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):Beginning April 1, 2023, all Medicaid members enrolled in MetroPlusHealth Medicaid, Partnership In Care, and Enhanced (HARP) plans will receive their prescription drugs through NYRx, the Medicaid Pharmacy Program.Information about the transition of the pharmacy benefit from MetroPlusHealth to NYRx, the Medicaid Pharmacy Program can be found here.
General information about NYRx, the Medicaid Pharmacy Program can be found here along with information for Members and Providers.
General information about NYRx, the Medicaid Pharmacy Program can be found here along with information for Members and Providers.
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.
