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The following sections of the Fidelis Care authorization grids have been updated effective November 1, 2025.   The following codes have been updated on the Medicaid, Medicare, Essential Plan, and Metal-Level Products Authorization Grids: III.       Outpatient surgery: The following services require prior authorization:                        D.  Skin surgery and other dermatological procedures: Only the following codes require authorization for any place of service: A2030, A2031, A2032, A2033, A2034, A2035, A2036, A2037, A2038, A2039, 11200, 11201, 11719, 15769-15829, 17340-17999, Q4354, Q4355, Q4356, Q4357, Q4358, Q4359, Q4360, Q4361, Q4362, Q4363, Q4364, Q4365, Q4366, Q4367, Q4383, Q4384, Q4385, Q4386, Q4387, Q4388, Q4389, Q4390, Q4391, Q4392, Q4393, Q4394,

Effective October 1, 2025, Ambetter from Fidelis Care will implement a Site of Care Optimization Program to promote cost-effective, high-quality care for members receiving infusion therapies.   Under this initiative, providers will be asked to transition eligible members from outpatient hospital infusion settings to clinically appropriate home infusion or ambulatory infusion suite (AIS) options. Outreach to participating providers will begin in October via fax or phone to gather preferred site-of-care selections.   National Infusion Providers: AcariaHealth, Accredo, KabaFusion, Option Care Local Infusion Providers: Prime Infusions, OptumCare, CNY Infusion, Soleo Health The above are a few examples of contracted providers. Visit fideliscare.org/Find-A-Doctor#/search for a complete list of

Timely follow-up care after a mental health discharge is a vital component of recovery. Clinical guidelines recommend that individuals discharged from an emergency department (ED) or inpatient setting receive a follow-up visit within seven (7) days. This window is crucial for maintaining continuity of care, reducing the risk of readmission, and supporting long-term wellness. To help meet this need, Fidelis Care has partnered with Brave Health, a virtual behavioral health provider offering accessible services such as therapy, psychiatry, and care coordination. Brave Health’s telehealth model allows members to receive care from the comfort of their homes, making it easier to stay

In today’s healthcare landscape, effective coordination between primary care providers (PCPs) and specialists is essential for delivering safe, timely, and patient-centered care. When providers collaborate, patients benefit from accurate diagnoses, appropriate treatments, and a smoother care experience. Why It Matters PCPs manage preventive care and chronic conditions, serving as the first point of contact for members. When specialized care is needed, such as for heart disease or skin conditions, specialists become key partners. Without coordination, patients may face delays, conflicting advice, medication errors, and increased healthcare costs. Referrals: A Vital Link Referrals are more than administrative steps; they ensure patients receive the right care

The role of primary care providers in preventing vaccine-preventable diseases includes more than administering vaccines. Timely documentation in New York’s immunization registries (New York State Immunization Information System (NYSIIS) for providers outside New York City, and the Citywide Immunization Registry (CIR) for providers within New York City) is essential to protecting children and supporting public health. Why Timely Reporting Matters Accurate updates to NYSIIS and CIR: Ensure continuity of care Prevent missed or duplicate vaccinations Support public health surveillance Improve office efficiency Comply with New York State law (reporting required within 14 days) The Value of Timely Vaccination Vaccines are most effective when given

Fidelis Care’s Pharmacy Services would like to provide clarification on how medications are covered under member’s medical and pharmacy benefits.   Medications Covered Under Fidelis Care Medical Benefit Physician Administered Drugs – medications administered to a member during an outpatient visit Providers obtain medication via “buy-and-bill” or shipment to their practice site from a vendor of their choosing. Coverage is dictated by Fidelis Care Authorization Grids, Prior Authorization Lookup Tool and/or Evolent Specialty Services (formerly NCH) Authorization Grids (Oncology Regimen Specific). Medical Benefit Authorization Grids are plan specific. If a medication is listed on one of the above authorization grids/tools, an authorization