¡Bienvenidos, proveedores!

Fidelis Care’s Pharmacy Services would like to provide clarification on how medications are covered under member’s medical and pharmacy benefits.   Medications Covered Under Fidelis Care Medical Benefit Medications that are administered to a member during an outpatient visit are covered under the member’s medical benefit.  The authorization requests and claims for these medications should be processed through Fidelis Care using the guidelines and tips below, for all Lines of Business. Physician Administered Drugs – medications administered to a member during an outpatient visit: Providers obtain medication via “buy-and-bill” or shipment to their practice site from a vendor of their choosing.

Fidelis Care is pleased to announce that a new Provider Bulletin is now available. The bulletin features updates on important initiatives and the latest news of interest to our provider community. Articles in this issue: ·         Don't Forget to Use the Authorization Look Up Tool ·         Notify Fidelis Care of Any Changes to Your Practice ·         Access and Availability Standards ·         Annual Wellness Visits and Follow-Up Patient Reminders ·         Importance of Submitting Medical Records ·         Support Your Patients in Managing Diabetes Please download Fidelis Care Provider Bulletin – Volume 11, Issue 2.   To view our Provider Bulletin Library, please visit: Provider Bulletins.

Fidelis Care would like to notify our providers of an update to our Children and Family Treatment and Support Services (CFTSS) Utilization Review Process.  Effective July 1, 2025, Fidelis Care will begin Utilization Management on certain CFTSS Services with a service date of July 1, 2025 or later. Services rendered and billed through June 30, 2025, will process with no authorization requirements.   Fidelis Care will require notification of the initiation of CFTSS Services, and provider must request prior authorization after the 3rd Visit for the following services. Other Licensed Practitioner (OLP) Community Psychiatric Supports and Treatment (CPST) Psychosocial Rehabilitation (PSR) Family

The following section of the Fidelis Care authorization grids have been updated effective July 1, 2025.   The following DME codes have been removed from the Medicaid, Essential Plan, and Ambetter Metal-Level Products Authorization Grids and no longer require prior authorization: K0001  Standard wheelchair L0621  SIO flex pelvisacral prefab L2630  Pelvic control band and belt B L3809 Whfo w/o joints pre ots   The following code has been updated on the Medicaid, Essential Plan, and Ambetter Metal-Level Plans Authorization Grids and requires prior authorization: Q0224   pemivibart (Pemgarda)   The following codes have been updated on the Medicare, Medicaid, Essential Plan, and Ambetter Metal-Level Plans Authorization Grids and require prior authorization: C9174   datopotamab deruxtecan-dlnk

The Centers for Medicare and Medicaid Services (CMS) requires that providers receive Medicare Special Needs Program (SNP) Model of Care (MOC) Training annually.  As part of our ongoing commitment to access, quality of service, and quality of care for our members, Fidelis Care provides this training annually and during the new contract process to all network providers, as well as to providers who regularly see our SNP members.    The training module can be accessed by logging into our provider portal, please visit Provider Access Online.  After logging in, if training and attestation is required, you will receive a notification on the Home Page. 

Fidelis Care will host three Provider Office Hours in June 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 – June 2025   Topic: Behavioral Health Overview When:  Thursday, June 12th – 11 AM – 12 PM EST Click here to register*   Topic: Fidelis Care and Wellcare - Quality Programs When:  Wednesday, June 25th – 10 AM – 11 AM EST