Welcome, Providers!

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 through December 22, 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.

The suspension of certain utilization review and notification requirements per the December 2020 DFS Circular Letter 17 expired on February 21, 2021. Prior authorization for a variety of inpatient hospital services were suspended effective December 23, 2020 for 60 days.

Should there be additional direction from the state or an extension of the Circular Letter, Fidelis Care would be updating accordingly.Fidelis Care will continue to work with DFS, DOH, and provider partners as authorization provisions evolve during the course of the emergency response.

As of June 1, 2021, Medicare outpatient treatment with a COVID-19 diagnosis will be subject to review for medical necessity and therefore, plan participating providers will be required to submit authorization requests for Medicare members including those with a COVID-19 diagnosis. Telehealth services will also see reinstatement of prior authorization requirements effective June 1, 2021 for the Medicare line of business. Fidelis Care expects to continue to auto-approve COVID-19 admission requests for Medicaid and Marketplace members until the New York State of emergency ends.

Effective immediately, Fidelis Care requires an authorization for physical medicine services provided to Fidelis Care members with Medicaid, CHP, Exchange, and Essential plans for services conducted in person and via telehealth. Requests should be submitted via RadMD or NIA’s call center. Authorization requests will be reviewed for medical necessity and will count against the member’s benefit limit if one exists.

Beginning October 1, 2021, an authorization through NIA will be required for Fidelis Care members receiving Physical Medicine (Medicare, Dual Advantage, and Qualified Health), Advanced Imaging/Cardiac, or Radiation Oncology services in an in person setting or via telehealth.

If you have additional questions, please contact our Provider Services Line at 1-800-327-0641.

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. 

Effective for dates of service on & after June 1, 2021 Fidelis Care plans to reinstate contractual member cost share responsibility for our Medicare Lines of Business on any/all services for COVID treatment, telehealth services, & behavioral health services.

Effective for dates of service on & after June 15, 2021 Fidelis Care has reinstated contractual member cost share responsibility for our Health Exchange & Essential Plan Lines of Business on behavioral health services. For Behavioral Health services rendered via telehealth, the telehealth cost share waiver should remain applicable until June 28th, 2021.

Effective for dates of service on & after June 28^th, 2021, Fidelis Care plans to reinstate contractual member cost share responsibility for Telehealth services on the Health Exchange Lines of Business.

On August 5, 2020, 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.

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 continue to follow evolving CDC ICD-10-CM Official Coding Guidelines available here: https://www.cdc.gov/nchs/icd/icd10cm.htm  when selecting a diagnosis code and procedure code to ensure proper reporting.

*Please Note:  The coding guidelines referenced below is not a guarantee of reimbursement in all products, as codes may not have published rates for all products.  In addition, coding may be subject to National Correct Coding Initiatives or CMS standards.

*On April 16, 2021, the FDA revoked the EUA that allowed for the investigational monoclonal antibody therapy bamlanivimab, when administered alone, to be used for the treatment of mild-to-moderate COVID-19 in adults and certain pediatric patients. Due to this revocation, the Medicaid and Medicare programs will not pay for claims with HCPCS codes M0239 or Q0239 with dates of service after 4/16/2021.

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.

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.

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 .

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.

Consistent with DFS Circular Letter 10 and the subsequent executive orders extending these provisions, Fidelis Care is waiving member cost share (deductible, copay, and coinsurance) on all in network outpatient mental health and substance use treatment effective May 2^nd, 2020.

In-network Providers are reminded not to collect member cost share for outpatient mental health and substance use treatment during this timeframe, and if such cost share was inaccurately collected, to issue member refunds.Claims processing has been updated to waive member liability reflected in provider payments when a behavioral health diagnosis is included on the claim.Fidelis has applied this provision not only to members who are or were employed as ‘essential’, but to all members. This provision is currently scheduled to expire on May 26, 2021, subject to additional state directives. 

Beginning June 15, 2021 cost share requirements have been reinstated for behavioral health services under our Health Exchange/ Metal-Level & Essential Plan lines of business.

Fidelis Care is closely following advancements in the prevention and treatment of COVID-19, including vaccinations. As a healthcare provider, you will play an integral role as COVID-19 vaccines become available. We want to update you on important new information about vaccine coverage.

To prepare for vaccine administration, the Centers for Medicare and Medicaid (CMS) have published billing guidance:

The following codes have been published as of November 10, 2020.  Similar to other COVID-19 services, the vaccines will be offered at no cost to your patients

Fidelis Care will configure its systems to properly adjudicate COVID-19 vaccine-related claims, both for the vaccine and its administration, in accordance with New York’s coverage determinations for Medicaid beneficiariesMedicaid , Healthier Life, Essential Plan, Qualified Health Plan and Children’s Health Insurance Program (CHIP):

• Member liability will be $0
• Non-participating provider pre-authorization requirements will be waived
• Provider reimbursement rates and emergency use authorizations (EUA) are all still pending and we will update you as that information becomes available

Medicare:

• For Calendar Years (CYs) 2020 and 2021, Medicare payment for the COVID-19 vaccine and its administration for Medicare Advantage plan members will be made through the original fee-for-service Medicare program.
• Fidelis Care will not be able to process these claims.
• Therefore, providers must submit claims for administering the COVID-19 vaccine to their CMS Medicare Administrative Contractor (MAC) using product-specific codes for each vaccine approved.

The American Medical Association (AMA) has published updates to the Current Procedural Terminology (CPT®) code set that includes new vaccine-specific codes to report immunizations for the novel coronavirus (SARS-CoV-2). The code set will continue to be updated as additional vaccines receive EUA approval by the U.S. Food & Drug Administration (FDA).

Additionally, CMS has also published a set of toolkits to help providers prepare to swiftly administer the vaccine once it is available. If you have any further questions about this upcoming vaccine or the COVID-19 services Fidelis Care covers, please contact Provider Services at 1-888-FIDELIS (1-888-343-3547).

*COVID-19 Provider Alert: Johnson & Johnson Vaccine: On April 13, 2021, the Centers for Disease Control (CDC) and the U.S. Food and Drug Administration (FDA) announced they are currently reviewing data involving six reported U.S. cases of a rare and severe type of blood clot in individuals after receiving the Johnson & Johnson vaccine. Out of an abundance of caution, they have recommended a pause in the use of the Johnson & Johnson vaccine as they review this data. COVID-19 vaccine safety remains a top national priority and for additional details please see our full posting on the recent recommendation by the CDC & FDA to pause use of the Johnson & Johnson COVID-19 vaccine.

Fidelis Care will continue to support, promote, and align with rapidly evolving New York State and CMS guidance to providers on allowable parameters to render telehealth and telephonic services to our members. Fidelis Care will also continue to ensure alignment and state and federal directives regarding the waiving of member cost share for telehealth services for the duration of the declared state of emergency.

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. The Place of Service (POS) code to be used when billing for Telehealth services is POS Code 02 for the facility setting & POS Code 11 in a Physician setting.

Effective January 1, 2021 , Teladoc will no longer be participating in Medicaid Managed Care, Healthier Life, Child Health Plus, The Essential Plan, Qualified Health Plans. Members can still get access to telehealth services from our broad network of participating providers, often times from the same providers a member is already established with for primary care or behavioral health needs. Members should contact their provider to learn if their provider offers telehealth services and determine how to get started.

Teladoc is offered as an online option for Fidelis Care Medicare Advantage, and Dual Advantage members. Babylon can be utilized for the Qualified Health Plan members.

Effective June 1, 2021 Babylon can be utilized for the Medicaid, Essential Plan, Child Health Plus & Healthier Life members.

Effective for dates of service on & after June 28^th, 2021, Fidelis Care plans to reinstate contractual member cost share responsibility for Telehealth services on the Health Exchange Lines of Business.