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To facilitate the timely processing of provider demographic and termination requests, and to ensure appropriate member notification, Fidelis Care would like to remind providers of the required submission timeframes and methods. Providers are encouraged to review these requirements carefully and submit all requests in accordance with the outlined procedures.

Timely Submission Requirements

• Provider Demographic/Office Changes: Submit at least 30 days prior to the effective date.
• Provider Terminations: Submit at least 60 days prior to the effective date.

Please note: The effective date of the requested change will be no earlier than the date Fidelis Care is notified.

Submission Methods

• Online: Directory changes can be submitted through the Provider Portal.

• Forms: Submit via the designated Provider Termination Form or Demographic Change Form through email.
  • Please use these forms to submit changes under a singular TIN. In order to expedite the request, all fields on the forms are required. If not complete, the request will be delayed.
  • Please note: These forms should not be used by delegated credentialing entities. Delegated groups should continue to submit termination requests through the established process.
• Providers joining an existing participating TIN:
  • Please submit a Link Letter requesting to be added. The request must include the following information:
• TIN (Tax Identification Number)
• Group Name & NPI
• Provider Name, Specialty & NPI
• Billing and Service Address
• Phone and Fax Number
• Provider Office Hours (including days and times)
• Wheelchair Accessibility Status
• Requested Effective Date
• Completed W-9 Form

Quarterly Review & Attestation

Practices are required to complete a quarterly review and attest to provider demographic information via the Provider Portal.

Compliance with the No Surprises Act

Providers and facilities must maintain business processes to ensure timely updates to provider directory information.