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As a reminder to our Fidelis Care providers, COB Claims can be submitted via Electronic Data Interchange (EDI) as of January 1, 2022.  This includes corrected claims and resubmissions.

Electronic Submission of Corrected COB Claims

• The original claim number must be submitted 
• The claim frequency type code must be a 7 (replacement of prior claim)
• 2300 Loop, CLM Claim Information Segment, CLM05-3 Claim Frequency Type Code Element must be set to a 7 and 2300 Loop
• REF Original Reference Number (ICN/DCN) Segment where REF01 Element equals F8, REF02 Element must contain Fidelis Care Original Claim Number
• Only one correction for a Fidelis Care Original Claim Number should be submitted per day

Paper Submission of Corrected COB Claims:

• A fully completed Reconsideration/Appeal Request Form
  • A valid Claim form (CMS-1500 or UB-04) containing:
    • Resubmission code 7 and the previous claim #
    • An EOB from another insurance carrier/supporting documentation should be sent to:

Electronic Submission of First Time COB Claims (the claim has never been billed to Fidelis Care & where Fidelis Care is secondary for the member): 

• Loop 2320 contains insurance information about:  Other insurance carriers and their payment information for the Subscriber being billed.
• Segments NM1-N4 contain name and address information of the insurance carriers referenced in loop 2320.

Fidelis Care’s preferred clearinghouse for electronic claims submission is Availity. To enroll, please call Availity Client Services at 1-800-AVAILITY (1-800-282-4548).

Claims can also be submitted through clearinghouse Ability, or another clearinghouse. Fidelis Care offers free online claims submission through Ability’s claims portal. To learn more about Ability, call 1-888-499-5465 or visit www.mdon-line.com/fideliscare. 

You also have the option to contact another clearinghouse to initiate 837-claim submission to Fidelis Care. Please confirm with the clearinghouse that they will forward claims to Fidelis Care on your behalf.

COB Related Reconsiderations (the claim has previously been billed to Fidelis Care, and you are requesting a reconsideration or appeal)

• Accepted via paper submission only at this time. 
• Please include the following:
  • A fully completed Reconsideration/Appeal Request Form
  • A valid Claim form (CMS-1500 or UB-04)
  • An EOB from another insurance carrier/supporting documentation
• Please submit to the appropriate address below based on line of business being billed: