06/14/2021

Fidelis Denials

We have 100's of denials for DX code inconsistent with procedure. We have sent Provider Reconsideration/Appeal forms for every denial. Along with a letter. We now received notification yesterday stating that we needed to send along another claim for each denial. We have been on the phone numerous times with Fidelis and our Provider Rep Carole Adams. Why should we have to resend all these denials in again. Unacceptable. I want to know #1 Have you contacted NYS Insurance department about this huge problem and #2 what does Fidelis say about this? I would like some answers about this immediately.

Members of the Association's Insurance Committee, along with the NYSPMA consultant Arnie Tannen, had a conference call with the medical directors of Fidelis this past week. There were several topics on the agenda including the recent spate of members with denied X-ray claims being told by Fidelis representatives that the current pre-auth policy requirement was initiated at the urging of the Association in concert with Fidelis medical directors. That is completely false. The Fidelis medical directors on the call apologized for these statements to our membership and have spoken internally to representatives who have been disseminating this false information. We anticipate it will stop. On the positive side, committee members are in active discussions with the medical directors to develop the correct logic in their claims system that will match radiological procedures with Dx codes so that the claims will process correctly. And it is anticipated that prior denied claims will pay as long as the procedure and the Dx match under the revised logic in the Fidelis system. Details of these changes will be provided to members in a subsequent newsletter. The change will not be immediate and we appreciate everyone's patience while these changes are worked through by Fidelis.