Fidelis SecureCare of North Carolina Provider Manual

Referral and Prior Authorization Procedures
Prior Authorizations
Prior authorization is designed to promote the utilization of medically necessary
services, to prevent unanticipated denials of coverage, to ensure that participating
providers are utilized, and that all services are provided at the appropriate level of care
for the member’s needs.
Please refer to the end of the chapter for a summary of services that require referral and
prior authorization. Criteria for authorizing skilled nursing intervention are also included.
Member benefit plans change annually, so we advise that providers review
benefit and authorization requirements or call local Fidelis resources prior to
providing services.
How to Obtain Prior Authorization
Fidelis providers can call or fax all prior authorization requests into the Utilization
Management (UM) Department Care Coordinator 24 hours per day, 7 days per week
utilizing the Service Request form (Attached).
The following information will be required for prior authorization processing:
• Member name
• Date of birth and/or social security number
• Facility name
• Requesting provider
• Referral provider
• Diagnosis
• Requested service with CPT code(s) and ICD-9 code(s)
• Clinical information for medical necessity including patient progress notes, labs
and imaging as appropriate
Referral and Prior Authorization