Fidelis Care has received notice from the Office of the Medicaid Inspector General (OMIG) of new compliance program requirements for Medicaid participating providers.
Effective April 2020, for New York State (NYS) Social Services Law (SSL) §363-d, and effective December 28, 2022, for the corresponding regulations at 18 New York Codes, Rules and Regulations (NYCRR) Subpart 521-1, NYS Medicaid providers shall adopt, implement, and maintain effective compliance programs aimed at detecting fraud, waste, and abuse in the NYS Medicaid program.
Who is Required to Have a Compliance Program?
NYS Social Services Law (SOS) § 363-d and Title 18 of the New York Codes, Rules and
Fidelis Care is pleased to inform you that the most recent 2022 QARR Non-Compliance Report has been posted on Provider Access Online (provider portal). This information is indicative of all encounter data on file with Fidelis Care as of 12/12/2022. Please refer to the most recent "Non-Compliance Report" instruction letter to understand the information being provided on each tab of the Excel Spreadsheet. Please notify any staff involved with quality management and advise that these documents have been posted. If you have any questions, please call the Provider Call Center at 1-888-FIDELIS (1-888-343-3547).
Fidelis Care would like to inform our providers of a new claim denial reason code that will be used when duplicate claim resubmissions are submitted on the same day.
EX CODE: 5V
Description: Exceeded daily submission limit (or frequency) for this claim
Fidelis Care will process the first corrected claim received. Any duplicate submissions of the claim on the same day will reject through the Electronic Data Interchange (EDI) system with the code ‘5V’. This claim denial will not show on the remittance.
Providers will continue to see denial reason code ‘9L’ for invalid corrected claims.
In order to avoid denial, please follow the instructions
Annual cultural competency training for participating providers is required by the New York State Department of Health. At this time, The New York State DOH will only accept the approved training offered by the United States Department of Health and Human Services (HHS), Office of Minority Health education program, Think Cultural Health, to fulfill the requirement for provider annual cultural competency training.*
Once the cultural competency training has been completed, providers need to verify completion of the program by emailing the Cultural Competency Attestation Form to:
The required Cultural Competency Training needs to be completed annually by
Fidelis Care partners with providers to develop and deliver high-quality, cost-effective health care solutions. We understand that maintaining a healthy community starts with providing care to those who need it most. Special Supplemental Benefits for Chronically Ill (SSBCI) are offered to Fidelis Care’s highest-risk members who meet specific criteria for eligibility based on the Centers for Medicare and Medicaid Services (CMS) guidelines.
Effective January 1, 2023, you can check eligibility requirements and submit attestations on behalf of members online at ssbci.rrd.com*; fax attestations will no longer be accepted.
Steps to determine eligibility, submit attestations and activate benefits:
Members are required to schedule an