Bienvenidos, Corredores!

As a reminder to our Fidelis Care providers, please use the mailing addresses below when submitting paper appeals, reconsiderations, and corrected claims. Using these addresses will help Fidelis Care process your claims more quickly and efficiently.

* Providers are strongly encouraged to submit corrected claims electronically.  Please see below for detailed instructions.

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.

Electronic Submission of Corrected COB Claims

• The original claim number must be submitted 
• The claim frequency type code must be a 7 (replacement of prior claim)
• 2300 Loop, CLM Claim Information Segment, CLM05-3 Claim Frequency Type Code Element must be set to a 7 and 2300 Loop
• REF Original Reference Number (ICN/DCN) Segment where REF01 Element equals F8, REF02 Element must contain Fidelis Care Original Claim Number
• Only one correction for a Fidelis Care Original Claim Number should be submitted per day

Electronic Submission of Corrected Claims

• The original claim number must be submitted 
• The claim frequency type code must be a 7 (replacement of prior claim)
• 2300 Loop, CLM Claim Information Segment, CLM05-3 Claim Frequency Type Code Element must be set to a 7 and 2300 Loop
• REF Original Reference Number (ICN/DCN) Segment where REF01 Element equals F8, REF02 Element must contain Fidelis Care Original Claim Number
• Only one correction for a Fidelis Care Original Claim Number should be submitted per day