Fidelis SecureCare of North Carolina Provider Manual

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Re-credentialing • Providers: Fidelis re-credentials providers on a set schedule in accordance with state and federal law and national accreditation standards. At a minimum of every 36 months, a re-credentialing application will be sent to the provider. Fidelis will identify and evaluate any changes in the provider’s licensure, clinical privileges, training, experience, current competence, or health status that may affect the provider’s ability to perform the services they are providing to Fidelis members. Recredentialing activities may also be triggered as a result of quality investigations or information received from state and/or federal agencies. • Delegated Re-credentialing: On an annual basis, Fidelis conducts group audits and may delegate the re-credentialing function to delegated groups using the same process used to initially delegate the credentialing function. All Primary Care Providers, OB/GYN providers and identified high-volume specialists and high-volume behavioral health care providers are required to have performance monitors considered by the Quality and Peer Review Committees at the time of recredentialing. Provider specific information considered at re-credentialing will be: • Quality activities • Member complaints • Utilization patterns • Quality of care issues • Fraud and abuse • Pharmacy and therapeutics patterns • Member satisfaction survey results (optional)
Eligibility You may verify the eligibility of a Fidelis member in one of the following ways: The Fidelis Identification Card Each Fidelis member is issued a member identification card within 7 days of enrollment. Members are instructed to present the Fidelis ID card as verification of insurance when seeking health care services. The member will also receive a letter that will have the member’s name, their member identification number or “ID number”, and any applicable cost sharing information. This card identifies the member as a Fidelis SecureCare member. (Sample below) Members may select from any of a number of health plans that Fidelis offers, and benefits vary by plan. The I.D. card does not guarantee eligibility. It is for identification purposes only. Eligibility must be verified at each visit. Failure to verify eligibility may result in nonpayment of claims. [FRONT] Fidelis Secure Comfort Plus (HMO) Name RxBin: ID RxPCN: Policy # RxGrp: Effective Date PCP Office Visit Cost Share 0% / 20% Lab Cost Share 0% / 20% Pharmacy benefits provided by Partners Rx H2323, H5575, H5980 PBP Plan 006 CMS Approved 08/17/2009 10_02 MRT [BACK] Submit Claims to: P.O. Box 3597 Scranton, PA 18505 Customer Service: Phone: 1-877-372-8085 TTY Line: 1-888-844-5530 Hours of Operation: Monday - Friday 8:00 a.m. – 8:00 p.m. Pharmacy Help Desk: 1-877-372-Rx4U (7948) For Prior Authorizations: 1-877-372-Rx4U (7948) Eligibility
Page 1 and 2: Provider Manual North Carolina
Page 3 and 4: Utilization Management Affirmative
Page 5 and 6: Fraud, Waste and Abuse Provider and
Page 7 and 8: Regulations and Responsibilities Co
Page 9 and 10: • Contracted providers agree to r
Page 11 and 12: Physician Responsibilities Primary
Page 13 and 14: Access to Care Fidelis has adopted
Page 15 and 16: The Care Management team is compris
Page 17 and 18: • Psychotropic Medication Managem
Page 19 and 20: Credentialing Credentialing Program
Page 21 and 22: SecureCare members only as a result
Page 23 and 24: • Have no significant utilization
Page 25: Medical/treatment record keeping re
Page 29 and 30: You can receive your username and p
Page 31 and 32: Quality Program Purpose The purpose
Page 33 and 34: Referral and Prior Authorization Pr
Page 35 and 36: Referrals to Non-Participating Prov
Page 37 and 38: Criteria for Authorizing Part A Ski
Page 39 and 40: Fidelis SecureCare Criteria for Aut
Page 41 and 42: OUTPATIENT CARE COORDINATION PHONE:
Page 43 and 44: Remittance Advice (RA) Payments rec
Page 45 and 46: Claims Look-Up Once logged in, you
Page 47 and 48: Claim Disputes and Appeals Appealin
Page 49 and 50: Fidelis will reimburse the facility

Fidelis SecureCare of North Carolina Provider Manual

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