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Fidelis Care is notifying providers of key updates to the Applied Behavior Analysis (ABA) Clinical Policy (FC.CP.BH.104) The updated policy includes revisions to medical necessity criteria, treatment planning standards, and utilization management requirements for ABA services. Fidelis Care has also adopted a related policy CP.BH.105 ABA Documentation, outlining documentation standards to support medical necessity review and ongoing authorization requests.   In addition, CMS has released the State Medicaid and Children’s Health Insurance Program Applied Behavior Analysis Toolkit, which is being shared as a reference resource.   Effective 10/1/2026, the following changes, which are outlined in greater depth within the policy attached will apply:  

Fidelis Care has updated its 30-Day Readmission Payment Policy which establishes reimbursement guidelines for hospital readmissions occurring within thirty (30) days of discharge. This policy replaces the previous 14-Day Readmission Payment Policy and expands the readmission review period to thirty (30) days following discharge. The updated policy, effective October 1, 2026, outlines circumstances when a readmission may not qualify for separate reimbursement. Certain readmissions may be reviewed to determine whether they meet Fidelis Care’s reimbursement criteria. When applicable, separate payment for the readmission may be denied because the readmission is considered an extension of the initial admission. Providers should review the policy

As part of our ongoing work to improve the prior authorization (PA) process for both providers and members, Fidelis Care wants to share some important updates to our PA requirements. Our goal is to reduce administrative burden, simplify submission and approval processes, and facilitate timely access to appropriate, high-quality care.    Code change details are noted in the table below. The changes may include: Removing PA requirements based on criticality of review and clinical need.  Creating a more uniform set of prior authorization requirements across our markets and lines of businesses, including adding and changing some PA requirements, to simplify processes, reduce

Fidelis Care will host two Provider Office Hours in September 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 – September 2026   Topic: Fidelis Care and Wellcare Quality Programs When:  Wednesday, September 16th – 10:30AM – 11:30AM EST Click here to register*   Topic: Fidelis Care – Back to Basics When:  Thursday, September 17th – 11AM – 12PM EST Click

The Centers for Medicare & Medicaid Services (CMS) require health plans to provide annual education and training regarding our Special Needs Plan (SNP) Model of Care to providers who treat our SNP members. This applies to our Dual Eligible Special Needs Plan (D-SNP) members, who are eligible for both Medicare and Medicaid, and our Chronic Condition Special Needs Plan (C-SNP) members. As stated in our provider manual, all providers who treat our SNP members, regardless of network participation status, must complete Model of Care (MOC) training annually by Dec. 31. The training is designed to help you better understand our approach