Provider 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 (TTY: 711) or Medicare at 1-866-986-0356 if you need help or have questions.

Register or get directed to online trainings through the calendar.

IMPORTANT REMINDER TO OUR PROVIDERS REGARDING OUR NATIONAL DRUG CODE (NDC) REQUIREMENT POLICY, PROFESSIONAL AND FACILITY

The Deficit Reduction Act of 2005 (DRA) requires Medicaid agencies to collect NDC numbers on pharmaceuticals. Our NDC billing requirements for providers enrolled in the 340B Program can be found here.
Read our NDC billing requirements for 340B Program providers here.

IMPORTANT NOTICE TO OUR PEDIATRIC PRIMARY CARE PROVIDERS REGARDING 2023 ENHANCED CHILDREN’S BENEFITS:

MetroPlusHealth has been ramping up for the expansion of services that will become available to children and youth in 2023. Learn more here about new benefits and services coming in 2023.

IMPORTANT NOTICE TO OUR APPLIED BEHAVIORAL ANALYSIS (ABA) PROVIDERS REGARDING 2023 ABA BENEFIT CHANGES

MetroPlusHealth has been ramping up for the expansion of Applied Behavior Analysis Services to eligible Medicaid members diagnosed with autism spectrum disorder. Services will become available January 1, 2023, for those members under 21 years of age. Learn more here about new benefits and services coming in 2023.

IMPORTANT NOTICE: THE PROVIDER DUE DATE FOR COMPLETION OF THE MODEL OF CARE TRAINING IS DECEMEBER 31, 2023. CLICK HERE TO ACCESS THE ONLINE TRAINING.

You can access the digital attestation form here.

IMPORTANT MESSAGE ANNOUNCING AN END OF YEAR BONUS PAYMENT FOR OUR PROVIDERS IN ASSISTING MEMBERS TO OBTAIN THEIR KEY WELLNESS TESTS/VISITS.

This incentive is separate from our Pay for Performance (P4P) Program. Learn more here.

IMPORTANT NOTICE TO 1915(c) CHILDREN’S WAIVER RESPITE HCBS PROVIDERS:

The New York State Department of Health is evaluating various policy flexibilities allowed during the COVID-19 Public Health Emergency (PHE) and determining which flexibilities will be ending and which ones will be extended (temporarily/permanently).

Effective January 1, 2023, the Children’s Respite Services flexibility will end and providers are required to revert to the original guidance provided in the HCBS Manual.  Read the guidance here.

IMPORTANT NOTICE: PHARMACY BILLING GUIDANCE EXCEPTIONS FOR NON-ENROLLED PRESCRIBERS

The New York State (NYS) Medicaid program requires enrollment of all licensed prescribers and pharmacies who serve Medicaid members, including prescribing practitioners identified on pharmacy claims per the Centers for Medicare and Medicaid Services (CMS) and federal regulations. However, under the Medicaid Provider Enrollment Compendium (MPEC) found here: https://www.medicaid.gov/medicaid/program-integrity/affordable-care-act-program-integrity-provisions/index.html, there are two exceptions to the provider enrollment requirement that are allowed. Learn more here.

IMPORTANT NOTICE REGARDING PT AND OT VISITS

Effective January 1, 2023, the number of visits allowed without prior authorization for both Physical Therapy (PT) and Occupational Therapy (OT) will change. Ten (10) visits will be allowed without prior authorization, inclusive of the initial evaluation.

Effective January 1, 2023, all Speech Therapy and Chiropractic Care will require prior authorization. There will be no visits allowed without prior authorization.

Overall benefits allowed vary by Line of Business (LOB), so it is important to verify both LOB and eligibility prior to rendering services.  Click here to learn more about facilitating review when requesting visits for PT or OT.

IMPORTANT NOTICE FOR OUR PROVIDERS:

Effective November 1, 2022, we will no longer have a contract with VNS Health (formally known as Visiting Nurse Service of New York) for skilled home care services provided by their Certified Home Health Agency (CHHA) including skilled nursing, home therapy services, and home health aide services.

This change does not include Behavioral Health (BH) or Hospice services. VNS Health will continue to provide BH and Hospice services for MetroPlusHealth members.

Click here for a list of MetroPlusHealth participating home care providers to which you can refer members..

If you have any questions, please contact MetroPlusHealth Provider Services Call Center at 1.800.303.9626.

IMPORTANT NOTICE FOR OUR MEDICAID, HIV-SNP, HARP , MLTC, AND CHP PROVIDERS:

MEDICAID UPDATES REGARDING SUSPECTED ORTHOPOXVIRUS/MONKEY POX CASES AND BILLING GUIDELINES EFFECTIVE JULY 26, 2022. Read here.

IMPORTANT NOTICE: ESSENTIAL PLAN MONKEY POX VACCINE COST-SHARING GUIDANCE FROM NY STATE OF HEALTH, EFFECTIVE JULY 29, 2022.

Read here.

IMPORTANT NOTICE TO OUR PROVIDERS: UPDATED GUIDANCE REGARDING COVID COUNSELING BILLING, CODING, AND REIMBURSEMENT

Many of our participating providers can continue to bill MetroPlusHealth for COVID-19 vaccination counseling for our Medicaid, HIV SNP, and HARP members to encourage the administration of the COVID-19 vaccine. Qualified Providers may bill up to four (4) counseling visits per vaccine dose (up to 12 visits per member, annually) and receive reimbursement. Click here to learn more regarding our COVID counseling billing, coding, and reimbursement policy. Click here to review the updated NYS DOH COVID-19 Fact Sheet. Click here to review updated NYS DOH guidance on COVID-19 Vaccine Counseling Coverage. Please note the Pharmacy billing implementation is in progress.

Discontinued Coverage for TerSera Therapeutics LLC Drugs Effective May 14, 2022: Update for MetroPlusHealth Medicaid Managed Care, Partnership in Care (PIC) HIV-SNP, and Enhanced (HARP) Plan Members

TerSera Therapeutics LLC voluntarily withdrew from participation in the Medicaid Drug Rebate Program (MDRP). As instructed by NY State Department of Health, effective May 14, 2022,  MetroPlusHealth can no longer provide coverage for most drugs manufactured by TerSera Therapeutics LLC.

Pursuant to Social Security Law Sec. 1927 [42 U.S.C. 1396r-8] (a), Centers for Medicare and Medicaid Services (CMS) requires drug manufacturers to participate in the MDRP for their drugs to be eligible for coverage under Medicaid, except in certain circumstances. ZOLADEX® (goserelin implant) is a practitioner-administered drug manufactured by TerSera Therapeutics LLC which is available through a Patient Assistance Program (PAP) from the manufacturer free of charge for those who qualify. For program applications and additional information, providers must visit the ZOLADEX® “Access and support” web page or contact TerSera Support Source at (855) 686-8725.

Coverage of ZOLADEX® will continue to be provided for Medicaid members who are unable to obtain the medication through the PAP and when used under the following conditions:

• for a Food and Drug Administration (FDA)-approved indication for which there are no alternative options and
• as a continuation of established therapy if another gonadotropin-releasing hormone (GnRH) product has been tried and failed or if transition to another GnRH is medically contraindicated.

NEW FOR INTERESTED PROVIDERS: MATERNAL MENTAL HEALTH SUPPORT SERVICES FOR CLINICIANS FROM PROJECT TEACH

Funded by New York State Office of Mental Health. Click here to learn more about MMH resources available to you and your practice. For general information about Project TEACH contact 716-878-2454 or [email protected].

IMPORTANT MESSAGE REGARDING OUR PHARMACY NETWORK

Starting January 1, 2022, Walgreens and Duane Reade will no longer be in the pharmacy network for members of these plans:

• Medicaid Managed Care, including Partnership in Care and HARP Plans (click here to find a list of 2022 network pharmacies)
• Child Health Plus (click here to find a list of 2022 network pharmacies)
• Exchange/Marketplace Plans here to find a list of 2022 network pharmacies)

Members may call and request their prescriptions be sent to a different pharmacy.

IMPORTANT MESSAGE TO OUR BEHAVIORAL HEALTH PROVIDERS REGARDING CORE SERVICES

Effective February 1, 2022, in order to improve access to services, NYS is transitioning four BH HCBS to a new service array called Community Oriented Recovery and Empowerment (CORE) Services. These four services include Community Psychiatric Support and Treatment (CPST), Psychosocial Rehabilitation (PSR), Family Support and Training (FST), and Empowerment Services – Peer Support (Peer Support). BH HCBS Short-term and Intensive Crisis Respite services will be transitioned to Crisis Intervention Benefit Crisis Residence services, already available to all adult Medicaid Managed Care enrollees. All other existing BH HCBS will remain available as BH HCBS with previously established requirements, workflows, and processes.

For members who are 21 or older, covered by Medicaid, and enrolled in a Health and Recovery Program (HARP), CORE services may be just right. Additionally, some individuals enrolled in HIV-Special Needs Plans or Medicaid Advantage Plus Plans will be eligible for CORE. CORE services are covered by health insurance, at no cost to our members.

Our providers who may be serving members receiving CORE services are required by the DOH to take specific trainings.  Read the CORE training memo here for more information.  You can access the CORE Benefit and Billing Guidance here. Please review the links below and register for trainings as soon as possible.

Registration and Helpful Links
To access the required trainings, log in to the CPI Learning Community using your username and password.
For registration assistance or to report technical issues: CPI Online Assistance Unit
For questions about training requirements for CORE Services, please contact your host agency
• OMH: [email protected]
• OASAS: [email protected]
Please visit the Center for Practice Innovations Homepage and FAQs for more information on the Learning Community.

IMPORTANT MESSAGE TO OUR PROVIDERS REGARDING FOSTER CARE

Meeting the Health Care Needs of Children/Youth Placed in Foster Care:
Children/youth placed in foster care may have Medicaid or SNP coverage. MetroPlus will cover all services covered by the Medicaid Managed Care benefit package.

Providing access to comprehensive, high quality health care is an essential goal of transitioning the care of children in foster care from fee-for-service Medicaid to Managed care. To accomplish this, MetroPlus has made special provisions to ensure immediate access to services upon a youth’s placement in foster care without interruption in the provision of ongoing services:

• To meet the requirement for an initial medical required health assessment, MetroPlus will allow members to see any participating primary care physician (PCP) or other qualifying provider for the first 30 days of placement.
  • Because changes in placement may occur requiring additional health assessments, MetroPlus will allow members to see participating PCP providers not listed on their ID card
    • Call MetroPlus Customer Services 800-303-9626 to verify coverage and notify about need for future visits
• MetroPlus will cover these pharmacy issues:
  • A 30- day supply (transition fill) for non-formulary or Prior Auth (PA) required drugs within the first 90 days of enrollment,
    • If the member requires an additional transition fill because of new placement, providers should send the request to CVS and indicate the reason
  • Members can receive “refill-too-soon” overrides when transferring between foster homes
  • Members can fill prescriptions at pharmacies that are out of network when they are placed out of our service area

For more information, click here.

IMPORTANT NOTICE FOR PROVIDERS: Understanding How Adverse Childhood Experiences Affect Patients’ Health Across the Lifespan

Adverse Childhood Experiences (ACEs) are stressful or traumatic events, such as neglect and/or violence during childhood. ACEs are strongly related to brain development and a wide range of health problems throughout a person’s lifetime and may include, but are not limited to, physical or sexual abuse, domestic violence, living in poverty, death of a caregiver, exposure to discrimination, or living in a household with someone with mental illness, substance use disorder, or who has experienced incarceration. Read what ACEs research shows here.

IMPORTANT MESSAGE FOR OUR PROVIDERS: ANNUAL MEDICARE SPECIAL NEEDS PROGRAM (SNP) MODEL OF CARE (MOC) PROVIDER TRAINING

The Centers for Medicare and Medicaid Services (CMS) requires that providers receive Medicare Special Needs Program (SNP) Model of Care (MOC) training annually.  As part of our ongoing commitment to access, quality of service and care for our members, MetroPlusHealth provides this training annually an­­d during the new orientation process to all network providers, as well as to providers who regularly see our SNP members.

The training module can be accessed by logging into our provider website/portal, or you can access it through this link: MAP-MOC for providers.

After logging in to the MetroPlusHealth Portal, training for MAP-MOC for providers and attestation is required.  The user can click the training link, then view the training module by selecting “Next”. You must attest to the training after completion.  If you are attesting on behalf of your group/organization, in doing so, you agree to communicate the information to other providers in your group/organization.  The user’s attestation will be automatically sent to MetroPlusHealth for acknowledgement of training.   Please be sure to complete this required Medicare Special Needs Program (SNP) Model of Care (MOC) provider training on or before December 31, 2023.

Click here to access the digital attestation form.

IMPORTANT NEWS FOR PROVIDERS REGARDING OUR MEDICARE & MAP MEMBERS

Beginning January 1, 2022, as per CMS guidance, MetroPlusHealth will cover the COVID-19 Vaccine, approved boosters, along with its administration, without cost sharing for our Medicare and UltraCare (MAP) members. For additional guidance, read the CMS memo here.

IMPORTANT NEWS: CULTURAL COMPETENCY TRAINING FOR OUR MEDICAID, PIC, AND HARP PROVIDERS

At MetroPlusHealth, it is critical that our providers know how to communicate effectively with our members in the most culturally appropriate way. The New York State Department of Health (DOH) has approved cultural competency training offered by the US Department of Health and Human Services (HHS) Office of Minority Health education program, Think Cultural Health. The training is online, free, and offers several provider-specific modules. This training must be initially completed by appropriate staff within the next 12 months and then on an annual basis. Once this training has been completed, our participating providers will be able to provide more effective care delivery to our members and help reduce health disparities.

Providers may access the cultural competency training and virtual attestation form here.

IMPORTANT NEWS: METROPLUSHEALTH ANNOUNCES A NEW PRIMARY CARE COVID-19 VACCINE COUNSELING INCENTIVE PROGRAM FOR PCPS

Starting October 15 through December 31, 2021, MetroPlusHealth will incentivize our Primary Care Providers for completing Covid-19 Vaccine Counseling with their unvaccinated Child Health Plus, Medicaid, HARP, HIV SNP and Medicare MetroPlusHealth patients. City and health plan surveys suggest that health plan members may be more likely to respond to vaccine advice from their primary care providers than other sources. The goal of this new incentive program is to provide compensation to primary care providers to encourage New Yorkers (their patients; our members) to get vaccinated. Get rewarded for performing this important public service. Learn more about this program and how to participate, and access the Vaccine Encounter form and instructions here.

IMPORTANT NEWS: STARTING OCTOBER 1, 2021, METROPLUSHEALTH IS IN-SOURCING THE SPECTRUM OF BEHAVIORAL HEALTH SERVICES AVAILABLE TO OUR MEMBERS PREVIOUSLY MANAGED BY BEACON HEALTH OPTIONS

Our participating behavioral health providers will now work directly with us to ensure MetroPlusHealth members get the right mental health and substance use care. Learn more and access our BH resources here.

PROVIDER TOOLS​

• View the NYS Health Care Proxy form here.
• View updated Medicaid COVID-19 Counseling here.
• View our Nursing Home Transition Tip sheet here.
• To view the OMH and Office of Addiction Services and Supports Telehealth Webinar Update and Next Steps, click here (PDF)
• To view the LOCADTR manual, click here
• To view our Medical Policies, click here
• To view our Pharmacy Policies, click here
• To view our Medicare Advantage provider claims reconsideration process, click here (PDF)
• To view our Provider Manual, updated April 2023, click here (PDF)
• Medicare Part B Drugs Step Therapy, click here (PDF)
• Physician Administered Drug Step Therapy, Effective January 1, 2022, click here (PDF)
• To view our Clinical Practice Guidelines, click here (PDF)
• To view our UB04 User Guide, click here (PDF)
• New OMH COVID-19 Guidance: Consolidated Telemental Health Guidance, including a new attestation for providers. Read more here. (PDF)
• Important Information for Insurers and Providers on Coverage for Mental Health Services for Essential Workers click here (PDF)

NEW PROVIDER TRAINING AVAILABLE

Non-Dental Practitioner Application of Fluoride Varnish in a Primary Care Setting.

Providers, please click here to be directed to New York State Department of Health’s website for training resources. Fluoride varnish is a reimbursable service. 

IMPORTANT REMINDER FOR ALL HEALTH CARE PROVIDERS FROM NYS DOH

Please click here for an important message from the NYS Department of Health regarding the necessity for reporting COVID-19 vaccinations accurately and timely and acceptance of the Excelsior Pass as proof of COVID-19 vaccination and negative COVID-19 test results.  If you have any questions, please address them to [email protected]

IMPORTANT NOTICE TO OUR PROVIDERS:

Announcing a New Foster Care Transition to Medicaid Managed Care- Special Population for Medicaid and Special Needs Plan members

Starting July 1, 2021, MetroPlusHealth will cover Article 29-I Voluntary Foster Care Agency (VFCA) Health Facility services for children and youths under age 21 in foster care.

Also starting July 1, 2021, some children and youth must join a Medicaid managed care plan, including:

• children and youth placed in foster care in New York City, and
• children and youth placed in foster care and a 29-I VFCA Health Facility

Some children and youth placed in foster care cannot join a Medicaid managed care plan. They will keep getting services through regular Medicaid.