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Home > Physicians > Physicians FAQs |
Claims
MetroPlus is a capitated plan - why do I have to submit claims?
Where do I send claims?
How do I check the status of a claim?
What do I do when a claim is denied
When will I receive payment for submitted claims?
Clinical & Quality
What is QARR?
What is the Provider Performance Profile?
What specialized care management/health programs does MetroPlus offer?
Eligibility
How do I verify member eligibility?
What services do not require an authorization from a MetroPlus PCP?
Claims
MetroPlus is a capitated plan - why do I have to submit claims?
As contractually required, providers must submit claims so MetroPlus can report to the State Department of
Health that its members are receiving the appropriate types of care, such as well child visits, pre-natal
care, regular check-ups and other indicators in accordance with QARR (Quality Assurance Reporting Requirements).
MetroPlus also has Provider Performance Profiles which rewards providers for meeting quality indicators.
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Where do I send claims?
Claims must be submitted to MetroPlus within 90 days of the date of service.
- Submit claims Electronically via:
WEBMD
Please use MetroPlus Payor Number 13265
- Mail claims to:
MetroPlus Health Plan
PO Box 1966
New York, NY 10116
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How do I check the status of a claim?
You may check the status of a claim by using the "secured claims status check" on the MetroPlus website.
You must be registered to access this feature on the website. If you are not registered yet,
click here.
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What do I do when a claim is denied?
If you disagree with a claim payment determination, you have the write to appeal.
Written Inquiries:
MetroPlus Health Plan
Claims Service Department
160 Water Street - 3rd Floor
New York, New York 10038
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Telephone Inquiries:
Claims Service Department
(800) 597-3380
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FAX Inquiries:
(212) 908-8789
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When will I receive payment for submitted claims?
Please allow 30 days from claim submission date.
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Clinical & Quality
What is QARR?
QARR stands for Quality Assurance Reporting Requirements. QARR is the New York State Department of
Health's version of HEDIS, which is the national Health Plan Employer Data and Information Set. The
National Committee on Quality Assurance (NCQA) developed and routinely monitors HEDIS. The QARR is a
set of performance measures that the Plan must report on an annual basis to NYSDOH for the following
programs:MedicaidFamily Health Plus Child Health Plus To review MetroPlus Health Plan's 2002 QARR Results
click here
The NYSDOH publishes QARR results for each Plan on its website at:
http://www.health.state.ny.us/nysdoh/mancare/mcmain.htm
What is the Provider Performance Profile?
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 MetroPlus to monitor and reward providers, providing optimal and timely
care to members.
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What specialized care management/health programs does MetroPlus offer?
MetroPlus offers a number of care management programs for our members. Click here to learn more about our
care management programs.
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Eligibility
How do I verify member eligibility?
There are a number of methods to verifying member eligibility. You may check a member's eligibility by
accessing the secured member eligibility function on this website. You may also download your Medicaid,
Child Health Plus and Family Health Plus Member Rosters from this website.
However, to access these functions, you must be a registered user. If you have not registered yet,
click here.
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What services do not require an authorization from a MetroPlus PCP?
Authorization for the following services must be obtained from MetroPlus 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
- Includes home infusion services
- Durable Medical Equipment, including Orthotics and Prosthetics
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