MetroPlus Health provider portal, phone and payer ID quick facts
| Provider portal | https://www.metroplus.org/providers/ |
|---|---|
| Provider phone | 1-800-303-9626 |
| Claims payer ID | 13265 |
| Eligibility payer ID | 13265 |
| ERA payer ID | 13265 |
| Timely filing | 120 days |
| Prior auth route | X12 278 plus provider portal |
| Last reviewed | 2026-04-23 |
MetroPlus Health at a glance
| Legal name | MetroPlus Health Plan, Inc. |
|---|---|
| Also known as | MetroPlus, NYC MetroPlus |
| Category | Medicaid MCO |
| Parent organization | NYC Health + Hospitals (public) |
| Claims payer ID | 13265 |
| Eligibility (270/271) payer ID | 13265 |
| ERA (835) payer ID | 13265 |
| NAIC company code | Not published |
| States covered | New York |
| Members covered | ~700k members |
| Provider portal | https://www.metroplus.org/providers/ |
| Provider phone | 1-800-303-9626 |
Always verify claims-routing details against the member ID card and the payer's current EDI companion guide before submission.
Timely filing & appeals for MetroPlus Health
MetroPlus Health's standard timely filing window for participating providers is 120 days from the date of service. Plan-specific products (Medicare Advantage, Medicaid, employer groups, secondary claims) may have shorter or longer windows — always confirm against the policy linked below before disputing a TFL denial.
| Submission type | Window |
|---|---|
| In-network initial claim | 120 days |
| Out-of-network initial claim | 120 days (verify per plan) |
| Secondary / coordination of benefits | 120 days from primary EOB |
| Corrected / appeal | 60 days from denial |
Appeal levels
- Level 1: First-Level ReconsiderationFile within 60 days
Written request for claim reconsideration with supporting documentation, filed within the stated window of the denial notification.
- Level 2: Second-Level Formal AppealFile within 60 days
Formal appeal reviewed by a party not involved in the initial determination; typically requires the first-level decision letter.
- Level 3: External / Independent ReviewFile within 120 days
External Independent Review Organization (IRO) review per ACA §2719 and applicable state law.
Source: MetroPlus Health provider policy. Always confirm before disputing a TFL denial — payer policies are versioned and product-specific.
Prior authorization with MetroPlus Health
MetroPlus Health accepts X12 278 prior-authorization transactions electronically. The procedures most commonly subject to prior authorization include advanced imaging, inpatient admissions, specialty pharmacy, and certain outpatient surgical procedures. Use the payer's authorization tool below to confirm requirements per CPT before scheduling a service.
MetroPlus Health maintains a live prior-authorization code lookup tool that supersedes any cached list. Use the provider portal or the policy documents below to confirm the current PA list before rendering a service.
Top denial reasons for MetroPlus Health
Per-payer denial benchmarks publish here once the QuickIntell anonymized ETL pipeline ingests sufficient MetroPlus Health volume. Until then, see the broader CARC reference for industry-wide remediation guides.
Electronic claims, eligibility & ERA
| Transaction | Supported | Payer ID |
|---|---|---|
| 837P / 837I claims | Yes | 13265 |
| 270 / 271 eligibility | Yes | 13265 |
| 278 prior authorization | Yes | 13265 |
| 835 ERA | Yes | 13265 |
Payer IDs vary by clearinghouse — confirm against your clearinghouse payer list (Availity, Change Healthcare/Optum, Waystar) before configuring submitter routing.
State coverage
MetroPlus Health operates in the following states. Each link opens state-level Medicaid program details, dominant commercial payers, and state-specific RCM regulations.
QuickIntell coverage for MetroPlus Health
- QuickRCM
End-to-end claim lifecycle automation tuned to MetroPlus Health's edits and adjudication patterns.
- QuickAuth
Automated prior-authorization submissions and status checks for MetroPlus Health services that require PA.
- QuickERA
Automated 835 ERA posting from MetroPlus Health with payment reconciliation and denial routing.
Frequently asked questions about MetroPlus Health
Where is the MetroPlus Health provider portal?
The MetroPlus Health provider portal is available at https://www.metroplus.org/providers/. Use it for eligibility checks, claim status, prior authorization workflows, appeals, and payer-specific routing updates. QuickIntell links to the payer's provider-facing portal as a reference and is not the official payer portal.
What is the timely filing limit for MetroPlus Health?
MetroPlus Health's standard timely filing limit for participating providers is 120 days from the date of service. Plan-specific products (Medicare Advantage, Medicaid managed care, employer groups) may have different windows — confirm against the payer's provider manual before disputing a TFL denial.
What is the MetroPlus Health payer ID?
The primary claims payer ID for MetroPlus Health is 13265. Eligibility (270/271) uses 13265 and ERA (835) uses 13265. Always verify against the member ID card and your clearinghouse payer list before submitting.
Does MetroPlus Health accept electronic claims?
Yes — MetroPlus Health accepts ANSI X12 837P and 837I electronic claims through standard clearinghouses. Real-time eligibility (270/271) is supported and X12 278 prior authorization is supported.
How do I appeal a MetroPlus Health denial?
MetroPlus Health uses a 3-level appeal process. Level 1 (First-Level Reconsideration) must be filed within 60 days of the denial. Each escalation level requires the prior decision letter and supporting clinical or coding documentation. See the appeal-levels block above for deadlines and process.
How long do MetroPlus Health prior authorization approvals take?
MetroPlus Health's prior-authorization decision turnaround typically follows standard industry windows: 72 hours for urgent requests and up to 14 calendar days for non-urgent requests. Specialty drugs and high-cost imaging may extend further. Submit through X12 278 or the MetroPlus Health provider portal for the fastest turnaround.
What is the MetroPlus Health provider phone number?
Providers can reach MetroPlus Health at 1-800-303-9626 for claims status, eligibility verification, and authorization questions. Have the member ID, date of service, and tax ID ready before calling. Most operational tasks are faster through the provider portal at https://www.metroplus.org/providers/.
Run cleaner claims to MetroPlus Health with QuickIntell
QuickAuth, QuickRCM, and QuickERA are validated against MetroPlus Health's EDI behavior — eligibility, prior auth, claim scrubbing, and ERA posting all run on real payer rules.
Disclaimer
This page is operational reference for medical-billing professionals. It is not legal, clinical, or contractual advice. Payer policies change without notice — always verify against MetroPlus Health's current published documents before submission. CPT® is a registered trademark of the American Medical Association.