2024/6/27
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Posted by Provider Relations
Fidelis Care is implementing changes to our Peer-to-Peer process.
Due to CMS regulations, Fidelis Care is introducing a new Medicare procedure, effective immediately. We will no longer provide a Post-Decision Peer-to-Peer review for services pertaining to Medicare members. It is important to note that submitting a formal appeal will be necessary for any post-decision reviews.
For all other lines of business, Fidelis Care will continue to offer Peer-to-Peer reviews, which may result in a reversal of the initial decision based on the information provided as part of the Peer-to-Peer review. It is important to note that all Peer-to-Peer requests must be submitted within five (5) business days of the initial determination date, and can only be submitted before a formal appeal is requested. After this period, a formal appeal will be required for review and reconsideration of the initial determination. Please note that a formal appeal can be submitted at any time after the initial determination is made, within the allotted regulatory appeal timeframes for the member’s line of business.
For additional questions, or if we can be of assistance in any way, please contact your Fidelis Care Provider Relations Specialist. To identify your designated representative, please visit Contact Your Designated Provider Relations Specialist.