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.