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

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

    Appendix IV: Cage A Instrument

    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

    Appendix VIII: Prenatal Guidelines

    Appendix IX: Provider's Guide to Public Health Issues

    Appendix X: Medicaid Member Handbook

    Appendix XI: Retired

    Appendix XII: Child Health Plus Member Handbook

    Appendix XIII: Sample Member ID Cards

    Appendix XIV: Guide to Billing for Obstetrical Providers

    Appendix XV: Bill Above List

    Appendix XVI: Special Needs Plan

    Appendix XVII: Special Needs Model of Care Training

    Appendix XVIII: Retired

    Appendix XIX: Cultural Sensitivity and ADA

    Appendix XX: Continuity of Care Responsibilities

    Appendix XXI: Columbia Suicide Severity Rating Scale

    Appendix XXII: Generalized Anxiety Disorder 7 Item GAD 7 Scale


    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

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

    Appendix IV: Cage A Instrument

    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

    Appendix VIII: Provider's Guide to Public Health Issues

    Appendix IX:  Sample Member ID Cards

    Appendix X: Columbia Suicide Severity Rating Scale

    Appendix XI: Generalized Anxiety Disorder 7 Item GAD 7 Scale

    Provider Tip Sheets

    Products 

    Access and Availability Standards Tip Sheet

    Ambetter from Fidelis Care FAQ

    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

    Express Scripts (ESI) FAQ

    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

    2023 RxEffect Bonus Program

    Adult Wellness Visit Tip Sheet

    BabyCare Provider Incentive Tip Sheet

    Behavioral Health ABA Provider Tip Sheet

    Behavioral Health Case Management Services Tip Sheet

    Child and Adolescent Well Care Visits Tip Sheet

    Continuity of Care 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

    Improving Cardiometabolic Health for Members with Diabetes Tip Sheet

    Low Back Pain Tip Sheet

    Patient Satisfaction Surveys Tip Sheet

    Primary Care Provider (PCP) Quality Tip Sheet

    Smoking Cessation Provider Tip Sheet

    Viral Load Suppression Tip Sheet

    Well Child - Birth to 30 Months Well Care Visits 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

    MCG Cite Guideline Tool Quick Reference Guide

    Medicaid Authorization Look Up Tool Reference Guide

    Member Insurance Renewal Tip Sheet

    Pharmacy Electronic Prior Authorizations

    Prior Authorization Look Up Tool Reference Guide

    Provider Portal User Guide - Claims Appeals QRG

    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)

    Diagnosis Related Group (DRG) Change Dispute Form (PDF)

    Form UB-04 (PDF)

    Health Savings Unit (HSU) Recoveries Reconsideration Form (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)


    Provider Termination Form

    Provider Termination Request Form (PDF)


    Transportation

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

    Long Distance Non-Emergency Transportation Approval Request 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.