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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 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

Effective August 1, 2026, Fidelis Care will implement a new pre-pay claims review process for certain claims that may involve Third-Party Liability (TPL) or Workers' Compensation coverage. This initiative is designed to help ensure claims are billed to the appropriate payer and processed accurately. As part of this effort, Fidelis Care has partnered with Machinify, a leader in subrogation, TPL identification, and Coordination of Benefits services, to support the review of select claims that may be related to accidents, injuries, or other situations where another insurer may have primary payment responsibility. What Types of Claims May Be Reviewed? Claims that indicate an accident

Effective August 17th, 2026, Pre- and Post-Decision Peer-to-Peer (P2P) discussions will no longer result in reconsideration of inpatient and post-acute care authorization determinations. Any reconsideration of an adverse coverage determination will instead be managed exclusively through the formal appeals process. The Wellcare Model of Care includes a standard provision stating that “provider peer-to-peer requests are permitted for disagreement with UM clinical decision making.” This language does not supersede Medicare UM or appeal requirements; any P2P process is limited to clarification of clinical rationale rather than decision-making or reconsideration of the determination. This operational change to the utilization management (UM) process is effective

Fidelis Care would like to remind providers of the importance of using the appropriate submission process when requesting an expedited authorization review. Our provider portal is designed to support standard authorization requests only. At times, authorization requests submitted through the portal include clinical documentation indicating the request should be reviewed on an expedited basis. Because expedited requests require a different review pathway and turnaround time, submitting these requests through the standard portal workflow may result in delays and can impact timely processing. If a request meets criteria for expedited review, please follow the expedited authorization submission process outlined in the Provider