Section Twenty Two-B
Fidelis Care At Home
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:
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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.
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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 1-888-FIDELIS (1-888-343-3547).
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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 .
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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.
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Member Benefits:
Below is the list of covered services under the FCAH program.
Services covered by FCAH include
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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.
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Care Management
Home health care
Nursing
Home health aide
Outpatient Physical therapy (certain
limitations apply)
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
limitations apply)
Prosthetics and orthotics (certain
limitations apply)
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).
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")
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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 1-800-688-7422.
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Fidelis Care will call members on a regular basis to ensure that members are satisfied
with the services offered.
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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.
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Fidelis Care will discuss Advance Directives with all applicants.
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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.
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To obtain an updated provider listing, please call the Fidelis Care at Home (FCAH) at
1-800-688-7422.
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Fidelis Care may also assist members in obtaining non-covered services or those
covered by Medicaid or Medicare.
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Fidelis Care will also arrange transportation for the members if needed.
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If services are approved, Fidelis Care will issue an authorization for each service.
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Providers should notify Fidelis Care if a member requires any additional services.
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Fidelis Care At Home
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 1-800-688-7422.
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:
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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 14226-0825
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
95-25 Queens Blvd.
7th Floor
Rego Park, NY 11374
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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:
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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.
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