FAQs for Providers

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.

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

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.

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.

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

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.

More than 500 New York pharmacies across all five boroughs accept MetroPlusHealth insurance. These include CVS, Rite Aid, and Duane Reade as well as over 400 independent community pharmacies that our members love.

Delivery services are also available from CVS’s Caremark and other in-network pharmacies, although some pharmacies may charge a delivery fee on their end.

We proudly work with over 40 hospitals and urgent care centers including:

• NYC Health + Hospitals
• NYU Langone
• Mt. Siani
• CityMD
• Montefiore
• Labcorp
• Lenox Hill Radiology

Yes! Delivery services are also available from CVS’s Caremark and other in-network pharmacies, although some pharmacies may charge a delivery fee on their end.

Our claims department also handles all appeals. You always have the right to appeal a determination within 45 calendar days of either a payment receipt or a denial notification.

All appeals of claim denials that result from authorization or medical management issues should refer to section 7.15 of the Provider Manual.

For all other claims, be sure to include:

An explanation for the appeal
All other pertinent information and supporting documentation
A copy of the original claim
A copy of the original EOP
For Medicare appeals only, an AOR form (INN) or a WOL statement (OON)

For Medicaid, Partnership In Care (PIC), Enhanced (HARP) Plan, Gold, GoldCare, Child Health Plus (CHP), Essential Plan (EP), and Managed Long Term Care (MLTC), send an appeal by regular mail to:

MetroPlusHealth
PO Box 830480
Birmingham, AL 35383-0480

For Medicare plans (Advantage, UltraCare, and Platinum) and MarketPlace Plans (QHP), send an appeal by regular mail to:

MetroPlusHealth
PO Box 381508
Birmingham, AL 35383-0480

Send any appeal by fax to 212-908-8789.

For Medicaid, Child Health Plus (CHP), Essential Plan (EP), Enhanced (HARP) Plan, Partnership In Care (PIC), MetroPlusHealth Gold, and Gold Care, Managed Long Term Care (MLTC) send paper claims on CMS 1500 or UB-04 forms to:

MetroPlusHealth
PO Box 830480
Birmingham, AL 35383-0480

For Medicare plans (Advantage, UltraCare, and Platinum) and MarketPlace Plans (QHP) send paper claims on CMS 1500 or UB-04 forms to:

MetroPlusHealth
PO Box 381508
Birmingham, AL 35383-0480

Absolutely! Our Provider Services Center is open Monday – Friday, 9:00 a.m. to 5:00 p.m. ET and can be reached at both 1-800-303-9626 or 1-212-908-4780.

You always have the right to appeal a determination within 45 calendar days of either a payment receipt or a denial notification.

All appeals of claim denials that result from authorization or medical management issues should refer to section 7.15 of the Provider Manual.

Log into Change Healthcare to submit a claim electronically using our Emdeon Payer ID #13265.

There’s two ways: Log into the Provider Portal or give our excellent member service team a call at 1-800-303-9626.

We ask our providers to allow us 30 days to reimburse electronic claims and 45 days to reimburse paper claims.