Quality Management

Important Information on Coverage Decisions

As required by NCQA accreditation guidelines, Fidelis Care is providing the following information to employees, providers, and members. 

Each day, Fidelis Care's Utilization Management (UM) Department makes decisions on numerous health insurance claims. These decisions are based only on appropriateness of care and the existence of coverage. 

Fidelis Care does not reward practitioners or other individuals for issuing denials of coverage, and does not offer financial incentives to UM staff that would encourage decisions that result in underutilization of services. 

Fidelis Care is committed to ensuring that members have the care and services they need. 

BabyCare Incentive Program

Fidelis Care is pleased to continue its BabyCare Incentive Program for 2018.

Treatment / Service Request Forms
Based on your feedback, Fidelis Care has streamlined the process for requesting certain covered services.

Weight Assessment and Counseling for Children/Adolescents (WCC) and Adolescent Preventive Care (APC)
New York State Department of Health (SDOH) and the National Committee for Quality Assurance (NCQA) have both stressed the importance of guiding children and adolescents towards healthy behaviors. SDOH and NCQA outline the importance of correct medical record documentation to assure that providers’ counseling efforts are acknowledged. One way to ensure that patients are appropriately assessed is for providers to use a checklist to document their work. Fidelis Care has created one-page documents for WCC and APC that are easy to use and cover the key elements of both measures. Providers need to complete the forms annually and place them in their medical record, or scan them into their electronic medical record. 
Click here for cover letter from Fidelis Care’s Chief Medical Officer
Click here to access WCC_APC Forms