Fidelis Care is proud to work with a network of more than 67,000 primary care physicians, specialists, hospitals, and health care professionals across New York State to provide our members with the highest quality care and service.
National Drug Codes (NDC)
ATTENTION PROVIDERS: Effective July 1, 2015 Fidelis Care will REJECT claims with drug codes that do not contain the REQUIRED National Drug Code (NDC). This is a mandatory requirement that applies to all provider types and is in accordance with Section 6002 of the 2005 Federal Deficit Reduction Act (DRA).
Claims MUST INCLUDE the 11-digit NDC, in addition to the CPT/HCPCS code and units. The NDC dispensing quantity and the NDC unit of measurement are also mandatory. NDC information can be obtained from the drug invoice and/or package information.
Please ensure applicable claims contain the required NDC information to avoid rejection of your claims. For guidance on billing NDC’s, please click here. Additional billing information can also be found within the eMedNY New York State Medicaid General Billing Guidelines Manual.
2015 Second Quarter Generation of Provider Report Cards – Released as of May 18th
Please notify any staff involved with Quality Management and/or the Fidelis Care QCMI Program that the 2015 Q2 Provider Report Cards have been posted to accounts on Provider Access Online as of May 18th.
Child Health Plus Benefit Update
Please be advised of the following updates to the Child Health Plus benefits package:
Autism Spectrum Disorder - Effective immediately, the $45,000 per calendar year coverage limit for applied behavioral analysis for treatment of an autism spectrum disorder is replaced by a 680 hour per calendar year coverage limit.
Ostomy Equipment - Effective May 1, 2015, the Child Health Plus Program will provide coverage for ostomy equipment and supplies prescribed by a licensed health care provider legally authorized to prescribe under title eight of the Education Law.
2014 Well Child and Adolescents Visits
Fidelis Care is pleased to inform you that the request letter and details for Well Child and Adolescent Visits in 2014 have been posted on our Provider Portal, Provider Access Online.
Fidelis Care sent you a letter about these services on February 12, 2015. Since Fidelis Care has refreshed our claims, we ask that you focus your efforts based on information outlined in the updated report and disregard the previous one.
Please review these updated materials and send the requested documentation, in the form of a corrected claim, by April 30, 2015. Fidelis Care will reimburse your practice $50 for each corrected claim received by April 30, 2015. Please note that if the corrected claim that is submitted is not relevant to the measure, no payment will be made. Please notify any staff involved with Quality Management and/or the Fidelis Care QCMI program that these documents have been posted. If you have any questions, please call the Provider Call Center at 1-888-FIDELIS (1-888-343-3547).
National Correct Coding Initiative Edits
The Center for Medicare & Medicaid Service (CMS) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate claim payment. These policies are based on coding conventions defined in the American Medical Association's (AMA) CPT Manual, National and Local Coverage Determinations (NCD and LCD), coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. These standards set the coding requirements that all plans and providers must follow in order to secure reimbursement for Medicare services.
Claims that are found to be noncompliant with these guidelines may be returned and/or denied.
Please visit the sites below for additional information:
NCCI Edits - http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html
AMA - http://www.ama-assn.org/ama
NCD - http://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx
LCD - http://www.cms.gov/medicare-coverage-database/indexes/lcd-state-index.aspx
Patient Centered Medical Home Statewide Program Incentive Payments
In order to allow providers additional time to achieve Patient Centered Medical Home (PCMH) recognition from the National Committee for Quality Assurance (NCQA) under the 2014 standards, New York State Medicaid is extending the implementation date of the Statewide PCMH Incentive Payment Program changes affecting payments to providers recognized under 2011 or 2014 standards, which was announced in the February 2015 Medicaid Update. The implementation date related to payment changes for recognition under 2011 and 2014 standards years will be delayed from April 1, 2015 to January 1, 2016. This extension only applies to providers recognized under the 2011 standards and all incentive payments for PCMH-recognized providers under NCQA’s 2008 standards will still be discontinued as of April 1, 2015.
Please click on the link above for a summary of Medicaid updates. These changes will impact the following benefits and services:
- Oncotype DX® Test for Breast Cancer
- Low Dose CT Lung Cancer Screening
Fully Integrated Duals Advantage (FIDA) Provider Training
Providers participating within the FIDA Demonstration are required to complete provider training on a number of key subjects. The training offers education on FIDA and also addresses the special needs of this vulnerable population, with the goal of ensuring the delivery of quality care to FIDA participants. We recognize your time is valuable. That is why FIDA plans, along with Medical Directors and Providers, CMS, and SDOH have worked collaboratively to develop web-based uniform training modules applicable to all FIDA health plans. The first uniform training module can be found by visiting https://fida.resourcesforintegratedcare.com. When registering for the training, please be sure to indicate that you are participating with Fidelis Care so that we may verify your training was completed. For additional information, click on the link above to view a copy of the correspondence mailed to offices this week. Please complete this training within 30 days of receipt of this notice, and we will notify you once additional trainings are made available.
2015 HEDIS/QARR Medical Record Review Request
Fidelis Care is pleased to inform you that the medical record request letter and details for 2015 HEDIS/QARR have been posted on our Provider Portal, Provider Access Online. Please review these materials and send the requested documentation to Fidelis Care or arrange for us to retrieve the records from your office as soon as possible. Fidelis Care will reimburse your practice $25 for each record received by February 26, 2015 (or for each record received at site visits scheduled by February 16th). Please note that if the medical record information that is submitted is not relevant to the measure, no payment will be made. Please notify any staff involved with Quality Management and/or the Fidelis Care QCMI program that these documents have been posted. If you have any questions, please call the Provider Call Center at 1-888-FIDELIS (1-888-343-3547).
Provider Access Online - New Look and Improved Features
Fidelis Care is redesigning its Provider Access Online (PAO) portal in February 2015 to better address your needs. Our user-friendly, secure provider portal will have a new look, with additional resources and features - including improved search capabilities and additional controls. The portal’s self-service layout will provide even more functionality and will continue to be available 24 hours a day, 7 days a week!
New PAO features include:
- Mobile-friendly design compatible with your smart phone or laptop
- Improved search capabilities for member eligibility, provider participation and claims history
- New home page layout for easier access to important announcements
- Additional controls for account administrators
- Enhanced security features
Providers accessing PAO for the first time following the upgrade will be asked to provide additional information to ensure security of their PAO accounts. This includes a valid email address, answers to security questions, and stricter password requirements. For additional information, please login to PAO using your current credentials and review our NEW Provider Access Online User Guide.
Providers who need help accessing PAO can contact their Provider Relations Representative or the Provider Call Center at 1-888-FIDELIS (1-888-343-3547).
Fidelis Care has Posted Revised QARR Non-Compliance Reports
Please use these updated reports. This information reflects all encounter data on file with Fidelis Care as of December 16, 2014. Please refer to the "January 2015 Non-Compliance Report" instruction letter to understand the information being provided on each tab of the Excel Spreadsheet. Please notify any staff involved with Quality Management and/or the Fidelis Care QCMI program that these documents have been updated and re-posted. We apologize for any confusion or inconvenience. If you have questions or if we can be of help in any way, please call 1-888-FIDELIS (1-888-343-3547).
Peer-to-Peer Reconsiderations (non-Medicare products)
Providers may contact Fidelis Care to request a peer-to-peer reconsideration of an adverse determination. Peer-to-Peer Reconsiderations can be requested following an adverse determination of a pre-service or concurrent request.
How to request: Peer-to-Peer Reconsiderations are conducted telephonically and may be requested either by contacting Provider Services at 1-888-FIDELIS (1-888-343-3547) or by fax at 800-860-8720. Following receipt of the request, Fidelis Care will contact the provider to schedule and conduct the peer-to-peer discussion within one business day. The peer-to-peer discussion will be conducted by the same clinical peer reviewer who rendered the original determination if he/she is available.
When is a peer-to-peer reconsideration not available? Peer-to-Peer Reconsiderations are not available if an appeal has already been requested or if the original review was retrospective (after services had been rendered). The completion of a peer-to-peer reconsideration does not affect the right to request an appeal. An appeal may be initiated whether or not there has been a reconsideration, or after a reconsideration has occurred.
Can an appeal be requested following a Peer-to-Peer Reconsideration? Yes. The completion of a peer-to-peer reconsideration does not affect the right to appeal.
Nursing Home Transition
Effective February 1, 2015 in New York, Kings, Queens, Bronx and Richmond counties and effective April 1, 2015 in Nassau, Suffolk, and Westchester counties, all eligible recipients over age 21 in need of long term care/permanent placement in a Nursing Home (NH) will be required to join a Medicaid Managed Care Plan (MMCP) or a Managed Long Term Care Plan (MLTCP). All current long term/permanent custodial care beneficiaries in a Medicaid-certified NH prior to the phase-in date will remain in fee-for-service Medicaid, but may enroll in a MMCP on a voluntary basis beginning October 1, 2015. Members will not be required to change nursing homes as a result of this transition. New placements will be based upon Fidelis Care’s contractual arrangements and the specific needs of the individual. For additional information, please click on the link above to preview a copy of the Nursing Home Provider Tip Sheet.
Medicare Special Needs Plan and Model of Care Provider Training
The Centers for Medicare and Medicaid Services (CMS) requires that providers receive Medicare Special Needs Plan (SNP) Model of Care Training (MOC) annually. As part of our ongoing commitment of Access, Quality of Service and Quality of Care for our members, Fidelis Care provides this training annually during the new contract process to all network providers, as well as to providers who regularly see our SNP members. This training can be accessed by logging onto Provider Access Online and by clicking on File Downloads. Please be sure to complete this required training by or before December 31st, 2014.
Please click on the link above for a summary of Medicaid updates. These changes will impact the following benefits and services:
- PCI Angioplasty Authorization Requirement Change
- Viscosupplementation of Knee for Osteoarthritis
- Selective Bariatric Surgery
- Hospice Care
- Adult Day Health Care
- Increase Limits for Smoking Cessation Counseling
For more information call the Fidelis Provider Call Center at 1-888-FIDELIS (1-888-343-3547).
Niagara County Transportation Benefit Update
Effective January 1, 2015, the Non-emergency Transportation benefit for Fidelis Care Medicaid members transitions from Fidelis Care to Medicaid Fee-for-Service in Niagara County. Non-emergency services that were approved in Niagara County prior to January 1, 2015, for trips that occur on or after January 1, 2015, will be honored by Medical Answering Services, LLC (MAS). For all dates of service in Niagara County occurring on or after January 1, 2015, prior authorizations and claims for non-emergency services should be directed to MAS by calling 1-866-753-4430. For additional information, please refer to the Fidelis Care Transportation Manual.
New Coding Requirements for HCPCS Modifier -59
Effective January 1st, 2015 CMS is establishing new coding requirements related to HCPCS modifier -59 which is used to define a “Distinct Procedural Service.” CMS guidelines will require billers use the following newly established HCPCS modifiers to define a specific subset of the -59 modifier:
- XE Separate Encounter - A Service That Is Distinct Because It Occurred During A Separate Encounter
- XS Separate Structure - A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure,
- XP Separate Practitioner - A Service That Is Distinct Because It Was Performed By A Different Practitioner, and
- XU Unusual Non-Overlapping Service - The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service.
CMS will continue to recognize the -59 modifier, but notes that CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available. For additional information, please click on the link above.
Anesthesia Modifier Guidelines for Medicare Claims
In accordance with the Centers for Medicare & Medicaid Services (CMS) coding guidelines, Anesthesiology claims for Medicare patients must include the appropriate modifier(s), in the correct positions, in order to qualify for payment by Fidelis Care. Please click on the link above for a summary of anesthesia coding guidelines.
2014 Fourth Quarter Generation of Provider Report Cards – Released as of November 5th
Please notify any staff involved with Quality Management and/or the Fidelis Care QCMI Program that the 2014 Q4 generation of the Report Cards have been posted to accounts on Provider Access Online as of November 5, 2014.
Prospective Member Details Lists for 2015 – Released as of November 5th
Please notify any staff involved with Quality Management and/or the Fidelis Care QCMI program that there is a one-time posting of members due for timely preventive health services during 2015 that has been posted to accounts on Provider Access Online as of November 5, 2014.
Regulatory Time Frames for Utilization Management Decisions
As a reminder to hospital providers, the attached documents define the regulatory time frames for utilization management that apply to Medicaid, Medicare, and NY State of Health & Child Health Plus members.
Requests for Administrative Review and Corrected Claims
Fidelis Care has developed new forms to improve the process for Requesting Administrative Review of a Previously Processed Claim and for submitting Corrected Claims. These forms can be viewed via the links above and can also be found within the Fidelis Care Provider Manual. Before submitting these forms, please be sure they are completed in full and when submitting corrected claims, please send a complete replacement claim containing all required information or your claims will be returned. When submitting corrected claims electronically, the original claim number must be submitted and the claim frequency type code must be a 7. For additional information on the electronic submission of corrected claims, please click here. If you have any questions, please call the Provider Call Center at 1-888-FIDELIS (1-888-343-3547).
Care of Older Adults Assessment Form
The Fidelis Care of Older Adults Assessment form was recently updated to include additional criteria to assist providers in their functional assessments of senior members. A copy of this form can be found by clicking above, as well as within Provider Resources.
Fluoride Varnish Applied by Physicians and Nurse Practitioners
Fidelis Care is now accepting the application of fluoride varnish (D1206) to be administered by certified physicians or nurse practitioners. Prior to providing fluoride varnish treatments, practitioners must complete a web-based or in-person training in order to receive payment for claims. Providers that are not certified should visit the New York State Department of Health website for a list of training programs: https://www.health.ny.gov/prevention/dental/child_oral_health_fluoride_varnish_for_hcp.htm
For information on additional requirements, claims processing and reimbursement please click here.
Updated 2014 QCMI Brochure Now Available
Fidelis Care is pleased to announce the update of the 2014 QCMI Brochure.
Based on changes to the 2015 HEDIS (measurement year 2014) technical specifications from the National Committee for Quality Assurance (NCQA), we have made important changes to the 2014 QCMI Program indicators. The updated QCMI Brochure has been posted to Provider Access Online. Please review the QCMI Brochure carefully to ensure your practice understands these changes and how they impact your QCMI. In particular, please review each measure's coding specifications to ensure that you are able to take full advantage of these incentive payments.
The following changes have been made to the 2014 QCMI Program for both Medicare and Medicaid:
Medicare Risk Adjustment 2014 Medical Record Request Letter is Now Available
- Controlling High Blood Pressure: The changes in blood pressure specifications for this measure are in the measure descriptions on pages 7 and 9 of the enclosed brochure.
- The Cholesterol Management for Patients with Cardiac Conditions (CMC) measure has been removed.
- The Diabetes Care Low Density Lipoprotein Cholesterol (LDL-C) Test measure has been removed.
- Glaucoma Screening in Older Adults has been removed (Medicare only).
The Medicare Risk Adjustment 2014 Medical Record Request Letter is now available. Please notify any staff involved with Quality Management and/or the Fidelis Care QCMI program that the Medicare Risk Adjustment Letter and members’ medical record request lists have been posted to Provider Access Online. Please ensure that all requested medical records are received no later than October 31, 2014.
ACTION REQUIRED - Important Time Sensitive 2013 Quality Care Management Incentive Update
Providers who participate in the Quality Care Management Incentive (QCMI) Program are requested to log into Provider Access Online and go to File Download to access important information that could impact your 2013 Quality Care Management Incentive for two measures. Please click on the link above to access Provider Access Online.
HIPPS Rate Codes Required for Skilled Nursing Facilities and Home Health Agency Claims
As mandated by the Centers for Medicare & Medicaid Services (CMS), effective for dates of service occurring on or after July 1, 2014, skilled nursing facilities (SNF) and home health agencies (HHA) must include the appropriate Health Insurance Prospective Payment System (HIPPS) rate codes when submitting Medicare claims for patient assessments. Medicare claims that do not contain the applicable HIPPS rate and Resource Utilization Groups (RUGs) codes will be returned or denied. For additional information, please click here.
Medicaid Update – New Obstetric Delivery Billing Requirements
The New York State Medicaid Redesign Team (MRT) recently mandated changes that will impact billing for elective obstetric deliveries that take place prior to 39 weeks gestation. Effective July 1, 2013 for Medicaid fee-for-service claims and October 1, 2013 for Medicaid Managed Care claims, all obstetric deliveries will require the use of a modifier or condition code to identify the gestational age of the fetus as of the date of the delivery. Failure to provide the appropriate modifier/condition code, along with the appropriate diagnosis code, will result in a 10% reduction in reimbursement and/or the claim being denied.
Please click here and refer to pages 6-11 of the June 2013 Medicaid Update Newsletter
Please click here for an update to this policy issued on May 7, 2014 by the NYSDOH
Outpatient Blood Clotting Factor Services
Effective April 1, 2014, Fidelis Care will provide coverage for outpatient blood clotting factor products and treatments in connection with the care of children with Hemophilia and other blood clotting protein deficiencies who are enrolled in Child Health Plus (CHP). Previously, CHP coverage for blood clotting factor products and treatments was limited to inpatient services only, but will now be expanded to include treatment needed when infusion occurs in an outpatient setting or in the home by a home health care agency, a properly trained parent or guardian, or a child who is capable of self-administering such products. For more information, call the Fidelis Care Provider Call Center at 1-888-FIDELIS (1-888-343-3547).
To provide you with the most effective and efficient customer service, Fidelis Care will require, effective March 24, 2014, that provider office staff members have the following information readily available when calling to request an authorization:
- Tax ID
- IPA Affiliation, if applicable
- Member ID
- Date of Service(s)
- Procedure Code
- ICD-9 Diagnosis Code
If this information is not readily available, our Provider Call Center staff will ask the caller from your office to retrieve the information and call again. This will enable Fidelis Care to more quickly and efficiently establish authorization requests, and to provide you and our members with the best possible care and service. Please share this information with your appropriate staff members.
Fidelis Care Now Accepting CMS 1500, Version 02/12
Fidelis Care is able to currently accept claim submissions on the new CMS 1500 claim form, version 02/12, recently approved by CMS. Revisions were developed to accommodate for reporting requirements necessary for the ICD-10 implementation. At this time, and until further notice, Fidelis Care will be accepting both the current 08/05, as well as the revised 02/12 claim form. However, providers who are not currently submitting claims on version 02/12 are encouraged to begin the transition in preparation for the ICD-10 implementation scheduled to occur on October 1, 2015. Please note that although the new CMS 1500 form is equipped for the submission of ICD-10 codes, those codes will not be recognized as valid until October 1, 2015. Providers should continue to utilize the current ICD-9 codes. Please click here to view a copy of the new CMS 1500 claim form, version 02/12.
Breast Pump Update
Fidelis Care provides coverage for medically necessary breast pumps. Members can receive these from participating Fidelis Care durable medical equipment suppliers in their area, or have the pump delivered by mail order. A prescription is needed and can be given directly to the member or faxed to their preferred participating durable medical equipment vendor.Vendors will be required to obtain prior authorization before dispensing electric breast pumps (E0603). Click here to search for participating Fidelis Care providers. Select the member's product, indicate the zip code or county in which the member is located, and set the provider type to "Durable Medical Equipment." Please click here to visit the NYS Department of Health website for additional information.
In accordance with state and federal regulation, Fidelis Care is required to obtain a Disclosure of Ownership and Control form from contracted providers rendering services to Medicaid and Family Health Plus members. To ensure compliance with Medicaid Integrity requirements, as well as continued participation with Fidelis Care, please complete, sign and return this document no later March 3, 2014.
Please click here to obtain a copy of the Disclosure of Ownership and Control form.
Completed forms should be mailed to the following address:
Credentialing Department – DOC
Fidelis Care New York
480 Cross Point Parkway
Getzville, NY 14068
If you have any questions, please call Fidelis Care’s Provider Call Center at 1-888-FIDELIS (1-888-343-3547).
Fidelis is pleased to announce that the following Core Mandated Requirements have been implemented
CAQH CORE 350: Health Care Claim Payment/Advice (835) Infrastructure Rule
- CAQH CORE 360: Uniform Use of CARCs and RARCs (835) Rule
- CAQH CORE 370: EFT & ERA Reassociation (CCD+/835) Rule
- CAQH CORE 380: EFT Enrollment Data Rule
- CAQH CORE 382: ERA Enrollment Data Rule
Medicaid and Family Health Plus Benefits Update - Effective November 1, 2013
Important changes in effect for Medicaid and Family Health Plus (FHP) coverage which will impact the following services:
- Implantable Infusion Pump for Opioid Administration for Purposes of Pain Management
- Transcutaneous Electrical Nerve Stimulation (TENS)
- Functional Electrical Stimulation (FES)
For more information, please refer to the September 2013 Medicaid Update - http://www.health.ny.gov/health_care/medicaid/program/update/2013/2013-09.htm
Fidelis Care releases updated information and FAQ on the New York State of Health: The Official Health Plan Marketplace
As part of the federal Patient Protection and Affordable Care Act (ACA), New York's Health Benefit Exchange--the New York State of Health--has started its open enrollment period, with coverage to begin on January 1, 2014.
Modification of behavioral health authorization requirements
Fidelis Care is pleased to announce changes in the authorization requirements for outpatient behavioral health (BH) services that will significantly simplify and streamline the process for providers and members.
Effective for dates of service on or after September 1, 2013, authorizations will no longer be required for most outpatient behavioral health (mental health and substance abuse) services and behavioral health professional home care visits provided by participating providers.
All BH services provided by non-participating providers will continue to require authorization.
These changes apply to all products offered by Fidelis Care.
Please see the Fidelis Care Authorization Requirements Grids for Medicaid /Family Health Plus /Child Health Plus and Medicare for full details of these changes, including a list of those outpatient BH services that will continue to require authorization.
Medicaid Benefits Update - August 1, 2013
Effective August 1, 2013, Fidelis Care will assume responsibility for Case Management and reimbursement for the following services previously managed by Medicaid Fee for Service.
- Directly Observed Therapy for Tuberculosis Disease
- Adult Day Health Care
- AIDS Adult Day Health Care
This benefit applies to Fidelis Medicaid Managed Care Members. For more information call the Fidelis Provider Call Center at 1-888-FIDELIS (1-888-343-3547).
Please click here to read the Medicaid Update Newsletter-July 2013 for more information on these benefits.
*Important Notice for Primary Care Practitioners*
Information about the attestation process for the primary care rate increase can now be found on the eMedNY website. Under the Affordable Care Act, primary care practitioners may qualify for increased reimbursement at the rate that would be paid for primary care services under Medicare. Visit the above website to view the attestation form and frequently asked questions. If you qualify submit your attestation to Computer Sciences Corp., PO Box 4610, Rensselaer, N.Y. 12144-4610.
Immunization Administration Processing Guidelines
Please refer to the following notice regarding the new National Correct Coding Initiative (NCCI) editing for billing an office visit (E&M) code and a vaccine administration service on the same day. If you have any questions, please call Fidelis Care’s Provider Call Center at 1-888-FIDELIS (1-888-343-3547)
Important update on HIV treatments
Medicaid Managed Care and Family Health Plus Benefit Package Changes
Certain Pain Management procedures have been excluded by the New York State Department of Health
This program provides incentive payments to eligible professionals (EPs) and eligible hospitals (EHs) as providers adopt, implement, or upgrade and subsequently demonstrate meaningful use of certified EHR technology.
Joining the Fidelis Care Provider Network
If you would like to join our growing provider network and help make a difference in the lives of local residents, please click here to complete the inquiry form.