Fidelis SecureCare of North Carolina Provider Manual

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Fidelis SecureCare Contacts At A Glance • Care Coordination InPatient / OutPatient Authorization, Scheduling and Notification All States Phone: (877) 372-6121 North Carolina Fax: (866) 596-1054 Texas Fax: (866) 511-5906 Michigan Fax: (866) 596-1054 • Pharmacy Prior Authorization: Phone: (877) 897-3390 Fax: (866) 308-6294 Fax: (866) 308-6296 • Provider Services: Phone : (877) 372-8085 Fax: (866) 852-3141 provider.contracting@fidelissc.com • Provider Portal (Claim, Eligibility): www.fidelissc.com • Mail Claims To: Fidelis SecureCare, Inc. P.O. Box 3597 Scranton, PA 18505 • Electronic Claim Processing Contact: Navicure, Inc. at 770-342-0200 Fidelis Payor ID # 77054 • Appeals: Fidelis SecureCare, Inc. Attention: Appeals Dept. 20 N. Martingale Road, Suite 180 Schaumburg, IL 60173 (847) 592-9483 appeals@fidelissc.com
Utilization Management Affirmative Statement Regarding Incentives This statement is intended to comply with the Code of Federal Regulations 42 (CFR) 422.208 regarding Utilization Management Affirmative Statement Regarding Incentives. In accordance with the regulations above, Fidelis requires that all utilization-related decisions regarding member coverage and/or services must be based on appropriateness of care and service. Financial rewards or incentives must not influence any utilization decision. To assure that the risks of underutilization are considered, no rewards or incentives can be issued by Fidelis that will discourage appropriate care and services to members. Fidelis does not reward providers, employees, or other individuals for issuing denials of coverage, service, or care. Denials for medical service requests are reviewed by medical directors and are based strictly upon review of the available clinical information, clinical judgment and plan benefits.
Page 1: Provider Manual North Carolina
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 and 26: Medical/treatment record keeping re
Page 27 and 28: Eligibility You may verify the elig
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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