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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

Annual cultural competency training for participating providers is required by the New York State Department of Health.  At this time, The New York State DOH will only accept the approved training offered by the United States Department of Health and Human Services (HHS), Office of Minority Health education program, Think Cultural Health, to fulfill the requirement for provider annual cultural competency training.*   Once the cultural competency training has been completed, providers need to verify completion of the program by emailing the Cultural Competency Attestation Form to: CulturalCompetencyTrainingAttestation@fideliscare.org.   The required Cultural Competency Training needs to be completed annually by December 31st. Providers that completed

As a reminder, providers now have access the Availity Clinical Quality Validation (CQV) tool designed to help providers close care gaps quickly and accurately. Through the Availity Essentials portal, CQV streamlines documentation and improves quality scores while reducing administrative burden.   What is CQV? Clinical Quality Validation (CQV) is an Availity Essentials application that helps providers: ·         Monitor targeted care gaps/measures for the measurement year. ·         View and respond to payer requests for clinical/medical data. ·         Improve quality scores and reduce administrative burden.   Benefits ·         Streamlined workflow for care gap closure. ·         Faster access to clinical data. ·         Enhanced provider experience across multiple markets.   Availity-led Training for Providers: A live webinar, Centene

Effective July 1, 2026, the following procedures will be removed from prior authorization.   The following RADIOLOGY AND DIAGNOSTIC CARDIOLOGY (RBM) codes have been removed from the Evolent’s Utilization Review Matrix and no longer require prior authorization for Medicaid. Modality Impacted CPT CT ORBIT/EAR/FOSSA WITH O DYE 70480,70481,70482 CT MAXLOFCE AREA; W/O CONTRAST MATL

The following section of the Fidelis Care authorization grids has been updated effective July 1, 2026.             The following codes have been updated on the Medicaid, CHP, Essential Plan, Ambetter Metal-Level Plans, and Medicare Authorization Grids and require prior authorization: C9310 leucovorin calcium (avyxa), inj J1289 narsoplimab-wuug, inj (Yartemlea) J1577 immune globulin, inj (Qivigy) J2361 depemokimab-ulaa, inj (Exdensur) J2789 riboflavin 5'-phosphate, ophthalmic (Epioxahd/Epioxa) J3386 etuvetidigene autotemcel, inj (Waskyra) J3405 onasemnogene abeparvovec-brve, inj (Itvisma) J9053 belantamab mafodotin-blmf, inj (Blenrep) J9062 amivantamab and hyaluronidase-lpuj, inj (Rybrevant) J9232 docetaxel (hospira), inj Q5164 ustekinumab-hmny, inj (Starjemza) Q5165 denosumab-mobz, inj (Oziltus) Q5166 denosumab-desu, inj (Osvyrti/Jubereq) Q5167 denosumab-qbde, inj (Enoby/Xtrenbo) Q5168 ranibizumab-leyk, inj (Nufymco) Q5169 pegfilgrastim-unne, inj (Amlupeg) Q5170 aflibercept-boav, inj (Eydenzelt) Q5171 denosumab-mobz, inj (Boncresa)   For