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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

Go here.


CLAIM SUBMISSIONS

Go here,


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.

last updated: November 28, 2023

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