Provider Resources

Fidelis Care Provider Tip Sheet Library
A Tip Sheet Library has been developed to provide information on the various products and benefits managed by Fidelis Care. 

Fidelis Care Treatment/Service Request Forms
To request prior authorization from Fidelis Care:

  • By Fax - visit Treatment/Service Request Forms
  • By provider portal submission - visit Provider Access Online (Fidelis Care's Provider Portal) to request the following services only: outpatient behavioral health (BH), occupational therapy (OT), physical therapy (PT), speech therapy (ST), or durable medical equipment (DME). 

Fidelis Care Authorization Requirements
To provide you with the most effective and efficient customer service, Fidelis Care requires that provider office staff have the following information readily available when calling to request an authorization:

  • Tax ID
  • IPA Affiliation, if applicable
  • Member ID
  • Date of Service(s)
  • Procedure Code
  • ICD-10 Diagnosis Code 

If this information is not readily available, our Provider Call Center staff will ask the caller from your office to obtain the information and call again. This will enable Fidelis Care to process authorization requests in a more efficient manner, and provide you and our members with the best possible care and service. Please share this information with your appropriate staff members. 

eviCore Authorization Program
Fidelis Care has engaged eviCore healthcare* (eviCore) to implement a new prior authorization program to manage outpatient high-tech Radiology services, Non-Obstetrical Ultrasounds, diagnostic Cardiology services, and Radiation Therapy services being rendered on or after October 1, 2017. 

For further details regarding this new prior authorization program, refer to the additional links provided below.
Provider Tip Sheet: eviCore Program (Includes FAQs)
For a full list of the procedure codes included in this eviCore Program, visit eviCore's website at: https://www.evicore.com/healthplan/fideliscare

If you have any questions about this new prior authorization program, contact Fidelis Care's Provider Call Center at 1-855-505-5327, or your Provider Relations Representative. *Learn more about eviCore healthcare

Smoking Cessation Resource Guide
Fidelis Care and its Quality Health Care Management team (QHCM) are pleased to provide a Smoking Cessation Resource Guide to help support our members who are ready to quit smoking. Please encourage your Fidelis Care patients to use this resource and sign up for one of the many Free Smoking Cessation Classes that are available to them across NYS.

National Correct Coding Initiative Edits
The Center for Medicare & Medicaid Service (CMS) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate claim payment. These policies are based on coding conventions defined in the American Medical Association's (AMA) CPT Manual, National and Local Coverage Determinations (NCD and LCD), coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. These standards set the coding requirements that all plans and providers must follow in order to secure reimbursement for all lines of business.

Claims that are found to be noncompliant with these guidelines may be returned and/or denied.

Please visit the sites below for additional information:

NCCI Edits - http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html
AMA - http://www.ama-assn.org/ama
NCD - http://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx
LCD - http://www.cms.gov/medicare-coverage-database/indexes/lcd-state-index.aspx

Anesthesia Modifier Guidelines for Medicare Claims
In accordance with the Centers for Medicare & Medicaid Services (CMS) coding guidelines, Anesthesiology claims for Medicare patients must include the appropriate modifier(s), in the correct positions, in order to qualify for payment by Fidelis Care. Please click on the link above for a summary of anesthesia coding guidelines.

Peer-to-Peer Reconsiderations (non-Medicare products)
Providers may contact Fidelis Care to request a peer-to-peer reconsideration of an adverse determination. Peer-to-Peer Reconsiderations can be requested following an adverse determination of a pre-service or concurrent request.

How to request: Peer-to-Peer Reconsiderations are conducted telephonically and may be requested either by contacting Provider Services at 1-888-FIDELIS (1-888-343-3547) or by fax at 800-860-8720. Following receipt of the request, Fidelis Care will contact the provider to schedule and conduct the peer-to-peer discussion within one business day. The peer-to-peer discussion will be conducted by the same clinical peer reviewer who rendered the original determination if he/she is available.

When is a peer-to-peer reconsideration not available? Peer-to-Peer Reconsiderations are not available if an appeal has already been requested or if the original review was retrospective (after services had been rendered). The completion of a peer-to-peer reconsideration does not affect the right to request an appeal. An appeal may be initiated whether or not there has been a reconsideration, or after a reconsideration has occurred.

Can an appeal be requested following a Peer-to-Peer Reconsideration? Yes. The completion of a peer-to-peer reconsideration does not affect the right to appeal.

Regulatory Time Frames for Utilization Management Decisions
As a reminder to hospital providers, the attached documents define the regulatory time frames for utilization management that apply to Medicaid, Medicare, and NY State of Health & Child Health Plus members.

The Care Of Older Adults Assessment (.pdf)
The care of older adults is increasingly important. Older adults are faced with various health issues: physical, mental and psychosocial. Many of them are on medication regimens than can be challenging and complicated. Most older adults would prefer to discuss advance care planning with their doctors with whom they have a relationship while they are well. The four elements to ensure a comprehensive assessment of older adults are:

  • Advance care planning
  • Medication review
  • Functional status assessment
  • Pain assessment 

All four elements are captured on the Care of Older Adults Assessment Form. Completing this form annually and making it part of the patients medical records would allow for early intervention and also meet the HEDIS requirement.

Case Management Services

Fidelis Care offers case management services to members by phone. Our case managers provide support to encourage appointment and medication adherence. We also work with members to increase their engagement and participation in improving their health care outcomes. We have several different programs that are staffed by registered nurses and other trained professionals, including but not limited to: 

  • Diabetes Case Management
  • Cardiac Case Management
  • Prenatal Case Management
  • Behavioral Health Case Management
  • HIV Case Management
  • Complex Case Management

To make a referral or to receive more information, please call Fidelis Care Clinical Services at 1-800-247-1441.


Fidelis Care Claims Editing Software
Fidelis Care utilizes TriZetto's Claims Editing Software to automatically review and edit health care claims submitted by physicians and facilities. The software checks each claim for errors, omissions, and coding relationships by testing the data against an expansive knowledge base containing government, industry and corporate rules, regulations, and policies governing health care claims. The software is designed to streamline claims processing workflows, reduce reimbursement errors, and improve payment integrity.

New York City Providers: Online Reporting of Blood Lead Testing
You are now able to electronically report blood lead level (BLL) results for children to the NYC Department of Health and Mental Hygiene (DOHMH) via the Online Registry. Reporting results electronically via the Online Registry is now the preferred method of reporting. For additional information, visit  
http://www1.nyc.gov/assets/doh/downloads/pdf/cir/cir-full-guide.pdf

Personal Care Services
Personal Care Services (PCS) benefits have been added to the Medicaid managed care benefit effective 8/1/11. For new referrals, physicians will need to fax the completed order form to Fidelis Care at 1-877-882-5875 before an in-home assessment can be scheduled. Please click on the link above to access the required PCS forms.

Provider Transportation Application For Members
Fidelis Care New York Provider Transportation Application For Members.

HIPPS Rate Codes Required for Skilled Nursing Facilities and Home Health Agency Claims
As mandated by the Centers for Medicare & Medicaid Services (CMS), effective for dates of service occurring on or after July 1, 2014, skilled nursing facilities (SNF) and home health agencies (HHA) must include the appropriate Health Insurance Prospective Payment System (HIPPS) rate codes when submitting Medicare claims for patient assessments. Medicare claims that do not contain the applicable HIPPS rate and Resource Utilization Groups (RUGs) codes will be returned or denied. Find additional information here.

Immunization Administration Processing Guidelines
Please refer to the following notice regarding the new National Correct Coding Initiative (NCCI) editing for billing an office visit (E&M) code and a vaccine administration service on the same day. If you have any questions, please call Fidelis Care’s Provider Call Center at 1-888-FIDELIS (1-888-343-3547).

Medicaid Update – New Obstetric Delivery Billing Requirements
Payment Reductions on Elective Delivery (C-Section and Induction of Labor) Less than 39 Weeks without Medical Indications:
Effective September 1, 2017, Fidelis Care will further reduce payment for early elective deliveries without an acceptable medical indication. Claims for elective deliveries prior to 39 weeks, without medical indication, will be reduced by 75% per a recent Medicaid policy update. The increased penalty from 50% to 75% reflects the Medicaid Program's commitment to providing high quality prenatal care by ensuring appropriate delivery for both mothers and babies.

Additionally, for medical claims modifiers U8 or U9 will continue to be required for all deliveries and claims for hospital inpatient stays associated with a delivery will continue to require a condition code 81, 82, or 83 for payment. Failure to include the appropriate modifiers and/or condition codes will result in claim denials. For further information on elective delivery billing requirements, visit Further Payment Reductions on Deliveries