Specialty Care Provider Orientation - MetroPlus Health Plan

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ClaimsClaims Submission• Claims must be submitted detailing all services rendered for everyencounter within 90 days of the date of service or discharge This applies regardless of whether the provider is paid on acapitated or fee-for-service methodology• Please allow 30 days from claim submission date to receive payment• Claims for all members can be submitted electronically usingMetroPlus Emdeon Payer ID# 13265• Paper claims must be submitted on CMS 1500 or UB-04 forms Send paper claims for Medicaid, CHP, FHP and MetroPlus Goldto: MetroPlus Health Plan, P.O. Box 1966, New York, NY 10116-1966 Send paper claims for MetroPlus Medicare to: MetroPlus HealthPlan, P.O. Box 381508, Birmingham, AL 35238-150825
Claims con’tClaim Status & Appeals• Check Claim Status MetroPlus Provider Portal: http://public.metroplus.org MetroPlus Customer Services: 800-303-9626• If you disagree with a claim payment determination, you have theright to appeal. You must explain the reason for the appeal andinclude all pertinent information as well as a copy of the original claim. In writing:MetroPlus Health PlanClaims Department160 Water Street, 3rd FloorNew York, New York 10038 By phone: 800-303-9626 By fax: 212-908-878926
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 and 22: MetroPlus Fraud and Abuse Preventio
Page 23 and 24: Pharmacy/Prescriptions• Effective
Page 25: Laboratory Services & Approved In-O
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

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