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In an effort to continue promotion of quality improvement for services provided to Fidelis Care members, as of January 1, 2024, Fidelis Care expanded its existing partnership with Evolent (NIA) to provide the management and prior authorization of non-emergent Musculoskeletal (MSK) procedures including: inpatient and outpatient hip, knee, shoulder, lumbar and cervical spine surgeries.

Fidelis Care encourages providers to use the new Prior Authorization Requirement Lookup Tools to determine which procedure codes require pre-authorization for Medicaid (including Child Health Plus and HARP products), Medicare, Essential Plans, and Qualified Health Plans (Ambetter from Fidelis Care).

To access the lookup tool on fideliscare.org:

• Navigate to Providers
• Under Provider Resources, find Authorization Grids
• Click on the Medicaid, Child Health Plus, HealthierLife (HARP), Medicare, Essential Plan or Qualified Health Plan drop-down menu
• Select Authorization Lookup Tool at the top of the menu

Reference Guide:  For further information and instructions on using the tool, providers can review the Authorization Lookup Tool Reference Guide.

If you have any questions, please contact your Fidelis Care Provider Relations Specialist. To find your designated representative, please visit Contact Your Designated Provider Relations Specialist.

DISCLAIMER:  While every effort is made to provide the most current information on the Pre-Authorization Tool, it is important to note that this does not guarantee payment or confirm patient eligibility. For specific details, please refer to the current authorization grids and provider manual. If you are uncertain whether prior authorization is needed, please submit a request for authorization through the Provider Portal.