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Fidelis Care has received notice from the Office of the Medicaid Inspector General (OMIG) of new compliance program requirements for Medicaid participating providers. Effective April 2020, for New York State (NYS) Social Services Law (SSL) §363-d, and effective December 28, 2022, for the corresponding regulations at 18 New York Codes, Rules and Regulations (NYCRR) Subpart 521-1, NYS Medicaid providers shall adopt, implement, and maintain effective compliance programs aimed at detecting fraud, waste, and abuse in the NYS Medicaid program.   Who is Required to Have a Compliance Program? NYS Social Services Law (SOS) § 363-d and Title 18 of the New York Codes, Rules

In accordance with Chapter 645 of the Laws of 2005, the New York State (NYS) Medicaid program does not cover prescription or physician-administered drugs used for the treatment of sexual dysfunction (SD) or erectile dysfunction (ED). Additionally, Medicaid does not reimburse any supplies or procedures used to treat SD/ED for persons required to register as sex offenders. Before providing services to Fidelis Care Medicaid members, providers must first obtain authorization for any prescription or physician-administered drugs and procedures or supplies related to SD or ED. Peyronie’s Disease (N48.6) is also classified as a SD diagnosis by the New York State Department

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

Fidelis Care would like to remind our provider community of the required protocols for submitting corrected claims and to clarify how these differ from appeals. Following these guidelines helps ensure timely and accurate claims processing.   What Is a Corrected Claim? A corrected claim is used when the provider needs to modify or replace a previously submitted claim due to an error—such as coding, billing, or demographic inaccuracies. Examples include: Incorrect procedure code Wrong units of service Member demographic correction Billing error requiring claim replacement Corrected claims must follow the format requirements above and be submitted within 60 calendar days from the date of the