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Home > Providers > Providers FAQs |
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 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 require an authorization?
Claims
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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How can I appeal a claim denial?
If you disagree with a claim payment determination, you have the right 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 set of indicators used by the New York State Department of
Health to monitor health plan performance and awrd quality incentives. QARR measures are based on HEDIS, which is the national Health Plan Employer Data and Information Set. The
National Committee on Quality Assurance developed and routinely monitors HEDIS. The Plan must report on an annual basis to NYSDOH for the following
programs:Medicaid, Family Health Plus and 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 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 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, you may also download your 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 require an authorization?
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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