided in a facility setting (lab, x‑rays, E/M, procedures); reimbursement made to the hospital
ExamplesFacility overhead, equipment, technical staff services
Relation to split billingTechnical component billed separately when split billing applies
Global reimbursement
Global reimbursement — definitionOne bill representing both professional and technical services; reimbursed at a global rate typically paid to the physician practice
ImplicationNo separate technical payment to facility when global reimbursement applies unless employed by hospital
TerminologyAlso referred to as non‑facility or private practice billing
Facility-Based vs Non-Facility (Global)
Facility‑Based vs Non‑Facility mapping'Split billing' = facility/hospital‑based (separate technical and professional); 'Global' = non‑facility/private practice combined payment
Financial flowsHospital receives technical reimbursement; physicians paid professional fee consistent with facility RVUs
Billing implicationsPlace of service and billing entity must reflect facility vs non‑facility arrangement
Audiological diagnostic testing
Audiological diagnostic testing — scopeTests of audiological and vestibular systems including hearing, balance, auditory processing, tinnitus, and diagnostic programming of certain prosthetic devices
Timed audiology codesTimed audiology CPT codes billed only when testing meets the designated time (>=51%); specific codes include 92620, 92621, 92626, 92627, 92640
15‑minute unit rules15‑minute code unit ranges apply (e.g., 1 unit = 8 to <23 min) and non‑test activities should not be included in timed test time
CPT
CPT — definitionCurrent Procedural Terminology (CPT) is the medical code set used to report procedures and services
UsagePublished by AMA for use in billing and reporting
Relation to policyPolicy references CPT codes for procedures, timed codes, and E/M code ranges
E&M Codes
E&M Codes — definitionEvaluation and Management (E&M) Codes are CPT codes (e.g., 99202-99499) representing services involving evaluation and management of patient health
Documentation guidanceMVP follows CMS 1995/1997 and CMS 2021 E&M documentation guidelines
ImplicationMedical necessity and documentation determine appropriate E&M level
Specialty physician
Specialty physician (AF) — abbreviationUsed as modifier/identifier in HARP/Mainstream BH carve‑in reporting (AF = Specialty physician)
ContextModifier codes used for HARPs and Mainstream BH carve‑in to identify provider types
SourceModifier list in policy
Clinical psychologist
Clinical psychologist (AH) — abbreviationUsed as modifier/identifier in HARP/Mainstream BH carve‑in reporting (AH = Clinical psychologist)
ContextModifier codes used to designate provider taxonomy in behavioral health claims
SourceModifier list in policy
HARP
HARP — definitionHealth and Recovery Plan (Medicaid program with enhanced behavioral health benefits); MVP manages HARP members effective Jan 1, 2020
ImplicationBH services and BH‑HCBS claims for HARP members are submitted to MVP and must follow NYS DOH billing/coding manual
Provider requirementsRate codes and MEDS submission requirements apply for outpatient MH/SUD claims
Qualified Licensed Practitioner
Qualified Licensed Practitioner — definitionA provider who is licensed and credentialed by MVP and acting within the scope of his/her practice
Billing implicationMay supervise Qualified Non‑Licensed Practitioners and bill under supervised billing rules
ContextUsed in Vermont supervised billing policy
Qualified Non-Licensed Practitioner
Qualified Non‑Licensed Practitioner — definitionA provider actively working towards licensure as specified by their profession
Billing implicationServices may be reimbursable when under direct supervision of a Qualified Licensed Practitioner (per supervised billing rules)
ContextApplies to Vermont supervised billing provisions and roster requirements
Supervised Billing
Supervised Billing — definitionA Qualified Licensed Practitioner can bill for covered services provided by a Qualified Non‑Licensed Practitioner when the latter is under direct supervision
DocumentationSupervising clinician name/NPI/taxonomy requirements apply on claim forms (per VT guidance)
ApplicabilityVermont supervised billing rules; Medicare Advantage variations may apply
Non-ionic vs ionic contrast cost parity and routine use
Contrast materials — reimbursement rationaleNon‑ionic and ionic contrast materials are considered part of the primary contrast‑enhanced examination and are not reimbursed separately
ReasoningCost parity and routine use of non‑ionic contrast have made separate reimbursement inappropriate
Applicable codesHCPCS contrast codes listed in policy are denied when billed separately (e.g., A9579, Q9951, Q9965, etc.)
Diagnostic test (COVID-19)
COVID-19 diagnostic test — definitionVirus/antigen detection (diagnostic) test determines if a person is currently infected with COVID‑19
Antibody (serology) test — noteAntibody test may determine prior exposure; per FDA it should not be used to diagnose current infection
CodingApplicable COVID‑19 codes found in CPT (AMA) or HCPCS (CMS); follow CDC ICD‑10‑CM Official Coding Guidelines for diagnosis selection
Antibody test
Antibody test — definition and noteAntibody (serology) test may detect prior exposure to COVID‑19; per FDA should not be used to diagnose current infection
Policy scopePolicy defines coverage, reimbursement and billing guidelines for viral and antibody testing across all lines of business
Coding guidanceUse CPT/HCPCS as published by AMA/CMS and follow CDC ICD‑10‑CM coding guidance
Nutritional Counseling
Nutritional Counseling — definitionReimbursable when medically necessary for chronic diseases where dietary adjustment has a therapeutic role; must be prescribed and furnished by recognized providers (e.g., licensed nutritionist, registered dietitian)
Service examplesMedical nutrition therapy (97802‑97804) and follow‑up codes (G0270, G0271)
Documentation/ProvisionServices must be prescribed by physician or qualified practitioner and provided by qualified licensed professionals
Diabetic Management / Medical Nutrition Therapy
Diabetic Management / Medical Nutrition Therapy — definitionEducation and management services for diagnosis and treatment of diabetes; DSME considered medically necessary when prescribed and provided by qualified professionals (CDEs)
Reimbursable codesG0108 (individual DSME per 30 min) and G0109 (group DSME per 30 min); nutritional therapy codes 97802‑97804 and G0270‑G0271
DocumentationDSME documentation should include assessment of needs, goals, interventions, and evaluation of attainment
Diabetes self-management education (DSME)
DSME — definition and scopeAn interactive, collaborative, ongoing process to help persons with or at risk for diabetes develop knowledge and skills to reach self‑defined goals; documentation requirements specified
Provider requirementsServices must be provided by licensed healthcare professionals who are certified diabetes educators when prescribed
CodesG0108 and G0109 listed as reimbursable for Diabetic Management
Right/Left/Bilateral eye designations for diabetic retinopathy codes
Right/Left/Bilateral eye designations — diabetic retinopathy codesDiabetes-related ICD‑10 codes include laterality variants for right, left, and bilateral eye designations (e.g., E09.3211, E10.3311, E11.3511)
ImplicationSelect the specific laterality code that matches clinical findings to ensure correct reimbursement
ExamplesE09.3211 (drug‑induced mild NPDR with ME, right eye); E11.3511 (Type 2 proliferative DR with ME, right eye)
Diabetic outpatient self-management training services (G0108/G0109)
G0108/G0109 — definitionG0108: Diabetes outpatient self‑management training services, individual, per 30 minutes; G0109: group session (2+), per 30 minutes
Coverage noteG0108/G0109 reimbursable for Diabetic Management; Medicare MSA plans limit these to specified diagnoses while other plans reimburse ICD‑10 in range E08‑E09
DocumentationUse appropriate ICD‑10 diagnosis codes as specified for Medicare MSA plans
Macular edema
Macular edema notationMany diabetic retinopathy codes specify presence/absence of macular edema and laterality (e.g., E09.3211 etc.)
Billing implicationEnsure macular edema variant in ICD‑10 code matches clinical documentation to avoid denials
ExamplesE09.3211 (mild NPDR with macular edema, right eye); E11.3511 (proliferative DR with macular edema, right eye)
NKHHC
NKHHC — abbreviationNKHHC stands for nonketotic hyperglycemic‑hyperosmolar coma
ContextAppears in ICD‑10 diagnosis descriptions for diabetes due to underlying condition (E08 series) and gestational/secondary diabetes codes
UseInclude when selecting appropriate diagnosis codes from E08–E13 ranges
Medical Necessity (CMS Medicare's definition)
CMS Medical Necessity (Medicare) — definitionMedical necessity is the overarching criterion for payment; documentation should support the level of service reported and billing a higher level when a lower level is warranted is inappropriate
Documentation guidanceVolume of documentation should not be the primary influence upon which level of service is billed; documentation must support reported level
ReferenceCMS Medicare definition cited in policy
CMS LCD references
CMS LCD references — sourceMedicare Coverage Database Advanced Search (cms.gov/medicare-coverage-database) for accessing LCD/NCD documents
UseConsult specific LCD/NCD document IDs referenced in policy for diagnosis matching edits
ImplicationClaims failing to include LCD‑consistent diagnoses may be denied
Appendix (reimbursable diagnosis codes)
Appendix — purposeContains reimbursable diagnosis codes for listed laboratory services
Use in claimsRefer to Appendix codes when submitting claims for laboratory services to ensure alignment with covered diagnoses
LocationAppendix referenced in policy document for specific tests
Policy Summary
PayerMVP Health Care
PolicyMVP Health Care 2022 Payment Policies (partial)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateDec 1, 2021
Last ReviewDec 1, 2021
Next Review DateN/A
Key ActionProviders must check member eligibility, the Member Benefits Display, and MVP Utilization Management Guides to determine if prior authorization is required.
SourceLink
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