Manuals, Forms and Policies

Click to download provider manuals, tip sheets, important forms, and applications.

Provider Manuals

Medicaid Managed Care, Child Health Plus, Medicare Advantage and Dual Advantage, Fidelis Care at Home (MLTC), and HealthierLife (HARP)

  • Qualified Health Plans and Essential Plans
  • Transportation Services

  • Infertility Services:  


    APPENDICES - Provider Manual

    Appendix I: Authorization Grids

    Appendix II: Pharmacy Services

    Appendix III: Coverage of Vaccines for Medicaid and Child Health Plus Members (Effective December 1, 2020)

        Coverage of Vaccines for Metal-Level Product and Essential Plan Members (Effective December 1, 2020)

    Appendix IV: Cage A Instrument (PDF)

    Appendix V:  Depression Screen: Patient Health Questionnaire (PHQ-9) and Scoring Instructions for PHQ-9

    Appendix VI: HIV Names Reporting and Partner Notification Regulations

    Appendix VII: New York State Child/Teen Health Program (PDF)

    Appendix VIII: Prenatal Guidelines (PDF)

    Appendix IX: Provider's Guide to Public Health Issues (PDF)

    Appendix X: Medicaid Member Handbook (PDF)

    Appendix XI: Retired

    Appendix XII: Child Health Plus Member Handbook (PDF)

    Appendix XIII: Sample Member ID Cards (PDF)

    Appendix XIV: Guide to Billing for Obstetrical Providers (PDF)

    Appendix XV: Bill Above List (PDF)

    Appendix XVI: Special Needs Plan (PDF)

    Appendix XVII: Special Needs Model of Care Training (PDF)

    Appendix XVIII: FIDA Grievances and Appeals (PDF)

    Appendix XIX: Cultural Sensitivity and ADA (PDF)

    Appendix XX: Continuity of Care Responsibilities (PDF)

    Appendix XXI: Columbia Suicide Severity Rating Scale (PDF)

    Appendix XXII: Generalized Anxiety Disorder 7 Item GAD 7 Scale (PDF)


    APPENDICES - Qualified Health Plans/Essential Plan Provider Manual

    Appendix I: Authorization Grids

    Appendix II: Pharmacy Services

    Appendix III: Coverage of Vaccines for Medicaid and child Health Plus Members  (PDF)

        Coverage of Vaccines for Metal-Level Product and Essential Plan Members (PDF)

    Appendix IV: Cage A Instrument (PDF)

    Appendix V:  Depression Screen: Patient Health Questionnaire (PHQ-9) and Scoring Instructions for PHQ-9

    Appendix VI: HIV Names Reporting and Partner Notification Regulations

    Appendix VII: New York State Child/Teen Health Program (PDF)

    Appendix VIII: Provider's Guide to Public Health Issues (PDF)

    Appendix IX:  Sample Member ID Cards (PDF)

    Appendix X: Columbia Suicide Severity Rating Scale (PDF)

    Appendix XI: Generalized Anxiety Disorder 7 Item GAD 7 Scale (PDF)

    Provider Tip Sheets

    Products 

    Access and Availability Standards Tip Sheet

    Children's Benefit Claiming Tip Sheet

    Children's Home and Community Based Services (HCBS) Tip Sheet

    CHP Provider Tip Sheet

    Essential Plan Provider Tip Sheet

    Medicaid Provider Tip Sheet

    Medicaid and HealthierLife: Behavioral Health (BH) Carve-in and Health and Recovery Plan (HARP) HCBS Claims Tip Sheet

    Medicaid Foster Care Program 29-I Health Facility Tip Sheet

    Metal-Level Products Tip Sheet

    Metal-Level Products Tip Sheet - Chinese version

    MLTC Tip Sheet

    MLTC Tip Sheet- Chinese version

    Wellcare By Fidelis Care Provider FAQ

    Wellcare By Fidelis Care Medicare Advantage/ Dual Advantage Tip Sheet




    Quality

    BabyCare Provider Incentive Tip Sheet

    Behavioral Health Case Management Services Tip Sheet

    Controlling High Blood Pressure Tip Sheet

    Flu Shot for Adults Tip Sheet

    Follow-up Care for Children Prescribed ADHD Medication (ADD) Tip Sheet

    HEDIS® Tip Sheet 2021 Antidepressant Medication Management (AMM)

    Importance of Chlamydia Screening Tip Sheet

    Low Back Pain Tip Sheet

    Patient Satisfaction Surveys Tip Sheet

    Primary Care Provider (PCP) Quality Tip Sheet

    Viral Load Suppression Tip Sheet




    Provider User Guides 

    Electronic Data Interchange (EDI) Provider Tip Sheet

    Find a Doctor Provider Guide

    Interactive Voice Response Application for Checking Claim Status Tip Sheet

    Pharmacy Electronic Prior Authorizations

    Provider Portal User Guide - Online Authorizations Tip Sheet




    Other Services 

    Adult Day Health Care (ADHC) Program Tip Sheet

    AIDS Adult Day Health Care Provider Tip Sheet

    Asthma Medication Ratio (AMR) Tip Sheet

    Consumer Direct Personal Assistance Services Tip Sheet

    Hospice Services Tip Sheet

    Nursing Homes Tip Sheet

    Personal Care Services (PCS) Tip Sheet

    Servicing Homeless Members Tip Sheet

    Transportation Services (Non-Emergency) - Livery-Taxi/Ambulette/Ambulance Tip Sheet

    Forms and Applications

    BabyCare 

    BabyCare Prenatal Encounter Form (PDF)

    BabyCare Postpartum Encounter Form (PDF)


    Claims Forms

    Affidavit of Lost/Stolen/Destroyed Checks (PDF)

    Children and Family Treatment and Support Services Claims Testing Survey (PDF)

    CMS 1500 Insurance Claim Form (PDF)

    Form UB-04 (PDF)

    Provider Reconsideration/Appeals Form (PDF)

    Provider Invoice Fax Form (PDF)


    Miscellaneous

    LHCSA - Request for Emergency Preparedness Plan for COVID-19 (Word Document)

    Self-Attestation to Deliver Services via Telemental Health during the Disaster Emergency (PDF)

    Special Supplemental Benefits for the Chronically Ill Attestation

    Supplemental Guidance- Expansion of Telemental Health During Disaster Emergency (PDF)

    Use of Telemental Health for People Affected by the Disaster Emergency (PDF)


    Personal Care Services

    Personal Care Benefit Physician's order form (Outside of New York City) DOH 4359 (2010) (PDF)

    Personal Care Benefit Physician's request form (New York City) Form M-11q (12/2014) (PDF)


    Transportation

    Provider Transportation Application For Members to request non-emergency livery, ambulette, & ambulance transportation (PDF)

    Tip Sheet: How to Complete Form (PDF)

    Long Distance Non-Emergency Transportation Approval Request Form (PDF)

    Tip Sheet: How to Complete Form (PDF)


    Treatment/Service Request Forms - MLTC (Managed Long Term Care)

    Certified Home Health Agency (CHHA) Request Form (PDF) 

    Durable Medical Equipment Request Form (PDF)

    Hearing Aid Services and Products Request Form (PDF)

    Skilled Nursing Facility (SNF) Request Form (PDF)


    Treatment/Service Request Forms

    Applied Behavioral Analysis Treatment Report (PDF)

    Care for Older Adults Assessment Form (PDF)

    Concurrent Inpatient Rehabilitation Request Form (PDF)

    Durable Medical Equipment Request Form (PDF)

    Home Health Care Request Form (PDF)

    Inpatient Emergency Room Request Form (PDF)

    Inpatient Rehabilitation Request Form (PDF)

    OB Ultrasound Authorization Request Form (PDF)

    Podiatry Services Treatment Request Form (PDF)

    Preventive Care Assessment Form for Children and Adolescents (PDF)

    Primary Care Provider Change Request Form (PDF)

    Primary Care Provider Change Request Form (Spanish) (PDF)

    Prior Authorization Request Form (PDF)

    Psychological Testing Request Form (PDF)

    Speech, Physical, or Occupational Therapy Treatment Request Form (PDF)



    Provider Policies

    Provider Policies Library

    Click for Clinical and Payment Policies
    Cultural Competency Attestation Form
    Cultural Competency Training is required for all in-network Fidelis Care Providers. Upon completion, please forward this attestation form to CulturalCompetencyTrainingAttestation@fideliscare.org for processing.
    Attestation Form

    Provider Access Online

    Verify member eligibility or renewal status, check claims, send e-scripts, and more.

    Pharmacy Services

    Formularies, utilization management programs, and specialty drug programs.

    Authorization Grids

    Authorization Grids for Medicare, Medicaid, CHP, and NYSOH Marketplace plans.