Tools

Our goal is to give our Providers help finding and managing day-to-day needs. Please contact Provider Services at 1.800.303.9626 or for Medicare at 1.866.986.0356 if you need help or have questions.
 
 

Transportation Benefit Reference Guide

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November 2017 Download
Check Member Eligibility

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 Member Services and advise a Member Services Representative that the member cannot produce a member ID card. The Member 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 Member 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 Medicaid 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 - 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, Member Services can be reached Monday through 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.

MetroPlus Enhanced Drug Coverage Changes (Behavioral Health)
Effective October 1, 2015

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Drug Coverage Changes for Behavioral Health
Drug Enhanced (HARP) Plan MetroPlus Medicaid
Long Acting Atypical Injectable Antipsychotics

• Abilify Maintena
• Invega Sustenna
• Risperdal Consta

Zyprexa Relprevv (Non-Formulary) Invega Trinza (Non-Formulary)
Covered as a Pharmacy Benefit for all members

• No Prior Authorization required

- The member can fill the prescription at any network pharmacy
Covered as a Pharmacy benefit for:

• All Non-SSI members
• SSI members 21 years of age or older
• No Prior Authorization required

- The member can fill the prescription at any network pharmacy

Covered as a NYS Fee-For-Service Medical Benefit
• SSI members less than 21 years of age
Alcohol Deterrent

Vivitrol (Naltrexone)
Prior Authorization required
Covered as a Pharmacy Benefit for all members

- For Pharmacy Coverage please call 1.866.814.5506 for authorization. Vivitrol can be filled by any network Specialty Pharmacy after approval
Covered as a Pharmacy Benefit for all members

- For Pharmacy Coverage please call 1.866.814.5506 for authorization. Vivitrol can be filled by any network Specialty Pharmacy after approval
Opioid Antagonist

Naloxone 0.4mg/mL vial

Naltrexone (Revia)
Naloxone 0.4mg/0.4mL auto-injector syringe (Evzio) Step Therapy Required
Covered as a Pharmacy Benefit for all members

- For Pharmacy coverage the member can fill the prescription at any network pharmacy

• Evzio auto-injector requires previous treatment with buprenorphine, buprenorphine/naloxone, hydromorphone ER, fentanyl, meperidine or Zohydro ER
Covered as a Pharmacy Benefit for all members

- For Pharmacy coverage the member can fill the prescription at any network pharmacy

• Evzio auto-injector requires previous treatment with buprenorphine, buprenorphine/naloxone, hydromorphone ER, fentanyl, meperidine or Zohydro ER
Partial Opioid Agonist

Buprenorphine sublingual
Covered as a Pharmacy Benefit for all members

-For Pharmacy coverage the member can fill the prescription at any network pharmacy
Covered as a Pharmacy Benefit for all members

- For Pharmacy coverage the member can fill the prescription at any network pharmacy 
Partial Opioid Agonist/Opioid Antagonist

Buprenorphine/naloxone sublingual tablets

Suboxone Film (Non-Formulary)
Covered as a Pharmacy Benefit for all members

- For Pharmacy coverage the member can fill the prescription at any network pharmacy
Covered only as a Pharmacy Benefit for all members

- For Pharmacy coverage the member can fill the prescription at any network pharmacy
Smoking cessation products

• Buproprion
• Chantix
• Nicotine Replacement Therapy gum and transdermal patch
Covered as a Pharmacy Benefit for all members

• No limitations on length or number of therapies

- For Pharmacy coverage the member can fill the prescription at any network pharmacy
Covered as a Pharmacy Benefit for all members

• No limitations on length or number of therapies

- For Pharmacy coverage the member can fill the prescription at any network pharmacy
Communication and Patient Engagement Videos

The Patient Engagement Video Series

The “Patient Engagement” video covers how to properly assess patients for their readiness to change. It guides the provider through the five stages of change: pre-contemplation, contemplation, preparation, action, and maintenance. And it provides evidence-based approaches for better patient engagement.

Watch the video
 

Teach Back Technique

The “Teach-Back-Technique” guide providers on how to help their patients to remember and understand information about their diagnosis, treatment, and medications.

Watch the video

Source: Merck

HEDIS / QARR Materials

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HEDIS / QARR 2017 - All Measures Download
HEDIS / QARR 2017 - Reference Guide Download
HEDIS / QARR 2017 - CODES Sheet Download

 
Provider Guide to HIV Testing
As recommended by NYS Department of Health AIDS Institute

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HIV Testing Guide Download
NYS Department of Health 340 B Requirements

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Per the New York State Department of Health Medicaid Update issued December, 2016, effective April 1, 2017, the NYS Department of Health intends to change the way that it identifies 340B drugs for exclusion from rebates, by relying solely on the mandated 340B claim level identifiers.
 
The table below summarizes the claim level reporting requirements:
 
Claim Type Field Fee-For-Service (FFS) Managed Care (MCO)
837P/8371 Modifier UD* UD
NCPDP 420-DK, Submission Clarification Code (SCC) 20 20
NCPDP 23-DN, Basis of Cost Determination (BCD) 08*  
* All Fee-For-Service (FFS) 340B claims must be submitted at acquisition cost, by invoice, inclusive of all discounts. Please note that a FFS NCPDP claim with a 20 SCC should have a corresponding 08 BCD.
Quality Improvement Tips

View and download the tools below

Antidepressant Medication 
Follow Up After Mental Health Discharge
Getting Care Quickly for Children
Pharmacotherapy Management of COPD 
Well Care Visit (First 15 Months)
Well Care Visit (For 3 - 6 Year Olds) 

HPV Vaccination Recommendation

Low HPV vaccination rates could leave another generation of boys and girls vulnerable to devastating HPV cancers. But there are vaccines that can prevent infection with the most common types of HPV. Studies have shown that HPV vaccination is reducing HPV disease in the U.S., and also in other countries with strong HPV vaccination programs. Three HPV vaccines have been licensed by the U.S. Food and Drug Administration (FDA) since 2006. CDC recommends these HPV vaccines for routine use among girls and boys between the ages of 9 to 13 years. HPV vaccines are administered as a 3-dose series with doses given at 0, 1-2, and 6 months. Studies consistently show that a health care provider’s recommendation is a key factor in parental decision-making about vaccination. For more information, click here.

PCP Toolkit

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Get resources to help deal with Behavioral Health Issues in a Primary Care Setting Download