Provider Forms Library

Comprehensive Listing of Common Forms Needed by MVP Providers

From prior authorization and provider change forms to claim adjustments, MVP offers a complete toolkit of resources for our providers.

• Provider Change of Information Form
• Using the Provider Change of Information Form
• Facility/Ancillary Provider Change of Information
• Provider Participation Guide
• Provider Application Request—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
• MVP Contracted Hospitals
• Practitioner Continuity of Care Statement
• Provider Leave of Absence Notification
• Provider Credentialing Rights
• Federal Tax W-9

• 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.

• 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

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)
• CORE Overview

• 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.
• Children’s HCBS Authorization and Care Manager Notification Form (PDF)—For use by Children Home and Community Based Service providers when requesting continued authorization for HCBS for children

• 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.