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Access to quality care is essential to reducing health disparities and improving the quality and length of life for all New Yorkers.   The New York State Department of Health (NYSDOH) and CMS require that specific Access and Availability Standards be met by Primary Care Providers (PCPs), OB/GYNs, Specialists, and Behavioral Health Providers.   To ensure compliance, Fidelis Care conducts regular Access & Availability surveys to confirm providers meet these state-mandated standards for all Fidelis Care members.   The survey evaluates: Timeliness of appointment scheduling by appointment type Accuracy of provider directory listings Responsiveness of phone systems and office staff   Common issues leading to non-compliance include: Appointment

Fidelis Care has received notice from the Office of the Medicaid Inspector General (OMIG) of new compliance program requirements for Medicaid participating providers. Effective April 2020, for New York State (NYS) Social Services Law (SSL) §363-d, and effective December 28, 2022, for the corresponding regulations at 18 New York Codes, Rules and Regulations (NYCRR) Subpart 521-1, NYS Medicaid providers shall adopt, implement, and maintain effective compliance programs aimed at detecting fraud, waste, and abuse in the NYS Medicaid program.   Who is Required to Have a Compliance Program? NYS Social Services Law (SOS) § 363-d and Title 18 of the New York Codes, Rules

Fidelis Care would like to remind our providers of a claim denial reason code that is used when COB claim resubmission requirements are not met.  EX CODE:  50M Short Description:  Claim resubmission requirements not met Long Description:  COB resubmission requirements not met - missing resubmission code and/or reconsideration form The denial reason will occur when providers do not indicate the appropriate resubmission code or do not include the reconsideration form. This denial reason code is specific to COB claims that have been resubmitted to Fidelis Care.   In order to avoid this denial, please follow the instructions below for claim corrections and reconsiderations:  Electronic Submission of Corrected

September is National Substance Use Prevention Month, a time to raise awareness, reduce stigma, and promote prevention, harm reduction, treatment, and recovery resources for individuals and families affected by substance use disorders. Substance use disorders impact millions of people each year, affecting individuals, families, workplaces, and communities. Prevention begins with education, early intervention, and ensuring that people know help is available when they need it. By encouraging open conversations and increasing access to care, we can help prevent substance misuse and support individuals on their recovery journey.   Harm Reduction Saves Lives Harm reduction is an evidence-based approach that focuses on reducing the negative

The HEDIS® behavioral health F-series measures focus on timely transitions of care following behavioral health and substance use-related hospitalizations or emergency department visits. These measures highlight the importance of connecting members to follow-up care within 7 days to support recovery and improve outcomes. They include: •           Follow-Up After Hospitalization for Mental Illness (FUH) •           Follow-Up After Emergency Department Visit for Mental Illness (FUM) •           Follow-Up After High-Intensity Care for Substance Use Disorder (FUI) •           Follow-Up After Emergency Department Visit for Substance Use (FUA) The days immediately following discharge are critical. Without timely follow-up, members may experience worsening symptoms, challenges with treatment adherence, or an increased risk