Prior Authorizations

• Assistant Surgery List (Effective July, 2019)
  MVP may reimburse assistant-at-surgery services by physicians, physician assistants, nurse practitioners, and clinical nurse specialists when extenuating circumstances are documented.
• Durable Medical Equipment Prior Authorization List (Effective April 1, 2026)
  Codes and descriptions for DME prior authorization are provided. Keep in mind that just because a code appears on the prior authorization list, it does not guarantee coverage.
• In-Office Procedure List (Effective June 1, 2021)
  Coverage for these procedures applies only to services performed in a physician’s office. Claims for other locations require prior authorization or will be denied.
• MVP Inpatient Surgical List (Effective May 1, 2023)
  Procedures on the MVP Inpatient Surgical List do not need Prior Authorization for inpatient settings. Procedures not on the list should be completed outpatient or in office; if performed inpatient, they require prior authorization and medical necessity documentation.
• DME Non-Covered Items (Effective February 27, 2024)
  Check this list for coverage differences by plan. Codes not covered will be denied. Use the MVP Durable Medical Equipment Prior Authorization List to see if prior authorization is needed.
• UM Policy Guide (New York)
  This UM Policy Guide provides a quick reference of prior authorizations for all MVP health plans in New York. The guide should be used in coordination with the Prior Authorization Request form (PARF).
• UM Policy Guide (Vermont)
  This UM Policy Guide provides a quick reference of prior authorizations for all MVP health plans in Vermont. The guide should be used in coordination with the Prior Authorization Request form (PARF).

Admissions

Notification of Unplanned, Urgent, or Emergency Room Admission

Medical Prior Authorizations

• Prior Authorization Request Form (PARF)
• Vermont Uniform Medical Prior Authorization Form
• Prior Authorization Request Form for DME/O&P Items & Services
• Prior Authorization Request Form for Skilled Nursing and Inpatient Rehabilitation Facility

Medicare Part D

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

Oncology Medications

MVP delegates utilization management for oncology medications billed under the medical benefit to Optum; however, the Optum portal is not used for CART therapies, certain chemotherapy services, oral drugs, or stemcell/bone marrow transplant regimens. Sign in to Availity for prior authorization requirements.

Genetic Testing - Avalon

Avalon manages prior authorization for Precision Genetic testing via your MVP Payer Spaces in Availity, call 1-844-227-5769, or fax 1-813-751-3760.

Vermont Gold Card Prior Authorization Pilot Program

The Vermont Gold Card Prior Authorization Pilot Program seeks to eliminate or streamline certain prior authorization requirements. The Vermont Gold Card Prior Authorization Program is for Commercial and Exchange Members in Vermont. Learn more on our Vermont Gold Card Prior Authorization Pilot Program Page.

To access Behavioral Health forms for prior authorization and notifications, visit our dedicated BH page.

• View Behavioral Health Forms