7/31/2024
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Posted by Provider Relations
in
Provider News
Effective June 24, 2024, Fidelis Care implemented changes to our Peer-to-Peer process. In response to inquiries from our providers, we are providing the following clarification and reminder.
Clarification – Medicare: To comply with CMS regulations, Fidelis Care is no longer providing a Post-Decision Peer-to-Peer review for most services pertaining to Medicare members. It is important to note that submitting a formal appeal will be necessary for any post-decision reviews. Note that a concurrent peer-to-peer discussion can be provided for emergent hospital admissions only, if requested while the member is still in the hospital OR if requested within 2 business days of the denial decision when the member was discharged prior to the denial notification.
Reminder - For all other lines of business, Fidelis Care will continue to offer Peer-to-Peer/Reconsideration reviews, which may result in a reversal of the initial decision based on the information provided as part of the Peer-to-Peer/Reconsideration review. It is important to note that all Peer-to-Peer/Reconsideration requests must be submitted within five (5) business days of the initial determination date, and can only be submitted before a formal appeal is requested. After this period, a formal appeal will be required for review and reconsideration of the initial determination. Please note that a formal appeal can be submitted at any time after the initial determination is made, within the allotted regulatory appeal timeframes for the member’s line of business.
For additional questions, or if we can be of assistance in any way, please contact your Fidelis Care Provider Relations Specialist. To identify your designated representative, please visit Contact Your Designated Provider Relations Specialist