Specialty Care Provider Orientation - MetroPlus Health Plan

More documents

Recommendations

Info

Required Authorizations• You must call MetroPlus Customer Services at 800-303-9626 to obtain prior authorization and/orverification of benefits for the following services: Services provided by a Non-Participating Provider All Ambulatory Surgical Procedures scheduled at non-HHC facilities Behavioral Health and Substance Abuse Services• Authorization required for inpatient services• Authorization for outpatient services required for Medicaid and HIV SNP members over60 visits/year Inpatient Admissions, Home Health Care, Skilled Nursing Facility Care, Durable MedicalEquipment, Personal Care, Erectile Dysfunction Treatments, Potentially Cosmetic Procedures Physical Therapy, Occupational Therapy and Speech Therapy• MetroPlus members enrolled in Medicare Advantage, Child Health Plus, MetroPlusGold and “exempt” Medicaid and Family Health Plus members who are children 0 – 20years of age and/or members with developmental disabilities will not be subject to themandated benefit limit of twenty (20) visits per specialty type per calendar year, but willstill require authorization for services after visit number twenty.• For all other non-exempt Medicaid and Family Health Plus members, there is a benefitlimit of 20 visits per specialty type per calendar year. There is no means or opportunity torequest an approval or an authorization that will allow for additional visits to be approved.21
Pharmacy/Prescriptions• Effective October 1, 2011, MetroPlus took over responsibility formanaging pharmacy benefits for our Medicaid Managed Care(including HIV SNP) and Family Health Plus members; this benefitwas previously provided by Fee for Service Medicaid• MetroPlus transitioned to a new Pharmacy Benefit Manager (PBM),CVS Caremark, effective October 1, 2011, and as of this date CVSCaremark manages Medicaid (including HIV SNP) and FHPmembers• Effective January 1, 2012, MetroPlus transitioned from informed Rxto CVS Caremark for its remaining lines of business which areMetroPlus' Child Health Plus, Medicare Advantage and MetroPlusGold22
Page 1 and 2: Specialty Care Provider Orientation
Page 3 and 4: MetroPlus Overview• MetroPlus is
Page 5 and 6: New Managed Care BenefitsMedicaid M
Page 7 and 8: New Managed Care Benefits con’tPe
Page 9 and 10: MetroPlus Medicare• Beneficiaries
Page 11 and 12: Member Eligibility Verification•
Page 13 and 14: Access to Care• MetroPlus Members
Page 15 and 16: HIV Testing• HIV testing must be
Page 17 and 18: MetroPlus Model of Care con’t•
Page 19 and 20: Quality Management• MetroPlus is
Page 21: MetroPlus Fraud and Abuse Preventio
Page 25 and 26: Laboratory Services & Approved In-O
Page 27 and 28: Claims con’tClaim Status & Appeal
Page 29 and 30: MetroPlus Website & Provider Portal
Page 31 and 32: Care ManagementCare Management Prog
Page 33 and 34: Transportation Services• Provider
Page 35 and 36: HHC Facility Referral Contact List

Specialty Care Provider Orientation - MetroPlus Health Plan

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?