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Fidelis Care is pleased to announce a new addition to the Provider Manual—the Quality Policy. The policy seeks to set forth the core quality requirements for any provider contracted with Fidelis Care. Those requirements include 1) a minimum Medicare Stars rating of 2.5 or higher, 2) ensuring that at least 50% of the Medicaid HEDIS measures perform at the 75th percentile or higher, 3) 100% medical record submissions for HEDIS & Risk Adjustment purposes, and 4) adherence to digital methods of records submission, or allowing remote access when otherwise not covered. Failure to meet those core requirements will lead to

Fidelis Care’s Pharmacy Services would like to provide clarification on how medications are covered under member’s medical and pharmacy benefits.   Medications Covered Under Fidelis Care Medical Benefit Physician Administered Drugs – medications administered to a member during an outpatient visit. Providers obtain medication via “buy-and-bill” or shipment to their practice site from a vendor of their choosing. Coverage is dictated by Fidelis Care Authorization Grids, Prior Authorization Lookup Tool and/or Evolent Specialty Services (formerly NCH) Authorization Grids (Oncology Regimen Specific). Medical Benefit Authorization Grids are plan specific. If a medication is listed on one of the above authorization grids/tools, an authorization

Fidelis Care would like to remind providers that it is appropriate to bill a problem‑oriented E&M on the same day as a surgical or preventive service when the issue is separate and significant.  In these cases, correct use of modifier 25 and proper documentation are essential to ensure accurate reimbursement and to avoid duplicate payment for services not separately performed.   Key Rules Use modifier 25 to show the E&M service is distinct from the main procedure or preventive exam. Claims are clinically reviewed to confirm the E&M is separate. If validated, payment includes: 100% of the primary service 50%

You asked and we listened!  Fidelis Care is pleased to announce that Authorization Determination letters on Fidelis Care’s Provider Portal, will now indicate if the letter is an Initial Adverse Determination (IAD) or a Final Adverse Determination Letter (FAD).    Current Letter Details: ABC Medical Center - Member Name - Auth# New Letter Details: ABC Medical Center - Member Name - Auth# - IAD or FAD   To Access the Letters: Use the menu on the left of the Provider Access Online home page to navigate to the File Downloads section. On the File Download page, providers can search by File Type and File Created