TIP SHEET FOR PRIMARY CARE PHYSICIANS

TIP SHEET
Nursing Homes
Effective February 1, 2015 in New York, Kings, Queens, Bronx and Richmond counties and effective April 1, 2015 in
Nassau, Suffolk and Westchester counties, all eligible recipients over age 21 in need of long term care/permanent
placement in a Nursing Home (NH) will be required to join a Medicaid Managed Care Plan (MMCP) or a Managed Long
Term Care Plan (MLTCP). All current long term/permanent custodial care beneficiaries in a Medicaid-certified NH prior to
the phase-in date will remain in fee-for-service Medicaid, but may enroll in a MMCP on a voluntary basis beginning
October 1, 2015. Members will not be required to change nursing homes as a result of this transition. New placements will
be based upon Fidelis Care’s contractual arrangements and the specific needs of the individual.
Contact Information
Provider Call Center
Member Services
Case Management
DentaQuest
Davis Vision
1-888-FIDELIS (1-888-343-3547) - option 2, then option 4
1-888-FIDELIS (1-888-343-3547) - option 1
1-888-FIDELIS (1-888-343-3547) - option 2, then option 5
1-800-341-8478
1-800-773-2847
Caremark Pharmacy
1-800-345-5413
ELIGIBILTY
To verify enrollment in a Fidelis Care plan, check the member's ID card and log on to our provider portal, Provider Access
Online, to verify current eligibility and coverage details: https://portal.fideliscare.org/provider/ or contact the Fidelis Care
Provider Call Center and use the automated eligibility tool at 1-888-FIDELIS (1-888-343-3547), option 2, then option 1.
ENROLLMENT IN LONG TERM PLACEMENT
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The recommendation for long term care placement is made by the NH physician or clinical peer and is submitted
to Fidelis Care for review and approval.
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The NH and Fidelis Care will assist the enrollee in submitting documentation for Medicaid coverage of the longterm placement to the Local Department of Social Services (LDSS) within 90 days of the date of long term
placement in a New York State facility.

NH will continue to receive reimbursement during this process; however, if the member is deemed to be ineligible,
payments may be recouped.
AUTHORIZATIONS
Prior authorization is required for certain services. To determine the services that require authorization, please refer to the
Authorization Grids, which can be found at http://www.fideliscare.org/en-us/providers/authorizationgrid.aspx, as well as
within the Fidelis Care Provider Manual (Appendix I).
Authorization Request Contact Information
Authorization Type
Phone
Fax
Medical
1-888-FIDELIS (1-888-343-3547)
option 2, then option 2
1- 800-860-8720
Behavioral Health
1-888-FIDELIS (1-888-343-3547)
option 2, then option 3
1-718-896-1784
BILLING
Bed Holds or Leaves of Absence
Limitations
Revenue Codes
For Temporary Hospitalization
14 Days in a 12 Month Period
0185
For Therapeutic Leaves of Absence
10 Days in a 12 Month Period
0183
"Other" Therapeutic Leaves of Absence
10 Days in a 12 Month Period
0189
Nursing Home Tip Sheet
V15.0 – 1/28/15
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Provider – Standard RHCF
Description of Bed Types/Services included in FFS
Daily Rate
Revenue Codes
Residential Health Care Facility (RHCF)
Room and Board (R&B) and Ancillary Services (All
Inclusive)
190; 191; 192; 193
Residential Health Care Facility (RHCF)
Room and Board (R&B) Only (All Inclusive)
190; 191; 192; 193
AIDS - Room & Board
Sub-acute care includes medical (General Classification)
194
Ventilator Dependent - Room & Board
Sub-acute care includes medical (Other)
194
Pediatrics - Room & Board
Semi-Private - two beds
194
Neuro-Behavioral - Room & Board
General classification
194
Traumatic Brain Injury (TBI)
Room & Board
Semi-Private - 2 beds, medical or general (General
Classification)
194
Facilities are expected to hold beds if the resident is expected to return within 15 days.
Reimbursement for bed hold or leave of absence for temporary hospitalization will be 50 percent of the Medicaid
FFS daily rate.
Reimbursement for bed hold or leave of absence due to therapeutic leave will be 95 percent of the Medicaid FFS
daily rate.
CLAIMS
All claims must be submitted within 90 days from the date of service.

Claims are processed within 30 days after receipt of a clean claim submitted electronically and 45 days after
receipt of a clean paper claim (Note: A "Clean Claim" is a claim for health care services that contains all required
data elements).

Participating providers may not, under any circumstance, bill a Fidelis Care member for any covered services
except for applicable copayments, deductibles, or coinsurances.

To obtain the status of a claim, please visit Provider Access Online at https://portal.fideliscare.org/provider/ or
contact the Provider Call Center from 8:30 AM to 5 PM Monday through Friday at 1-888-FIDELIS (1-888-3433547), option 2, then option 4.

Claims Remittances are available through Fidelis Care's Provider Access Online at
https://portal.fideliscare.org/provider/. If you do not have a log-on and password to access this resource, please
contact your Provider Relations Representative. Remittances are also available through a HIPAA-mandated 835
Electronic Remittance Advice.
Claim Submission Options
Electronic Claims
Fidelis Care Payer ID # 11315 - For list of vendors, fideliscare.org
Paper Claims
Fidelis Care Corporate Claims Department
P.O. Box 806
Amherst, NY 14226-0806
APPEALS AND REQUESTS FOR ADMINISTRATIVE REVIEWS
Standard Appeals
Appeals must be received within 60 business days of the adverse determination and should be mailed to:
Attn: Chief Medical Officer, Fidelis Care, 95-25 Queens Blvd., 7th Floor, Rego Park, NY 11374
Requests for Administrative Review of Previously Processed Claim
Requests for claims reconsiderations must be submitted within 60 calendar days of the date of the remittance advice.
Requests for administrative review must be sent to the following address: Attn: Claims Reconsideration,
Fidelis Care, 480 CrossPoint Parkway, Getzville, NY 14068.
Please visit Fidelis Care's website, fideliscare.org, for a complete Fidelis Care Provider Manual, Authorization
Grids, educational resources, announcements, participating provider search engine, and other helpful tools.
Albany Regional Office
31 British American Blvd.
Albany, NY 12110
(518) 427-0481
Nursing Home Tip Sheet
New York City Regional Office
95-25 Queens Blvd.
Rego Park, NY 11374
(718) 896-6500
Syracuse Regional Office
5010 Campuswood Drive
E. Syracuse, NY 13057
(315) 437-1835
Buffalo Regional Office
480 CrossPoint Parkway
Getzville, NY 14068
(716) 564-3630
V15.0 – 1/28/15