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Effective September 1, 2026, Fidelis Care will implement the Leveling of Care: Emergency Department Evaluation and Management (E/M) Overcoding for Facility Services Policy (CC.PP.80) for applicable lines of business. This policy is designed to help ensure facility Emergency Department E/M coding accurately reflects the level of resources used during a patient visit. Claims will go through a review prior to payment to determine if the billed level of service is supported by the claim evidence and resources.  This approach is consistent with national billing guidance and industry oversight priorities. Both the Centers for Medicare & Medicaid Services (CMS) and the Office of

Fidelis Care will host three Provider Office Hours in August 2026. During the webinars, Fidelis Care staff will be available to share information, provide an overview of provider resources, and answer your questions. Provider Office Hours – August 2026 Topic: Fidelis Care – Back to Basics When:  Thursday, August 13th – 12PM – 1PM EST Click here to register*   Topic: Fidelis Care and Wellcare Quality Programs When:  Wednesday, August 19th – 10:30AM – 11:30AM EST Click here to register*

Effective August 1, 2026, Fidelis Care will implement a new pre-pay claims review process for certain claims that may involve Third-Party Liability (TPL) or Workers' Compensation coverage. This initiative is designed to help ensure claims are billed to the appropriate payer and processed accurately. As part of this effort, Fidelis Care has partnered with Machinify, a leader in subrogation, TPL identification, and Coordination of Benefits services, to support the review of select claims that may be related to accidents, injuries, or other situations where another insurer may have primary payment responsibility. What Types of Claims May Be Reviewed? Claims that indicate an accident

Effective August 17th, 2026, Pre- and Post-Decision Peer-to-Peer (P2P) discussions will no longer result in reconsideration of inpatient and post-acute care authorization determinations. Any reconsideration of an adverse coverage determination will instead be managed exclusively through the formal appeals process. The Wellcare Model of Care includes a standard provision stating that “provider peer-to-peer requests are permitted for disagreement with UM clinical decision making.” This language does not supersede Medicare UM or appeal requirements; any P2P process is limited to clarification of clinical rationale rather than decision-making or reconsideration of the determination. This operational change to the utilization management (UM) process is effective