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In accordance with Chapter 645 of the Laws of 2005, the New York State (NYS) Medicaid program does not cover prescription or physician-administered drugs used for the treatment of sexual dysfunction (SD) or erectile dysfunction (ED). Additionally, Medicaid does not reimburse any supplies or procedures used to treat SD/ED for persons required to register as sex offenders. Before providing services to Fidelis Care Medicaid members, providers must first obtain authorization for any prescription or physician-administered drugs and procedures or supplies related to SD or ED. Peyronie’s Disease (N48.6) is also classified as a SD diagnosis by the New York State Department

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 would like to remind our provider community of the required protocols for submitting corrected claims and to clarify how these differ from appeals. Following these guidelines helps ensure timely and accurate claims processing.   What Is a Corrected Claim? A corrected claim is used when the provider needs to modify or replace a previously submitted claim due to an error—such as coding, billing, or demographic inaccuracies. Examples include: Incorrect procedure code Wrong units of service Member demographic correction Billing error requiring claim replacement Corrected claims must follow the format requirements above and be submitted within 60 calendar days from the date of the

Fidelis Care is committed to strengthening our partnership with providers and enhancing the overall experience when addressing claims‑related concerns. As part of this ongoing effort, we are introducing a new Fidelis Care Claims Inquiry Template, which will be required beginning March 1, 2026 for all claims inquiries submitted after the standard appeals process has been completed.   This updated process was designed to support a smoother, more transparent experience for your practice — with several key benefits: Improved Service and Support The new claims grid template allows us to collect all essential information at the start of your inquiry. With complete information in hand,

New York CMS Cell Gene Therapy Access Model Update The New York State (NYS) Department of Health has applied to participate in the federal Centers for Medicare and Medicaid Services (CMS) Cell and Gene Therapy (CGT) Access model. The model is voluntary for State Medicaid programs and manufacturers and will test whether a CMS-led approach to developing outcomes-based agreements (OBAs) for cell and gene therapies increases Medicaid beneficiaries’ access to innovative treatment, improve health outcomes, and reduces health care costs to State Medicaid programs. The initial focus of the model is on gene therapies for people living with sickle cell disease,

Fidelis Care would like to inform providers that evaluation and management (E&M) services billed on a facility claim with treatment room revenue codes are not eligible for reimbursement.  Evaluation and Management procedure codes represent the professional service – the physician or qualified provider’s time, assessment and decision- making. Treatment room revenue codes (760, 761 and 769) represent the facility charge for use of space, supplies, and staff for treatment or observation of a patient. Treatment rooms are typically used when a therapeutic or diagnostic procedure (e.g., an infusion, injection wound care) is performed, not when the visit consists primarily of evaluation