Authorization Requirement Inquiries Will Transition to Self-Service on March 1, 2025
2025/1/31
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Posted by Provider Relations
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Provider News
Beginning March 1, 2025, all Fidelis Care providers inquiring about authorization requirements will need to use the Authorization Grids and the Authorization Requirement Lookup Tool available on fideliscare.org. The Authorization Requirement Lookup tool will help providers 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). Authorization requirements will no longer be available by contacting the Call Center.
Streamlined Access for Providers: Access the lookup tool on fideliscare.org:
- Navigate to Providers
- Under Provider Resources, find Authorization Resources then 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
Benefits of the Authorization Requirement Lookup Tool:
- Faster Determinations: Providers can more quickly determine whether or not a code requires a prior authorization.
- Real-Time Procedure Code Updates: Experience quicker updates to both new and existing procedure codes, enabling more accurate and timely information.
Reference Guide: For further information and instructions on using the tool, providers can review the Authorization Lookup Tool Reference Guide.
Authorization Grids: If a code is not found while using the tool, providers should refer to the authorization grids located here.
- How to quickly find codes within the authorization grids: With the authorization grid open, click "Ctrl" plus "F" to open up a find box. Use the find box to type in the first 3 digits of the code; using the first 3 digits allows results to show those codes within a range. Scroll through the results that populate until the code is found. All codes listed require authorization. If not listed on the grid, no authorization is required as long as the service is outpatient, and all providers participate with the plan.
- For example, if the code is 19375, type "193" where you will see the code is located within the range of 19370-19396 in Section II.C.
If still uncertain whether prior authorization is required, providers should submit a request for authorization through the Provider Portal or Availity Essentials.
If you have any questions, please contact your Fidelis Care Provider Engagement Account Manager. 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 or Availity Essenials.