Bienvenidos, Corredores!

The following sections of the Fidelis Care authorization grids have been updated effective May 1, 2024.   The following codes have been added on the Medicaid, Medicare, Essential Plan, and Metal-Level Products Authorization Grids and require prior authorization: C9166   secukinumab C9167   apadamtase alfa C9168   mirikizumab-mrkz J0177    aflibercept hd J0589    daxibotulinumtoxina-lanm J1202    miglustat J1203    cipaglucosidase alfa-atga J1323    elranatamab-bcmm J2277    motixafortide J2782    avacincaptad pegol J2801    risperidone (Rykindo) J3055    talquetamab-tgvs J7165    prothrombin complex concentrate (Balfaxar) J9073    cyclophosphamide (ingenus) J9074    cyclophosphamide (sandoz) J9075    cyclophosphamide, not otherwise specified J9248    melphalan (hepzato) J9249    melphalan (apotex) J9376    pozelimab-bbfg Q5133  tocilizumab-bavi (tofidence) Q5134  natalizumab-sztn (tyruko)   The following codes have been added on the Medicare Authorization Grids and require prior authorization: J0577    buprenorphine extended-release (brixadi), less than or equal to 7 days of therapy  J0578   

Beginning March 2, 2024, current enrollees in Qualified Health Plans (Ambetter from Fidelis Care) who are within 200-250% FPL were notified via letter from NY State of Health about the expansion of Essential Plan (EP) coverage in New York State. Members that now qualify for Essential Plan coverage will automatically be moved from their Qualified Health Plan to Essential Plan 200-250, effective April 1, 2024. In addition to the Essential Plan Expansion, effective April 1, 2024, NYS will be implementing the EP Pregnancy Choice Provision.  Individuals who are currently in EP and who report being pregnant will remain EP eligible, instead

The METS program is an integrated, whole health approach to support members with significant behavioral health challenges. It includes behavioral health, medical, therapeutic, pharmacy, and supplemental services. METS’ purpose is to focus on the recovery and resiliency of each person. The goal is to help members remain in their community. Members are internally identified using claims history over a 12-month period. If you have a patient identified for the program, a METS Clinical Liaison will reach out to you to discuss the member’s treatment plan and progress. The METS team partners with both the provider and the member to ensure the member achieves

Fidelis Care is pleased to inform you that the medical record request letter and details for 2023 HEDIS/QARR have been posted on our Provider Portal, Provider Access Online (PAO). Please review these materials and send the requested documentation to Fidelis Care as soon as possible. Thank you in advance for your cooperation on this important matter. Should you have any questions or concerns, please do not hesitate to contact Fidelis Care’s Provider Call Center at 1-888-FIDELIS (1-888-343-3547). As part of the New York State Quality Assurance Reporting Requirements (QARR), National Committee for Quality Assurance (NCQA), and HEDIS reporting requirements for the Centers

As of January 1, 2024, Fidelis Care has partnered with MCG Health to implement the MCG Cite Guideline Transparency Tool. Providers can access this feature through the Fidelis Care Provider Portal. With the MCG Cite Guideline Transparency Tool, Fidelis Care shares clinical indications with providers. The tool is a secure resource that helps meet regulations around transparency for care delivery. Benefits include: Transparency: Delivers industry-leading medical determination transparency. Access: Allows the review of MCG clinical evidence used by payers to support         member care decisions. Security: Ensures easy and flexible access via secure web access. This Quick Reference Guide details how to