Fidelis Care Practices for Medications Billed Under the Medical Benefit
3/14/2025
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Posted by Provider Relations
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Provider News
Fidelis Care’s Pharmacy Services would like to provide a reminder and clarity on how to submit claims for medications billed under the member’s medical benefit, as well as the appropriate Servicing Provider to document when submitting a Pharmacy Prior Authorization request for such medications.
A Pharmacy Prior Authorization Request form can be found on the Fidelis Care website within the Utilization Management Programs section.
Documenting the Appropriate Serving Provider
When submitting a Pharmacy Prior Authorization, the Servicing Provider should be the individual provider, facility, or pharmacy who will be supplying and subsequently billing for the supply of the requested medication. This should be clearly indicated on the request form.
- “Buy and Bill” – The individual provider or facility administering the medication will also be supplying the medication. In this case the name of the provider/facility and their NPI or TIN should be provided on the request form.
- “Drop Shipment” – A Specialty Pharmacy will supply the medication to the provider who will be administering the medication. In this case the name of the Specialty Pharmacy and their NPI or TIN should be provided on the request form.
Submitting A Claim
The individual provider, facility, or pharmacy supplying the medication, as indicated on the authorization request form, should be the entity submitting the claim to Fidelis Care for the supply of the requested medication. It is expected that only one claim should be submitted for the supply of the medication. This claim submission should be initiated by the Servicing Provider indicated on the request form.
- “Buy and Bill” – It is expected that the claim for the supply of the medication is submitted by the individual provider/facility indicated on the request form, who is both supplying and administering the medication to the member. Claim submissions should also include a claim line for the appropriate administration CPT code that corresponds to the medication administered to the member. Please ensure that the individual provider and the facility the member is receiving services through do not both bill for the supply of the medication.
- “Drop Shipment” – It is expected that the Specialty Pharmacy indicated on the request form submits the claim for the supply of the medication to Fidelis Care. The individual provider or the facility solely administering the medication should not submit a claim for the supply of the medication as this service is being provided by the Specialty Pharmacy.
For additional questions, or if we can be of assistance in any way, please contact your Fidelis Care Provider Engagement Account Manager. To find your designated representative, please visit Contact Your Designated Provider Relations Specialist.