In need of a form, have a question or need more information on a topic, choose from the resources below.  If you can’t find what you are looking for or need more help, don’t hesitate to email us at providerrelations@monroeplan.com.

 Send completed forms to pfmemails@monroeplan.com.

Practitioner Enrollment Application

Use this form when enrolling brand new providers to the health plan. Examples: Audiologists, Diabetic Educators, Podiatrists, Medical Doctor, Midwives, Chiropractors, Occupational Therapists, Optometrists, Oral Surgeons, Osteopathic Doctors, Physical Therapists, Speech Pathologists, and Pain Management Physicians.

Click here to download

Non-Credentialed Practitioner Application

Use this form when enrolling providers who do not require credentialing. Examples: Nurse Practitioners, Physician Assistants, CRNA, Registered Dietician, Emergency Room Physicians, Pathologists, Anesthesiologist, and Hospitalists.

Click here to download

Demographic Change Form

Use this form when an update needs to be made for an existing group, facility, or individual practitioner. These updates could include: Name Changes, TIN Changes, Additional Locations, Terminations, Remit Changes, Sponsoring MD Changes, etc.

Click here to download

Provider Employee Attestation Form

Use this form to certify that all employees and other provider personnel are not excluded or otherwise prohibited from participating in any state or federal healthcare program. This form needs to be attested and sent to Monroe Plan yearly.

Click here to download

HIV Attestation Form

Use this form when attesting that you agree that you are an accredited HIV Provider. This form needs to be attested and sent to Monroe Plan yearly.

Click here to download

Ownership Disclosure Form

Use this form to attest disclosure of ownership and financial interest of the group or facility.

Click here to download

PCP Change Form

Use this form when removing or adding a patient to your roster.

Click here to download

Molina Healthcare of New York, Inc.

Provider Portal - Availity

If you have not already done so, sign up for Molina’s Provider portal to check member eligibility, claims status, PCP rosters and more at your fingertips.  Please follow the instructions in this document to register for portal access.

Login: https://www.availity.com/

 

Electronic Funds Transfer - Timely & Efficient Payment

Sign up for EFT to make the best use of your time and resources.  Please follow the instructions in this document to register for EFT payments

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