Welcome, Providers!

Fidelis Care is closely monitoring the developments across New York State and is following COVID-19 guidance from the New York State Department of Health (SDOH) and Department of Financial Services (DFS) guidance.

New York State was at one point among the highest number of confirmed COVID-19 cases in the country, prompting a coordinated and decisive statewide response. We continue to prioritize the health and safety of our employees as we care for the nearly 2 million members who rely on us for their health and well-being.

As we respond to this unprecedented and dynamic situation, Fidelis Care’s goals are to continue to serve our members and providers, minimize disruption, and support the health and safety of our employees. 

As an important resource for providers, we encourage you to access the information on Fidelis Care’s provider portal at providers.fideliscare.org. On the portal, you can:

• check claim status
• confirm member eligibility and benefits
• submit authorization requests
• check on the status of an authorization
• view provider remittance advice

We also encourage you to use Fidelis Care’s Interactive Voice Response as another way to check claim status and member eligibility.

Using these tools and resources will provide you with the information you need, 24/7, and help to reduce anticipated call volume and wait times for our Provider Call Center.

Emergency Preparedness Plan Providers should have an emergency preparedness plan in place for their facilities. The latest NYS-specific information can be found on the SDOH website at the following link: https://www.health.ny.gov/diseases/communicable/coronavirus/.
 

Authorizations: The suspension of certain utilization review and notification requirements per the March 2020 DFS Insurance Circular Letter had expired on June 18, 2020. Authorization requirements have been reinstated for claims with dates of service on or after June 19, 2020. Providers are required to contact Fidelis Care for prior authorization on services as described in the authorization grid, and can complete this request via the portal or by dialing 1-888-FIDELIS. Should there be additional direction from the state or an extension of the Circular Letter, Fidelis Care would be updating accordingly.

The March 20, 2020 DFS’ guidance letter advised insurers that they should suspend the following requirements for 90 days:  

• Pre-authorization review for scheduled surgeries or admissions at hospitals; 
• Concurrent review for inpatient hospital services provided;  
• Retrospective review for inpatient hospital services and emergency services provided at in-network hospitals; 
• Pre-authorization review for home health care services and inpatient rehabilitation services following an inpatient hospital admission; 
• To the extent currently required, pre-authorization review for inpatient rehabilitation services following an inpatient hospital admission for mental health and substance use disorders; 
• Deadlines for hospitals to submit an internal or external appeal for a medical necessity denial; and 
• Non-essential payment audits of hospitals and the timeframe for the insurer to recover overpayments. 

As clarification, Fidelis Care continues to require Home Care, Skilled Nursing Facilities and inpatient rehabilitation services to be subject to concurrent medical necessity review. Providers are required to continue to contact Fidelis Care for concurrent authorization for services beyond the fifth day of admission.

Fidelis Care has updated claims systems to retroactively adjust claims meeting specifications in the DFS Guidance letter with dates of service of March 20, 2020, that otherwise denied for an authorization related reason.  Claims adjustments have also been completed.

Coverage and Copays: Fidelis Care covers treatment services related to COVID-19, including inpatient hospital treatment, and will be waiving all cost sharing for COVID-19 treatment effective retroactively to February 4^th, 2020. To ensure that cost-sharing is not a barrier to testing or treatment, Fidelis Care will cover services including testing and treatment for COVID-19 and for physician, clinic, urgent care, inpatient admissions, and emergency visits without copays, deductibles, or coinsurances for members across all plans.

Effective February 4, 2020, providers are responsible to ensure any copays, coinsurance, or deductible charges are waived for Fidelis Care members at the time of an office visit, urgent care visit, clinic, inpatient admission, or emergency room visit when the purpose of that visit is testing or treatment for COVID-19.  If you provided treatment to a member during this time and collected any copays, deductible or coinsurance, Fidelis Care expects you to refund the money collected to the member.

Claims with correct coding have been adjusted to reflect provider payments with $0 member liability upon processing. Providers should follow CDC coding guidelines below when submitting claims to Fidelis Care and ensure accurate diagnosis codes are included with other required elements of a clean claim.

Charges for Personal Protective Equipment: On August 5th, The New York State Department of Financial Services (DFS) posted Circular Letter #14 regarding Charges for Personal Protective Equipment (PPE) by Participating Providers.  PPE consists of personal protective equipment such as masks, gowns and gloves. The DFS letter reminds participating providers that they should not charge insured members fees that are above their responsibility for covered services.  

In adherence to the letter, participating providers are reminded not to bill, seek, or accept payment from Fidelis Care members other than copayments, coinsurance, or deductible. Participating providers should contact Fidelis Care at 1-888-FIDELIS to report if charges have been inappropriately sought or collected from our members and begin issuing refunds to impacted members.

Coding: Fidelis Care has updated our claims systems to be able to receive new codes associated with COVID-19 testing and has added Healthcare Common Procedure Coding System (HCPCS) codes as they become available.

Providers should use the appropriate CDC coding elements on claims for outpatient services related to COVID-19 testing to ensure $0 member liability upon claims processing, including one of the following diagnosis codes referenced in CDC guidelines:                      

Providers should use the appropriate CDC coding elements on claims for services related to COVID-19 treatment when infections are confirmed to ensure $0 member liability upon claims processing, including one of the following diagnosis codes (often in combination with others) referenced in CDC guidelines consistent with industry coding standards:

On March 13, 2020, the American Medical Association Current Procedural Terminology (CPT^® ) Editorial Panel approved a new, specific CPT code to describe laboratory testing for severe acute respiratory syndrome coronavirus 2. Fidelis Care will reimburse for CPT code 87635 using the recently published NYS rate of $51.31. Providers should not submit more than one testing HCPCS or CPT code on the same day for the same patient.  The fact sheet for this new code can be accessed at the following link: https://www.ama-assn.org/system/files/2020-03/cpt-assistant-guide-coronavirus.pdf

Providers should follow CDC ICD-10-CM Official Coding Guidelines https://www.cdc.gov/nchs/data/icd/ICD-10-CM-Official-Coding-Gudance-Interim-Advice-coronavirus-feb-20-2020.pdf  and https://www.cdc.gov/nchs/data/icd/COVID-19-guidelines-final.pdf when selecting a diagnosis code to ensure proper reporting.

On April 10, 2020, The American Medical Association announced updates to Current Procedural Terminology (CPT^® ) that included two codes approved for the use of COVID-19 antibody tests. Information on these new codes can be found at the following link: https://www.ama-assn.org/system/files/2020-04/cpt-assistant-guide-coronavirus-april-2020.pdf

Providers performing COVID-19 antigen tests can bill Fidelis Care for testing services that occurred after June 25, 2020, using the following HCPCS codes. Please note: reimbursement rates are still pending from CMS and this communication will be updated when available:

Neutralizing Antibody Screening Codes: Used to determine whether or not a patient recovering from COVID-19 has neutralizing antibodies, and is a candidate to be a convalescent serum donor. Effective August 10^th, 2020: Fidelis Care will configure its systems across all product lines to apply $0 member liability to both par and non-par provider claims when submitted utilizing these new COVID 19 screening codes. Please note: reimbursement rates are still pending from CMS and this communication will be updated when available.

Pharmacy: Fidelis Care covers a 90-day supply for most prescription and over-the-counter (OTC) maintenance medications. Please note, prior authorization may be required for 90-day supplies for some medications. Practitioners and pharmacists should consider ordering 90-day supplies of long-term maintenance medications for individuals in quarantine. Providers can find additional important updates regarding pharmacy changes in the context of the emergency declaration available here.

Telehealth: Fidelis Care will continue to support, promote, and align with rapidly evolving New York State guidance to providers on allowable parameters to render telehealth and telephonic services to our members.

Fidelis Care expanded coverage of telehealth services in 2019 and strongly encourages providers to deliver their services via the telehealth modality wherever reasonably possible in order to support current social distancing and containment strategies. More information on the telehealth policy that predated the state of emergency can be found in the Provider Manual here, Section 26. To the extent it is practical, Fidelis Care encourages the use of telehealth to provide COVID-19 related services to members and offers reimbursement for these services across all products.

Starting April 1, 2020, in response to the COVID-19 emergency, Teladoc is offered as a new online option for Fidelis Care Medicaid, Child Health Plus, Essential Plan, Health and Recovery Plan (HARP), Medicare Advantage, and Dual Advantage members.

• Through Teladoc, members can access online care by phone or video, from board-certified, NY State-licensed doctors, 24 hours a day, 7 days a week.
• Members can speak with a Teladoc provider about COVID-19 concerns or symptoms, or about other general concerns they may have about their or their child’s health like: sore throats, earaches, the flu, allergies, sinus infections, rashes, and more. Support for anxiety, depression, post-traumatic stress, and family issues is also available.
• Fidelis Care Medicaid, HARP, and Child Health Plus members who have an assigned primary care provider can also use the Teladoc service. If necessary, a Teladoc provider will coordinate care with a member’s PCP.
• Before a member’s first virtual care visit, the best place to start is by downloading the Teladoc app (available from the App Store or Google Play) or get started online at https://member.teladoc.com/fideliscare. Members can also call Teladoc at 1-800-835-2362; TTY: 711. Members will be asked to fill out a brief medical history, just like they would at their doctor’s office. This will help the Teladoc doctor provide treatment and advice.
• At this time, the need for care has never been greater, and members may experience extended wait times. To avoid waiting, members can request a call-back when a Teladoc provider is available.
• Special Note for Fidelis Care Qualified Health Plan (QHP) members: Fidelis Care QHP members continue to have access to telehealth services through Teladoc and Babylon, at no cost. The Teladoc and Babylon apps are available from the App Store or Google Play.
• Whether Fidelis Care QHP members use Teladoc, Babylon, or both, their telehealth benefit is the same, and is offered at no cost.

New York State Department of Financial services issued additional information and answered frequent questions regarding Telehealth on March 23, 2020. The full posting of frequently asked questions and answers can be found here: https://www.dfs.ny.gov/industry_guidance/coronavirus/telehealth_ins_prov_info

Effective March 1, 2020, Fidelis Care has waived cost sharing on all telehealth services rendered from in network and out of network providers across all products.  Providers rendering care via telehealth are responsible to ensure any copays, coinsurance, or deductible charges are waived for Fidelis Care members at the time of telehealth services, and claims will be adjusted to reflect provider payments with $0 member liability upon processing. Providers should use the Place of Service and/or modifier that is appropriate for the procedure rendered.  

Fidelis Care is following recent CMS guidance issued that permits reimbursement for Telehealth services with dates of service on or after March 1, 2020 for the duration of the federal Public Health Emergency using the Place of Service equal to what it would have been had the service been furnished in person (such as POS 11 for office setting) and the appropriate telehealth modifier indicating that the service rendered was actually performed via telehealth.  More information on this can be found here: https://www.cms.gov/files/document/se20011.pdf

On March 21, 2020 New York State Medicaid issued additional comprehensive updates available here: https://www.health.ny.gov/health_care/medicaid/program/update/2020/index.htm 

providing clarified and broadened definitions related to telehealth, authorizing telephonic services for reimbursement, and specifying additional reimbursement and coding details specific to NYS Medicaid Fee-for-Service. While Fidelis Care is aligned with coverage described in this update, including aligning with expanded definitions and parameters related to telehealth, the coding and reimbursement referenced is not relevant to our claims processing requirements.  Providers existing contract defining services and rates continue to prevail for the same services rendered through the telehealth modality. Dental providers should contact Dentaquest at 888.308.2508 for specific tele-dental coding guidance.  Dentaquest guidance can be found using this link: https://success.ada.org/~/media/CPS/Files/COVID/ADA_COVID_Coding_and_Billing_Guidance.pdf

Several Medicare specific telehealth coding guidelines have been published by CMS, and this telehealth guidance will apply to the Medicare Advantage product line.  Providers can find the full coding detail for Medicare Telehealth here: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

Behavioral Health: Fidelis Care’s telehealth coverage and reimbursement approach described throughout also applies to our network of participating behavioral health providers, including all individual practitioners currently contracted with Fidelis Care (including but not limited to licensed clinical social workers, psychologists, licensed mental health counselors, licensed marriage and family therapists, and ABA providers) as well as facilities delivering OMH and OASAS licensed programs. Additional telehealth information for OMH programs regarding recent changes to telehealth regulations can be found in these guidance, self-attestation, and supplemental guidance documents.   Additional information for OASAS licensed programs can be found here, including the self-attestation and supplemental guidance.  

As guidance continues to evolve over time, OMH licensed or funded programs should continue to monitor updates available here: https://omh.ny.gov/omhweb/guidance/  as well as referencing recently published guidance here: https://omh.ny.gov/omhweb/guidance/omh-covid-19-disaster-emergency-faqs.pdf .  OASAS licensed or funded programs should continue to monitor updates available here: https://oasas.ny.gov/keywords/coronavirus . Providers must follow continued guidance from their respective licensing authorities, and any questions on these forms or waiver approvals should be directed to the respective OMH and OASAS contacts indicated on the forms. Fidelis Care does not require the submission of any additional documentation, contracting documents, or forms from OMH or OASAS providers in order to reimburse for telehealth claims.  Fidelis Care is not requesting and will not be able to accept any OMH or OASAS self-attestation forms, and providers should ensure the submission of these requests are directed to the contacts indicated on the guidance.

Fidelis Care will continue to monitor changes in state and federal regulations related to any expansion of, additional approval, or change in regulation regarding telehealth services.

COVID-19 Background

Treatment: Currently there is no available antiviral to treat COVID-19, though some international clinical trials are underway.

Vaccine: At this point, there is no vaccine for COVID-19.

Identification and Testing of Persons Under Investigation (PUI): As of March 13, 2020, COVID-19 tests are being conducted at the CDC, the NYS Wadsworth Center, and the New York City Public Health Laboratory. Tests performed for suspected individuals at these current public health sites are provided at no cost. Additionally, some hospitals and commercial laboratories are now authorized to perform COVID-19 testing. Providers should follow CDC guidance for evaluating members with suspected illness. This information can be found on the CDC website at the following links: https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html and https://www.cdc.gov/coronavirus/2019-ncov/infection-control/control-recommendations.html.

When a test is ordered and referred to a public health lab, it is critical that the order form included with the test sample is legible and completed in its entirety.

Healthcare providers should regularly check the SDOH website for the latest guidance on reporting of suspected cases of COVID-19 as the outbreak evolves.

https://www.health.ny.gov/diseases/communicable/coronavirus/providers.htm%20

Prevention: COVID-19 can be spread from infected individuals to others through close personal contact and through the air by coughing and sneezing. Providers should encourage their patients to practice good hand washing, avoid touching their faces as much as possible, and avoid unnecessary contact with individuals who are ill.

Additional guidance can be found on the CDC website: 

https://www.cdc.gov/coronavirus/2019-ncov/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2Findex.html

https://www.cdc.gov/coronavirus/2019-ncov/specific-groups/high-risk-complications.html

https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/summary.html

More Online Resources:

Source for number of cases is from Johns Hopkins University (Updated daily)

https://coronavirus.jhu.edu/map.html

Centers for Medicare & Medicaid Services (CMS) 
CMS is part of the U.S. Department of Health and Human Services (HHS)

www.cms.gov/newsroom

COVID-19 FAQs for State Medicaid and CHIP agencies 
www.medicaid.gov/state-resource-center/disaster-response-toolkit/covid19/index.html

American Medical Association

https://www.ama-assn.org

World Health Organization (WHO) Q&A

www.who.int/news-room/q-a-detail/q-a-coronaviruses