Fidelis Care New York Authorization Updates
Fidelis Care has updated their Authorization Grids with the following changes that are effective starting August 1,2023.
Medicaid Grid Update:
- Podiatry Services: Authorization is no longer required for podiatric services however, authorization requirements will apply to individual services that are indicated on this grid and rendered by podiatrists.
NOTE: 11719 is a non-covered code for Medicaid when rendered by a physician per the Medicaid Fee Schedule. When rendered by a facility using POS 11, it is covered and requires prior authorization.
Medicaid, Medicare, Essential Plan and Metal-Level Grids Update:
- Outpatient Surgery: The following services require prior authorization:
- Services for the following codes (10060, 11100, 11900, 17000, 20600, 20605, and 20610) should not need to be performed in freestanding ambulatory surgery centers- If performed in ambulatory surgery centers billing with bill type 0831, they require an authorization. CPT code 20610 is non-covered for joint injection of hyaluronic acid ONLY when billed with any of the following osteoarthritis diagnosis codes: M17.0, M17.10-M17.12, M17.2, M17.30, M17.31 (new codes), M17.32, M17.4, M17.5, M17.9.
The following codes have been updated on the Medicare Authorization Grid and require prior authorization:
- J1439 Injectafer (ferric carboxymaltose)
- J1437 Monoferric (ferric derisomaltose)
- Q0138 Feraheme (non-ESRD)
Click here view all the Fidelis Care Authorization Grids.
Martin’s Point Referral and Authorization Updates
Referral requirement for Martin’s Point US Family Health Plan:
Effective 10/1/2023, Martin’s Point US Family Health Plan will require PCPs to submit any referral to other providers or specialists to the health plan using ProAuth, an online referral and authorization portal. Specialists with an approved referral should also submit referrals for treatment from other specialists pertinent to the episode of care.
All medically necessary referrals from a participating PCP to a participating specialist will generate an auto-approval when submitted online via ProAuth. Referrals to non-participating providers will be reviewed for access-to-care standards and availability of network providers. An approved referral is not a waiver of authorization requirements.
The ProAuth portal will be available to accept referrals closer to the effective date of this change.
Authorization requirements for Martin’s Point US Family Health Plan & Martin’s Point Generations Advantage:
Effective 10/1/23, ALL authorization requests will be required to be submitted through the ProAuth online referral and authorization portal only. The ProAuth portal IS currently available for submission of authorization requests.
NGS Medicare Webinars
Medicare contractor, National Government Services (NGS), hosts weekly webinars for various topics related to Medicare claims, provider enrollment, fraud, and medical necessity, to name just a few. Keep up to date on the latest news and increase your knowledge base.
Click Click here to view the various webinars available.
Wellcare of New Jersey is now Fidelis Care
WellCare of New Jersey, the Medicaid/NJ Family Care plan, will become Fidelis Care on August 1, 2023.
New ID cards have been mailed to patients prior to August 1, 2023. This name change does not automatically give members access to any providers contracted with Fidelis Care in New York unless those providers are also contracted in New Jersey.
Wellcare Medicare Billing Reminders
As a reminder, Wellcare has shared several Medicare billing updates that went into effect back on January 1, 2022.
The Centers for Medicare and Medicaid (CMS) had released several billing changes and updates for various Medicare services that took effect on January 1, 2022. As valued Wellcare By Allwell provider partners, they wanted to make you aware of how these changes will impact your billing activities with them in 2022.
COVID-19 Vaccination Claims
- Effective January 1, 2022, providers may submit Medicare claims for COVID-19 vaccines and their administration directly to Wellcare for payment.
- Previously, COVID-19 vaccination claims were submitted directly to Medicare Fee-for-Service. For dates of service 1/1/22 and after, Wellcare will now process and adjudicate all COVID-19 vaccination claims for its Medicare members.
- Wellcare will employ the reimbursement rates as they are established by CMS and our state regulators in accordance with provider contract terms for COVID-19 vaccine payments.
New/Modifications to the Place of Service (POS) Codes for Telehealth Services
- Effective for dates of service January 1, 2022 and after, CMS is revising the description of POS code 02 and adding POS code 10 for telehealth services to meet the overall industry needs.
- POS 02: Telehealth Provided Other than in Patient’s Home
- Patient is not located in their home when receiving health services or health related services through telecommunication technology.
- POS 10: Telehealth Provided in Patient’s Home
- Patient is located in their home (which is a location other than a hospital or other facility where the patient receives care in a private residence) when receiving health services or health related services through telecommunication technology.
- POS 02: Telehealth Provided Other than in Patient’s Home
- Claims adjudication for POS 10 will begin 4/4/2022.
- Claims submitted before 4/4/2022 for POS 10 will be not reimbursed, and providers will be asked to resubmit those claims on or after 4/4/2022.
- For more information, please see CMS’ MLN Matters release.
Home Health Notice of Admission (NOA) Change
- Effective January 1, 2022, CMS will require home health providers to submit one NOA via a type of bill (TOB) 32A form as an initial bill for home health services. This NOA will cover contiguous 30-day periods of care, beginning with admission and ending with patient discharge.
- Providers must then submit a TOB 0329 for the periods of care following the submission of the NOA. The NOA is not separately reimbursable but is required to process and calculate the reimbursement payment via the final bill submission of TOB 0329.
- Per CMS regulation, providers must submit a NOA within the first five (5) calendar days of a period of care using TOB 32A.
- If this is not submitted within 5 days, penalty will be applied following CMS methodology.
- For more information, please see CMS’ MLN Matters release.
Skilled Nursing Facility (SNF) Interim Billing Update
- Effective January 1, 2022, Wellcare will accept and adjudicate interim bills from SNFs for their Medicare members.
- No final bill is required.
If you have questions about any of these billing changes, please contact Provider Services at:
- HMO/PPO: 1-855-766-1456; (TTY: 711)
- HMO SNP: 1-866-330-9368; (TTY: 711)