Welcome to MetroPlusHealth!

Welcome to MetroPlusHealth’s Provider page – a dedicated resource designed to support our healthcare providers. Here, you can access essential tools, resources, and updates to help you deliver exceptional care to MetroPlusHealth members. From eligibility verification and claims submissions to prior authorization forms and provider manuals, we’re here to streamline your partnership with us. Together, we ensure the health and well-being of our communities.

We’re happy to have you join us.

With a focus on primary and preventive health care for people not profit, we’ve been providing a caring, high-quality customer experience for New Yorkers since 1985.

Healthcare professionals using the MetroPlusHealth Provider page for streamlined access to resources.
Discover tools, updates, and resources on MetroPlusHealth’s Provider pages

Important & Urgent Notifications

May 07, 2025
Availity Eligibility and Claim Inquiry Update
April 29, 2025
RE: HEALTH HOMES ADDED TO ELIGIBLE PROVIDERS FOR COMMUNITY HEALTH WORKERS
April 17, 2025
RE: TELEHEALTH – CHANGES TO AUDIO-ONLY BILLING
April 11, 2025
RE: eConsults Expansion
April 08, 2025
RE: SBHC COVERED SERVICES – DELAYED
April 01, 2025
URGENT MESSAGE FOR YOUR PATIENTS AND THEIR PAID CAREGIVERS
April 01, 2025
RE: New Medicare Behavioral Health Utilization Management (BHUM) and ABA Fax Line
March 19, 2025
RE: Doula Services IMPACTED PLANS: Medicaid, HIV SNP, HARP and EP
March 14, 2025
URGENT MESSAGE FOR YOUR PATIENTS AND THEIR PAID CAREGIVERS REGARDING CDPAP CHANGE
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Already part of our network?

The Provider Portal is your one-stop shop for:

  • Checking member eligibility and authorization statuses
  • Tracking submitted claims
  • Accessing information like orientation materials, benefit changes, and membership rosters
  • Procuring membership and utilization reports
  • Browsing provider performance profiles and diagnosis code lists
  • And more!

MetroPlusHealth is here to help you.

We exist to serve the community. That means helping providers like you deliver the best health care in the city while growing your business along the way.

How large is the MetroPlusHealth network?

Our network is always expanding! But to date, our network includes more than 34,000 providers like you, 40 hospitals, 110 urgent care centers, and 500 local and national pharmacies. Our Provider Search is a great place to get specifics.

What is the billing process?

We accept both electronic and paper-based claims. Log into the Provider Portal to any time.

What does the reimbursement process look like?

Both capitation and fee-for-service claims have to include a detailing of all services rendered within 90 days of the date of service. We ask our providers to kindly allow 30 days for the reimbursement of electronic claims and 45 days for the reimbursement of paper claims.

What does the authorization process look like?

We issue an Explanation of Payment (EOP) for every claim and adjustment regardless of whether payment or denial. Our EOPs offer a summary of payment or denial information for each billed service.

How many specialists are in network?

Our network is comprised of over 34,000 providers and specialists.

How many hospitals are in network?

There are more than 40 hospitals and urgent care centers in our network including NYC Health + Hospitals, NYU Langone, Mt. Sinai, CityMD, Montefiore, Labcorp, Lenox Hill Radiology, and more.

Restricted Recipient Program (RRP) FAQs

What is the Restricted Recipient Program (RRP)?

The New York Office of the Medicaid Inspector General (OMIG) administered a program that implemented set criteria to determine a pattern of misuse or abuse of services covered under the Medicaid Program. This program is known as the Restricted Recipient Program (RRP).

What is the Role of the RRP?

NYS DOH and OMIG have asked Managed Care Organization to administer restrictions for enrolled members who demonstrate a pattern of misusing or abusing the Medicaid Program. MetroPlusHealth Restricted Recipient Unit reviews members’ utilization of medical services to identify emerging trends in duplicate, excessive, contraindicated, or conflicting drugs, healthcare services, supplies, and abusive practices.

Who restricts the member’s account:

The Office of Inspector General (OMIG) identifies members who are demonstrating patterns of misuse and abuse of services and notifies the Plan on a monthly basis.  In addition, MetroPlus Health has a team of clinicians named the Restrictive Recipient Program Review team (RRPRT). The Clinical team comprises an MD, Pharmacist, and Registered Nurse. The RRPRT determines if a restriction is warranted. If a restriction is justified, the member may be assigned to the following type of restrictions:

  • PCP
  • Podiatry
  • Physician Group
  • Outpatient
  • Inpatient
  • Dental
  • Durable Medical Equipment (DME)
  • Nurse Practitioner

What is the purpose of having an RRP?

An RRP aims to provide restricted enrollees with tightly managed medical services. It is an aid for the member to meet with their assigned specified Provider to ensure members’ utilization of services is appropriately managed. 

How long is an enrollee restricted?

There are three restrictions periods:

  1. Initial restrictions-2 years
  2. Re-Restrictions (2nd restrictions)-3 years
  3. Subsequent restrictions (3rd or Greater)-6 years

 

What are my management responsibilities as an RRP provider?

Primary Care Providers (PCP) by contract are expected to manage the health care of the RRP members on their panel, including referrals to specialty services and participants. The physician is responsible for the medical management of the member if in the hospital and outside their practice. 

  • Restricted Recipients are individuals with a pattern of misusing or abusing benefit package services and are restricted to one or more providers to receive their services.
  • Restrictions may include PCPs, Specialists, dentists, podiatrists, and hospital settings.
  • During the member’s visit-the, the Restricted Recipient members will have an “R” on their ID Card.
  • Providers must verify member eligibility before every encounter to identify any restrictions.

 

Pharmacy Carved-out:

Managed Care Plans do not cover members’ prescription coverage/ Pharmacy Restrictions. The Department of Health-Office of Medicaid Inspector General-Medicaid NYRx manages members’ medications. For Provider assistance with prior authorizations, clinical concerns, and the Preferred Drug Program, contact the Magellan Clinical Call Center at (877) 309-9493.

If MetroPlusHealth members have any questions concerning their pharmacy coverage, please ask your patient to contact their local Human Resources Administration (HRA) at 212-273-0062:

PLEASE NOTE: If a member is restricted to a particular provider, they cannot be seen by another provider/specialist without prior authorization from their assigned PCP. Claims submitted without a referral from the assigned PCP will be denied. 

last updated: May 14, 2025

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