Guidance for Providers Treating MVP Health Care Members 

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 

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. 

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, use our Find a Doctor tool[link to: 1.12.6]. 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
  • 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). 

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.