Frequently Asked Questions (FAQ)
Benefits and Copay Questions 1. Do allergy injections have a copay for MVP Gold? Allergy injections carry a PCP or Specialist copay depending on the specialty of the provider. This also applies to allergy tests and evaluations. Allergy serum has no copay. Nurse level office visits 99211 have no copay. 2. If a member has an office visit and an injectable medication, are there one or two copays? There are a list of drugs and codes that are exceptions (do not have a copay), but typically there is both an office visit AND an injectable medication copay. 3. If the professionally administered medication has a copay, is it taken on the drug code itself, or on the administration code? (if three drugs are administered, are there three copays?) One copay (total) is taken from the drug code(s) billed for a single visit. 4. Are there any immunizations that are not covered for MVP Gold members? The immunizations must meet the Immunization BIM and may be subject to the Part D benefit if purchased at the pharmacy. 5. Are there any pre-existing condition restrictions when a member joins MVP Gold? No, no pre-existing condition restrictions apply under MVP Gold. 6. Will CPT code 99211 have a copay? It does not with MVP's other plans. No. MVP will not apply a copay to the 99211 code.
1/3/2007
MVP Gold – Frequently Asked Questions
7. If a patient has an office visit 99211 billed with chemotherapy, does the patient pay two copays? Nurse visit 99211 will not have a copay applied. Physician office visits billed with chemotherapy on the same day will have two copays applied. 8. If a patient has an office visit and multiple x-rays, do they pay the office visit copay or do they pay an additional copay for the x-rays? If x-rays done at physician office, only the office visit copay applies. 9. If a member has more than one x-ray or imaging test done on the same date of service at the same location, are there one or multiple copays taken? Only one imaging copay per day if all of the imaging is done at the same location. 10. If a member has both speech and occupational therapy on the same day would two copays apply? Yes, two copays would apply. 11. When is the urgent care level copay taken? When place of service is 20 (name location) or when an emergency medicine physician bills with place of service 11(name location), the urgent care copay will be taken. 12. What is the coinsurance amount for MVP Gold? There is no coinsurance amount (% patient pays) with the exception of Behavioral Health and Substance Abuse (patient pays 50%) and DME (patient pays 20%). All other services have copays, or are covered at 100%. 13. Are the PT/OT/ST dollar limits for office-based therapy only? Yes, the therapy caps (dollar maximums) are for office-based location codes only. 14. Will MVP provide reimbursement for osteopathic manipulation (CPT codes 98925, 98926, 98927, 98928 and 98929) to participating providers for MVP Gold members? Yes, MVP will pay for osteopathic manipulation codes for MVP Gold members. 15. Can PT/OT/ST providers bill with the KK modifier to override the $1740 benefit? The KK Modifier can be billed; however, it may be subject to review for diagnoses criteria, it is not necessarily an automatic override.
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MVP Gold – Frequently Asked Questions
16. Can G codes be used when billing for MVP Gold members? Yes, however, it may depend on the G code. Some are considered global to preventive care exams (such as pap smear G code). Billing Questions 17. How will Hospice care be billed? Hospice care is not a covered benefit under MVP Gold. Hospice providers must submit claims directly to CMS for reimbursement. 18. When will MVP be able to handle secondary claims via EDI? MVP is currently capable of receiving secondary claims via EDI. Contact the MVP EDI coordinator at 1-877-461-4911 for the EDI Companion Guide. 19. Will MVP allow only one consultant (inpatient) per day like MC does (whoever bills first gets paid, others are denied)? No. MVP will pay all inpatient consulting physicians, not just the first biller. 20. Will there be separate checks and remits for MVP Gold? Yes. Marketing and Enrollment Questions 21. Can a member end their MVP Gold participation at any time? No, members must meet specific criteria to be able to end their MVP Gold benefits outside the enrollment period, such as permanently moving out of the service area or if they have both Medicare and Medicaid they are allowed to switch plans at will. 22. Why are we only marketing to employer groups in Cayuga and Broome counties? The early indication was that there was a better market for Employer Groups, not Direct Bill (individuals) in those counties. We plan to add MVP Gold for Direct Bill in those counties in 2008. 23. When will MVP add other counties such as Oswego, Tioga or Warren? Perhaps 2008, but we must have a fully accessible network before we can apply. Applications go in 9 months ahead of time so it is a long process.
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MVP Gold – Frequently Asked Questions
24. Will MVP educate prospective members on the closed network and referral requirement? Yes. MVP Gold members are enrolled individually and the marketing representatives will discuss with the member how the network and referrals work, and that MVP Gold is replacing their Medicare benefits. 25. What are the individual member premiums going to be? Individual rates for 2007 are: Capital District - $22.40 per month without Part D, and $47.00 per month with Part D. For Onondaga - $47.70 per month without Part D, $69.50 with Part D. For Dutchess and Ulster - $102.10 per month without Part D and $126.80 with Part D. 26. What is the difference between MVP Gold and Medicare Advantage? MVP Gold is MVP's name for our Medicare Advantage HMO plan. 27. Can an MVP Gold member still use their Medicare benefits, and go to any provider that accepts Medicare (and not use their MVP Gold benefits)? No. Once the member signs up with MVP Gold they are required to receive non-emergent, non-urgent care with MVP Gold participating providers. Other than for Hospice benefits, Medicare will reject all submitted claims because the member is enrolled in MVP Gold. 28. Will there be a prompt system for phone calls to customer service? Seniors prefer to speak to someone in person. Member Services calls will be answered by live staff, unless there is a hold time prior to a live staff representative being available. Members will not have a prompt system for MVP Gold. Member ID Card Questions 29. Will there be a new ID number issued for MVP Gold members? If the member was an MVP member in the past five years they will not be reissued a new ID number. If they have not been an MVP member within that time frame, they will receive a new ID number. 30. Can MVP put rider information on the ID cards? Due to size restrictions, MVP does not plan to add rider information to the ID cards.
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MVP Gold – Frequently Asked Questions
31. When will MVP add the "Referral Required" to the MVP Gold ID card? MVP would need to re-file the ID card with CMS for a 45-day review. At this point that refiling will not occur until after 1/1/07. 32. Will MVP put the PCP name on the ID cards? No. MVP does not put PCP names on our ID cards due to space restrictions and the changing PCP factor (reissuing cards too often). Provider Participation in MVP Gold 33. Why was provider enrollment in MVP Gold not automatic if the provider already participated with MVP? MVP and the IPA's in each region needed to add language to the contracts to be compliant with CMS, and also felt that each provider/facility/group should make the decision to participate in MVP Gold. 34. Do providers need to be credentialed specifically for MVP Gold? No. If provider is participating with MVP for commercial lines of business, there is no need to re-credential the provider. 35. Can the MVP Gold Directory be found online? Yes. On the MVP Web site www.mvphealthcare.com use the Doctor Search and then click on MVP Gold to view participating MVP Gold providers. 36. Is it a CMS regulation that medical records for Medicare members be kept for 10 years? Yes - per CMS guidelines, records must be maintained for 10 years. 37. How does a facility become par for Silver Sneakers? Can hospitals or hospital-based exercise programs participate in the Silver Sneakers network? If a facility is not part of the initial network that MVP rolls out then the facility can apply online at www.silversneakers.com or they can contact the Silver Sneakers Account Manager for the MVP Service Area. Please note Silver Sneakers will work with the plan to determine if there is a need for a facility in that particular area. Not all centers will be Silver Sneakers sites.
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MVP Gold – Frequently Asked Questions
Pharmacy and Formulary Questions 38. If a member buys MVP Gold medical coverage, can they keep their Part D through another Part D plan? No, they must purchase their Part D with the same carrier as their medical if they have both. They can keep Epic or VA coverage. 39. Can individuals buy "donut hole" coverage through MVP Gold? No. This additional coverage is currently only available to employer groups. 40. Will all pharmacies be available for MVP Gold/Medco members? Most national chain pharmacies participate with Medco (CVS, RiteAid, Walgreens, Walmart, Target, Eckerd). Pharmacy network information will appear in the MVP provider directories and is available on the MVP Web site. 41. Do we require physicians to stock injectable meds, or can patients pick up meds at the pharmacy and bring in for administration? MVP expects PCPs to stock and provide immunizations for patients. Specialists should provide medications they prescribe that the member cannot self-administer. CuraScript and TAP purchasing programs are required by MVP for many high cost injectables. 42. If Medicare does not cover a drug, will MVP cover it (anti-anxiety drugs)? No, MVP Gold will not provide coverage for a drug that Medicare does not cover. 43. Will all MVP members with existing prescriptions need new prescriptions on January 1st with the switch to Medco? MVP members will refills available at the retail pharmacy will not need new prescriptions. Members will not routinely need new prescriptions for refilling medications through the mail service. Members who have prescriptions for controlled substances, compounds, or if there are no refills left on the prescription will need new prescriptions to be sent to Medco by mail.
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MVP Gold – Frequently Asked Questions
44. Will MVP provide a comparison between our current formulary and Medco so that providers know what drugs they will no longer be able to write for? (both for Gold and Commercial formularies?) Members who are impacted by the new formulary will be receiving communication regarding the changes. Their ordering physician will receive a copy of these letters. Because the Gold formulary is brand new and the only non-covered items are those mandated by CMS, a comparison will not be created. Referrals and Pre-Authorization Questions 45. Do all same day surgery procedures require pre-auth for MVP Gold? No. The SAME Same Day Surgery procedures that require pre-auth for MVP Commercial plans will require pre-auth for MVP Gold. These procedures are listed in the UM Policy Guide. 46. If bronchoscopies are done in outpatient surgery area of hospital do they require preauthorization, and do they take a copay (is it surgery or diagnostic testing)? No pre-authorization is required, but if the services are done in the hospital outpatient setting, the patient will pay their outpatient surgery copay. 47. During care management, if someone is speaking to a member, is his or her doctor notified of this conversation? Yes. Each time a member is enrolled (agrees to participate with Case/Disease Management program) the PCP is contacted by phone, fax or letter. 48. Will a referral be required if a specialist sees an MVP Gold member in a skilled nursing facility (SNF)? If a member is covered for SNF services (Part A) then all physicians’ visits are covered without additional referrals, providing the physician bills with the correct codes and place of service. Members who reside in a SNF (custodial care) and are not covered for Part A (covered for Part B) require an auth for specialists visits just the same as if they lived at a private residence. 49. Can referrals be backdated to allow payment of a claim? MVP does not encourage the backdating of referrals. PCPs should only backdate referrals in the case that a mistake was made (chart shows discussion about a referral but it wasn't written, referral written to wrong health plan). Specialists can use the one-visit referral form if the member does not have a referral, but then the member should be directed to get a new referral from their PCP.
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MVP Gold – Frequently Asked Questions
Travel Benefit Questions 50. If members have non-urgent/emergent services outside the 10-county area, will the Travel Benefit be used (even within MVP's commercial service area - e.g. Westchester County) or will the services deny if there is no referral/auth on file? Yes. The travel benefit will be used outside of the MVP approved counties if members see non-participating (MVP Gold) providers for non-urgent/emergent services. 51. Do specialty care services out of area (e.g. Florida) under the Travel Benefit require a referral or an authorization? Inpatient services, home health care and skilled nursing facilities require authorization out of area. All other services do not require referrals or authorization and will be applied to the Travel Benefit if they are non-urgent/emergent services. Vision Benefits and Billing Questions 52. With routine eye care exams, is the benefit for a visit every year or every 2 years? One routine eye exam is covered each calendar year. 53. Are glasses/lenses following cataract surgery covered? Yes. 54. If patient goes in for routine vision but a medical diagnosis is found, does the patient pay a copay, and is the referral waived? If the patient presents for a routine vision exam, the routine diagnosis should be the primary diagnosis and the medical diagnosis should be secondary. This is the same as current MVP policy. The routine vision exam copay would be required, but a referral would not be required as long as the claim is billed per the above instruction. 55. Will members submit for reimbursement for eyewear, or should providers bill MVP? The member can submit their receipt to MVP for reimbursement up to their benefit allowance. Providers may also submit claims to MVP if they choose to, and then bill the patient for the amount over the benefit allowance for eyewear.
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