Provider News and Communications

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PLEASE NOTE: Effective January 1, 2019, MetroPlus’ new Children’s Special Services (CSS) Program will offer additional Behavioral Health, Health Home, and Home and Community Based Services(HCBS) covered by NY State MedicaidLearn more here.
The Children’s Health & Behavioral Health Medicaid System Transformation Billing and Coding Manual can be accessed here.

The Children's Health & Behavioral Health Medicaid System Transformation Transition Guide (January 1, 2019 - January 1, 2020) can be accessed here.

PLEASE NOTE: Effective December 1, 2018, Integra Partners will begin managing DME Utilization Management (UM) services for MetroPlus. Learn more here.

PLEASE NOTE: Effective November 16, 2018, MetroPlus is transitioning utilization for high-tech radiology services and will require notification and authorization for a number of high-tech radiology services. Learn more here.

PLEASE NOTE: Update Regarding Universal Billing Codes for Long-Term Care Services in Effect for April 1, 2018: download here . View here.


As a result of updated CMS guidance, MetroPlus is required to make changes to our Pharmacy benefits regarding Opioids for Medicare members effective January 1st, 2019. Below is a highlight of these changes:
  • 7-Day Supply Limit for Opioid Naïve Member Edit: There will be a new safety reject edit at the pharmacy to limit initial opioid prescriptions fills for the treatment of acute pain to no more than 7-days supply. If a provider believes a member requires an exception to this edit, please contact CVS at 1-877-433-7758 or MetroPlus at 1-866-986-0356, 24 hours a day, 7 days a week.
  • 90 MME Opioid Care Coordination Edit Alert: An alert will be triggered at the pharmacy when a member fills a prescription which results in a cumulative morphine equivalent dose of 90mg or greater and the member has received opioid prescriptions from four or more prescribers in the previous 180 days. Pharmacists may consult with providers regarding opioid utilization for members affected by this alert. Please respond to pharmacies in a timely manner to minimize member disruption.
  • Drug Management Program: Members utilizing opioids and/or benzodiazepines will be closely monitored as part of our Drug Management Program. Based on our review, members may be locked into specific Prescribers and/or Pharmacies or have specific utilization edits for these drugs. These edits are not intended as prescribing limits.
 For more information please click here.

PLEASE NOTE: Effective January 1, 2019, CMS announced new strategies to further help Medicare Part D plans prevent and combat opioid overuse, including additional safety alerts at the time of dispensing as a proactive step to engage both patients and prescribers about overdose risk and prevention. Click here to learn more.

PLEASE NOTE:  MetroPlus has contracted with HMS to help identify other third-party coverage for our Medicaid members. Through the Disallowance process, HMS has identified where MetroPlus has paid a provider for a claim(s), but another payer is liable.

In this recovery project, HMS will notify the provider that the claim has been paid incorrectly and request that the provider bill the appropriate entity. HMS will supply the provider with a notification letter, claim audit details, as well as a window to bill the liable payer and receive the recovery. At the end of the notification period, MetroPlus will retract the Medicaid payments for the claim(s) that have been identified. In several instances, the provider may receive a higher reimbursement from the other carrier than they would have if Medicaid paid. 

For more information please click here
Provider Education MetroPlus HIV Special Needs Plan (SNP) Newsletter
Intended for MetroPlus HIV SNP Providers

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