Provider Quick Reference Guide
PRIOR AUTHORIZATION REQUESTS
Medical and Radiology Services: Find out more about services requiring prior authorization. Call: 800.303.9626 or click here.
PROVIDER MANUAL
Includes medical coverage policies and other information. Click here for more information.
MEMBER ELIGIBILITY & BENEFITS
Member coverage, PCP and anyr estrictions must be verified before every encounter by using either Member ID Card, photo ID, or health plan. Call: 800.303.9626 or click here.
NOTIFY US AS SOON AS POSSIBLE OF CHANGES IN YOUR PRACTICE:
- Change of address
- Change of practice name/ownership
- New site or site closure
- Change of tax ID number
- Change of providers in group practice
- Extended leave of absence
To notify MetroPlus Health of changes in your practice, please visit MetroPlusHealth Provider Portal at https://metroplushealth.my.site.com/Providers/s/login/ to download a provider update form, or call: 800.303.9626 or Fax: 212.908.3691
Practice updates can also be mailed to: MetroPlusHealth
Attn: Provider Services
50 Water Street, 7th Fl.
New York, NY 10038
CLAIM SUBMISSIONS
Claims must be submitted within timelines defined in the Provider contract.
- Allow 30 days for electronic and 45 days for paper claims submission date to receive payment
- Claims for all members can be submitted electronically at changehealthcare.com and paper claims must be submitted on MCS 1500 or UB-04 forms
- Balance billing is prohibited.
- Sign up for EFT to receive claim payments electronically.
- To check claim status, please visit MetroPlusHealth Provider Portal at https://metroplushealth.my.site.com/Providers/s/login/ or call: 800.303.9626
PHARMACY SERVICES (CVS CAREMARK)
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 DepartmentCall: 800.303.9626 | Fax: 844.807.8455
DENTAL SERVICES
DentaQuest | Utilization Management:
For Utilization Management,
Call: 800.294.9650 or go to dentaquest.com/en/providers
DURABLE MEDICAL EQUIPMENT (DME)
Integra
Call: 800.303.9626 or click here.
TRANSPORTATION SERVICES
Modvicare
Call: 800.303.9626 or go to modvicare.com
NETWORK LABORATORIES
Click here
Note: To perform in-office lab testing, the location must have a CLIA certificate.
TRANSLATION SERVICES
For language interpreter services, contact Provider Services at 1-800-303-9626
BEHAVIORAL HEALTH SERVICES
CLAIM SUBMISSIONS
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
- Eliminate multiple logins – “one stop shop”
- Ask questions 24/7
- Fast, straightforward authorization requests:
– Diagnosis and service code lookup
– Clinical requirements: Go here.
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