Welcome, Providers!

Fidelis Care encourages our providers to participate in behavioral health claims testing opportunities. New York State (NYS) is carving additional Behavioral Health (BH) services into the Medicaid Advantage Plus (MAP) Plan benefit package.

 

All BH services that will be carved into the MAP Plan benefit package effective January 2023 are outlined below.

 

Mental Health (MH) Services:

 

- Psychiatric Inpatient

- Mental Health Outpatient Treatment and Rehabilitative Services

- Assertive Community Treatment (ACT)

- Continuing Day Treatment (CDT)

- Comprehensive Psychiatric Emergency Program (CPEP)

- Partial Hospitalization (PH)

- Personalization Recovery Oriented Services (PROS)

- Crisis Residence

 

Substance Use Disorder (SUD) Services:

 

- OASAS Service

- Medically Managed Detox – Inpatient

- Medically Supervised Detox – Inpatient

- Medically Supervised Detox – Outpatient

- Inpatient Rehabilitation

- Addiction Treatment Center -

- State Operated Inpatient

- Rehabilitation

- Residential Services

- Outpatient Clinic

- Outpatient Rehabilitation

- Opioid Treatment Program

 

Behavioral Health Services with Joint OMH and OASAS Oversight:

 

- OMH and OASAS Service

- Community Oriented

- Recovery and Empowerment

- (CORE) Services

- Mobile Crisis

 

To ensure a smooth transition to the new billing system, Fidelis Care wants to remind you to participate in electronic data transfer (EDI) and claims testing. 

Claims Testing Step #1:  If you would like to test claims for any of these services, please email BHClaimsTesting@fideliscare.org and we will send you a survey to complete.

Claims Testing Step #2:  Once a Fidelis Care Representative has contacted you to begin the testing process, you may begin sending files for claims testing. Please do not send test files prior to being contacted.

Fidelis Care is proud to be your health care partner. If you have any questions about Claims Testing, please contact your designated Behavioral Health Provider Specialist.

Submitting a Claims-Testing Request 

If your organization is interested in testing, please email BHClaimsTesting@fideliscare.org. 

Please fill out the survey completely to avoid processing delays. Once your survey has been received, a Fidelis Care Representative will contact you to begin the testing process. Please do not send test files before that time to avoid claim-processing issues. 

Electronic Submission

Fidelis Care strongly recommends using the electronic data interchange (EDI) system for claims submission. Electronic claims submissions expedite the processing and reimbursement of clean claims, reduce and/or eliminate the number of claims not being received, and prove timely submission through electronic acceptance reports.

•    Existing Providers:  If your organization currently submits claims to Fidelis Care, you are considered an existing provider. Existing providers who will be submitting claims may submit test claims through the normal EDI channels. Please prefix the file name with test_ and change ISA16 to T. Providers may use current members for testing or may request test member data from Fidelis Care.

•    New Providers:  Providers who have never before submitted claims to Fidelis Care should contact their clearinghouse or billing vendor to see if they have connectivity with Fidelis Care. Fidelis Care works with all major clearinghouses. If you are not working with an electronic submitter or if your clearinghouse does not have connectivity with Fidelis Care, please indicate that on the Fidelis Claims-Testing Survey, and a representative will contact you. Fidelis Care will provide test member data to all new providers interested in testing. 

 

General Information for Claims Submission 
Receiver Name:          Fidelis Care 
Fidelis Care Receiver ID:      113153422
Fidelis Care Payer ID:      11315

 

837 Standard Information Needed to Create the EDI X12 File:

 

Claim Loop/Segment                                               Value

ISA06 (Sender ID)                                                      593715944AVL

*ISA08 (Receiver ID)*                                              113153422

GS02 (Sender Code)                                                 593715944AVL

*GS03 (Receiver Code)*                                         113153422

Loop 1000A (Submitter Identifier) NM109           593715944AVL

**Loop 1000B (Receiver Name) NM103**         FIDELIS CARE NEW YORK

*Loop 1000B (Receiver ID Number) NM109*     113153422

 

PROFESSIONAL

**Loop 2010BB (Payer Name) NM103**                FIDELIS CARE NEW YORK

***Loop 2010BB (Payer ID Number) NM109***   11315

 

INSTITUTIONAL

**Loop 2010BC (Payer Name) NM103**                FIDELIS CARE NEW YORK

***Loop 2010BC (Payer ID Number) NM109***    11315

 

Response Reports
•    277 Report: electronic claim acknowledgement in X12 format.  
•    999 Report: receipt acknowledgment of claims and whether the transaction is in compliance with HIPAA requirements. 
•    RPT Report: information from Fidelis Care, in a non-X12 format, on the status of submitted claims (837 transactions).

 

Note: The above response reports will not be provided as part of the claims-testing process. A Fidelis Care representative will provide direct feedback after testing.

 

Corrected Claims

•    The original claim number must be submitted and the claim frequency type code must be 7 (replacement of prior claim). 
•    2300 Loop, CLM Claim Information Segment, CLM05-3 Claim Frequency Type Code Element must be set to 7
•    2300 Loop, REF Original Reference Number (ICN/DCN) Segment where REF01Element equals F8, REF02 Element must contain the Fidelis Care original claim number

Claims-Testing Feedback 
A Fidelis Care representative will contact you after testing to provide feedback on the testing process.  

If you have any questions about claims testing, please email BHClaimsTesting@fideliscare.org