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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

> Visit the Provider Portal


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

PRV 25


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

More Info

Note: To perform in-office lab testing, the location must have a CLIA certificate.


TRANSLATION SERVICES

Cyracom International
Cyracom.com


BEHAVIORAL HEALTH SERVICES

More Info

last updated: June 18, 2025

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