Welcome Providers!

Quick Links

Provider Access Online 

Provider Manual | Provider Manual - Metal-Level Products and Essential Plans | Transportation Provider Manual | Authorization Grids | Pharmacy Services | Access and Availability Standards | Provider Bulletins | Provider Education | Provider Resources | Quality Management | Electronic Submissions | Consumer Directed Personal Assistance Services (CDPAS) | eviCore HealthcareFind a Doctor


Special Announcements

2017 Medicare Risk Adjustment:  Medical Records Now Due
12/14/2017 • Posted by Fidelis Care
Fidelis Care has sent two previous requests for medical records. To date, we have not received all of the requested records. The Medicare Risk Adjustment Letter and member medical record request lists for the 2016 review year are now available on Provider Access Online. Please notify any staff members involved with quality management programs to ensure all requested medical records are received no later than January 12, 2018


Provider Remittance Advice Statements Revised
12/8/2017 • Posted by Fidelis Care
Fidelis Care is pleased to inform providers that beginning on December 15, 2017, you will find that enhancements have been made to the Provider Remittance Advice Statements (RAs). 

You will find that the RAs have been standardized across all lines of business so that they all have the same “look and feel” and contain the same information.  Some of the enhancements you will find are:

     • Claims COB PO Box added:
            Coordination of Benefits
            Fidelis Care
            P.O. Box 905
            Amherst, New York  14226-0905
      • Claims are categorized by:
            o Inpatient – inpatient institutional only
            o Outpatient – outpatient institutional; inpatient and outpatient professional
            o Adjusted – inpatient and outpatient institutional and professional
      • Remarks/Explanation Codes are now displayed after each claim (rather than on just the last page)
      • MOD field now displays multiple modifiers
      • Units Allowed – added
      • Computed DRG Codes – now display (if applicable)
      • Payment Summary has been enhanced. Some of these enhancements are:
            o Summary has moved to the bottom of the RA
            o Total Denied – sum of the total adjusted dollars and non-covered dollars
            o Member Cost Sharing

We hope you will agree that the enhancements we’ve made to the Provider Remittance Advice Statements are truly improvements and provide you a better user experience.   For a sneak peek at a revised RA, download Provider Remittance Advice


Universal Billing Codes for Home Care and Adult Day Health Care Services - *New Implementation Date*
12/8/2017 • Posted by Fidelis Care
Fidelis Care is notifying providers that the New York State Department of Health (DOH) has announced that the 1/1/2018 implementation date of the Universal Billing Codes has been moved to 4/1/2018

This change will allow additional time for plans and providers to update systems and prepare for proper training of this initiative.  It is expected that plans and providers will continue to work together to perform any necessary code testing in order to help prevent potential payment disruption.

For the NYSDOH update, visit DAL-Universal billing Codes for Home and Community LTC

Fidelis Care will continue to post updates on this initiative as information becomes available.


Important Medicare Part D Formulary Changes for the 2018 Plan Year
12/6/2017 • Posted by Fidelis Care
On January 1st, 2018, the Medicare Preferred Drugs lists will change.  Impacted members and providers have been notified of the upcoming changes.  The preferred drug lists for 2018 and a comprehensive list of comparable, alternative drugs can be found here:

https://www.fideliscare.org/en-us/products/medicareadvantageanddualadvantage/prescriptiondruginformation.aspx

Please review the formulary alternative(s) with your patients and determine if it is appropriate for his or her condition.  If you feel the suggested alternative is not appropriate, you may request a formulary exception by completing and submitting the form available at:

https://www.fideliscare.org/apps/medicareDrugRedetermination/


Flu Season 2018 - Tamiflu®
12/4/2017 • Posted by Fidelis Care
As the flu season is upon us, Fidelis Care is informing providers of the availability of oseltamivir (Tamiflu®) for our Fidelis Care members in the following lines of business:

Medicaid Managed Care (MMC)
Child Health Plus (CHP)
HealthierLife (HARP)

For additional detail regarding oseltamivir (Tamiflu®) quantity, day supply and age limits, as well as CDC influenza treatment recommendations and reminders, please download Flu Season 2018


Most Recent 2017 QARR Non-compliance Report Now Available
12/4/2017 • Posted by Fidelis Care
Fidelis Care is pleased to inform you that the most recent 2017 QARR Non-Compliance Report has been posted on our provider portal, Provider Access Online.  This information is indicative of all encounter data on file with Fidelis Care as of 10/16/2017.  Please refer to the most recent "Non-Compliance Report" instruction letter to understand the information being provided on each tab of the Excel Spreadsheet.  Please notify any staff involved with quality management and advise that these documents have been posted.  If you have any questions, please contact the Provider Call Center at 1-888-FIDELIS (1-888-343-3547).

 

11/29/2017 • Posted by Fidelis Care
The following sections of the Fidelis Care authorization grids have been updated effective January 1, 2018.
Applies to All Product Lines of Business (LOB).  The following services require prior authorization:

II or III.  Outpatient surgery: 
    J.  Facial cosmetic, septoplasty, rhinoplasty:  31298 (added)
    K.  Vascular procedures i.e. vein stripping, ligation, ablation and sclerotherapy:  36465-36466, 36482-36483 (added)

IV or V.  Outpatient and DME Services:
    F. Outpatient Therapy: Physical, Occupational, Speech Therapy:  The initial evaluation and the first 10 visits of each
    therapy type do not require prior authorization.  Additional visits beyond the first 10, do require authorization, including
    swallow function and therapy.

    Note: For Medicare LOB only:  Fidelis Dual Advantage Flex Members (Plan 017) have a separate $1,980.00 annual
    dollar limit for Physical and Speech Therapy combined, and $1,980.00 annual dollar limit for Occupational Therapy.

    H.  Therapeutic Services:
          1.  Phototherapy: 96573-96574 (added)
          3.  Pain Management Codes:  64551-64564, 64566-64594 (ranges added 
               to existing codes 64550, 64595)
          7 or 8.  Ambulatory continuous glucose monitoring:  95249 (added)                        
    
IX.  Pharmacy:  
     B.  Injectable codes:  J0596, J0597, J0598, J7327, J7328, Q2040 (added)


Prior Authorization Requirements are Changing in 2018 for Outpatient Physical Therapy (PT), Occupational Therapy (OT), & Speech Therapy (ST)
11/27/2017 • Posted by Fidelis Care
Beginning on January 1, 2018, Fidelis Care will no longer require prior authorization for the first ten (10) outpatient PT, first ten (10) outpatient OT, and first ten (10) outpatient ST visits each calendar year.  When requesting authorization for additional PT, OT, and ST visits (beyond the 10th visit within the calendar year), providers must submit supporting clinical documentation, including the progress notes for all visits incurred, in order for Fidelis Care to review the request and determine if additional visits are medically necessity.  It is not necessary to submit an authorization request until the first 10 visits, within each discipline, have occurred.  If you have any questions, please contact Fidelis Care’s Provider Call Center at 1-888-FIDELIS (1-888-343-3547).


Enrollment of Medicaid Managed Care Behavioral Health Providers in Medicaid
11/22/2017 • Posted by Fidelis Care
The NYS Office of Mental Health (OMH) and Department of Health (DOH) held a webinar to clarify the provider enrollment requirements for OMH Licensed Providers and Designated Adult Behavioral Health (BH) and Home and Community Based Services (HCBS) Providers. The webinar was focused on the recent DOH initiative to assure enrollment of enrollable MMC plan network providers into Fee-for-Service (FFS) Medicaid. The introduction of the 21st Century Cures Act in December 2016, points to a need to identify provider and agency types that may need to enroll before December 31, 2017. Visit the mctac-ctac website and click Download to view the PowerPoint training presentation.


IMPORTANT - Fidelis Care FIDA Plan Will Not be Offered in 2018
10/30/2017 • Refreshing Post by Fidelis Care
Fidelis Care will no longer be participating in the Fully Integrated Duals Advantage (FIDA) program as of December 31, 2017.  

 

Fidelis Care is notifying all members who are currently enrolled in the Fidelis Care FIDA Plan with information on choosing another FIDA Plan for 2018.  Members will need to take action by December 31, 2017, or will automatically be enrolled into another FIDA Plan by New York Medicaid Choice effective January 1, 2018.

Members who want to choose their plan, get more information about other FIDA plans, or learn about Managed Long Term Care (MLTC) plans in their county can call New York Medicaid Choice at 1-855-600-3432.  

For all other questions, please contact the Provider Call Center at 1-888-FIDELIS (1-888-343-3547).


QCMI Quarterly Reports Available on PAO
11/20/2017 • Posted by Fidelis Care
Effective with the 3rd quarter 2017 QCMI provider payments, the detail reports for the quarterly incentive awards are available on Provider Access Online (PAO).  The reports will no longer be mailed with the QCMI payments.  If you have any questions, please contact the Provider Call Center at 1-888-FIDELIS (1-888-343-3547).


Coming 1/1/2018 - Universal Billing Codes for Home Care and Adult Day Health Care Services
11/16/2017 • Posted by Fidelis Care
Fidelis Care is reminding providers that the New York State Department of Health (SDOH) has amended the New York State Public Health Law to require universal billing code changes for home and community-based long term care services claims.  The SDOH is requiring the implementation of the new required universal billing codes by January 1, 2018.

Below are links to the 9/22/2017 SDOH letter, to Providers and Plans, and informational materials on the required universal billing code changes:

 

• New York State Department of Health Letter:  Universal Billing Codes for Home Care and Adult Day Health Care Services
• Attachment A:  Home Care Billing Codes and Modifiers
• Attachment B:  Adult Day Health Care Billing Codes and Modifiers
 
As indicated in the SDOH letter, the Public Health Law has been amended to require electronic payments of claims under contracts or agreements between long-term care providers and managed long-term care plans or managed care plans.  These payments are required to be paid via electronic funds transfers (EFT).  If you are not currently receiving EFT payments, you will need to sign up and complete the online EFT Enrollment request for information.

Fidelis Care is currently reviewing the coding changes and will be communicating additional information including a “crosswalk” of codes to providers as soon as the analysis is completed.  Please be sure to continue to check this page and/or Provider Access Online (Fidelis Care’s secure provider portal) regularly for updates on this important mandate.  More information to follow.



Provider Manual Section 13B - Provider Invoice Fax Form

11/15/2017 • Posted by Fidelis Care
Fidelis Care is pleased to announce a new Provider Invoice Fax Form.  This form should be used when requesting a Claim Reconsideration for a denied claim that requires an original manufacturer’s invoice for payment consideration.  To help expedite review of your claim(s) for reconsideration, please be sure to limit this form and request to a maximum of three (3) claims per form.  

Requests for claim reconsiderations must be submitted within 60 days of the date of the remittance advice (RA) for the claim at issue.  For all requests, fax a copy of this form with the original claim, remittance advice, and original manufacturer’s invoice to Fidelis Care at 1-877-247-9187*.  *This fax number is for claim reconsiderations for invoices only. 


2017 Medicare Risk Adjustment Medical Record Request Reminder Letter is Now Available
11/03/2017 • Posted by Fidelis Care
Fidelis Care has previously sent a request for medical records. To date, we have not received the requested records. The Medicare Risk Adjustment Letter and member medical record request lists for the 2016 review year are now available on Provider Access Online.  Please notify any staff members involved with quality management programs to ensure all requested medical records are received no later than November 24, 2017.


Most recent 2017 QARR Non-compliance Report now Available
10/31/2017 • Posted by Fidelis Care
Fidelis Care is pleased to inform you that the most recent 2017 QARR Non-Compliance Report has been posted on our provider portal, Provider Access Online.  This information is indicative of all encounter data on file with Fidelis Care as of 09/18/2017.  Please refer to the most recent "Non-Compliance Report" instruction letter to understand the information being provided on each tab of the Excel Spreadsheet.  Please notify any staff involved with quality management and advise that these documents have been posted. If you have any questions, please call the Provider Call Center at 1-888-FIDELIS (1-888-343-3547).


Paper Claim Submission Updates
10/19/2017 • Posted by Fidelis Care
There may be situations where you need to submit paper claims.  When doing so, please follow the guidelines below for proper completion of paper claim forms.

Transportation Required field:
CMS-1500 Ambulance Services Point of Pick-up/Drop-off:
FL 32:  Service Facility Location Information field for ambulance services must include and be billed with the Point-of-Pickup and Point-of-Drop-off locations.

Claim Submission Guideline for Claims with Attachments
If a claim is being submitted with an attachment, please submit the claim form first with the attachment following the claim.

Guidelines for Corrected Claims
Effective immediately, providers who are submitting corrected claims to Fidelis Care must follow the claim and field billing guidelines below:

• UB-04 Corrected Claims:
         FL 04:  Type of Bill field should be billed with code “0XX7”, and
         FL 64:  Document Control Number field should be billed with the Fidelis Care original claim number.
 
• CMS-1500 Corrected Claims:
         FL 22:  Resubmission Code field should be billed with a “7” and the Original Reference Number field should be billed with the
         Fidelis Care original claim number.  


Provider Resources Page Update October 2017
10/12/2017 • Posted by Fidelis Care
The Provider Resources page has been updated to include the ‘eviCore Authorization Program’, which became effective 10/1/2017, the Smoking Cessation Resource Guide, and an update to ‘Medicaid Update – Obstetric Delivery Billing Requirements.’  To navigate to this page, go to fideliscare.org , click the Providers tab, and then click Provider Resources.


New Prior Authorization Program Effective 10/1/2017
08/01/2017 • Reposted by Fidelis Care
Fidelis Care has engaged eviCore Healthcare* (eviCore) to implement a new prior authorization program to manage outpatient high-technology Radiology services, Non-Obstetrical Ultrasounds, diagnostic Cardiology services, and Radiation Therapy services being rendered on or after October 1, 2017.

For further details regarding this new prior authorization program, refer to the additional links provided below.

Provider Tip Sheet:  eviCore Program(includes FAQs)

For a full list of the procedure codes included in this eviCore Program, visit eviCore’s website at:  https://www.evicore.com/healthplan/fideliscare

If you have any questions about this new prior authorization program, contact Fidelis Care’s Provider Call Center at 1-855-505-5327, or your Provider Relations Representative.
  * Learn more about eviCore healthcare


Fidelis Care Authorization Request Fax Lines Reference Tool Tip Sheet
09/29/2017 • Posted by Fidelis Care
To help expedite your authorization fax requests, please use the  Request for Authorization Fax Lines Reference Tool Tip Sheet .  The document lists the authorization fax lines by service and lines of business.


Important Notice - Medicaid Managed Care - Action Required by 12/1/2017
09/26/2017 • Posted by Fidelis Care
Effective January 1, 2018, Federal law requires that all Medicaid Managed Care and Children´s Health Insurance Program network providers be enrolled with New York State (NYS) Medicaid programs. 

Fidelis Care will be notifying Medicaid Managed Care providers who are providing services to Fidelis Care Medicaid eligible members who are not actively enrolled with the NYS Medicaid program.  Providers must enroll in NYS Medicaid by 12/1/2017, or you may be removed from the Fidelis Care Medicaid Managed Care network.

The Medicaid provider enrollment process is to ensure appropriate and consistent screening of providers and improve program integrity.  In order to enroll, you will need to complete paperwork and submit it to NYS Medicaid. Please go to: https://www.emedny.org/info/ProviderEnrollment/index.aspx and navigate to your provider type to print and review the Instructions and the Enrollment form. At this website, additional instructions on enrollment are provided.

Important: Your application must be received by CSRA, the Medicaid fiscal agent, by December 1, 2017. If you have questions during the NYS Medicaid Enrollment process, please contact CSRA’s eMedNY Call Center at (800) 343-9000.


Provider Manual Section 12 - Affidavit Form Update
09/26/2017 • Posted by Fidelis Care
The Provider Manual, Section Twelve (12) – Affidavit of Lost/Stolen/Destroyed Check has been updated with the following additional information:

Send this ‘Affidavit of Lost/Stolen/Destroyed Check’ to:

Attn: Provider Reimbursement – Finance
Fidelis Care
95-25 Queens Blvd
Rego Park, NY 11374

Provider Manual - Section 12A - Affidavit Form

Provider Manual - Metal-Level Products and Essential Plans - Section 12B - Affidavit Form


Fidelis Care Authorization Grids Effective November 1, 2017
09/22/2017 • Posted by Fidelis Care
The following section of the Fidelis Care authorization grids has been updated effective November 1, 2017:  

Applies to All Product Lines of Business:
IV.  Outpatient and DME Services:

          The following services require prior authorization:

H.  Therapeutic Services:

      3 or 4.  Pain Management Codes:

                   62327 (added to the range 62320 – 62327)



Care for Older Adults Assessment Form – September 2017 Update
09/22/2017 • Posted by Fidelis Care
As your partner in quality care, Fidelis Care would like you to know that providing appropriate and timely care for older adults (COA) is becoming increasingly more important.   


The National Committee for Quality Assurance (NCQA) has created an annual HEDIS measure to evaluate the care of older adults by reporting the proportion of adults over 66 years of age who had an annual review to cover:  advance care planning, medication review, complete functional status assessment, and comprehensive pain assessment.   

Fidelis Care has created a one-page document that covers the four key elements of the HEDIS measure. These four assessments must be conducted at least once a year.  Send a copy of the completed form and a current medication list no later than January 1, 2018, via mail or fax, to:

 

Quality Management Department (Attention: Care for Older Adults)

Fidelis Care

95-25 Queens Boulevard, 8th floor

Rego Park, NY 11374

 

Or fax: 718-896-1610 (Subject: Care for Older Adults)

 

Visit Care for Older Adults Assessment Form


Provider Directory Attestation
09/13/2017 • Posted by Fidelis Care
Beginning September 19, 2017, participating providers will be asked to verify their provider directory information that is available on Provider Access Online (Fidelis Care's Provider Portal).  After logging in to the provider portal, if you have not yet attested to your provider directory information, you will find an alert message, "Please verify your information for our provider directory", displayed at the top of the Home page.  To begin the provider directory review and attestation of records, visit Provider Access Online.


Fidelis Care to Join with Centene, One of the Largest Medicaid Managed Care Organizations in the Country

09/13/2017 • Posted by Fidelis Care
For nearly 25 years, the mission of Fidelis Care has led us to be a high-quality health plan that is a healthcare partner, neighbor, and friend in communities across New York State. 

Today, we are taking a major step to 
ensure that the mission of Fidelis Care will be strengthened for the future by announcing that we have reached an agreement under which Fidelis Care will become Centene’s health plan in New York State. Centene will maintain the Fidelis Care name, mission, management team and staff, and our grassroots, community-based approach will continue across New York State.

This announcement is the result of a lengthy, comprehensive review of strategic options by our Board of Directors, in partnership with executive leaders, to determine how we could best continue our mission and position Fidelis Care for the future. 

By joining with Centene, Fidelis Care will have the support, investment, and innovation that are necessary to meet the health care needs of our members and your patients – today and in the future. Centene’s scale, expertise, and resources – including its advanced data and analytics – will enable us to further enhance the well-being of Fidelis Care’s members and continue to build linkages and systems for the coordination of care and services. Our shared goal is to improve the health care experience not only for members, but also for providers.

Most importantly, Fidelis Care’s mission and values are shared by Centene. Centene’s core philosophy is that quality healthcare is best delivered locally, and that a local, decentralized approach helps to provide members with access to high-quality and culturally sensitive care and service. Fidelis Care has always focused on this local commitment. Our relationship with Centene will enhance our work together on behalf of members and providers. 

Please note that until the closing, Fidelis Care and Centene remain separate companies, and all current contracts remain in effect. There is nothing that Fidelis Care members need to do. Members will continue to use their Fidelis Care member ID card, and have the same coverage and benefits.

If you have any specific questions related to this announcement, please see your Fidelis Care Provider Relations Representative. Fidelis Care is proud to be your health care partner, and we look forward to our continued relationship on behalf of the members we serve.


HealthierLife (HARP) Performance Improvement Project (PIP)
09/07/2017 • Posted by Fidelis Care
2017-2018 HealthierLife (Health and Recovery Plan - HARP) Performance Improvement Project (PIP): Improving HARP Behavioral Health Inpatient Care Transitions Back into the Community

For the next 2 years (2017-2018), Fidelis Care is required by the New York State Department of Health (SDOH) to engage in a HARP Performance Improvement Project around HealthierLife (HARP) member care transitions following an inpatient behavioral health episode. Fidelis Care is using this opportunity to collaborate with all of our providers to improve our members’ behavioral health experiences. The goals of this project are to: identify and improve discharge processes; ensure warm hand-offs; improve the facilitation of communication and coordination among the inpatient providers; increase frequency of contact with members, community providers, and member stakeholders; and increase focus on post discharge follow-up.

To learn more about the Fidelis Care HARP PIP, contact Kevin Jerry, Project Manager, at (718) 393-6566 or visit the link above.


Information on the Importance of Chlamydia Screening
09/06/2017 • Posted by Fidelis Care
Fidelis Care has posted a tip sheet with information from the Centers for Disease Control (CDC) on the importance of chlamydia screening.  According to the CDC, any sexually active person can be infected with chlamydia.  Specifically, chlamydial infections in women can lead to serious consequences.  For further CDC information on chlamydia and screening, who should be tested, diagnosing chlamydia, and billing and reporting practices, visit Fidelis Care’s Importance of Chlamydia Screening Tip Sheet.


Provider Manual Updates
08/31/2017 • Posted by Fidelis Care
Provider Manual Sections ‘Introduction to Fidelis Care’, ‘Referral and Prior-Authorization’, and ‘Product Information’ have been updated with information specific to services that require prior authorization from eviCore healthcare.   The section updates are listed below.

Applies to all product lines of business:

Section 01 – Introduction to Fidelis Care

How to Contact eviCore healthcare
Fidelis Care has engaged eviCore healthcare* (eviCore) to implement a new prior authorization program to manage outpatient high-technology Radiology services, non-Obstetrical Ultrasounds, diagnostic Cardiology services, and Radiation Therapy services being rendered on or after October 1, 2017.
 

Authorization Program:  Radiology, Cardiology, and Radiation Therapy
eviCore healthcare
(866) 706-2108 - phone
(800) 540-2406 - fax
* https://www.evicore.com/healthplan/fideliscare

 The update below applies to the following sections and lines of business:

 Section 11 – Referrals and Prior Authorization - All product lines of business

 Section 18 – Product Information - Applies to Medicaid Managed Care, Child Health Plus, Medicare
                       Advantage, Dual Advantage, Fully Integrated Duals Advantage, Fidelis Care at Home and
                       HealthierLife

 Section 17 – Product Information - Applies to Metal-Level Products and Essential Plans

  • Effective 10/1/2017, outpatient high-tech radiology services, outpatient non-obstetrical ultrasounds, outpatient diagnostic cardiology services, and outpatient radiation therapy services, for all products except Fidelis Care at Home (FCAH) and Fully Integrated Duals Advantage (FIDA), require prior authorization from eviCore healthcare.  For a complete list of procedures that require prior authorization from eviCore healthcare, visit:       https://www.evicore.com/healthplan/fideliscare.   



Fidelis Care Authorization Grids Effective October 1, 2017
08/29/2017 • Posted by Fidelis Care
The following section of the Fidelis Care authorization grids has been updated effective October 1, 2017:

Applies to All Product Lines of Business, Except:  Fully Integrated Duals Advantage (FIDA) and Fidelis Care at Home (FCAH).
IV.  Outpatient and DME Services:

          The following services require prior authorization:

E.  Imaging Studies: 

            2.  Radiology services require prior authorization through eviCore 
                 healthcare. A full list of CPT codes can be found at
                 
https://www.evicore.com/healthplan/fideliscare

 

H.  Therapeutic Services:

6.  Radiation Therapy services require prior authorization through eviCore     
     healthcare. A full list of CPT codes can be found at
    
https://www.evicore.com/healthplan/fideliscare

 

Fidelis Care Drug Formulary Updated July 2017
08/09/2017 • Posted by Fidelis Care
Fidelis Care is notifying providers that the Preferred Drug List for Medicaid Managed Care (MMC), Child Health Plus (CHP), and HealthierLife (HARP) has been updated as of July 2017, and is available here:  Download the full drug formulary



Smoking Cessation Resource Guide
08/04/2017 • Posted by Fidelis Care

Fidelis Care partners with organizations and health care facilities across New York State (NYS) to offer members the support and resources needed to help them stay smoke free.  Fidelis Care and its Quality Health Care Management Team (QHCM) are pleased to provide a Smoking Cessation Resource Guide to help support our members who are ready to quit smoking. 


This Resource Guide identifies Free Smoking Cessation Classes across NYS.  It also includes several helpful links for additional online resources, such as: 
American Lung Association, New York State Smokers’ Quitline, Freedom from Smoking, and more.  Please encourage your Fidelis Care patients to use this Resource Guide and sign up for the Free Smoking Cessation Classes that are available to them.  Visit:  Fidelis Care’s Smoking Cessation Resource Guide



IMPORTANT UPDATE Issued by Endo Pharmaceuticals Regarding OPANA® ER
08/03/2017 • Posted by Fidelis Care
Fidelis Care is notifying Providers of an important update regarding Endo Pharmaceuticals’ official statement on the status of OPANA® ER being voluntarily withdrawn from the US market as requested by the FDA.  The generic formulation oxymorphone ER is still available, and is currently not affected by this voluntary drug removal. 

 

For the full News Release, visitEndo Provides Update On OPANA® ER

For Endo Pharmaceuticals website, visit:  Endo Pharmaceuticals




New Prior Authorization Program Effective 10/1/2017
08/01/2017 • Posted by Fidelis Care
Fidelis Care has engaged eviCore Healthcare* (eviCore) to implement a new prior authorization program to manage outpatient high-technology Radiology services, Non-Obstetrical Ultrasounds, diagnostic Cardiology services, and Radiation Therapy services being rendered on or after October 1, 2017.

For further details regarding this new prior authorization program, refer to the additional links provided below.

 

Provider Tip Sheet:  eviCore Program (includes FAQs)

For a full list of the procedure codes included in this eviCore Program, visit eviCore’s website at:  https://www.evicore.com/healthplan/fideliscare

 

If you have any questions about this new prior authorization program, contact Fidelis Care’s Provider Call Center at 1-855-505-5327, or your Provider Relations Representative.  * Learn more about eviCore healthcare

 


Fidelis Care Authorization Grids Effective September 1, 2017

07/31/2017 • Posted by Fidelis Care
The following sections of the Fidelis Care authorization grids have been updated effective September 1, 2017:

Applies to All Product Lines of Business: 
II.  Outpatient surgery:  The following services require prior authorization: 
        N. or O.  Vertebroplasty 22853, 22854, 22859, 22867–22870, 62380. (Added)
       P.  Esophageal sphincter augmentation:  43284. (Added)
           
IV.  Outpatient and DME Services:  The following services require prior authorization:
        A.  Diagnostic testing
              5 or 6.  Infectious Agent detection by DNA or RNA:  87483 (Added)          
        B.  Durable Medical Equipment: 
              1. The following DME codes do not require an authorization:
               L1902, L3221 (Added)
        H.  Therapeutic Services:
               3 or 4. Pain Management Codes (i.e. injections, TENS, therapeutic services):
               62320, 62321, 62323, 62324, 62325, and 62326 (for non-orthopedists only).  (Added)

VIII.  Pharmacy (Check specific Product grid for requirement on the codes indicated below)
         B.  These injectable codes require authorization.
         C9489, C9490, J1322, J1556, J1568, J1575, J2941, J3357, J7504, Q5102,  Q9984, Q9989 (Added)
         C9136 (Deleted)

IX.  All services for “Unlisted” or “Temporary” Codes require authorization
      “or Temporary” (added)    

Applies to Child Health Plus, HealthierLife, and Medicaid ONLY: 
V.   Counseling Services
       B.  Asthma Self-Management Training (ASMT):
       diagnosis codes J45x (Added)
       diagnosis codes 493.xx (Deleted)

Applies to Essential Plan ONLY:
V.   Counseling Services
        B.  Education and Training for patient self-management:  98960 (Added)


 
Provider Manual Update:  Section 22A - Dual Eligible Beneficiaries and Financial Protection
07/31/2017 • Posted by Fidelis Care
The Provider Manual, Section Twenty-Two A (22-A) – Medicare Advantage/Dual Advantage has been updated with information on Dual Eligible Beneficiaries and Financial Protection .  

Federal law prohibits Medicare providers from charging Qualified Medicare Beneficiaries (QMBs) (persons in both Medicare and Medicaid plans) cost-sharing (“balance billing”).  For more information, visit:  Provider Manual – Section 22A – Medicare Advantage/Dual Advantage
 


Weight Assessment and Counseling for Children/Adolescents (WCC) and Adolescent Preventive Care (APC)
07/27/2017 • Posted by Fidelis Care
New York State Department of Health (SDOH) and the National Committee for Quality Assurance (NCQA) have both stressed the importance of guiding children and adolescents towards healthy behaviors. SDOH and NCQA outline the importance of correct medical record documentation to assure that providers’ counseling efforts are acknowledged. One way to ensure that patients are appropriately assessed is for providers to use a checklist to document their work. Fidelis Care has created one-page documents for WCC and APC that are easy to use and cover the key elements of both measures. Providers need to complete the forms annuallyand place them in their medical record, or scan them into their electronic medical record. The cover letter describing the measures and the forms for each measure are available via the links below.
Click here for cover letter from Fidelis Care’s Chief Medical Officer
Click here to access WCC_APC Forms



Provider Manual Update:  Section 2 - Member Rights and Responsibilities
07/26/2017 • Posted by Fidelis Care
The Provider Manual, Section Two (2) – Member Rights and Responsibilities has been revised and is available to you on this site.  You can access this revised documentation by selecting ‘Provider Manual’ or ‘Provider Manual – Metal-Level Products and Essential Plans’ and then by selecting Section 2 – Member Rights and Responsibilities.  

Or, visit:  Provider Manual:   Section 2 – Member Rights and Responsibilities
Provider Manual – Metal-Level Products and Essential Plans:   Section 2 – Member Rights and Responsibilities



2017 Updated QCMI Brochure is Now Available
07/25/2017 • Posted by Fidelis Care 

Fidelis Care is pleased to announce that the updated 2017 Quality Care Management Incentive (QCMI) brochure is now available on Provider Access Online.  There is one update that we would like to make you aware of in the brochure:    

  • NCQA has changed the Immunizations for Adolescents (IMA) measure to align with the CDC’s, AAP’s, AAFP’s and ACOG’s current HPV (Human Papillomavirus) vaccine recommendation/standard of care for the HEDIS 2017 measurement year.  Therefore, Fidelis Care has updated the 2017 QCMI brochure to reflect that change.



Provider Manual Update:  Section 8 - Emergency and Inpatient Services
07/17/2017 • Posted by Fidelis Care  
The Provider Manual, Section Eight (8) – Emergency and Inpatient Services has been updated with the following additional information:


Inpatient Emergency Admissions
Fidelis Care follows National Committee for Quality Assurance (NCQA) guidelines for timeliness of Utilization Management (UM) decisions.  Emergency inpatient admissions are considered “Urgent Concurrent” requests and must be addressed within 24 hours.  In situations where initial Inpatient authorization requests are not accompanied by sufficient clinical documentation, Fidelis Care will contact the facility to request the necessary information.  If Fidelis Care is unable to obtain the information within 72 hours (3 calendar days) of receipt of the initial request, the inpatient admission will be subject to denial for lack of sufficient clinical information. 

Clinical information for an Inpatient Emergency Admission should be faxed to Fidelis Care ER eFax at:  347-868-6411.


This revised documentation is available to you on this site.  Please visit:

Provider Manual: Section 8 - Emergency and Inpatient Services

Provider Manual: Metal-Level Products and Essential Plans: Section 8 - Emergency and Inpatient Services




2017 Medicare Risk Adjustment Medical Record Request Letter is Now Available
07/17/2017 • Posted by Fidelis Care
The Medicare Risk Adjustment letter and member medical record request lists for the 2016 review year are now available on Provider Access Online. Please notify any staff members involved with quality management programs to ensure all requested medical records are received no later than September 1, 2017. 



Fidelis Care Provider Bulletin - Volume 3, Number 2

07/17/2017 • Posted by Fidelis Care  

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 included are:
     •  Fidelis Care’s Chronic Disease Management Programs
     •  BabyCare Incentive Program Update
     •  New Online Medicaid Recertification:  We are Here to Help
     •  How Fidelis Care Determines the Medicaid Managed Care Formulary
     •  Fidelis Care Network Includes Broad Access to Specialists
     •  Committees Seek Provider Participants

To view our Provider Bulletin Library, please visit:  Provider Bulletins 


 

Nursing Home Provider Tip Sheet Revised
Posted 07/13/2017
Fidelis Care is notifying providers that the Nursing Home Tip Sheet has been revised and is available to you on this site.  You can access this Tip Sheet by selecting Provider Resources and then by selecting Tip Sheets.  Or, visit: Nursing Home Tip Sheet.


Fidelis Care Authorization Grids Effective August 1, 2017

Posted 06/22/2017
The following section of the Fidelis Care authorization grids has been updated effective August 1, 2017

Applies to all Product Lines of Business:  Child Health Plus, Essential Plan, Fully Integrated Duals Advantage, HealthierLife, Medicaid, Medicare, and Metal-Level Products.

II.  Outpatient surgery:  The following services require prior authorization: 

           N. or O.  Vertebroplasty 22510, 22511, 22512, 22513, 22514, 22515 (added)


Outpatient Clotting Factor Products Expansion into Medicaid Managed Care
Posted 06/22/2017
Effective July 1, 2017, the NYS Department of Health (DOH) has mandated that hemophilia outpatient clotting factor products and services transition from Medicaid Fee-for-Service to Medicaid Managed Care.

Inclusion of this benefit applies to clotting factors administered in all non-inpatient settings, including in the home.  Currently, administration of clotting factors during an inpatient stay is covered by the managed care plan.

For additional details, visit:  Coverage of Outpatient Clotting Factor for Managed Care Enrollees

If you have any questions regarding this matter, please contact the Provider Call Center at 1-888-FIDELIS (1-888-343-3547).



Valid Units of Measure for NDC Claim Submissions
Posted 06/13/2017
When submitting claims with a National Drug Code (NDC), please be sure to bill your claims with a valid unit of measure abbreviation.  Listed below are the NDC valid units of measure abbreviations and their descriptions:

Abbreviation

Description

F2

International Unit

GR

Gram

ML

Milliliter

UN

Unit


  

Note:  ME is also a recognized billing qualifier that may be used to identify milligrams as the NDC unit of measure; however, drug costs are generally created at the UN or ML level.  If a drug product is billed using milligrams, it is recommended that the milligrams be billed in an equivalent decimal format of grams (GR).

Effective 8/1/2017, Fidelis Care will reject any claim submitted with a NDC with an invalid unit of measure.  Rejected claims should be corrected using a valid unit of measure and resubmitted to Fidelis Care as soon as possible to prevent any timely filing issues.   

If you have any questions regarding this matter, please contact the Provider Call Center at 1-888-FIDELIS (1-888-343-3547).

 

Fidelis Care’s Chronic Disease Management Programs
Posted 06/06/2017
Fidelis Care is committed to supporting members with chronic diseases through programs that help them better manage their health through a combination of education and care planning.

Once diagnosed, members can access our disease management programs in two ways: written information that is mailed to their home, or one-on-one phone outreach from a Nurse Case Manager.

We provide important educational information in our newsletters and on our website, fideliscare.org, as well as through customized letters, brochures, and other materials that are sent to members.

Learn more about Fidelis Care’s Chronic Disease Management Programs




Provider Manual Update:  Section 3 - Medicare Opt-Out
Posted 06/02/2017

The Provider Manual, Section Three (3) – The Provider’s Roles and Responsibilities has been updated with information on Medicare Opt-Out

If you have opted out of Medicare, you are not permitted to submit claims to Fidelis Care for treatment of Medicare Advantage enrollees unless services provided are for emergent or urgent care treatment.  If claims submitted are not for emergent or urgent care treatment, the claims will not be paid by Fidelis Care.  For additional information, visit:  Provider Manual Section 3 The Provider’s Roles and Responsibilities


Fidelis Care Authorization Grids Effective July 1, 2017

Posted 05/31/2017

The following section of the Fidelis Care authorization grids has been updated effective July 1, 2017:

VIII.  Pharmacy: 

B.  These injectable codes require authorization.

Medicaid, Child Health Plus and HealthierLife (HARP):
J0485, J0800, J1071, J1602, J1950, J2353, J2354, J3121, J3145, J3380, J7197, J9217, J9225, J9226, and J9310*.  (added)
Medicare:
J1071, J3121, J3145, and J9310*.  (added)       

Metal-Level Products:

J0485, J0800, J1071, J1602, J1950, J2170, J2353, J2354, J2941, J3121, J3145,  J3380, J7181, J7182, J7186,
J7191, J7197, J7200, J7201, J9217, J9225, J9226, 
and J9310*. (added)

Essential Plan:

J0485, J1071, J1602, J1950, J2170, J2353, J2354, J2941, J3121, J3145,  J3380, J7181, J7182, J7186, J7191,
J7197, J7200, J7201, J9217, J9225, 
J9226, and J9310*.  (added)    
Fully Integrated Duals Advantage (FIDA):

J1071, J3121, J3145, and J9310*.  (added)

                                   

*authorization is not required for oncology indications

 

Click here to view all of our Authorization Grids by product type.

 

 

2017 QCMI Brochure Update is Now Available
Posted 05/30/2017
An update to the 2017 Quality Care Management Incentive (QCMI) Brochure is now available on Provider Access Online.

The BabyCare Prenatal Encounter Form has been revised to include a separate section on Current Pregnancy Risk Factors.  Please continue to refer your pregnant patients to the Fidelis Care BabyCare Program and ensure all risk assessment screenings are completed and documented during your patients’ first two prenatal visits.



BabyCare Incentive Program Update
Posted 5/26/2017
Effective July 1, 2017, please be advised that Fidelis Care has updated the BabyCare Prenatal Encounter Form to include a separate section on Current Pregnancy Risk Factors.  Please continue to refer your pregnant patients to the Fidelis Care BabyCare Program and ensure all risk assessment screenings are completed and documented during your patients’ first two prenatal visits.

Refer to the links below to access the forms on this Provider page:
BabyCare Prenatal Encounter Form (Attachment A)
BabyCare Prenatal/Postpartum Encounter Form (Attachment B)

Please note that the BabyCare Prenatal Encounter Forms have also been updated in the QCMI Brochure which is available on Provider Access Online (Fidelis Care’s Provider Portal).

For full details on the changes to the Program, click here BabyCare Incentive Program .

    

Finding Helpful Information about Fidelis Care
Posted 5/23/2017
Providers, please remember to review content available in Provider Access Online (Fidelis Care’s secure Provider Portal) and the rest of the Provider section of the Fidelis Care website.   Both locations are excellent resources for information about our programs and services.  One example of a resource contained in this site is our Provider Manual.  The Provider Manual contains details about our credentialing processes and our member rights and responsibilities statement.  It also includes information about the clinical criteria used in utilization management (UM) decision making, our pharmacy authorization processes, and Fidelis Care’s policy statement on how coverage decisions are made.  

Other items you will find in the Provider section of the Fidelis Care website include information about referring members for case and disease management services.

If you have further questions regarding any of the content on the website, please contact us at 1-888-FIDELIS (1-888-343-3547).



Requesting OT, PT, or ST Authorizations via Provider Access Online Now Available

Posted 5/11/2017
Fidelis Care is pleased to announce that providers can now request occupational therapy (OT), physical therapy (PT), and speech therapy (ST) authorizations online via Provider Access Online, Fidelis Care’s secure provider portal.  This new online authorization tool, available to providers 24/7, allows greater flexibility and convenience with no hold or wait time. 

To get started, visit https://providers.fideliscare.org/Login .    If you need help in setting up a Provider Access Online User Account, contact the Provider Call Center at 1-888-FIDELIS (1-888-343-3547) or contact your Provider Relations Representative.  Learn more about creating online OT, PT, and ST authorizations.

 

Important Notice - Medicaid Recertification for MAGI Population: We Are Here To Help!
Posted 5/5/2017
To ensure consistent health coverage and no lapses in critical care for your patients, Fidelis Care is here to help with the renewal process for Medicaid coverage in New York State. 

In 2016, a Statewide initiative began to centralize Medicaid recertification by transitioning to an online process through NY State of Health (NYSOH). Members affected by this change will receive a letter from the State instructing them to log into the NYSOH online system using provided account information, and then follow the steps for renewal.  Sample NY State of Health - Renew Your Coverage Letter

This is a significant change in the process, and those who do not comply are in danger of losing their health coverage. 

Fidelis Care Representatives are available to provide clear and helpful 1:1
onsite assistance for patients who may be impacted by this change. If your patients have not yet taken action and need help with the new recertification process, please advise them to call 1-888-FIDELIS (1-888-343-3547). 

 

Fidelis Care Authorization Grids Effective June 1, 2017
Posted 4/28/2017
Fidelis Care would like to notify you of a change to our authorization grids.  Please carefully review the following section for an update effective June 1, 2017:

            IV.  Outpatient and DME Services:  The following services require prior authorization:

                    H.  Therapeutic Services:

         3 or 4.  Pain Management Codes (i.e. injections, TENS, therapeutic services):

         62322 (added)   

 

Click here to view all of our Authorization Grids by product type.

 

Provider Manual Update Section 11 Provider Request for Clinical Criteria
Posted 4/12/2017
Fidelis Care is notifying providers of an update to the Provider Manual in Section 11 - Referrals and Pre-Authorization regarding provider request for clinical criteria:

Provider Request for Clinical Criteria
Providers may request a copy of the clinical criteria used to render a utilization management decision, free of charge.

Providers are notified of their right to obtain clinical criteria via:
            a.  Utilization Management notifications (adverse determinations) include an appeal
            rights attachment.
            b.  The provider portal or provider bulletin.

Requests can be submitted by calling 1-888-FIDELIS (1-888-343-3547) and speaking with a Call Center representative.

The applicable clinical criteria will be mailed to the requesting provider within 15 business days.

Provider Manual – Section 11 – Referral and Pre-Authorization
Provider Manual – Metal-Level Products and Essential Plans – Section 11 – Referral and Pre-Authorization


Fidelis Care Authorization Grids Effective April 1, 2017
Posted 03/27/2017
Fidelis Care would like to notify you of some changes to our authorization grids.  Please carefully review the following section for updates effective April 1, 2017:

           Inpatient Admissions:  All inpatient admissions require an authorization.

          
E. OASAS Licensed Inpatient Substance Use Disorder Treatment:

Effective 01/01/2017, Fidelis Care will not conduct prior authorization review for the initial 14 days of OASAS licensed Inpatient Detoxification,  Inpatient Rehabilitation or Inpatient Residential treatment services. Providers are required to notify Fidelis Care of each admission within 48 hours by faxing or emailing the OASAS Appendix A Notification Form and OASAS LOCADTR Medical Necessity Tool to 646-829-1421 or LOCADTR@fideliscare.org

All services require periodic consultation between the providers and the plan during the initial 14 days and may be subject to utilization review after the 14th day from admission or upon discharge. Out–of-State and Out-of-Network providers continue to be required to request prior authorization for inpatient substance use disorder treatment. Providers with questions regarding these changes are encouraged to call Fidelis Care at 1-888-FIDELIS (1-888-343-3547), follow Option 2, Option 2, and then Option 1 during regular business hours.

Click here to view all of our Authorization Grids by plan type.


Home and Community Based Services (HCBS) Billing and Coding Tip Sheet Supplement
Posted 3/9/2017
Fidelis Care is pleased to provide a new HCBS Billing and Coding Claims Tip Sheet Supplement.  This new Tip Sheet is in addition to the existing Tip Sheet ‘Medicaid and HealthierLife: Behavioral Health (BH) Carve-in and Health and Recovery Plan (HARP) HCBS Claims’ that is currently available.

The new HCBS Billing and Coding Tip Sheet Supplement includes important reminders and requirements for HCBS claims submission.
Learn more about HCBS billing and coding supplement
Learn more about BH and HCBS billing and claiming guidance


National Correct Coding Initiative Edits
Posted 3/8/2017
The Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate claim payment. These policies are based on coding conventions defined in the American Medical Association's (AMA) CPT Manual, National and Local Coverage Determinations (NCD and LCD), coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. These standards set the coding requirements that all plans and providers must follow in order to secure reimbursement for all lines of business. Claims that are found to be noncompliant with these guidelines may be returned and/or denied.

Please visit the sites below for additional information:

 


Annual Medicare Special Needs Program (SNP) Model of Care (MOC) Provider Training
Posted 3/8/2017
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 the Provider Portal (Provider Access Online).  To login, visit  Provider Access Online.  After logging in, if training and attestation is required, you will receive a notification on the Home Page.  The user can click the notification, view the training module by selecting File Downloads, and then attest to the training.  If you are attesting on behalf of your group/organization, in doing so, you agree to communicate the information to other providers in your group/organization.  The user’s attestation will be automatically sent to Fidelis Care for acknowledgement of training.   Please be sure to complete this required training on or before December 31, 2017.



Participating Providers Quarterly Provider Directory Attestation
Posted 3/2/2017

Beginning March 2, 2017, and on a quarterly basis going forward, participating providers will be asked to verify provider directory information. The directory information will be available for review and attestation via Provider Access Online.  To get started, visit Provider Access Online  where additional information will be provided. 



Fidelis Care Authorization Grids Effective April 1, 2017

Posted 02/22/2017

Fidelis Care would like to notify you of some changes to our authorization grids.  Please carefully review the following section for updates effective April 1, 2017:

            VIII. Pharmacy: 

                       B.  These injectable codes require authorization.  

                       All Plan Types:

 

                       J0275, J1050, J3355, J7297, J7298, J7300, J7301, J7303, J7304, J7306, J7307, S4981, S4993, S0191, S0122,
                       S0126, S0128,  S0190  - added                      

Click here to view all of our Authorization Grids by plan type.

 


Important Update to Utilization Procedures for Inpatient OASAS Provider Effective 01/01/2017
Posted 02/13/2017
Effective January 1, 2017, Fidelis Care will begin a new utilization management process for specific types of Substance Use Disorder inpatient treatment across all product lines.  This change impacts the following In-Network Office of Alcohol and Substance Abuse Services (OASAS) licensed inpatient programs:

  • Inpatient Detox

  • Inpatient Rehabilitation

  • Residential Treatment

This legislation does not apply to Out-of-Network Providers or Fidelis-Contracted providers that are not licensed by OASAS, such as Out-of-State Providers.  Out–of-State and Out-of-Network providers continue to be required to request prior authorization for inpatient substance use disorder treatment.  

In compliance with New York State Chapters 69 and 71 of the Laws of 2016, prior authorization review is not permitted for the initial 14 days of such treatment services. Providers are required to notify Fidelis of the admission within 48 hours with faxed or emailed completed LOCADTR and OASAS Appendix A. All treatment services require periodic consultation between the providers and the plan during the initial 14 days and may be subject to utilization review after the 14th day from admission or upon discharge.

Please be advised that providers are required to notify plans within 24 hours of when a member is discharged.

Providers are required to notify Fidelis Care that a member has started treatment in each of these levels of care within 48 hours from the admission start time by faxing or emailing the OASAS Appendix A Notification Form and OASAS LOCADTR Medical Necessity Tool.

The dedicated fax line and email to submit the OASAS Appendix A Notification Form and OASAS LOCADTR Medical Necessity Tool is 646-829-1421 or LOCADTR@fideliscare.org

When Fidelis Care receives the requisite documentation during normal business hours, providers will receive a phone call from Fidelis with a reference number for the notification and the contact information for the assigned Care Manager within 1 business day of receipt. When Fidelis Care receives such documentation after normal business hours, providers can expect to receive this information the following business day. Providers can expect the Fidelis Care Managers to conduct periodic outreach and request additional information to assist in care coordination  and discharge planning during the course of treatment.  The Care Managers may also request additional information to better understand the care being provided to the member.

Failure to submit the required notification paperwork (OASAS Appendix A Notification Form and completed LOCADTR Medical Necessity Tool) within 48 hours from the admission start time shall result in an immediate utilization review of medical necessity for treatment delivered from the date of admission forward even if such utilization review occurs within the first 14 days of admission. 

Providers with questions regarding these changes are encouraged to call Fidelis Care at 1-888-FIDELIS, follow Option 2, Option 2, and then Option 1 during regular business hours.

OASAS guidance with Notification Form Appendix A:
https://www.oasas.ny.gov/mancare/documents/InsurancelawguidanceFINAL.pdf
OASAS LOCADTR Information can be found here:
https://oasas.ny.gov/treatment/health/locadtr/index.cfm
Additional guidance from New York State DFS can be found here:
http://www.dfs.ny.gov/insurance/health/guidance_subs_disorder.htm 

 

2017 Prospective List for 4 Key QCMI Measures
Posted 01/20/2017
At the request of many providers, Fidelis Care is pleased to provide your practice with information about patients eligible for four age sensitive measures in 2017: Well Child Visits in First 15 Months of Life, Childhood Immunization, Lead Screening in Children, and Immunization for Adolescents. The prospective list, posted to the Provider Portal, will assist you to ensure these patients receive the appropriate services by their age sensitive birthday. If you have any questions with regard to understanding the list and measure compliancy, please refer to the accompanying letter or contact the Fidelis Care Provider Call Center at 1-888-FIDELIS (1-888-343-3547).


Checking Authorization Status Online – Now Available on Provider Access Online
Posted 1/20/2017
Fidelis Care is pleased to inform providers that Provider Access Online (Fidelis Care’s secure provider portal) has updated functionality which allows providers to check the status of their authorizations online, any time of the day or night. This tool allows you to retrieve information about authorization requests with no hold or wait time!  This updated functionality allows both the requesting and treating providers to view authorization status.

To get started, providers will need a User Account established on Provider Access Online.
For users new to Provider Access Online, click here for information on ‘What is Provider Access Online?
For establishing a new User Account - click here for information on ‘Obtaining a User Account’.

 

For new or existing User Accounts, the Account Administrator will need to assign the access role ‘Authorizations Viewer’ to any user who needs the ability to view authorizations.  Click here for a Provider Portal Authorizations – Checking Authorization Status User Guide.   When the access role Authorizations Viewer has been assigned, login to Provider Access Online at https://providers.fideliscare.org/Login , and click on Authorizations Status to begin checking your authorizations status. 

 

If you require assistance in setting up a Provider Access Online User Account, please contact the Provider Call Center at 1-888-FIDELIS (1-888-343-3547) or your Provider Relations Representative.


Fidelis Care Authorization Grids Effective February 1, 2017
Posted 12/30/2016
Fidelis Care would like to notify you of some changes to our authorization grids.  Please carefully review the following section for updates effective February 1, 2017:
            VIII. Pharmacy: 
                        B.  These injectable codes require authorization.  
                        All Plan Types:

                        J7188, J7205 – added            

Click here to view all of our Authorization Grids by plan type. 


Fidelis Care Authorization Grids Effective January 1, 2017
Posted 12/30/2016

Fidelis Care would like to notify you of some changes to our authorization grids.  Please carefully review the following section for updates effective January 1, 2017:
            VIII. Pharmacy: 
                        B.  These injectable codes require authorization.  
                        All Plan Types:

                        C9140, J0570, J2182, J2786, J2840, J7175, J7179, J7202, J7207,
                        J7209, J7320, J7322 – added

                        Essential Plan, Medicaid, Child Health Plus, HealthierLife (HARP) and
                        Metal-Level Products

                        Note  J7320 (added), J7321, J7322 (added), J7323, J7324, J7325, J7326 are non-covered when billed with CPT code
                        20610 or any of the following diagnosis: M17.0, M17.10-M17.12, M17.2, M17.20-M17.32, M17.4, M17.5, M17.

Click here to view all of our Authorization Grids by plan type.

 
Important Information on Coverage Decisions
Posted 12/29/2016
As required by NCQA accreditation guidelines, Fidelis Care is providing the following information to employees, providers, and members: 

Each day, Fidelis Care’s Utilization Management (UM) Department makes decisions on numerous health insurance claims. These decisions are based only on appropriateness of care and the existence of coverage.

Fidelis Care does not reward practitioners or other individuals for issuing denials of coverage, and does not offer financial incentives to UM staff that would encourage decisions that result in underutilization of services.

Fidelis Care is committed to ensuring that members have the care and services they need.

Payment Reductions on Elective Delivery (C-Section and Induction of Labor) Less than 39 Weeks without Medical Indication
Posted 12/29/2016
Effective July 1, 2016, Fidelis Care will further reduce payment for early elective deliveries without an acceptable medical indication. Claims for elective deliveries prior to 39 weeks, without medical indication, will be reduced by 50% per a recent Medicaid policy update. The increased penalty from 25% to 50% reflects the Medicaid Program's commitment to providing high quality prenatal care by ensuring appropriate delivery for both mothers and babies.

Additionally, for medical claims modifiers U8 or U9 will continue to be required for all deliveries and claims for hospital inpatient stays associated with a delivery will continue to require a condition code 81, 82 or 83 for payment.  Failure to include the appropriate modifiers and/or condition codes will result in claim denials. For further information on elective delivery billing requirements please
click here.

 

Medicaid Behavioral Health (BH) Carve-in and HealthierLife (HARP) Home and Community Based Services (HCBS) Tip Sheet Now Available
Posted 12/21/2016
Fidelis Care is pleased to announce that a revised Medicaid Behavioral Health (BH) Carve-in and HealthierLife (Fidelis Care’s Health and Recovery Plan Product) Home and Community Bases Services (HCBS) Provider Tip Sheet is now available. This Tip Sheet includes additional BH and HCBS claim submission and billing guidance information along with several links to NYS Resources.  Also included is a link to the Form UB-04 Billing Tool which details the fields required for billing.  Learn more about BH and HCBS billing and claiming guidance 



Providers Billing Facility Claims with Bill Type (TOB) 073x
For dates of service (DOS) on or after April 1, 2010, Bill Type (TOB) 073x will continue to be a valid bill type for certain non-Medicare claims.  However, for Medicare claims, 073x is not a valid Bill Type.  Effective immediately, Fidelis Care would like to inform providers submitting facility claims for Medicare members, that Bill Type (TOB) 073x is not valid and claims will be returned. Providers must review billing guidelines and determine the appropriate Bill Type for claim submission. 


All Claims Related to Coordination of Benefits (COB)  – New Post Office Box

Fidelis Care would like to inform providers that there is a new Post Office (PO) Box for all COB claims.  Please submit all claims related to COB, CMS-1500 or UB-04, to: 

All Claims related to COB
Fidelis Care
PO Box 905
Amherst NY  14226-0905


Medicaid Managed Care to Implement an Opioid Fill Limit of Four Prescriptions Every 30 Days 
New York State Medicaid Managed Care has implemented a State Law that prohibits patients from filling more than 4 opioids in 30 days without a prior approval from their prescriber. As a result of the enactment of Social Services Law section 364-j(26-a), effective October 1, 2016, Medicaid Managed Care providers must require prior authorization for prescriptions of opioid analgesics in excess of four prescriptions in a 30- day period. Prior authorization will not apply to prescriptions for patients receiving hospice care, prescriptions for patients with a diagnosis of cancer or sickle cell disease, or any other condition or diagnosis for which the Commissioner of Health determines prior authorization is not required. As a provider of Medicaid Managed Care, this may impact a few of our members, and Fidelis Care will be strictly adhering to this new law moving forward. We are  focused on putting the safety and wellbeing of members first, and are happy to assist in this transition process in any way possible. We can provide education to members and providers about maximizing current analgesic regimens, the role of adding non-steroidal anti-inflammatory drugs to pain management regimens, and whether members should be on alternate therapy if their current pain regimen is not sufficient. Medicaid Fee-for-Service previously implemented such a limit of 4 opioids in 30 days with a prior approval, and experienced positive patient outcomes.



2017 Fidelis Care Medicare Drug Formulary Changes
Fidelis Care would like to inform providers about upcoming changes to the 2017 Medicare Drug Formulary.  Prescribing physicians are advised to check the appropriate Formulary carefully for changes specific to:
  • Drugs that have been removed from the Formulary
  • Drugs that have tier changes, which may impact your patients’ out-of-pocket costs
Fidelis Care Prescription Drug Formulary for 2017 (Managed by CVS Caremark)

Please note that for 2017 we have different formularies depending on which Medicare Advantage or Dual Advantage Plan your patient(s) is enrolled in. Please make sure to click on the formulary link that is below the plan your patient(s) is enrolled in. 

Fidelis Dual Advantage, Fidelis Medicaid Advantage Plus and Fidelis Dual Advantage Flex
2017 (English .pdf)

Fidelis Medicare Advantage Flex (HMO POS) and Fidelis Medicare $0 Premium (HMO)
2017 (English .pdf)

Fidelis Care encourages providers to review and familiarize themselves with the formulary changes to help provide for a smooth transition for their patients who may be affected.  For more details on Medicare Advantage and Dual Advantage prescription drug information, click here.


Fidelis Medicare Advantage Product Update for 2017
As we look ahead to the annual election period (October 15-December 7, 2016) for Medicare Advantage coverage, Fidelis Care would like to provide you and your staff with updates regarding our 2017 products and benefits.

Fidelis Care will continue to offer Medicare Advantage products in 53 counties for 2017. Our overall product portfolio features:
• Medicare Advantage without Rx (HMO-POS) Plan 001
• Medicare Advantage Flex (HMO-POS) Plan 003
• Medicare Advantage $0 Premium (HMO) has been segmented into two plans, Plan 020-01 and 020-02
• Dual Advantage (HMO-SNP) Plan 002, and Dual Advantage Flex (HMO-SNP) Plan 017 

Every year, Fidelis Care adjusts cost sharing levels, premiums, and pharmacy benefits - including the formulary - to keep pace with rising health care cost trends. The most significant change for 2017 will be in a five-county area of the Hudson Valley, specifically Dutchess, Ulster, Putnam, Sullivan and Orange counties.  We replaced plan 19 with Plan 020-002 and we withdrew Plan 003 from these counties. 

The following Fidelis Care Medicare Advantage products will be available in Dutchess, Orange, Sullivan, Ulster, and Putnam counties for 2017:

• Medicare Advantage without Rx (HMO) Plan 001 

• Dual Advantage Flex (HMO-SNP) Plan 002

• Medicare Advantage $0 Premium (HMO) Plan 020-02 (will be available in these five counties only)

Fidelis Care’s licensed Medicare Sales Representatives are available to meet with patients in your office or other convenient location in the community. For more information, or to discuss an inservice for your office staff and how we can work together on behalf of your patients, please call the Provider Call Center at 1-888-FIDELIS (1-888-343-3547).



Now Available – Checking Authorization Status Online
Fidelis Care is excited to announce that providers now have the ability to check authorization status online, any time of the day or night.  This new tool allows you to retrieve information about your previously submitted authorizations with no hold or wait time!  To get started, provider account administrators will need to login to Provider Access Online and assign the new role “Authorization Viewer” to account users who need access to view authorizations.  For complete authorization checking status details and user guide, providers can visit Provider Access Online at providers.fideliscare.org and click “Authorization Status”.


Payment Reductions on Elective Delivery (C-Section and Induction of Labor) Less than 39 Weeks without Medical Indication
Effective July 1, 2016, Fidelis Care will further reduce payment for early elective deliveries without an acceptable medical indication. Claims for elective deliveries prior to 39 weeks, without medical indication, will be reduced by 50% per a recent Medicaid policy update. The increased penalty from 25% to 50% reflects the Medicaid Program's commitment to providing high quality prenatal care by ensuring appropriate delivery for both mothers and babies.

 Additionally, for medical claims modifiers U8 or U9 will continue to be required for all deliveries and claims for hospital inpatient stays associated with a delivery will continue to require a condition code 81, 82 or 83 for payment.  Failure to include the appropriate modifiers and/or condition codes will result in claim denials. For further information on elective delivery billing requirements please click here.

 

Interactive Voice Response Application for Checking Claim Status

Fidelis Care is excited to now offer a new automated service that allows providers to check claim status over the phone, any time of the day or night.

 

Just call 1-888-FIDELIS (1-888-343-3547) and follow the prompts. From here, you can obtain basic claim information, such as the paid amount and member responsibility. For complete claim details, log in to Provider Access Online at fideliscare.org.

 

Access the full guide to checking claim status over the phone:  Interactive Voice Response Application for Checking Claim Status.

 

With this service, Fidelis Care aims to provide you with a valuable, convenient way to get claim status information. We welcome your feedback! Please contact Fidelis Care’s Provider Call Center at 1-888-FIDELIS (1-888-343-3547) with any questions or concerns.

Admission/Discharge Hour Required on Inpatient Institutional Claims
Effective September 1, 2016, Fidelis Care will no longer accept inpatient institutional claims that do not contain valid admission/discharge hour values.

The admission hour field contains the hour during which the patient was admitted for inpatient care.  The discharge hour field contains the hour during which the patient was discharged from inpatient care.

 

  • Required on inpatient claims except for SNF inpatient, TOB 021X.

  • Hours are entered in military time using two numeric characters.

    For example:  12:00 a.m. (midnight) = 00

                           12:00 p.m. (noon) = 12

                           11:59 p.m. = 23 

    Omitting the hour or submitting a claim with an incorrect value will result in your claim being rejected or denied.  

REMINDER: Discharge Status Code Required on Institutional Claims
Fidelis Care would like to remind you that we can no longer accept institutional claims that do not contain valid discharge status codes. A patient discharge status code is a two-digit code that identifies where the patient is at the conclusion of a health care facility encounter (this could be a visit or an actual inpatient stay) or at the time end of a billing cycle (the ‘through' date of a claim). The Centers for Medicare & Medicaid Services (CMS) requires patient discharge status codes for:

 

  • Hospital Inpatient Claims (type of bills (TOBs) 11X and 12X);
  • Skilled Nursing Claims (TOBs 18X, 21X, 22X and 23X);
  • Outpatient Hospital Services (TOBs 13X, 14X, 71X, 73X, 74X, 75X, 76X and 85X); and
  • All Hospice and Home Health Claims (TOBs 32X, 33X, 34X, 81X and 82X).

It is important to select the correct patient discharge status code, and in cases in which two or more patient discharge status codes apply, you should code the highest level of care known. Omitting a code or submitting a claim with an incorrect code could result in your claim being rejected or denied. For more information please click here.


Transportation Update - Suffolk and Nassau 
As part of the work of the Medicaid Redesign Team under the New York State Department of Health, the non-emergency transportation benefit (NEMT) for Medicaid members is being phased out of the managed care benefit package by region.

Effective December 1, 2015, non-emergency transportation for Fidelis Care Medicaid members will be transitioned from Fidelis Care to fee-for-service Medicaid in the following counties:  Nassau and Suffolk.

Prior authorization requests and claims for non-emergency services for these members should be directed to Logisticare Solutions, LLC, the NEMT manager for Nassau and Suffolk counties. Additionally, providers should contact Logisticare at the county-specific numbers below to arrange for NEMT services. 

 

On and After December 1, 2015

 

Logisticare Solutions, LLC

Nassau County

844-678-1106

Logisticare Solutions, LLC

Suffolk County

844-678-1106


Fidelis Care will continue to manage non-emergency transportation services for Dual Advantage Flex and Fidelis Care at Home members residing in Nassau and Suffolk counties. For more information, please see the Fidelis Care Transportation Provider Manual.

 


Regulatory Time Frames for Utilization Management Decisions
As a reminder to hospital providers, the attached documents define the regulatory time frames for utilization management that apply to Medicaid, Medicare, and NY State of Health & Child Health Plus


Joining the Fidelis Care Provider Network

If you would like to join our growing provider network and help make a difference in the lives of local residents, please click here to complete the inquiry form.