Welcome, Providers!

As of January 1, 2022, Fidelis Care will begin accepting First Time Submissions of Coordination of Benefits (COB) Claims for processing via Electronic Data Interchange (EDI). Please note, we will still accept paper submissions as well.

For Electronic Submission Of First Time COB Claims (the claim has never been billed to Fidelis Care & where Fidelis Care is secondary for the member): 

• Loop 2320 contains insurance information about:  Other insurance carriers and their payment information for the Subscriber being billed.
• Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

As of January 1, 2022, we will begin accepting Submissions of COB Corrected Claims for processing via EDI.  We will still accept paper submissions as well. 

• For Electronic Submission of COB Corrected Claims:

• Loop 2320 contains insurance information about:  Other insurance carriers and their payment information for the Subscriber being billed.
• 2300 Loop, CLM Claim Information Segment
• CLM05-3 Claim Frequency Type Code = 7
• F8, REF02 Element must contain Fidelis Care Original Claim Number

For Paper Submission Of First Time COB Claims (the claim has never been billed to Fidelis Care):

• Claim form (CMS-1500 or UB-04) and EOB from the primary carrier should be submitted along with any necessary supporting documentation to:

COB Fidelis Care

PO Box 905

             Amherst NY 14226-0905

• For Paper Submission Of COB Corrected Claims:
  • A valid Claim form (CMS-1500 or UB-04) containing:
    • Resubmission code 7 and the previous claim #
    • An EOB from another insurance carrier/supporting documentation should be sent to:

COB Related Reconsiderations (the claim has previously been billed to Fidelis Care, and you are requesting a reconsideration or appeal)

• These will continue to be accepted via paper submission only at this time. 
• Please include the following:
  • A fully completed Reconsideration/Appeal Request Form
  • A valid Claim form (CMS-1500 or UB-04)
  • An EOB from another insurance carrier/supporting documentation
• Please submit to the appropriate address below based on line of business being billed: