Welcome, Brokers!

As part of our ongoing work to improve the prior authorization (PA) process for both providers and members, Fidelis Care wants to share some important updates to our PA requirements for Medicaid, Ambetter From Fidelis Care and Medicare lines of business. Our goal is to reduce administrative burden, simplify submission and approval processes, and facilitate timely access to appropriate, high-quality care.     Code change details for each line of business can be found below. These changes may include:    ·         Removing PA requirements based on criticality of review and clinical need.  ·         Creating a more uniform set of prior authorization requirements across our markets and

The following sections of the Fidelis Care authorization grids have been updated effective April 1, 2026.             The following codes have been added to the Medicaid Authorization Grid and requires prior authorization:   III.       Outpatient surgery: The following services require prior authorization:                                     A.  Bariatric surgery: 43644, 43645                                                       D.  Skin surgery and other dermatological procedures: Only the following codes continue to require authorization for any place of service: 15271, 15274, 15275, 15276                                                      M.  Spinal Surgery: 22830, 63200                                 

Fidelis Care will host three Provider Office Hours in March 2026. During the webinars, Fidelis Care staff will be available to share information, provide an overview of provider resources, and answer your questions. Provider Office Hours – March 2026   Topic: Fidelis Care – Back to Basics When:  Thursday, March 12th – 9AM – 10AM EST Click here to register*   Topic: Fidelis Care and WellCare Quality Programs When:  Wednesday, March 18th – 10:00AM – 11:00AM EST Click

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