New Pre-Pay Claims Review Process for Third-Party Liability and Workers' Compensation Claims Effective August 1, 2026
2026/7/21
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Posted by Provider Relations
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Provider News
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 or injury and may involve:
- Motor vehicle accidents, including claims potentially covered by No-Fault, Personal Injury Protection (PIP), or Medical Payments (Med Pay) coverage
- Work-related injuries or illnesses that may be covered under Workers' Compensation insurance may be subject to a pre-payment review.
What Providers Should Know
- No changes are required to your current billing process. Continue submitting claims to Fidelis Care according to established procedures.
- Claims identified for review may experience a temporary pend while eligibility for other primary coverage is verified.
- If another payer is determined to be primarily responsible, information needed to bill the appropriate carrier will be communicated when available.
- Once the review is complete, claims will be processed and adjudicated accordingly.
Why This Change?
The pre-pay review process helps ensure compliance with coordination of benefits requirements by identifying claims where another insurer may be responsible for payment before claim adjudication. This approach supports accurate claim processing, reduces billing errors, and promotes appropriate use of healthcare resources.
Fidelis Care appreciates your continued partnership and commitment to providing high-quality care to our members.
For additional questions, or if we can be of assistance in any way, please contact your Fidelis Care Provider Engagement Account Manager. To identify your designated representative, please visit Contact Your Designated Provider Relations Specialist.