|
Provider Frequently Asked Questions
Providers who are interested in applying for participation can contact the Provider Services
Claims
Where do I send claims?
How do I check the status of a claim?
How can I appeal a claim denial?
When will I receive payment for submitted claims?
Clinical & Quality
What is the Provider Performance Profile?
What specialized care management/health programs does MetroPlusGold offer?
Eligibility
How do I verify member eligibility?
What services require an authorization?
Claims
Claims must be submitted to MetroPlusGold within 90 days of the date of service.
Submit claims electronically via:
WEBMD
Please use MetroPlusGold Payor Number 13265
Mail claims to:
MetroPlusGold Health Plan
PO Box 1966
New York, NY 10116
You may check the status of the claim by using the “secured claim status check” on the MetroPlusGold website. You must be registered to access this feature on the website. If you are not registered yet, click here.
If you disagree with a claim payment determination, you have the right to appeal.
Written Inquiries:
MetroPlusGold Health Plan
160 Water Street-3rd Floor
New York, NY 10038
Telephone Inquiries:
Claims Service Department
800.597.3380
FAX Inquiries:
212.908.8789
Please allow 30 days from claim submission date.
Clinical & Quality
The Provider Performance Profile summarizes the clinical care provided to members by each health care facility and/or individual provider. It is produced quarterly and offers an opportunity for MetroPlusGold to reward providers for providing optimal and timely care to members.
MetroPlusGold offers a number of care management programs for our members. Click here to learn more about our care management programs.
Claims
There are a number of methods to verify member eligibility. You may check a member's eligibility by accessing the secured member eligibility function on this website. If you are a Primary Care Provider, yo may also download your Member Rosters form this website. However, to access these functions you must be a registered user. If you have not registered yet, click on the link to the left.
Auhtorization for the following services must be obtained from MetroPlusGold Health Plan's Utilization/Care Management Department:
- All Non-Participating Provider Services
- Inpatient Admissions (this includes medical, surgery and maternity admissions as well as admissions to 24-hour settings for rehabilitation and mental health and chemical dependency services.)
- Home Health Care (this includes home infusion services.)
- Durable Medical Equipment, including Orthotics and Prosthetics
|
|
