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Effective May 1, 2025, the provision of School-Based Health Center (SBHC) and SBHC-Dental (SBHC-D) services will be incorporated into the Mainstream Medicaid Managed Care (MMC) and HIV Special Needs Plan (HIV SNP) benefit package. Therefore, Fidelis Care will be responsible for reimbursing SBHC operators for SBHC services provided to Fidelis Care members. The goal of the transition is to maintain access to these critical SBHC and SBHC-D services while integrating the services into the larger health care delivery system. It is anticipated that the integration of SBHC and SBHC-D services within the existing managed care framework, and coordination of services with

The Fidelis Care Provider Relations Department is committed to building strong and lasting relationships with our providers and their staff.  To foster this partnership, we have assigned a Provider Relations Specialist to communicate important information and provide support to our providers. Please be sure to reference our Contact Your Designated Provider Relations Specialist web page if you do not know the name of the specialist assigned to your provider group.  To note, there are times that we adjust territory assignments to better serve our providers, so it important to periodically verify your assigned specialist. If you are unable to determine the identity

Fidelis Care will host three Provider Office Hours in May 2025. During the webinars, Fidelis Care staff will be available to share information, provide an overview of provider resources, and answer your questions. Provider Office Hours – May 2025   Topic: Fidelis Care – Back to Basics When:  Thursday, May 8th – 9 AM – 10 AM EST Click here to register*   Topic: Fidelis Care and Wellcare - Quality Programs When:  Wednesday, May 28th – 10 AM – 11

Due to regulatory requirements defined in Article 44 of the New York State Public Health Law for all Managed Care Organizations (MCO), Fidelis Care is implementing changes to our Utilization Management/Authorization Appeals process.  Effective June 1, 2025, Fidelis Care will require providers to adhere to a new procedure related to utilization management/authorization appeals.  As of June 1, 2025, Fidelis Care will require a written member consent to process any provider initiated post-decision appeal review requests.  Member consent can be submitted the following ways: Member or the member’s assigned designee signs the designated area on the Appeal Request Form, which is included

The following section of the Fidelis Care authorization grids have been updated effective June 1, 2025.   The following codes have been updated on the Medicaid, Essential Plan, and Ambetter Metal-Level Products Authorization Grids and require prior authorization: B. Durable Medical Equipment/Supplies:                                    T2101 (Donor Breast Milk) only requires an authorization when given in an outpatient setting.              The following codes have been updated on the Essential Plan and Ambetter Metal-Level Products Authorization Grids and require prior authorization: III.       Outpatient surgery: The following services require prior authorization:            D.  Skin surgery and other dermatological procedures: A2025   The following codes have been updated on the Medicaid, Essential Plan, and Ambetter

Fidelis Care would like to remind providers of the updated calculation of hospitals’ initial inpatient acute, exempt hospital, and exempt unit reimbursement rates for Medicaid Fee-for-Service (FFS) and Medicaid Managed Care (MMC), which were effective October 1, 2024.   As per Medicaid DOH site, an administrative letter was published to support reduction to the capital rate add-ons. Providers should have received notification from the State regarding this rate update.    The October 1, 2024 Medicaid FFS rates have been approved by the New York State Division of the Budget (Budget) and have been transmitted to eMedNY for payment and retroactive claims processing.   These rates are