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Behavioral Health Outliers Management Program
1/22/2019 • Posted by Provider Relations

Starting in 2019, Fidelis Care is expanding its behavioral health care management program. This expansion will include additional outreach and care coordination with behavioral health providers serving Fidelis Care members with higher needs for services and care coordination. Members will be identified using criteria outlined in an Outliers Management program developed by New York State’s Department of Health, Office of Mental Health, and Office for Alcohol and Substance Abuse Services. Further guidance on the program criteria can be found here

Fidelis Care clinical staff will reach out to providers for the purpose of discussing the member’s clinical needs, gathering information regarding the member’s progress in treatment, and identifying opportunities to collaborate with providers to enhance the member’s  clinical and quality outcomes. The information shared during these discussions will not be used to render utilization management decisions, but rather to coordinate care and assess what additional supports, if any, the member may need to improve their clinical quality outcomes.

Providers servicing a Fidelis Care member meeting the criteria for the Outlier Management program can expect to receive a telephonic request from Fidelis Care clinical staff to discuss the member’s treatment plan and progress, level of engagement in care, and known barriers to treatment goals.  Providers can also expect to receive additional information of value from Fidelis Care regarding any member gaps in care, recent emergency room / hospitalization services, and compliance with filling prescriptions. 

We expect this clinical conversation to require approximately 15 minutes per case with a frequency that varies from monthly to semi-annually, depending on the needs and risk stratification of the member.  Providers unable to meet the request for telephonic coordination within 14 days of the request will receive a follow up written request for the clinical record.

If you have any additional questions about the Outliers Management program please contact Fidelis Care at 718-896-6500: HARP member please dial extension x16077 and for BH member please dial extension x16072. Thank you for your cooperation.
 

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Each day, Fidelis Care's Utilization Management (UM) Department makes decisions on numerous health insurance claims. These decisions are based only on appropriateness of care and the existence of coverage. 

Fidelis Care does not reward practitioners or other individuals for issuing denials of coverage, and does not offer financial incentives to UM staff that would encourage decisions that result in underutilization of services. 

Fidelis Care is committed to ensuring that members have the care and services they need. 

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