Welcome, Providers!

Beginning in September 2018, there will be an authorization requirement change for Fidelis Care at Home (FCAH) members who are also covered by a Medicare plan, which is the member’s primary coverage plan.

When a FCAH (a managed long-term care) member is also covered by a Medicare plan, Medicare is the primary payer. Please note:

•    If a Medicare plan pays a service as primary payer, and a claim balance is submitted to FCAH for consideration:
          o    Prior authorization will no longer be required* or issued by FCAH when FCAH is the secondary payer.  
                FCAH will consider the claim balance on a covered service.

                *Prior authorization for the FCAH portion of the claim is no longer required.  Some examples are:

                •    Skilled Nursing Home (SNF) – Skilled Medicare Part A benefits
                •    Durable Medical Equipment (DME)
                •    Any Medicare-primary service in which the Medicaid plan (FCAH) is being considered for
                      reimbursement as the payer of last resort

•    If a Medicare plan denies a service as non-covered and FCAH covers the service with  prior authorization, FCAH pays as primary payer:
          o    Prior authorization is required by FCAH

•    If a service is covered by both a Medicare plan and FCAH, this change does not remove any current prior authorization that is required by the Medicare plan.  

Be sure to submit your claim balance(s) to Fidelis Care with a copy of the Explanation of Medicare Benefits (EOMB) for secondary reimbursement consideration.

If you have any questions, please contact the Provider Call Center at 1-888-FIDELIS (1-888-343-3547) and a representative will be glad to assist you.