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The following section of the Fidelis Care authorization grids have been updated effective June 1, 2025.   The following codes have been updated on the Medicaid, Essential Plan, and Ambetter Metal-Level Products Authorization Grids and require prior authorization: B. Durable Medical Equipment/Supplies:                                    T2101 (Donor Breast Milk) only requires an authorization when given in an outpatient setting.              The following codes have been updated on the Essential Plan and Ambetter Metal-Level Products Authorization Grids and require prior authorization: III.       Outpatient surgery: The following services require prior authorization:            D.  Skin surgery and other dermatological procedures: A2025   The following codes have been updated on the Medicaid, Essential Plan, and Ambetter

Fidelis Care would like to remind providers of the updated calculation of hospitals’ initial inpatient acute, exempt hospital, and exempt unit reimbursement rates for Medicaid Fee-for-Service (FFS) and Medicaid Managed Care (MMC), which were effective October 1, 2024.   As per Medicaid DOH site, an administrative letter was published to support reduction to the capital rate add-ons. Providers should have received notification from the State regarding this rate update.    The October 1, 2024 Medicaid FFS rates have been approved by the New York State Division of the Budget (Budget) and have been transmitted to eMedNY for payment and retroactive claims processing.   These rates are

Fidelis Care would like to notify providers that the MCG Cite Guideline Transparency Tool was upgraded to the 29th edition effective Saturday, April 26, 2025. Providers can access this tool through the Fidelis Care Provider Portal. Highlights of the changes in the 29th edition of the MCG care guidelines include: Five new observation care guidelines in MCG Inpatient & Surgical Care to support the use of observation care for specific diagnoses. In addition, a new calculator for mean arterial pressure (MAP) was added to the content (where applicable). A new “Gene and Cellular Therapy” section containing guidelines for cutting-edge treatments was added

Fidelis Care is pleased to announce that providers will soon have access to correct and resubmit a paid or denied claim, and view and reconcile remittances through their Availity Essentials account.   On April 21, Fidelis Care providers will have the following new functionality available on Availity Essentials. Claim Corrections - Correct and resubmit a paid or denied claim from the Claim Status Response page. Ask your Availity Essentials Administrator to assign you the Claim Status role if this task is appropriate for your role.   Remittance Viewer - Locate remittances with ease using the extensive search and filter options. You can

Fidelis Care would like to inform providers of updated requirements with the NYS Recipient Restriction Program. The goal of the Recipient Restriction Program (RRP) is to coordinate medical and/or pharmacy services and improve the quality of care for Medicaid recipients. Coordination of care reduces the potential over-utilization of health care services, prevents abusive or fraudulent behavior, and protects Medicaid recipients’ health and safety.   As of February 24, 2025, a restricted recipient must comply with the Recipient Restriction Program. If restricted to a pharmacy, the restricted recipient will be required to fill prescriptions at their designated pharmacy. Claims will not pay if