2026/4/6
• Posted by Provider Relations
Fidelis Care’s Pharmacy Services would like to provide clarification on how medications are covered under member’s medical and pharmacy benefits.
Medications Covered Under Fidelis Care Medical Benefit
Physician Administered Drugs – medications administered to a member during an outpatient visit.
Providers obtain medication via “buy-and-bill” or shipment to their practice site from a vendor of their choosing.
Coverage is dictated by Fidelis Care Authorization Grids, Prior Authorization Lookup Tool and/or Evolent Specialty Services (formerly NCH) Authorization Grids (Oncology Regimen Specific).
Medical Benefit Authorization Grids are plan specific.
If a medication is listed on one of the above authorization grids/tools, an authorization
2026/4/6
• Posted by Provider Relations
Fidelis Care would like to remind providers that it is appropriate to bill a problem‑oriented E&M on the same day as a surgical or preventive service when the issue is separate and significant. In these cases, correct use of modifier 25 and proper documentation are essential to ensure accurate reimbursement and to avoid duplicate payment for services not separately performed.
Key Rules
Use modifier 25 to show the E&M service is distinct from the main procedure or preventive exam.
Claims are clinically reviewed to confirm the E&M is separate.
If validated, payment includes:
100% of the primary service
50%
2026/4/3
• Posted by Provider Relations
You asked and we listened! Fidelis Care is pleased to announce that Authorization Determination letters on Fidelis Care’s Provider Portal, will now indicate if the letter is an Initial Adverse Determination (IAD) or a Final Adverse Determination Letter (FAD).
Current Letter Details: ABC Medical Center - Member Name - Auth#
New Letter Details: ABC Medical Center - Member Name - Auth# - IAD or FAD
To Access the Letters:
Use the menu on the left of the Provider Access Online home page to navigate to the File Downloads section.
On the File Download page, providers can search by File Type and File Created
2026/4/3
• Posted by Provider Relations
NY State of Health has notified health plans and members of Essential Plan 200-250 (also known as Essential Plan 5) that plan coverage will end. The last day of coverage is June 30, 2026. Your patients’ coverage remains the same through that date.
This change is due to anticipated cutbacks in federal funding, according to NY State of Health. It only affects people whose income is between 200% and 250% of federal poverty level. Your patients in Essential Plan 1–Essential Plan 4 are not impacted.
Impacted individuals received a letter on April 1 from NY State of Health outlining the timeline for
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