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As part of our ongoing Payment Integrity Program, a new initiative will begin September 1, 2025. This program involves review of the medical records associated with an identified inpatient claim to ensure that the documentation in the medical record fully supports the diagnosis and procedure codes that were billed.   What to Expect: Claims selected for review will be reflected as denied on the Remittance Advice with reason code 602 – Medical record required for DRG validation. You will receive a letter from Cotiviti requesting the medical records related to the denied claim(s). The letter will specify the required documentation needed to complete the review and the timeframe

The following section of the Fidelis Care authorization grids have been updated effective September 1, 2025.   The following code has been updated on the Medicare Authorization Grid and requires prior authorization:   Durable Medical Equipment/Supplies:            E1012 Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each   The following section of the Fidelis Care authorization grids have been updated effective July 1, 2025.   The following codes have been updated on the Medicare Authorization Grid and no longer require prior authorization:   Service Category Services

Fidelis Care would like to announce a new Explanation of Benefit (EOB) adjustment reason code that will be applied to claims where Fidelis Care has received a primary carrier payment. New EOB Reason Code Details: CARC Code: 216 – Based on the findings of a review, organization or the payer’s findings. RARC Code: N199 – Additional payment/recoupment approved based on payer-initiated review/audit. These are internal adjustments that reflect the primary carrier’s payment. They do not impact the provider’s Remittance Advice financially and are not considered recoupments.   Primary Carrier Billing and Payments: Medicaid is the payer of last resort and should always be

Fidelis Care will host three Provider Office Hours in August 2025. 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 – August 2025   Topic: Fidelis Care – Back to Basics When:  Thursday, August 14th – 12PM – 1PM EST Click here to register*   Topic: Fidelis Care and WellCare Quality Programs When:  Wednesday, August 20th – 10AM – 11AM EST Click

The following section of the Fidelis Care authorization grids have been updated effective September 1, 2025.   The following code has been updated on the Essential Plan and Metal-Level Products Authorization Grids: Durable Medical Equipment/Supplies:                                1.      These DME codes do not require an authorization: A7046                                                       The following codes have been updated on the Medicare Authorization Grid: A.    Durable Medical Equipment/Supplies:            1.      These DME codes do not require an authorization: A4557, A5500, A6530, A7046, E0443, E0730, E0849, E0951, E0955, E0956, E0961, E0971, E0973, E0990, E1392, E2210, E2365, E2601, E2607, E2624, K0001, K0019, K0040, K0195, K0738, L5685              2.       The following orthotic codes

Fidelis care would like to inform all participating providers that we will be conducting an Access & Availability Survey in the coming weeks. This survey ensures that providers are meeting NYS mandated Access & Availability standards for all Fidelis Care members. The survey will assess: Timeliness of appointment scheduling based on appointment type.  For example: Routine Care Urgent Care Non-Urgent Sick Visit After Hours Availability  Accuracy of provider directory information. This applies to Primary Care Providers, OB/GYNs, Oncologists, and Behavioral Health Providers. Typical reasons for non-compliance include: Appointment scheduling timeframes do not meet state guidelines. Office