Provider Quality

Fidelis Care would like to inform providers of a postpartum visit incentive being offered through the New York State (NYS) Medicaid program. This program will provide an additional payment to the current NYS Medicaid reimbursement for comprehensive, timely postpartum visits provided to Medicaid Managed Care (MMC)/Fidelis Care Medicaid members. The incentive payment will apply to postpartum visits for deliveries that occurred from July 1, 2024, through March 31, 2025.

Providers who delivered a person-centered comprehensive postpartum visit as outlined by the American College of Obstetricians and Gynecologists clinical guidelines, including a postpartum depression screen, to Fidelis Care members within 12 weeks of the date of delivery will receive an additional payment of $208.55. Obstetrician/gynecologists, certified nurse midwives, family practice providers, and clinics that provide perinatal services are eligible to receive the incentive. One incentive payment is available per member/delivery combination.

Comprehensive postpartum visits are identified for the additional payment by CPT code "59430" - Postpartum Care Only (Separate Procedure) or if billing the bundled/global procedures codes (“59400”, “59410”, “59510”, “59515”, “59610”, “59614”, “59618”, “59622”, “59426”, and “59425”), providers must submit a claim for the postpartum visit with Category II Current Procedural Terminology code “0503F”, as well as a $0.00 charge, to be considered for the incentive payment.

To better understand the timing and delivery of perinatal (prenatal and postpartum) services to New York State (NYS) Medicaid members and Medicaid Managed Care (MMC) enrollees, additional information is needed from providers. Providers using bundled/global procedure codes for billing will also be required to submit claims with non-payment Category II Current Procedural Terminology (CPT) codes for perinatal services to NYS Medicaid fee-for-service (FFS) and MMC.

These Category II CPT code claims are in addition to the global or bundled code claims.  The following CPT II codes should be used:

0500F             Initial Prenatal Visit

0502F             Subsequent Prenatal Visit

0503F             Postpartum Visit 

Providers that were unaware of the new billing guidelines can submit corrected claims for bundled/global procedure codes to Fidelis Care with the appropriate CPT II code, by the dates listed below.  Postpartum visits billed with CPT code 59430, do not need to be resubmitted.

Electronic Submission of Corrected Claims

To submit corrected claims electronically:

• The original claim number must be submitted 
• The claim frequency type code must be a 7 (replacement of prior claim)
• 2300 Loop, CLM Claim Information Segment, CLM05-3 Claim Frequency Type Code Element must be set to a 7 and 2300 Loop
• REF Original Reference Number (ICN/DCN) Segment where REF01 Element equals F8, REF02 Element must contain Fidelis Care Original Claim Number
• Only one correction for a Fidelis Care Original Claim Number should be submitted per day

Paper Claim Re-Submissions

To submit corrected claims by paper mail to:

Fidelis Care Attn: Corrected Claims

480 Crosspoint Parkway

Getzville, New York 14068

Earned payments will be distributed following claim reconciliation to confirm a postpartum visit that meets the guidelines stated above was performed. Once payments are received by Fidelis Care from the state, those payments will be applied to the claims submitted during the applicable time period.

For the initial announcement and additional information on this direction, providers should refer to the Submission of Prenatal and Postpartum Service Claims for Each Pregnancy Related Visit article published in the June 2024 issue of the Medicaid Update.  

Questions should be directed to MaternalandChild.HealthPolicy@health.ny.gov

For additional questions, or if we can be of assistance in any way, please contact your Fidelis Care Provider Engagement Account Manager. To find your designated representative, please visit Contact Your Designated Provider Relations Specialist.