Provider Tools
Provider Resources
New York State Department of Health Updates:
Provider Access and Availability Standards
Partnership in Care Rewards Program
Tell your patients living with HIV about the MetroPlusHealth Rewards Program. Your patients enrolled in Partnership in Care can get rewarded for health screenings and activities. There is even a substantial reward just for attending clinic appointments for their HIV care. Learn more about the program here.
NEW YORK STATE MEDICAID COVERAGE OF RESPIRATORY SYNCYTIAL VIRUS MONOCLONAL ANTIBODY (NIRSEVIMAB) FOR INFANTS
Effective October 1, 2023, New York State (NYS) is providing coverage for the administration of Nirsevimab for infants through the Vaccines for Children (VFC) program.
Nirsevimab is a monoclonal antibody preparation for the prevention of Respiratory Syncytial Virus (RSV) in infants, as recommended by the Advisory Committee on Immunization Practices (ACIP) of the Center of Disease Control and Prevention (CDC).
Impacted Plans: Medicaid, HARP, HIV SNP, AND MAP
Effective October 1, 2023, The NYS Office of Mental Health (OMH) and the NYS Department of Health (DOH) have updated the billing guidance for delivering interpreter services in an LOE (Language Other Than English), including American Sign Language within a OMH MHOTRS Program. This updated guidance establishes an additional new modifier combination to obtain an enhanced reimbursement when translation services are provided by a vendor or any translation professional, other than a MHOTRS staff person.
Self-Disclosure Notification Protocol
The Office of Mental Health (OMH) is informing Providers of their responsibility to notify OMH when a self-disclosure of a Medicaid overpayment is made to the Office of the Medicaid Inspector General (OMIG) using the Full Self-Disclosure Process.
Medicaid providers are required to report, return, and explain any overpayments they have received to the OMIG Self-Disclosure Program within sixty (60) days of identification, or by the date any corresponding cost report was due, whichever is later. Upon receiving this notice, the OMH Medicaid Compliance Office will review and issue a statement confirming that the oversight agency has been notified.
BILLING REQUIREMENT CHANGES AND UPDATES FOR CHILDREN’S HCBS AND CFTSS SERVICES
Effective December 1, 2023, NYS is implementing a billing change that will allow claims for Children’s Home and Community Based Services (HCBS) and Children and Family Treatment Support Services (CFTSS) to be paid based on the county in which services were provided, rather than a provider’s corporate headquarters or central office address.
APPROVAL OF THE NOVAVAX COVID 19 VACCINE
Effective October 3, 2023, the Federal Drug Administration (FDA) announced the approval of the updated 2023–2024 monovalent XBB.1.5 variant Novavax COVID-19 Vaccine, Adjuvanted.
Our goal is to give our Providers help finding and managing day-to-day needs. Please contact Provider Services at 1-800-303-9626 (TTY: 711) or Medicare at 1-866-986-0356 if you need help or have questions.
Register or get directed to online trainings through the calendar.
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NOTICE TO OUR PROVIDERS REGARDING New York State Medicaid’s reimbursement policy for administration of COVID-19 vaccines
The New York State Department of Health has updated the coverage policy and billing guidance document regarding New York State Medicaid’s reimbursement policy for the administration of COVID-19 vaccines. This guidance can be found on the COVID-19 Guidance for Medicaid Providers (ny.gov) webpage, which is updated regularly.
HELP PATIENTS PREVENT DIABETES WITH LIFESTYLE TIPS
Here are some lifestyle steps your patients can take to help reduce blood sugar levels and prevent diabetes:
Shed weight.
Losing weight can feel overwhelming for many patients. But it doesn’t take much to help improve their health. Shedding just 7% of body weight has been proven to lower the risk of diabetes. Move more.
Aim to get 30 minutes of exercise on most days — or 150 minutes a week — to help ward off chronic disease. Tweak diet choices Limit added sugars and choose whole foods instead of processed foods like chips, boxed dinners, and fast food. Non-starchy vegetables like carrots, broccoli, and spinach as well as lean meats and fish can help keep blood sugar stable.
Prioritize sleep.
Patients should aim for seven to eight hours of quality sleep every night. Good sleep can lower the risk of insulin resistance, which can lead to high blood glucose levels.
Follow up.
Follow up with patients yearly to check blood sugar levels and ensure they are taking proactive steps to prevent diabetes. It’s estimated that 80% of people with prediabetes are unaware they have it.
DIABETES RESOURCES
Patients who participate in American Diabetes Association diabetes self-management education and support (DSMES) are more likely to manage their health and take medicines as prescribed. To learn more, click here.
Updated Provider Letter Regarding Foster Care 2023
As a MetroPlusHealth network provider, you may find yourself in a position to provide trauma-informed care to Medicaid Managed Care (MMC) children/youth in direct placement foster care and in the care of Voluntary Foster Care Agencies (VFCA).
Provision and coordination of services for children/youth in foster care, must be done in compliance with the New York Medicaid Program 29-I Health Facility Billing Manual and the Transition of Children Placed in Foster Care and NYS Public Health Law Article 29-I Health Facility Services into Medicaid Managed Care guidance documents located at:
https://www.health.ny.gov/health_care/medicaid/redesign/behavioral_health/children/vol_foster_trans.htm.
PROVIDER SEMINAR: CANCER AND ENVIRONMENT
Wednesday, June 21st , 2023 | 9:30 AM – 5:00 PM
Roy and Diana Vagelos Education Center Auditorium & via Zoom
Join the Herbert Irving Comprehensive Cancer Center at Columbia University Irving Medical Center and the Sandra and Edward Meyer Cancer Center at Weill Cornell Medicine for a one-day CME event on the state of the science of environmental carcinogenesis and the role physicians, nurses, community leaders, and public health practitioners play in engaging on environmental chemicals and cancer risk reduction.
For more information.
Comprehensive Guidance Regarding Use of Telehealth including Telephonic Services After the Coronavirus Disease 2019 Public Health Emergency
Comprehensive updated guidance regarding use of telehealth (including telephonic services) and billing guidance and criteria following the end of the Coronavirus Disease 2019 Public Health Emergency on May 11,2023, released by the New York State Department of Health, can be found here.
Providers must comply with the DOH, OMH, OASAS, and OPWDD issued Billing Updates to applicable codes, modifiers, and Place of Service (POS) requirements, for Medical and Mental Health Services.
Frequently Asked Questions: CMS Waivers, Flexibilities, and the End of the COVID-19 Public Health Emergency
IMPORTANT MESSAGE TO OUR PROVIDERS: PCP IN-OFFICE NON-ALLOWABLE SERVICES
Effective April 15, 2022
The Primary Care Provider (PCP) In-Office Non-allowable services list is a compilation of procedure codes MetroPlusHealth deems non-allowable for reimbursement to our Network PCPs (Family Practice, Internal Medicine, Pediatrics, Geriatrics and Adolescent Medicine). MetroPlusHealth PCP non-allowable in-office services list will go into effect on April 15th, 2022. Click here to learn more and for the list of impacted codes.
IMPORTANT REMINDER TO OUR PROVIDERS REGARDING OUR NATIONAL DRUG CODE (NDC) REQUIREMENT POLICY, PROFESSIONAL AND FACILITY
The Deficit Reduction Act of 2005 (DRA) requires Medicaid agencies to collect NDC numbers on pharmaceuticals. Our NDC billing requirements for providers enrolled in the 340B Program can be found here.
Read our NDC billing requirements for 340B Program providers here.
IMPORTANT NOTICE TO OUR PEDIATRIC PRIMARY CARE PROVIDERS REGARDING 2023 ENHANCED CHILDREN’S BENEFITS:
MetroPlusHealth has been ramping up for the expansion of services that will become available to children and youth in 2023. Learn more here about new benefits and services coming in 2023.
IMPORTANT NOTICE TO OUR APPLIED BEHAVIORAL ANALYSIS (ABA) PROVIDERS REGARDING 2023 ABA BENEFIT CHANGES
MetroPlusHealth has been ramping up for the expansion of Applied Behavior Analysis Services to eligible Medicaid members diagnosed with autism spectrum disorder. Services will become available January 1, 2023, for those members under 21 years of age. Learn more here about new benefits and services coming in 2023.
IMPORTANT NOTICE: THE PROVIDER DUE DATE FOR COMPLETION OF THE MODEL OF CARE TRAINING IS DECEMEBER 31, 2023. CLICK HERE TO ACCESS THE ONLINE TRAINING.
You can access the digital attestation form here.
IMPORTANT MESSAGE ANNOUNCING AN END OF YEAR BONUS PAYMENT FOR OUR PROVIDERS IN ASSISTING MEMBERS TO OBTAIN THEIR KEY WELLNESS TESTS/VISITS.
This incentive is separate from our Pay for Performance (P4P) Program. Learn more here.
IMPORTANT NOTICE TO 1915(c) CHILDREN’S WAIVER RESPITE HCBS PROVIDERS:
The New York State Department of Health is evaluating various policy flexibilities allowed during the COVID-19 Public Health Emergency (PHE) and determining which flexibilities will be ending and which ones will be extended (temporarily/permanently).
Effective January 1, 2023, the Children’s Respite Services flexibility will end and providers are required to revert to the original guidance provided in the HCBS Manual. Read the guidance here.
IMPORTANT NOTICE: PHARMACY BILLING GUIDANCE EXCEPTIONS FOR NON-ENROLLED PRESCRIBERS
The New York State (NYS) Medicaid program requires enrollment of all licensed prescribers and pharmacies who serve Medicaid members, including prescribing practitioners identified on pharmacy claims per the Centers for Medicare and Medicaid Services (CMS) and federal regulations. However, under the Medicaid Provider Enrollment Compendium (MPEC) found here: https://www.medicaid.gov/
IMPORTANT NOTICE REGARDING PT AND OT VISITS
Effective January 1, 2023, the number of visits allowed without prior authorization for both Physical Therapy (PT) and Occupational Therapy (OT) will change. Ten (10) visits will be allowed without prior authorization, inclusive of the initial evaluation.
Effective January 1, 2023, all Speech Therapy and Chiropractic Care will require prior authorization. There will be no visits allowed without prior authorization.
Overall benefits allowed vary by Line of Business (LOB), so it is important to verify both LOB and eligibility prior to rendering services. Click here to learn more about facilitating review when requesting visits for PT or OT.
IMPORTANT NOTICE FOR OUR PROVIDERS:
Effective November 1, 2022, we will no longer have a contract with VNS Health (formally known as Visiting Nurse Service of New York) for skilled home care services provided by their Certified Home Health Agency (CHHA) including skilled nursing, home therapy services, and home health aide services.
This change does not include Behavioral Health (BH) or Hospice services. VNS Health will continue to provide BH and Hospice services for MetroPlusHealth members.
Click here for a list of MetroPlusHealth participating home care providers to which you can refer members..
If you have any questions, please contact MetroPlusHealth Provider Services Call Center at 1.800.303.9626.
IMPORTANT NOTICE FOR OUR MEDICAID, HIV-SNP, HARP , MLTC, AND CHP PROVIDERS:
MEDICAID UPDATES REGARDING SUSPECTED ORTHOPOXVIRUS/MONKEY POX CASES AND BILLING GUIDELINES EFFECTIVE JULY 26, 2022. Read here.
IMPORTANT NOTICE: ESSENTIAL PLAN MONKEY POX VACCINE COST-SHARING GUIDANCE FROM NY STATE OF HEALTH, EFFECTIVE JULY 29, 2022.
Read here.
IMPORTANT NOTICE TO OUR PROVIDERS: UPDATED GUIDANCE REGARDING COVID COUNSELING BILLING, CODING, AND REIMBURSEMENT
Many of our participating providers can continue to bill MetroPlusHealth for COVID-19 vaccination counseling for our Medicaid, HIV SNP, and HARP members to encourage the administration of the COVID-19 vaccine. Qualified Providers may bill up to four (4) counseling visits per vaccine dose (up to 12 visits per member, annually) and receive reimbursement. Click here to learn more regarding our COVID counseling billing, coding, and reimbursement policy. Click here to review the updated NYS DOH COVID-19 Fact Sheet. Click here to review updated NYS DOH guidance on COVID-19 Vaccine Counseling Coverage. Please note the Pharmacy billing implementation is in progress.
Discontinued Coverage for TerSera Therapeutics LLC Drugs Effective May 14, 2022: Update for MetroPlusHealth Medicaid Managed Care, Partnership in Care (PIC) HIV-SNP, and Enhanced (HARP) Plan Members
TerSera Therapeutics LLC voluntarily withdrew from participation in the Medicaid Drug Rebate Program (MDRP). As instructed by NY State Department of Health, effective May 14, 2022, MetroPlusHealth can no longer provide coverage for most drugs manufactured by TerSera Therapeutics LLC.
Pursuant to Social Security Law Sec. 1927 [42 U.S.C. 1396r-8] (a), Centers for Medicare and Medicaid Services (CMS) requires drug manufacturers to participate in the MDRP for their drugs to be eligible for coverage under Medicaid, except in certain circumstances. ZOLADEX® (goserelin implant) is a practitioner-administered drug manufactured by TerSera Therapeutics LLC which is available through a Patient Assistance Program (PAP) from the manufacturer free of charge for those who qualify. For program applications and additional information, providers must visit the ZOLADEX® “Access and support” web page or contact TerSera Support Source at (855) 686-8725.
Coverage of ZOLADEX® will continue to be provided for Medicaid members who are unable to obtain the medication through the PAP and when used under the following conditions:
- for a Food and Drug Administration (FDA)-approved indication for which there are no alternative options and
- as a continuation of established therapy if another gonadotropin-releasing hormone (GnRH) product has been tried and failed or if transition to another GnRH is medically contraindicated.
NEW FOR INTERESTED PROVIDERS: MATERNAL MENTAL HEALTH SUPPORT SERVICES FOR CLINICIANS FROM PROJECT TEACH
Funded by New York State Office of Mental Health. Click here to learn more about MMH resources available to you and your practice. For general information about Project TEACH contact 716-878-2454 or [email protected].
IMPORTANT MESSAGE REGARDING OUR PHARMACY NETWORK
Starting January 1, 2022, Walgreens and Duane Reade will no longer be in the pharmacy network for members of these plans:
- Medicaid Managed Care, including Partnership in Care and HARP Plans (click here to find a list of 2022 network pharmacies)
- Child Health Plus (click here to find a list of 2022 network pharmacies)
- Exchange/Marketplace Plans here to find a list of 2022 network pharmacies)
Members may call and request their prescriptions be sent to a different pharmacy.
IMPORTANT MESSAGE TO OUR BEHAVIORAL HEALTH PROVIDERS REGARDING CORE SERVICES
Effective February 1, 2022, in order to improve access to services, NYS is transitioning four BH HCBS to a new service array called Community Oriented Recovery and Empowerment (CORE) Services. These four services include Community Psychiatric Support and Treatment (CPST), Psychosocial Rehabilitation (PSR), Family Support and Training (FST), and Empowerment Services – Peer Support (Peer Support). BH HCBS Short-term and Intensive Crisis Respite services will be transitioned to Crisis Intervention Benefit Crisis Residence services, already available to all adult Medicaid Managed Care enrollees. All other existing BH HCBS will remain available as BH HCBS with previously established requirements, workflows, and processes.
For members who are 21 or older, covered by Medicaid, and enrolled in a Health and Recovery Program (HARP), CORE services may be just right. Additionally, some individuals enrolled in HIV-Special Needs Plans or Medicaid Advantage Plus Plans will be eligible for CORE. CORE services are covered by health insurance, at no cost to our members.
Our providers who may be serving members receiving CORE services are required by the DOH to take specific trainings. Read the CORE training memo here for more information. You can access the CORE Benefit and Billing Guidance here. Please review the links below and register for trainings as soon as possible.
Registration and Helpful Links
To access the required trainings, log in to the CPI Learning Community using your username and password.
For registration assistance or to report technical issues: CPI Online Assistance Unit
For questions about training requirements for CORE Services, please contact your host agency
• OMH: [email protected]
• OASAS: [email protected]
Please visit the Center for Practice Innovations Homepage and FAQs for more information on the Learning Community.
IMPORTANT MESSAGE TO OUR PROVIDERS REGARDING FOSTER CARE
Meeting the Health Care Needs of Children/Youth Placed in Foster Care:
Children/youth placed in foster care may have Medicaid or SNP coverage. MetroPlus will cover all services covered by the Medicaid Managed Care benefit package.
Providing access to comprehensive, high quality health care is an essential goal of transitioning the care of children in foster care from fee-for-service Medicaid to Managed care. To accomplish this, MetroPlus has made special provisions to ensure immediate access to services upon a youth’s placement in foster care without interruption in the provision of ongoing services:
- To meet the requirement for an initial medical required health assessment, MetroPlus will allow members to see any participating primary care physician (PCP) or other qualifying provider for the first 30 days of placement.
- Because changes in placement may occur requiring additional health assessments, MetroPlus will allow members to see participating PCP providers not listed on their ID card
- Call MetroPlus Customer Services 800-303-9626 to verify coverage and notify about need for future visits
- Because changes in placement may occur requiring additional health assessments, MetroPlus will allow members to see participating PCP providers not listed on their ID card
- MetroPlus will cover these pharmacy issues:
- A 30- day supply (transition fill) for non-formulary or Prior Auth (PA) required drugs within the first 90 days of enrollment,
- If the member requires an additional transition fill because of new placement, providers should send the request to CVS and indicate the reason
- Members can receive “refill-too-soon” overrides when transferring between foster homes
- Members can fill prescriptions at pharmacies that are out of network when they are placed out of our service area
- A 30- day supply (transition fill) for non-formulary or Prior Auth (PA) required drugs within the first 90 days of enrollment,
For more information, click here.
IMPORTANT NOTICE FOR PROVIDERS: Understanding How Adverse Childhood Experiences Affect Patients’ Health Across the Lifespan
Adverse Childhood Experiences (ACEs) are stressful or traumatic events, such as neglect and/or violence during childhood. ACEs are strongly related to brain development and a wide range of health problems throughout a person’s lifetime and may include, but are not limited to, physical or sexual abuse, domestic violence, living in poverty, death of a caregiver, exposure to discrimination, or living in a household with someone with mental illness, substance use disorder, or who has experienced incarceration. Read what ACEs research shows here.
IMPORTANT MESSAGE FOR OUR PROVIDERS: ANNUAL MEDICARE SPECIAL NEEDS PROGRAM (SNP) MODEL OF CARE (MOC) PROVIDER TRAINING
The Centers for Medicare and Medicaid Services (CMS) requires that providers receive Medicare Special Needs Program (SNP) Model of Care (MOC) training annually. As part of our ongoing commitment to access, quality of service and care for our members, MetroPlusHealth provides this training annually and during the new orientation process to all network providers, as well as to providers who regularly see our SNP members.
The training module can be accessed by logging into our provider website/portal, or you can access it through this link: MAP-MOC for providers.
After logging in to the MetroPlusHealth Portal, training for MAP-MOC for providers and attestation is required. The user can click the training link, then view the training module by selecting “Next”. You must attest to the training after completion. If you are attesting on behalf of your group/organization, in doing so, you agree to communicate the information to other providers in your group/organization. The user’s attestation will be automatically sent to MetroPlusHealth for acknowledgement of training. Please be sure to complete this required Medicare Special Needs Program (SNP) Model of Care (MOC) provider training on or before December 31, 2023.
Click here to access the digital attestation form.
IMPORTANT NEWS FOR PROVIDERS REGARDING OUR MEDICARE & MAP MEMBERS
Beginning January 1, 2022, as per CMS guidance, MetroPlusHealth will cover the COVID-19 Vaccine, approved boosters, along with its administration, without cost sharing for our Medicare and UltraCare (MAP) members. For additional guidance, read the CMS memo here.
IMPORTANT NEWS: CULTURAL COMPETENCY TRAINING FOR OUR MEDICAID, PIC, AND HARP PROVIDERS
At MetroPlusHealth, it is critical that our providers know how to communicate effectively with our members in the most culturally appropriate way. The New York State Department of Health (DOH) has approved cultural competency training offered by the US Department of Health and Human Services (HHS) Office of Minority Health education program, Think Cultural Health. The training is online, free, and offers several provider-specific modules. This training must be initially completed by appropriate staff within the next 12 months and then on an annual basis. Once this training has been completed, our participating providers will be able to provide more effective care delivery to our members and help reduce health disparities.
Providers may access the cultural competency training and virtual attestation form here.
IMPORTANT NEWS: METROPLUSHEALTH ANNOUNCES A NEW PRIMARY CARE COVID-19 VACCINE COUNSELING INCENTIVE PROGRAM FOR PCPS
Starting October 15 through December 31, 2021, MetroPlusHealth will incentivize our Primary Care Providers for completing Covid-19 Vaccine Counseling with their unvaccinated Child Health Plus, Medicaid, HARP, HIV SNP and Medicare MetroPlusHealth patients. City and health plan surveys suggest that health plan members may be more likely to respond to vaccine advice from their primary care providers than other sources. The goal of this new incentive program is to provide compensation to primary care providers to encourage New Yorkers (their patients; our members) to get vaccinated. Get rewarded for performing this important public service. Learn more about this program and how to participate, and access the Vaccine Encounter form and instructions here.
IMPORTANT NEWS: STARTING OCTOBER 1, 2021, METROPLUSHEALTH IS IN-SOURCING THE SPECTRUM OF BEHAVIORAL HEALTH SERVICES AVAILABLE TO OUR MEMBERS PREVIOUSLY MANAGED BY BEACON HEALTH OPTIONS
Our participating behavioral health providers will now work directly with us to ensure MetroPlusHealth members get the right mental health and substance use care. Learn more and access our BH resources here.
PROVIDER TOOLS
- View the NYS Health Care Proxy form here.
- View updated Medicaid COVID-19 Counseling here.
- View our Nursing Home Transition Tip sheet here.
- To view the OMH and Office of Addiction Services and Supports Telehealth Webinar Update and Next Steps, click here (PDF)
- To view the LOCADTR manual, click here
- To view our Medical Policies, click here
- To view our Pharmacy Policies, click here
- To view our Medicare Advantage provider claims reconsideration process, click here (PDF)
- To view our Provider Manual, updated August 2024, click here (PDF)
- Physician Administered Medical Benefit Drugs Requiring Prior Authorization or Step Therapy, Updated November 29, 2024, click here (PDF)
- To view our Clinical Practice Guidelines, click here (PDF)
- To view our UB04 User Guide, click here (PDF)
- New OMH COVID-19 Guidance: Consolidated Telemental Health Guidance, including a new attestation for providers. Read more here. (PDF)
- Important Information for Insurers and Providers on Coverage for Mental Health Services for Essential Workers click here (PDF)
NEW PROVIDER TRAINING AVAILABLE
Non-Dental Practitioner Application of Fluoride Varnish in a Primary Care Setting.
Providers, please click here to be directed to New York State Department of Health’s website for training resources. Fluoride varnish is a reimbursable service.
IMPORTANT REMINDER FOR ALL HEALTH CARE PROVIDERS FROM NYS DOH
Please click here for an important message from the NYS Department of Health regarding the necessity for reporting COVID-19 vaccinations accurately and timely and acceptance of the Excelsior Pass as proof of COVID-19 vaccination and negative COVID-19 test results. If you have any questions, please address them to [email protected]
IMPORTANT NOTICE TO OUR PROVIDERS:
Announcing a New Foster Care Transition to Medicaid Managed Care- Special Population for Medicaid and Special Needs Plan members
Starting July 1, 2021, MetroPlusHealth will cover Article 29-I Voluntary Foster Care Agency (VFCA) Health Facility services for children and youths under age 21 in foster care.
Also starting July 1, 2021, some children and youth must join a Medicaid managed care plan, including:
- children and youth placed in foster care in New York City, and
- children and youth placed in foster care and a 29-I VFCA Health Facility
Some children and youth placed in foster care cannot join a Medicaid managed care plan. They will keep getting services through regular Medicaid.
Click here for a complete list of our participating 29-I VFCA Health Facilities
COVID-19 Guidance for 1915(c) HCBS Children’s Waiver for Children’s Health Homes, C-YES, HCBS, and MMCP/HIV SNP
The NYSDOH has provided guidance for providers regarding face-to-face visits during the current health crisis. Click here for more information.
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