Provider Quick Reference Guide
PROVIDER PORTAL
The MetroPlusHealth SalesForce Provider Portal is more convenient than ever before.
- Online Claims and Authorization Entry
- P4P Reports, Patient Gaps in Care, Utilization Reports, and much more
- Check Eligibility, Claims, Payment and Authorization Status
- Eliminates multiple logins – “one stop shop”
- Ask questions 24/7
- Fast, straightforward authorization requests:
- Diagnosis and service code lookup
- Clinical requirements check
CLAIM SUBMISSIONS
Claims must be submitted within timelines defined in Provider contract.
- Allow 30 days for electronic/45 days for paper claims submission to receive payment
- Balance billing is prohibited
- Sign up for Electronic Funds Transfer (EFT) to receive claim payments electronically.
- To check claim status, go to: providers.metroplus.org or call: 800.303.9626
> Visit Claims Submissions Page
NOTIFY US AS SOON AS POSSIBLE OF CHANGES IN YOUR PRACTICE:
- Change of address/new site/site closure
- Change of practice name/ownership
- Provider Retired or Moved out of NYC
- Change of tax ID number
- Change of providers in group practice
- Extended leave of absence
Visit the Provider Portal
Call:800.303.9626 | 212.908.3691
Email:[email protected]
Mail: MetroPlusHealth
Attn: Provider Services
50 Water Street, 7th Floor
New York, NY 10038
PRIOR AUTHORIZATION REQUESTS
Medical and Radiology Services:
Find out more about services requiring prior authorization.
Call: 800.303.9626
More Info
PROVIDER MANUAL
Includes medical coverage policies and other information.
Download a Copy
MEMBER ELIGIBILITY & BENEFITS
Member coverage, PCP and any restrictions must be verified before every encounter by using either Member ID Card, photo ID, or health plan.
Call: 800.303.9626
More Info
PHARMACY SERVICES
For the following Plans:
- Medicaid Managed Care
- Partnership in Care (SNP)
- Child Health Plus
- MetroPlus Enhanced (HARP)
Prior Authorization (NYRX):
Call: 877.433.7643 | Fax: 866.255.7569
For Medicare Plans:
- MetroPlus Advantage Plan (HMO D-SNP)
- MetroPlus UltraCare Plan (HMO D-SNP)
MetroPlus Platinum Plan (HMO)
Call: 866.693.4615 | Fax: 855.633.7673
For all other Plans:
Call: 855.582.2022 | Fax: 855.245.8333
Specialty drugs for non-Medicare members:
MPH Pharmacy Department
Call: 800.303.9626 | Fax: 844.807.8455
DENTAL SERVICES
DentaQuest | Utilization Management:
For Utilization Management,
Call: 800.294.9650
Visit DentaQuest
DURABLE MEDICAL EQUIPMENT (DME)
Integra
Call: 800.303.9626
More Info
TRANSPORTATION SERVICES
Modvicare
Call: 800.303.9626
Visit Modvicare
PARTICIPATING LABORATORY SERVICES
Note: To perform in-office lab testing, the location must have a CLIA certificate.
TRANSLATION SERVICES
Cyracom International
Cyracom.com