Fidelis Care Updates

Fidelis Care Utilization Management Update: Addressing Healthcare Staffing Shortages 

Following Executive Order No. 4 dated September 27, 2021, issued by Governor Kathy Hochul to address hospital staffing shortages, the Department of Financial Services issued Insurance Circular Letter No. 9 (2021) on October 7, 2021.  

The Governor subsequently terminated the suspension of utilization review as well as internal & external appeal timeframes for hospitals by issuing Executive Order No. 4.12 (EO 4.12) dated August 28, 2022. The order was effective immediately.  

The suspension of utilization requirements for preauthorization included a review for: 

  • Hospital admissions; 
  • Hospital facilities; 
  • Hospital outpatient services; 
  • Home healthcare services; 
  • Inpatient & outpatient rehabilitation services following a hospital admission; 

  • Concurrent review for inpatient & outpatient hospital services;  
  • Retrospective review at in-network hospitals. 

Now, hospitals have 45 days and 60 days respectively for submitting an internal and an external appeal starting from August 28, 2022.  

Source: Supplement No. 1 to Insurance Circular Letter No. 9 (2021): Resumption of Utilization Review Requirements and Appeal Timeframes Previously Suspended Due to Hospital Staffing Shortages | Department of Financial Services ( 

Dispensing Update for Prescription Medications by Practitioner 

Medical practitioners who decide to dispense prescription medications to their patients can bill these medications only through a medical claim format. The new update came into effect on September 1, 2022.  

As per the new update, the medication bills will be reimbursed at the actual invoice cost for the drug dispensed. Furthermore, medical practitioners may not be eligible for submitting an office visit claim for the sole purpose of dispensing a drug that any person could buy from an NYS Medicaid enrolled pharmacy.  

Practitioners are advised to submit the claim by using an appropriate HCPCS code and corresponding NDC when billing for a medication. For any oral medication, where no specific HCPCS code is assigned, practitioners may utilize the following codes: 

ü J8999- Rx Drug Oral Chemotherapy 

ü J8499- Rx Drug Oral Non-Chemotherapy 

Oncology medications and supportive agents will require prior authorization (PA) from New Century Health. For the full list of drugs that require NCH review visit the Fidelis Care website.  


Effective October 1, 2022: Fidelis Care Authorization Grid

The Essential Plan, Medicaid, Medicare, and Metal-Level Products grids have been updated as per the following: 

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