¡Bienvenidos, proveedores!

New York CMS Cell Gene Therapy Access Model Update The New York State (NYS) Department of Health has applied to participate in the federal Centers for Medicare and Medicaid Services (CMS) Cell and Gene Therapy (CGT) Access model. The model is voluntary for State Medicaid programs and manufacturers and will test whether a CMS-led approach to developing outcomes-based agreements (OBAs) for cell and gene therapies increases Medicaid beneficiaries’ access to innovative treatment, improve health outcomes, and reduces health care costs to State Medicaid programs. The initial focus of the model is on gene therapies for people living with sickle cell disease,

Fidelis Care would like to inform providers that evaluation and management (E&M) services billed on a facility claim with treatment room revenue codes are not eligible for reimbursement.  Evaluation and Management procedure codes represent the professional service – the physician or qualified provider’s time, assessment and decision- making. Treatment room revenue codes (760, 761 and 769) represent the facility charge for use of space, supplies, and staff for treatment or observation of a patient. Treatment rooms are typically used when a therapeutic or diagnostic procedure (e.g., an infusion, injection wound care) is performed, not when the visit consists primarily of evaluation

Fidelis Care is pleased to announce the release of our 2025 Community Impact Report, a comprehensive look at how we worked together to make a difference in communities across New York State. The report reflects our shared commitment to health equity, access, and whole-person care. These values guide every interaction with our members and every partnership with providers like you. From expanding preventive services to addressing health-related social needs, the report showcases how collaboration drives meaningful change.   The report details initiatives that directly impact your work and your patients, including nearly $650,000 in Health Equity Grants, expanded StreetSide RV outreach, and

Fidelis Care would like to remind providers of the upcoming change to Medicaid pharmacy benefits for phosphate binders used by dialysis patients.   Effective January 1, 2026, phosphate binder prescription drugs for New York Medicaid members utilizing dialysis will no longer be covered as a pharmacy benefit via NYRx, the Medicaid Pharmacy Program, and must be provided by the dialysis clinic as part of the bundled dialysis payment. See below for a list of Phosphate Binders: Auryxia™ Calcium acetate Ferric citrate Fosrenol® Lanthanum carbonate Renvela® Sevelamer carbonate Sevelamer HCl Velphoro® Xphozah®   For additional information, please see the following communications from the New York

The following sections of the Fidelis Care authorization grids have been updated effective March 1, 2026.             The following codes have been added to the Medicaid, Medicare, Essential Plan, and Qualified Health Plan Authorization Grids and require prior authorization: III.       Outpatient surgery: The following services require prior authorization:                   D.  Skin surgery and other dermatological procedures:                        · Only the following codes continue to require authorization for any place of service: Q4398, Q4399, Q4400, Q4401, Q4402, Q4403, Q4404, Q4405, Q4406, Q4407, Q4408, Q4409, Q4410, Q4411, Q4412, Q4413, Q4414, Q4415, Q4416, Q4417, Q4420, Q4431, Q4432, Q4433                    K.  Vascular procedures

Effective January 1, 2026, providers are required to submit an authorization request for Group and Family Therapy services that exceed 30 visits in a calendar year. The concurrent review requirements will include Mental Health Group and Family Therapy, but excludes Substance Use Disorder (SUD) treatment when the provider/service(s) is/are Article 32 licensed, certified, or otherwise authorized.   The following Mental Health services will require concurrent authorization once the initial 30 visits have been completed: Family Psychotherapy - CPT Code 90847 Fidelis Care will have notification & concurrent review requirements for Family Psychoeducation for any requests after the initial 30 visits per calendar