Fidelis Care New York Provider Manual 22B-1 V /12/15

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1 This section of the Fidelis Care Provider Manual provides information for providers serving Fidelis Care at Home (FCAH) members Member Eligibility: Fidelis Care at Home provides managed long term care services to members who have Medicaid, are at least eighteen (18) years of age, and reside in an approved service area. Each member must be assessed by a Fidelis Care Assessment Nurse, and/or Maximus to be capable, as of the time of enrollment, of remaining in their home and community without jeopardizing their health or safety, or that of others. Members can continue to use their Medicare and/or Medicaid cards for non-covered services while in FCAH and can continue to use or select their own primary care physician. Delivery of Services to Fidelis Care at Home Members: Each FCAH member has a member identification card which shows the plan name, member s name, member identification number, member effective date and important telephone numbers. There are no copays or deductibles for FCAH members. The provider can also verify the member's current eligibility by either accessing Fidelis Care's Provider Access Online at fideliscare.org or by using the Integrated Voice Response (IVR) by calling FIDELIS ( ). Members are informed about, and encouraged to complete advance directives. It is important that these be retained in a prominent place in the member s medical records. Providers serving FCAH members must be informed and responsive to the cultural needs of the beneficiaries. Fidelis Care is responsible for coordinating, arranging, and authorizing FCAH payment to providers for the member s medically necessary covered services. Covered services are provided through a network of Fidelis Care participating healthcare providers as listed in our Provider Directory. Fidelis Care New York Provider Manual 22B-1 V /12/15

2 Member Benefits: Below is the list of covered services under the FCAH program. Services covered by FCAH include Care Management Home health care Nursing Home health aide Outpatient Physical therapy (certain Outpatient Occupational therapy Outpatient Speech pathology Medical social services Adult day health care Personal care aides Durable medical equipment and oxygen Medical and surgical supplies (certain Prosthetics and orthotics (certain Personal emergency response system Non-emergency transportation Podiatry Dentistry Optometry/eyeglasses Audiology/hearing aids and hearing aid batteries Home delivered or congregate meals Social day care Respiratory therapy Nutritionist Social and environmental supports In-home Physical therapy, occupational therapy, and speech pathology. Nursing Home care (Please note that if you have Medicaid but are not eligible for Institutional Medicaid you will be disenrolled from FCAH if you require such care). Services covered by Fee for Service Medicaid and/or Medicare FCAH may assist in obtaining these services and in making appointments and arranging non-emergency transportation and follow-up care if needed. Inpatient hospital services Outpatient hospital services Physician services including services provided in an office setting, a clinic, a facility, or in the home (includes nurse practitioners and physicians' assistants acting as "physician extenders") Fidelis Care New York Provider Manual 22B-2 V /12/15

3 Laboratory services Radiology and radioisotope services Emergency transportation Rural health clinic services Chronic renal dialysis Prescription and non-prescription medication Mental Health services Alcohol and Substance Abuse services Mental Retardation or Developmental Disabilities services provided Family Planning services Case Management: A Nurse Care Manager will be assigned to each member. She/he will assist members in living at home for as long as possible and will help them access services available in the community. Providers are required to contact the Nurse Care Manager to request authorization for all nonemergency services ; please call FCAH at Fidelis Care will call members on a regular basis to ensure that members are satisfied with the services offered. Members may leave the service area temporarily. Fidelis Care will make any necessary arrangements for the member to receive non-emergent services outside Fidelis Care s service area. Fidelis Care will discuss Advance Directives with all applicants. Fidelis Care will collaborate with the member, family, significant other and the member s primary care physician to evaluate the member s medical history and care needs and, with the member s cooperation, will formulate a member service plan of care outlining the services a member will be receiving. (i.e.: daycare, personal care, home delivered meals, personal emergency response system, durable medical equipment etc). Authorizations: Fidelis Care will coordinate and manage the covered services. To obtain an updated provider listing, please call the Fidelis Care at Home (FCAH) at Fidelis Care may also assist members in obtaining non-covered services or those covered by Medicaid or Medicare. Fidelis Care will also arrange transportation for the members if needed. If services are approved, Fidelis Care will issue an authorization for each service. Providers should notify Fidelis Care if a member requires any additional services. Fidelis Care New York Provider Manual 22B-3 V /12/15

4 Fidelis Care will be on call after regular business hours, from 5:00 PM to 8:30 AM and on weekends and holidays, in order to arrange care and coverage twenty-four (24) hours a day. Please call FCAH at Emergency Services Authorization is never required prior to providing services for emergency medical conditions. Consistent with Federal and State law, an Emergency Medical Condition is defined by using a Prudent Layperson Standard, which is as follows: A medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain that a prudent lay person, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in any of the following: Placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a pregnant woman, the health of the woman or her unborn child, or in the case of a behavioral health condition, placing the health of such person or others in serious jeopardy; Serious impairment to such person s bodily functions; Serious dysfunction of any bodily organ or part of such person; or Serious disfigurement of the person. Billing/Claims Providers Claims must be submitted electronically; Providers must submit claims for home healthcare services, durable medical equipment (DME), respiratory care, physical, occupational and speech therapies on a CMS-1500 or UB04 claim form within ninety (90) calendar days of the date of service. Mailing Address For Direct Claims Submission Fidelis Care at Home Corporate Claims Department P.O. Box 1707 Amherst, New York Please refer to section 12 of this manual for additional information. Clinical Appeals Process: Providers shall appeal Fidelis Care's clinical decision, within forty-five (45) days of the adverse determination by calling or sending clinical and/or other pertinent information to: Attn: Member Services Fidelis Care Queens Blvd. 7th Floor Rego Park, NY Fidelis Care New York Provider Manual 22B-4 V /12/15

5 Please refer to section 13 of this manual for additional information. Quality Assurance: For information please refer to Section 10 of this manual. Provider Credentialing and Termination: Please refer to Section 9 of this manual for additional information. Retention of Medical Records: Medical records must be retained for at least ten (10) years. For additional information please refer to section 7 of this manual. Confidentiality: For information please refer to section 3 of this manual. Fidelis Care New York Provider Manual 22B-5 V /12/15