Required Request Form for Administrative Reviews and Provider Appeals Updated
8/1/2019
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Posted by Provider Relations
Fidelis Care has updated the required Provider Appeals Form for providers to use for submitting Administrative Reviews and Provider Appeal requests.
The Provider Appeals Form must be used if a claim has been processed and a remittance advice has been issued from Fidelis Care and the provider is requesting a review. Do not use for first time claims or corrected claims. All claim requests for reconsideration, corrected claims, or claim disputes must be received within 60 calendar days from the date of the remittance.
Before submitting this required form, please be sure the form is completed in its entirety so that your request can be processed immediately. Currently, the form should be mailed as follows:
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Correspondence Type:
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Product:
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Mail to Current Address:
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Claim Administrative
Reconsiderations
Claim Appeals
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Medicaid Managed Care
Child Health Plus
Fidelis Care at Home (MLTC)
HealthierLife (HARP)
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Claims Department
Fidelis Care
480 CrossPoint Pkwy.
Getzville, NY 14068
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MarketPlace:
Qualified Health Plan
Exchange
Off Exchange
Essential Plans
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Medicare Advantage
Medicare Dual Advantage
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If you have any questions, please contact the Provider Call Center at 1-888-FIDELIS (1-888-343-3547).