¡Bienvenidos, proveedores!

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

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

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: CulturalCompetencyTrainingAttestation@fideliscare.org.   The required Cultural Competency Training needs to be completed annually by December 31st. Providers that completed

The following sections of the Fidelis Care authorization grids have been updated effective January 1, 2026.             The following codes have been updated on the Medicaid, CHP, Essential Plan, AmBetter Metal-Level Plans, and Medicare Authorization Grids and require prior authorization: C9307 linvoseltamab-gcpt inj C9308 carboplatin (Avyxa) inj J0013  esketamine, nasal spray J1073  testosterone pellet, implant J3387  elivaldogene autotemcel (Skysona) J3389  prademagene zamikeracel (Zevaskyn) J7528  mycophenolate mofetil, suspension J9184  gemcitabine (Avyxa) inj J9256  nipocalimab-aahu inj J9282  mitomycin intravesical J9326  telisotuzumab vedotin-tllv inj (Emrelis) Q5160 bevacizumab-nwgd (Jobevne)   For Medicaid, CHP, Essential Plan, AmBetter Metal-Level Plans, and Medicare, the following codes have been added to the list of drugs that require NCH review: C9307 linvoseltamab-gcpt inj C9308 carboplatin (Avyxa) inj J9184 

Access to quality care is essential to reducing health disparities and improving the quality and length of life for all New Yorkers.   The New York State Department of Health (NYSDOH) and CMS require that specific Access and Availability Standards be met by Primary Care Providers (PCPs), OB/GYNs, Specialists, and Behavioral Health Providers.   To ensure compliance, Fidelis Care conducts regular Access & Availability surveys to confirm providers meet these state-mandated standards for all Fidelis Care members.   The survey evaluates: Timeliness of appointment scheduling by appointment type Accuracy of provider directory listings Responsiveness of phone systems and office staff   Common issues leading to non-compliance include: Appointment

The Clinical Laboratory Improvement Amendments of 1988 is federal legislation with the objective of ensuring quality laboratory testing. It applies to any facility or individual Provider that performs laboratory services and wants to receive payments under Medicare and Medicaid programs. Fidelis Care will continue to uphold the Federal and State guidelines to ensure laboratory claims submitted by providers meet these requirements: A valid CLIA certificate for the type of tests performed at each location An active CLIA certificate Exceptions are based on both NYS and CMS Regulations          Providers should submit their CLIA number on the claim as follows: Electronic Claim: Loop