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Special Announcements

Most Recent 2016 QARR Non-compliance Report Now Available

Fidelis Care is pleased to inform you that the most recent 2016 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 August 22, 2016.  Please refer to the most recent "Non-Compliance Report" instruction letter, to understand the information being provided on each tab of the Excel Spreadsheet. WITH THIS REPORT, FIDELIS CARE IS PROVIDING AN OPPORTUNITY FOR PROVIDERS TO RECEIVE AN INCENTIVE FOR CORRECTED CLAIMS SUBMITTED FOR THE WELL CHILD/ADOLESCENT CARE MEASURES. Please notify any staff involved with Quality Management and/or the Fidelis Care QCMI program that these documents have been posted. You may also go to fideliscare.org and click on "Providers" to obtain more information on Provider Access Online. If you have any questions, please call the Provider Call Center at 1-888-FIDELIS (1-888-343-3547).


Weight Assessment and Counseling for Children/Adolescents (WCC) and Adolescent Preventive Care (APC) 
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 annually and place them in their medical record, or scan them into their electronic medical record. (Refer to cover letter and forms via links below)
Click here for cover letter from Fidelis Care’s Chief Medical Officer
Click here to access WCC_APC Forms

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.

Fidelis Care Provider Bulletin - Volume 2, Number 3
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.

2016 Updated QCMI Brochure is Now Available
Fidelis Care is pleased to announce that the updated 2016 Quality Care Management Incentive (QCMI) Brochure is now available on Provider Access Online. There were a few updates to the brochure:

  • All references to Family Health Plus were removed
  • The BabyCare prenatal/postpartum form was modified to include all prenatal services required by HEDIS
  • Page number references for Table A were corrected
  • Table C – Frequency of Prenatal Visits table was corrected

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.  

BabyCare Incentive Program Update
Effective August 1, 2016, Fidelis Care has made some updates to the BabyCare Incentive Program.  For full details on the changes to the Program, click the link above.

Fidelis Care Authorization Grids Effective August 1, 2016:
Fidelis Care would like to notify you of some changes to our authorization grids that could affect claim payment.  Please carefully review the following sections for updates effective August 1, 2016:

  • Outpatient Surgery codes:  31295, 31296, 31297 added
  • Essential Plan, NY State of Health:  Outpatient Surgery:  Gender reassignment surgery codes:  55970, 55980 added

Medicare Risk Adjustment 2016 Medical Record Request Letter is Now Available

The Medicare Risk Adjustment 2016 Medical Record Request Letter is now available. Please notify any staff involved with Quality Management and/or the Fidelis Care QCMI program that the Medicare Risk Adjustment Letter and members’ medical record request lists have been posted on Provider Access Online. Please ensure that all requested medical records are received no later than September 1, 2016.  


Medicaid/HARP Smoking Cessation Benefits and Counseling

The New York State Department of Health has asked Fidelis Care and other health plans to identify smokers and increase quit rates. As your health care partner, we would like to provide you with information about the Smoking Cessation benefit for your patients that includes prescription and non-prescription smoking cessation aids, as well as smoking cessation counseling services. The attached memo contains an outline of this benefit, clinical guidelines, and the corresponding billing criteria needed for reimbursement.


Fidelis Care Authorization Grids Effective July 1, 2016

Fidelis Care would like to notify you of some changes to our authorization grids that could affect claim payment. Please carefully review the following sections for updates effective July 1, 2016:

  • Transplants codes 38220-38221 removed

  • Inpatient procedure updated

  • Dx code lists added to DXA Scans

  • The following codes were removed from the list of DME supplies section - L2106, L2108,  L2112,  L2114,  L2116,  L2126,  L2128

  • Behavioral Health Benefits in Medicaid and HealthierLIfe (HARP) will be active in all of NYS as of 7/1/2016

Behavioral Health Committees Seek Provider Participants
As your partner in quality health care, Fidelis Care is seeking to increase participation on our Behavioral Health and HealthierLife (HARP) Quality Management Committees.

These Committees offer the opportunity for providers to have input on a variety of key programs and measures, including care management and HCBS services, clinical guidelines and policies, and utilization management and quality management data, as well as proposed initiatives.

Meetings are held on a quarterly basis. Interested providers can contact Alicia L. Delmont, Senior Vice President, Provider Services, by phone at (716) 564-6013 or by email at adelmon@fideliscare.org.

NEW  Medical Record Review Requests are Now Available as of April 11, 2016

Fidelis Care is pleased to inform you that a NEW medical record request letter and details for 2016 HEDIS/QARR have been posted on our Provider Portal as of April 11, 2016  Please review these materials and send the requested documentation to Fidelis Care or arrange for us to retrieve the records from your office as soon as possible.

Please notify any staff involved with Quality Management and/or the Fidelis Care QCMI program that these documents have been posted on PAO. If you have any questions, please call the Provider Call Center at 1-888-FIDELIS (1-888-343-3547).

HARP & Behavioral Health Carve-in Services Claims Testing Opportunity
Fidelis Care is proud to be your health care partner in providing quality Behavioral Health Carve-in services to members 21 and over in Medicaid Managed Care and HealthierLife (HARP), effective in all counties in New York on July 1, 2016. In preparation for these new service offerings, Fidelis Care would like to extend an invitation to providers of these new services to participate in Electronic Data Transfer (EDI) and Claims testing to ensure a smooth and efficient transition of these benefits into managed care.

If you would like to test claims for any Adult Carve-in Behavioral Health service, please complete the HARPS Claims Testing Survey and email it to BHClaimsTesting@fideliscare.org as soon as possible. Please be sure to complete the survey in full to avoid delays in the testing process. Claims testing for these services is scheduled to start April 15, 2016. Please click here for further instructions on claims testing. 

IMPORTANT: 2016 HEDIS/QARR Medical Record Review Requests are Now Available!
Fidelis Care is pleased to inform you that the medical record request letter and details for 2016 HEDIS/QARR have been posted on our Provider Portal, Provider Access Online (PAO).  Please review these materials and send the requested documentation to Fidelis Care or arrange for us to retrieve the records from your office as soon as possible. 

Please notify any staff involved with Quality Management and/or the Fidelis Care QCMI program that these documents have been posted on PAO. If you have any questions, please call the Provider Call Center at 1-888-FIDELIS (1-888-343-3547).  

Behavioral Health Carve-in and HARP Services Transition for the Rest of New York State
In preparation for the Behavioral Health Carve-in and HARP implementation for the rest of New York State scheduled for July 1, 2016, the Managed Care Technical Assistance Center (MCTAC) is offering several events for providers.

For more information, click on the below links:

After the HARP implementation, Home and Community Based Services (HCBS) will be added to the rest of the State on October 1, 2016.

To view all services and resources available through MCTAC, please visit their website

FIDA Provider Brochure 
The FIDA Provider Brochure, issued by NYS Department of Health, is now available. The brochure includes program features, important contact information, eligibility, benefits and more!

Essential Plans - PCP NOT Required
This is a reminder that Essential Plan (EP) members are NOT required to select a Primary Care Physician (PCP) and referrals are NOT required when seeing an in-network specialist. For more information about the Essential Plan, covered services, claims, authorizations, etc. please click here to view a copy of the EP Tip Sheet. For additional questions, please call the Provider Call Center at 1-888-FIDELIS (1-888-343-3547).

2016 Prospective List for 5 Key QCMI Measures
At the request of many providers, Fidelis Care is pleased to provide your practice with information about patients eligible for five age sensitive measures in 2016:  Well Child Visits in First 15 Months of Life, Childhood Immunization, Lead Screening in Children, Immunization for Adolescents and the Human Papillomavirus Vaccine for Female 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, please contact the Fidelis Care Provider Call Center at 1-888-FIDELIS (1-888-343-3547).


FIDA: New Flexibility Offered for Providers
The New York State Department of Health (DOH) and the Centers for Medicare and Medicaid Services (CMS) recently announced reforms to the Fully Integrated Duals Advantage (FIDA) demonstration, a plan for qualified dual eligible (Medicare and Medicaid) recipients. The programmatic changes were designed based on feedback from FIDA Participants, providers, and health plans, aimed at making the program more appealing to all stakeholders.

Many of the reforms target improving flexibility and simplifying procedures for FIDA providers. Highlights include:

  • The Interdisciplinary Team (IDT) for each FIDA Participant can now be small, consisting of only a Care Manager and Participant; or broader, including providers and/or caregivers.
  • The Care Manager can meet with IDT members at different times when developing the Person Centered Service Plan (PCSP).
  • Providers have flexibility around participating in the care planning process. For example, Primary Care Providers may review and sign off on a PCSP without attending IDT meetings.
  • IDT training is encouraged for providers, but is no longer mandatory.

For a complete list of the FIDA reforms, effective December 9th, 2015, click here.


DXA Scans for Medicaid Members

Fidelis Care is pleased to announce that we now cover DXA scans for Medicaid members.


Dual-energy X-ray absorptiometry (DXA) is an enhanced X-ray technology that is used to measure bone density and bone loss. It is most often used to diagnose osteoporosis, a condition involving the gradual loss of calcium, as well as certain structural changes that lead to thinner, more fragile bones. Osteoporosis is associated with an increased risk of fractures.


Certain individuals are at a higher risk for osteoporosis. For example, post-menopausal women have a greater risk of osteoporosis. Other risk factors include: family history of osteoporosis, personal history of fractures after the age of 50, poor diet and physical inactivity, smoking, certain medications that include some steroids and chemotherapy agents, and low body weight.


Fidelis Care will reimburse for medically necessary DXA scans for Medicaid members at a maximum of once every two years for women over the age of 65 and men over the age of 70. DXA scans are considered medically necessary and therefore reimbursed at a maximum of once every two years for women and men over the age of 50 with significant risk factors for developing osteoporosis. Fidelis Care does not cover the use of DXA scans to screen for vertebral fractures. The following CPT codes are affected by this frequency limitation:


  • 77080 dual-energy X-ray absorptiometry (dxa), bone density study, 1 or more sites; axial skeleton (e.g., hips, pelvis, spine)
  • 77081 dual-energy X-ray absorptiometry (dxa), bone density study, 1 or more sites; appendicular skeleton (peripheral) (e.g, radius, wrist, heel)

Please refer to the Medicaid Authorization Grid for authorization requirements.


Nursing Home Transition - Frequently Asked Questions
Recently the New York Department of Health released the Nursing Home Transition Frequently Asked Questions to assist providers with the conversion from Fee-for-Service to Managed Care. Please click on the link above to view a copy of the FAQ.



Health Republic – Provider Q&A

Effective December 1st, 2015, Fidelis Care began managing benefits for a significant number of former Health Republic members. For more information, please see the Health Republic Q&A.

Important Information Regarding Your Patients with Health Republic Coverage
As you may be aware, Health Republic members' health insurance will end on November 30, 2015. The New York State Department of Financial Services (NYDFS) and New York State of Health (NYSOH) Marketplace recently announced a series of additional actions to protect Health Republic consumers and help ensure continuity of care and coverage, including extending the NYSOH enrollment deadline for individual Health Republic customers to choose new coverage for the remainder of 2015, and creating an auto enrollment option. See NYDFS and NYSOH announcement and fact sheet.

Health Republic members will need to choose a new health plan through their www.nystateofhealth.ny.gov account by 11:59 PM on November 15 to keep their health insurance for December 1, 2015. From November 16-30, they will need to call a special NY State of Health Customer Service Center to enroll in coverage for December 1. After that date, to ensure continuous coverage, the State will auto-enroll individual Health Republic consumers who purchased insurance in the NYSOH Marketplace, into new plans.

Fidelis Care is here to be a resource for your patients with Health Republic coverage. Losing their health insurance unexpectedly can create a great deal of confusion and concern, and we recommend that they meet with a Representative who can guide them through the process and answer all their questions.

For more information or to make an appointment, your Health Republic patients can call 1-888-FIDELIS (1-888-343-3547) TTY: 1-800-421-1220. They can also meet with a Representative by visiting a Fidelis Care community office in your neighborhood. To find a convenient location near you, visit fideliscare.org/offices.

Fidelis Care Earns Highest Rating of 5 Stars for Health Plan Performance in New York State
Fidelis Care received an overall rating of 5 stars for health plan performance as part of the New York State Department of Health's 2015 Regional Consumer Guides for Child Health Plus and Medicaid Managed Care.

The 5-star rating, an increase from 4 stars in 2014, gives Fidelis Care the distinction of being the top-rated health plan Statewide. The ratings are based on measures such as preventive and well care, quality of care, and member satisfaction. Only one other plan, based in New York City, earned the same distinction.

The Consumer Guides are a resource for those looking for information about health insurers in their region. The star ratings are also seen by consumers when they shop for health insurance on the NY State of Health website.

This is an outstanding accomplishment for Fidelis Care. Thank you for being our partner in our year-round commitment to ensuring the highest levels of quality care and service for our members. 

Annual Medicare Special Needs Program (SNP) Model of Care (MOC) Provider Training

The Centers for Medicare and Medicaid Services (CMS) require that providers receive Medicare Special Need Program (SNP) Model of Care Training (MOC) annually. As part of our ongoing commitment of 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 updated training can be accessed by clicking on File Downloads. Please be sure to complete this required training by or before December 31st, 2015. After completing training, please sign the attestation form and submit it to the fax number provided.

Please click on the link above for a copy of the recently updated Fidelis Care ICD-10 FAQ.


Now Available: Updated Provider Manual With New Information and Features
To provide you with the most current resources for streamlining our work together, Fidelis Care is pleased to announce that our Provider Manual has been updated, effective October 12, 2015, and is now available on our website for you to easily reference. The updated Manual includes enhanced information, as well as several new sections and features to assist you as you provide care and services for our Medicaid Managed Care, Child Health Plus, Medicare Advantage and Dual Advantage, Fully Integrated Duals Advantage (FIDA), Fidelis Care at Home (MLTC), and HealthierLife (HARP) members.

Highlights include:

  • New Section 12 Par 2 – Billing Guidelines
  • Expanded language added Section 7 – Standards for Medical Record Documentation and Section 10 – Health Care Performance Standards
  • Updates to all benefit listings found within Section 18 – Product Information
  • New Products Sections 23 – FIDA and Section 24 – HealthierLife (HARP)
  • Several new appendices were also added covering topics such as: Special Need Plans (SNP) Model of Care Training, FIDA Grievances and Appeals, Cultural Sensitive and ADA, and LHCSA Responsibilities

Please click here to view the newly updated Fidelis Care Provider Manual. Fidelis Care also encourages all providers visit our Tip Sheet Library for a variety of helpful quick reference guides. Fidelis Care is proud to be your partner in quality care, and we trust that you will find our updated Manual a trusted and helpful resource.

New Behavioral Health Services Health and Recovery Plan (HARP) / HealthierLife & Behavioral Health Carve-in Services
Effective October 1, 2015, Fidelis Care will implement a new Health and Recovery Plan (HARP) for eligible members, and will also begin managing certain Behavioral Health (BH) services that will be carved into the Medicaid Managed Care service model for eligible members 21 and over.

The Fidelis Care HARP plan is called “HealthierLife,” and will provide members who qualify with all of the standard Medicaid benefits, along with comprehensive care management, access to Health Homes, as well as certain enhanced BH services commonly referred to as Home and Community Based Services (HCBS). HCBS services will be added to the HealthierLife benefit package on January 1st, 2016.

The focus of the HealthierLife program is to provide additional assistance and resources to individuals with serious mental illness (SMI) and/or substance use disorders (SUDs) diagnosis, with an emphasis on recovery and coordinated care. The program will begin on October 1, 2015 in the five boroughs of New York City and July 1, 2016 for the rest of New York State. Fidelis Care has approximately 23,000 eligible members for this program Statewide.

Provider Resources

Level of Care for Alcohol and Drug Treatment Referral (LOCADTR)

NYS OASAS, in partnership with The National Center on Addiction and Substance Abuse at Columbia University (CASA Columbia), developed the LOCADTR 3.0. This web-based tool is used by substance abuse treatment providers, Medicaid Managed Care plans, and other referral sources to determine the most appropriate level of care for a person with a substance use disorder. LOCADTR 3.0 represents a paradigm shift whereby risks and resources are factors that contribute to the identification of an appropriate treatment setting that is as close to the member's community as possible and is both safe and effective.

All substance abuse treatment providers and referral sources in New York City are required to use LOCADTR 3.0 effective October 1st, 2015. Providers and referral sources in the entire rest of the state are strongly encouraged to use the LOCADTR 3.0 for level of care determinations.   They will be required to use this tool as of July 1, 2016.  For more information, please click here.

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


Logisticare Solutions, LLC

Suffolk County


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.


ICD-10 Transition Approaching - October 1, 2015

On January 16, 2009, the ICD-10 Final Rule was published in the Federal Register, which adopts modifications to code set standards adopted by HIPAA. This rule modifies the standard medical data code sets for coding diagnosis by adopting ICD-10-CM.

The transition from ICD-9 to ICD-10 will take place this fall for dates of service on or after October 1, 2015. ICD-10 coding applies to all providers who use ICD-9 coding currently. Be sure to research the new ICD-10 code(s) so you will be ready for the October 1, 2015 deadline. Please note, the change to ICD-10 does not affect CPT coding for outpatient procedures and physician services.


Electronic and Paper Claims: ICD-9 claims (date of service prior to October 1, 2015) must be submitted separately from ICD-10 claims (date of service on or after October 1, 2015). ICD-10 codes cannot be used on claims with a date of service prior to October 1, 2015. Additionally, any prior-authorization that is requesting the review/approval of services starting on October 1, 2015 or later will require ICD-10 codes. For additional provider resources please visit the CMS website at: https://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html

FIDA Transportation Benefit Update
A range of non-emergent transportation services are covered under the Fidelis Care Fully Integrated Duals Advantage (FIDA) program. This includes transportation for both medical and non-medical events and services. Non-emergent medical transportation includes transportation essential for a Participant to obtain necessary medical care under the FIDA program. Non-medical transportation is also available for a variety of other services and events. Below are examples of allowable and non-allowable events and services:

Places of Worship
Supermarkets (include the transport of shopping bags)
Warehouse Stores (Costco, BJs, et. al.)
Food Outlets
Soup Kitchens/Community Food Banks
Senior Centers
Recreation Centers
Other Community Centers/Workshops
Hair Salons/Barber Shops (once every 30 days)

* Providers must allow room for transporting bags when applicable (i.e. grocery bags)


Retails Stores/Outlets/Malls
Movie Theaters
Family/Friend Places of Residence
Nail Salons
Other Retail Entertainment Outlets

For additional information regarding transportation services, please see our Transportation Provider Manual

Observation Services

The Centers for Medicare and Medicaid Services (CMS) and New York State Medicaid, including Medicaid fee-for-service (FFS) and Medicaid Managed Care plans, recognizes observation care as a well-defined set of clinically appropriate services that include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients, or if they are able to be discharged from the hospital. Recently NYS Medicaid expanded coverage of observation services. The following guidance was provided in the New York State Medicaid Update – May 2013 Volume 29 – Number 5. Please click here to learn more.


NEW Fax Line Available for Claim Invoices

In response to your feedback, Fidelis Care is excited to announce that we have a new fax line dedicated to the receipt of invoices. We are confident this new fax line will not only streamline the process and save time for you and your staff, but will also result in faster payment turnaround time. If you receive a request for a copy of the manufacture's invoice due to a N13 denial (Procedure Requires Report or Invoice), please fax documentation to 1-877- 247- 9187 | Attn: Claims Reconsideration. Please be sure to include the member’s name and member ID, as well as the claim number associated with the invoice request. Please be advised that this fax line is for the submission of invoices only. Please continue to send claims and supporting documentation through the existing channels to avoid delays in payment.


Smoking Cessation Benefits and Counseling
As you know, smoking and the use of tobacco products is one of the greatest public health challenges we face. The New York State Department of Health has challenged Fidelis Care and other health plans in the State with increasing the identification of smokers and increasing the quit rates over the next two years. To help this cause, a variety of smoking cessation products and services are available to members who want to quit. These products and services include: smoking cessation counseling, prescription and non-prescription smoking cessation products such as nasal sprays, inhalers, Zyban (bupropion), Chantix (varenicline), over-the-counter nicotine patches, and gum. Please click here to learn more about the smoking cessation benefits Fidelis Care has to offer.  

Clinical Depression and Follow up Memo posted for Provider Communication
Please notify any primary care provider and high volume specialist staff involved with Quality Management and/or the Fidelis Care Medicare and FIDA Program members that a Clinical Depression and Follow-up memo on claims coding has been posted on Provider Access Online as of July 6, 2015.

National Drug Codes (NDC)

ATTENTION PROVIDERS: Effective July 1, 2015 Fidelis Care will REJECT claims with drug codes that do not contain the REQUIRED National Drug Code (NDC). This is a mandatory requirement that applies to all provider types and is in accordance with Section 6002 of the 2005 Federal Deficit Reduction Act (DRA).


Claims MUST INCLUDE the 11-digit NDC, in addition to the CPT/HCPCS code and units. The NDC dispensing quantity and the NDC unit of measurement are also mandatory. NDC information can be obtained from the drug invoice and/or package information.


Please ensure applicable claims contain the required NDC information to avoid rejection of your claims. For guidance on billing NDCs, please click here. Additional billing information can also be found within the eMedNY New York State Medicaid General Billing Guidelines Manual.

Fully Integrated Duals Advantage (FIDA) Provider Training

Providers participating in the FIDA Demonstration are encouraged to complete provider training on a number of key subjects. The training offers education on FIDA and also addresses the special needs of this vulnerable population, with the goal of ensuring the delivery of quality care to FIDA participants. The courses are as follows:


  • FIDA Overview
  • Behavioral Health
  • Cultural Competency
  • Disability Awareness
  • Recovery and Wellness

The training courses are available at https://fida.resourcesforintegratedcare.com and are also available in a downloadable format. For information and directions on how to complete the downloadable training, please visit https://www.resourcesforintegratedcare.com/FIDA_Downloadable_Provider_Training. For additional information, please see click here to view the FIDA FAQ.


Child Health Plus Benefit Update

Please be advised of the following updates to the Child Health Plus benefits package:

Autism Spectrum Disorder - Effective immediately, the $45,000 per calendar year coverage limit for applied behavioral analysis for treatment of an autism spectrum disorder is replaced by a 680 hour per calendar year coverage limit.

Ostomy Equipment - Effective May 1, 2015, the Child Health Plus Program will provide coverage for ostomy equipment and supplies prescribed by a licensed health care provider legally authorized to prescribe under title eight of the Education Law.

National Correct Coding Initiative Edits 
The Center for Medicare & Medicaid Service (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 Medicare services.

Claims that are found to be noncompliant with these guidelines may be returned and/or denied.

Please visit the sites below for additional information:

NCCI Edits - http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html
AMA - http://www.ama-assn.org/ama
NCD - http://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx
LCD - http://www.cms.gov/medicare-coverage-database/indexes/lcd-state-index.aspx

Patient Centered Medical Home Statewide Program Incentive Payments
In order to allow providers additional time to achieve Patient Centered Medical Home (PCMH) recognition from the National Committee for Quality Assurance (NCQA) under the 2014 standards, New York State Medicaid is extending the implementation date of the Statewide PCMH Incentive Payment Program changes affecting payments to providers recognized under 2011 or 2014 standards, which was announced in the February 2015 Medicaid Update. The implementation date related to payment changes for recognition under 2011 and 2014 standards years will be delayed from April 1, 2015 to January 1, 2016. This extension only applies to providers recognized under the 2011 standards and all incentive payments for PCMH-recognized providers under NCQA’s 2008 standards will still be discontinued as of April 1, 2015.

Medicaid Update
Please click on the link above for a summary of Medicaid updates. These changes will impact the following benefits and services:

  • Oncotype DX® Test for Breast Cancer
  • Low Dose CT Lung Cancer Screening

Peer-to-Peer Reconsiderations (non-Medicare products)
Providers may contact Fidelis Care to request a peer-to-peer reconsideration of an adverse determination. Peer-to-Peer Reconsiderations can be requested following an adverse determination of a pre-service or concurrent request. 

How to request: Peer-to-Peer Reconsiderations are conducted telephonically and may be requested either by contacting Provider Services at 1-888-FIDELIS (1-888-343-3547) or by fax at 800-860-8720. Following receipt of the request, Fidelis Care will contact the provider to schedule and conduct the peer-to-peer discussion within one business day. The peer-to-peer discussion will be conducted by the same clinical peer reviewer who rendered the original determination if he/she is available.

When is a peer-to-peer reconsideration not available?  Peer-to-Peer Reconsiderations are not available if an appeal has already been requested or if the original review was retrospective (after services had been rendered).  The completion of a peer-to-peer reconsideration does not affect the right to request an appeal.  An appeal may be initiated whether or not there has been a reconsideration, or after a reconsideration has occurred.

Can an appeal be requested following a Peer-to-Peer Reconsideration?  Yes.  The completion of a peer-to-peer reconsideration does not affect the right to appeal.

Nursing Home Transition
Effective February 1, 2015 in New York, Kings, Queens, Bronx and Richmond counties and effective April 1, 2015 in Nassau, Suffolk, and Westchester counties, all eligible recipients over age 21 in need of long term care/permanent placement in a Nursing Home (NH) will be required to join a Medicaid Managed Care Plan (MMCP) or a Managed Long Term Care Plan (MLTCP). All current long term/permanent custodial care beneficiaries in a Medicaid-certified NH prior to the phase-in date will remain in fee-for-service Medicaid, but may enroll in a MMCP on a voluntary basis beginning October 1, 2015. Members will not be required to change nursing homes as a result of this transition. New placements will be based upon Fidelis Care’s contractual arrangements and the specific needs of the individual. For additional information, please click on the link above to preview a copy of the Nursing Home Provider Tip Sheet.

Medicaid Update
Please click on the link above for a summary of Medicaid updates. These changes will impact the following benefits and services: 

  • PCI Angioplasty Authorization Requirement Change
  • Viscosupplementation of Knee for Osteoarthritis
  • Selective Bariatric Surgery
  • Hospice Care
  • Adult Day Health Care
  • Increase Limits for Smoking Cessation Counseling

For more information call the Fidelis Provider Call Center at 1-888-FIDELIS (1-888-343-3547).

New Coding Requirements for HCPCS Modifier -59

Effective January 1st, 2015 CMS is establishing new coding requirements related to HCPCS modifier -59 which is used to define a “Distinct Procedural Service.” CMS guidelines will require billers use the following newly established HCPCS modifiers to define a specific subset of the -59 modifier:

  • XE Separate Encounter - A Service That Is Distinct Because It Occurred During A Separate Encounter
  • XS Separate Structure - A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure,
  • XP Separate Practitioner - A Service That Is Distinct Because It Was Performed By A Different Practitioner, and
  • XU Unusual Non-Overlapping Service - The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service.

CMS will continue to recognize the -59 modifier, but notes that CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available. For additional information, please click on the link above.

Anesthesia Modifier Guidelines for Medicare Claims

In accordance with the Centers for Medicare & Medicaid Services  (CMS) coding guidelines, Anesthesiology claims for Medicare patients must include the appropriate modifier(s), in the correct positions, in order to qualify for payment by Fidelis Care. Please click on the link above for a summary of anesthesia coding guidelines.


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.

1-888-FIDELIS (TTY: 1-800-421-1220)Available 24/7