Friday
• Posted by Provider Relations
Fidelis Care would like to advise Providers of an update to the Private Duty Nursing (PDN) manual as of July 1, 2026.
Member Demographic Information Form
Detailed in section 6.11 of the Private Duty Nursing (PDN) manual, this form is to be completed by the Billing Provider. If support is needed for completion, members’ Care Manager should be contacted.
The form includes a home safety attestation and applicable member information regarding school and day program.
This form must be submitted with new PDN cases and with 12-month documentation renewal requests, along with the required documentation detailed in Section 6.1 of the PDN
Last Week
• Posted by Provider Relations
As a reminder, providers now have access the Availity Clinical Quality Validation (CQV) tool designed to help providers close care gaps quickly and accurately. Through the Availity Essentials portal, CQV streamlines documentation and improves quality scores while reducing administrative burden.
What is CQV?
Clinical Quality Validation (CQV) is an Availity Essentials application that helps providers:
· Monitor targeted care gaps/measures for the measurement year.
· View and respond to payer requests for clinical/medical data.
· Improve quality scores and reduce administrative burden.
Benefits
· Streamlined workflow for care gap closure.
· Faster access to clinical data.
· Enhanced provider experience across multiple markets.
Availity-led Training for Providers:
A live webinar, Centene
Last Week
• Posted by Provider Relations
Effective July 1, 2026, the following procedures will be removed from prior authorization.
The following RADIOLOGY AND DIAGNOSTIC CARDIOLOGY (RBM) codes have been removed from the Evolent’s Utilization Review Matrix and no longer require prior authorization for Medicaid.
Modality
Impacted CPT
CT ORBIT/EAR/FOSSA WITH O DYE
70480,70481,70482
CT MAXLOFCE AREA; W/O CONTRAST MATL
Last Week
• Posted by Provider Relations
The following section of the Fidelis Care authorization grids has been updated effective July 1, 2026.
The following codes have been updated on the Medicaid, CHP, Essential Plan, Ambetter Metal-Level Plans, and Medicare Authorization Grids and require prior authorization:
C9310 leucovorin calcium (avyxa), inj
J1289 narsoplimab-wuug, inj (Yartemlea)
J1577 immune globulin, inj (Qivigy)
J2361 depemokimab-ulaa, inj (Exdensur)
J2789 riboflavin 5'-phosphate, ophthalmic (Epioxahd/Epioxa)
J3386 etuvetidigene autotemcel, inj (Waskyra)
J3405 onasemnogene abeparvovec-brve, inj (Itvisma)
J9053 belantamab mafodotin-blmf, inj (Blenrep)
J9062 amivantamab and hyaluronidase-lpuj, inj (Rybrevant)
J9232 docetaxel (hospira), inj
Q5164 ustekinumab-hmny, inj (Starjemza)
Q5165 denosumab-mobz, inj (Oziltus)
Q5166 denosumab-desu, inj (Osvyrti/Jubereq)
Q5167 denosumab-qbde, inj (Enoby/Xtrenbo)
Q5168 ranibizumab-leyk, inj (Nufymco)
Q5169 pegfilgrastim-unne, inj (Amlupeg)
Q5170 aflibercept-boav, inj (Eydenzelt)
Q5171 denosumab-mobz, inj (Boncresa)
For