A member's eligibility and PCP must be confirmed before all non-emergent services are provided regardless of how frequently the member is seen. Members must be eligible on the date of service for payment to be rendered.
Step 1. At the time of each service, the member should present a member ID card and a photo ID.
If the person claims to be a MetroPlus member and does not have a member ID card, the Provider must call Customer Services and advise a Customer Services Representative that the member cannot produce a member ID card. The Customer Services Representative will ask to speak directly to the member to verify the member's identity and give the Provider the member's identification number that can be used for claim submission and written confirmation of eligibility.
A member who recently transferred from one PCP to another may have not yet received their new card that shows the name of their new PCP; eligibility for these members must be verified through MetroPlus Customer Services.
Step 2. One or more of the following methods for verifying eligibility must be performed since possession of a member ID card does not guarantee coverage. Providers that see members with dual Medicare and Medicaid eligibility must verify both. Coverage may terminate or members may switch PCPs at any time.
Online Verification: Eligibility can also be verified by logging on to the MetroPlus Provider portal. Up to ten members may be verified at one time.
Electronic Medicaid Eligibility Verification System (EMEVS): For Managed Medicaid, FHP and HIV SNP members, the Medicaid Client Identification Number (CIN) may be used to check eligibility through the EMEVS website. EMEVS is available from 9 am to 7 pm daily. However, sites with the ability to "swipe" Medicaid cards to access eligibility information will not be able to verify FHP coverage in this manner. EMEVS does not identify a member's PCP.
The automated EMEVS telephone verification line can be used to obtain eligibility information by calling 1.800.997.1111 and entering the MetroPlus Provider Number 01529762 and the Plan Code 092. For questions regarding EMEVS call 1.800.343.9000.
If further clarification of eligibility information is needed, Customer Services can be reached Monday - Saturday, 8 am - 8 pm at 1.800.303.9626. At all other times, including holidays, eligibility can be verified by calling the MetroPlus After Hours Service Line at 1.800.442.2560.