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Required Request Form for Administrative Reviews and Provider Appeals Updated
8/1/2019 • Posted by Provider Relations

Fidelis Care has updated the required Provider Appeals Form for providers to use for submitting Administrative Reviews and Provider Appeal requests.

The Provider Appeals Form must be used if a claim has been processed and a remittance advice has been issued from Fidelis Care and the provider is requesting a review.  Do not use for first time claims or corrected claims.  All claim requests for reconsideration, corrected claims, or claim disputes must be received within 60 calendar days from the date of the remittance.

Before submitting this required form, please be sure the form is completed in its entirety so that your request can be processed immediately. Currently, the form should be mailed as follows:

Correspondence Type:


Mail to Current Address:



Claim Administrative 


 Claim Appeals


 Medicaid Managed Care
 Child Health Plus
 Fidelis Care at Home (MLTC)
 HealthierLife (HARP

 Claims Department
 Fidelis Care
 480 CrossPoint Pkwy.
 Getzville, NY  14068

 Qualified Health Plan
 Off Exchange
 Essential Plans

 Medicare Advantage
 Medicare Dual Advantage

If you have any questions, please contact the Provider Call Center at 1-888-FIDELIS (1-888-343-3547).

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Important Information on Coverage Decisions

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. 

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