Authorizations

Providers must obtain prior authorization for certain services and procedures. Authorization requirements are available in the Quick Reference Guide (QRG).

NOTE: Most services rendered by non-participating providers require authorization. Please consult the QRG for details.

Submitting an Authorization Request

The fastest and most efficient way to request an authorization is through our secure Provider Portal, however you may also request an authorization via fax or phone (emergent or urgent authorizations only).

The following information is generally required for all authorizations:

• Member name
• Member ID number
• Provider ID and National Provider Identifier (NPI) number or name of the treating physician
• Facility ID and NPI number or name where services will be rendered (when appropriate)
• Provider and/or facility fax number
• Date(s) of service
• Diagnosis and diagnostic codes
• CPT codes

Via Provider Portal

As a registered provider, you can submit authorization requests and download or print a summary report for your records. Simply log in and follow these instructions.

Not registered on our secure Provider Portal yet? It only takes a few moments to sign up for an account and start benefitting from the many useful features provided.

NOTE: Authorizations may not be visible in the secure Provider Portal until a final disposition has been determined. As a result, you may receive our fax response before seeing the determination online.  

Via Fax

Complete the appropriate Fidelis Care notification or authorization form for Medicaid. You can find these forms by selecting "Providers" from the navigation bar on this page, then selecting "Forms" from the "Medicaid" sub-menu.

Fax the completed form(s) and any supporting documentation to the fax number listed on the form.

Via Telephone

Emergent or Urgent Authorizations Only

Authorization requests that are emergent or urgent should be submitted via telephone. Emergent or urgent requests should only be submitted when the standard time frame could seriously jeopardize the member’s life or health. Requests for expedited authorization will receive a determination within three business days. Contact Provider Services at the phone number listed in the Quick Reference Guide (QRG) to request an expedited authorization.

Authorization Determinations

Authorization determinations are made based on medical necessity and appropriateness and reflect the application of Fidelis Care's review criteria guidelines.

Authorizations are valid for the time noted on each authorization response. Fidelis Care may grant multiple visits under one authorization when a plan of care shows medical necessity for this request.

Failure to obtain the necessary prior authorization from Fidelis Care could result in a denied claim. Authorization does not guarantee payment. All services or procedures are subject to benefit coverage, limitations and exclusions as described in applicable plan coverage guidelines.

Helpful Documents

• Quick Reference Guide (PDF)
• How to Submit an Authorization (PDF)
• Reinstatement of Prior Authorization Requests (PDF)

FAQs

How do I submit a Prior Authorization (PA)?

• Prior Authorizations, or PAs, may be submitted via Fax, electronically as an electronic Prior Authorization (ePA) via CoverMyMeds© for example, or Phone. Please visit our website HERE for more details on PAs.  

What do I need to submit a PA?

• It is important to be detail and compete in your submission, we recommend you include the following information as part of your submission as best practices along with any relevant clinical chart notes:
  • Member's previous medical history
  • Applicable Diagnoses
  • Previous history/dates of medication trials and failures
  • Any side effects the member experiences while on previous medications
• The more thorough your responses are on the PA form or in the ePA comment boxes, the more information our expert clinical staff has to make a decision on the PA.

Why does the diagnosis I include matter?

• We check to make sure that the diagnosis you are intending to use the medication for is appropriate.
• It may be important to include multiple diagnoses for some submissions. For example: if the member experiences migraines but the medication is for nausea, including just migraines as the diagnosis would not be sufficient.

Why do I need to include medications previously used?

• Listing the medications tried and failed, along with any adverse effects experienced, allows us to consider if a requested medication is appropriate for treatment based on what is currently available for the condition.

How soon will I have an answer on the PA we submitted?

• Once the information is completely received Fidelis Care has 24 hours to decide on the request.

Why did Fidelis Care call me about a PA I submitted?

• If you or your office receive a phone call from a representative here at Fidelis Care, it is important to return this phone call as soon as possible. It is likely we are calling to confirm some information that may be missing or unclear from the documentation that you submitted. If we are unable to confirm this information before the required reviewal time expires, it will likely result in a denial and you'll have to resubmit the requested information for review.

If the member needs a PA renewed, do I need to include any specific information?

• In addition to the information previously mentioned, for a renewal you should also include how the member is responding to the medication. If the member has control of their symptoms of their condition while on the medication, please indicate this on the PA renewal submission.

If the PA I send in is denied, what are my options to try for an approval?

• Before you appeal the initial decision, you can resubmit the case for reconsideration or a peer to peer.
  • A reconsideration can be sent in with any additional information mentioned in the denial that would be required to review the case, including but not limited to clinical chart notes or previous medication history. When sending in the additional information please be sure to include the word: “RECONSIDERATION” so the case is reviewed appropriately.
  • A peer to peer can be requested after a denial by contacting the Prior Authorization department and requesting to speak with someone on our pharmacy team to clarify the details of the case or provider additional information. Please make sure the contact information and times you are available to speak with our representatives is accurate.
  • An appeal is the final decision and can be done by resubmitting the information, along with any additional information requested with the word: APPEAL noted. Once the appeal is completed, the case may not be reopened and a new request would need to be submitted.