12/23/2020

Fidelis Pre Auth Requirements

Fidelis Pre-Authorization Requirements Eliminated In reviewing the 2021 authorization grids it ONLY states that the pre authorization requirement is eliminated for MEDICARE patients only. Medicaid, Essential and Metal level products all still require authorization unless they are diabetic (which has been the policy). Could you please clarify this NEW requirement. Thank you very much.

For office based services (POS 11), Fidelis Care does not have any authorization requirements for patients enrolled in their Medicare advantage plans as long as the provider is participating. All other managed care plans (Medicaid or commercial/exchange policies) will require prior authorization for each procedure unless the patient is diabetic.

For all plans, even if the patient is diabetic, authorization is required for each service if services are performed outside of the office setting. Examples include home visits, DME purchases, inpatient/outpatient hospital encounters, outpatient hospital clinics, etc. Fidelis will deny any procedures or visit codes where a provider does not request pre-certification from the HMO.