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Our network is always expanding! But to date, our network includes more than 34,000 providers like you, 40 hospitals, 110 urgent care centers, and 500 local and national pharmacies. Our Provider Search is a great place to get specifics.

We accept both electronic and paper-based claims. Log into the Provider Portal to any time.

Both capitation and fee-for-service claims have to include a detailing of all services rendered within 90 days of the date of service. We ask our providers to kindly allow 30 days for the reimbursement of electronic claims and 45 days for the reimbursement of paper claims.

We issue an Explanation of Payment (EOP) for every claim and adjustment regardless of whether payment or denial. Our EOPs offer a summary of payment or denial information for each billed service.

Our network is comprised of over 34,000 providers and specialists.

There are more than 40 hospitals and urgent care centers in our network including NYC Health + Hospitals, NYU Langone, Mt. Sinai, CityMD, Montefiore, Labcorp, Lenox Hill Radiology, and more.

The New York Office of the Medicaid Inspector General (OMIG) administered a program that implemented set criteria to determine a pattern of misuse or abuse of services covered under the Medicaid Program. This program is known as the Restricted Recipient Program (RRP).

NYS DOH and OMIG have asked Managed Care Organization to administer restrictions for enrolled members who demonstrate a pattern of misusing or abusing the Medicaid Program. MetroPlusHealth Restricted Recipient Unit reviews members’ utilization of medical services to identify emerging trends in duplicate, excessive, contraindicated, or conflicting drugs, healthcare services, supplies, and abusive practices.

The Office of Inspector General (OMIG) identifies members who are demonstrating patterns of misuse and abuse of services and notifies the Plan on a monthly basis.  In addition, MetroPlus Health has a team of clinicians named the Restrictive Recipient Program Review team (RRPRT). The Clinical team comprises an MD, Pharmacist, and Registered Nurse. The RRPRT determines if a restriction is warranted. If a restriction is justified, the member may be assigned to the following type of restrictions:

An RRP aims to provide restricted enrollees with tightly managed medical services. It is an aid for the member to meet with their assigned specified Provider to ensure members’ utilization of services is appropriately managed. 

There are three restrictions periods:

1. Initial restrictions-2 years
2. Re-Restrictions (2nd restrictions)-3 years
3. Subsequent restrictions (3rd or Greater)-6 years

Primary Care Providers (PCP) by contract are expected to manage the health care of the RRP members on their panel, including referrals to specialty services and participants. The physician is responsible for the medical management of the member if in the hospital and outside their practice. 

• Restricted Recipients are individuals with a pattern of misusing or abusing benefit package services and are restricted to one or more providers to receive their services.
• Restrictions may include PCPs, Specialists, dentists, podiatrists, and hospital settings.
• During the member’s visit-the, the Restricted Recipient members will have an “R” on their ID Card.
• Providers must verify member eligibility before every encounter to identify any restrictions.

Managed Care Plans do not cover members’ prescription coverage/ Pharmacy Restrictions. The Department of Health-Office of Medicaid Inspector General-Medicaid NYRx manages members’ medications. For Provider assistance with prior authorizations, clinical concerns, and the Preferred Drug Program, contact the Magellan Clinical Call Center at (877) 309-9493.

If MetroPlusHealth members have any questions concerning their pharmacy coverage, please ask your patient to contact their local Human Resources Administration (HRA) at 212-273-0062:

PLEASE NOTE: If a member is restricted to a particular provider, they cannot be seen by another provider/specialist without prior authorization from their assigned PCP. Claims submitted without a referral from the assigned PCP will be denied.