Fidelis SecureCare of North Carolina Provider Manual

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Referrals for Specialty Care The primary care physician (PCP) initiates and coordinates the referral management process to ensure that appropriate care is provided when medically necessary. The UM Care Coordinator will schedule the appointment, arrange the transportation, if needed, and provide a telephonic authorization if required followed by a faxed authorization. Continued Coverage of Care with Terminated Providers • Continuation of care with terminated providers is covered if a member is undergoing an active course of treatment for an acute or serious chronic condition. • If a member is receiving specialized services or an active course of treatment that should not be interrupted, the Medical Director will authorize care and services: - Through the lesser of the current period of treatment or for up to 90 calendar days for ongoing active treatment of a chronic or acute medical condition as long as the practitioner or provider agrees to provide on-going care (i.e. chemotherapy or facility specializing in vent dependent member) and the termination of the contract was not related to a professional review action. These time periods may be extended if Fidelis, in conjunction with the terminated provider, determines that safe transfer is not appropriate - The Care Coordinator will conduct ongoing referral management throughout the course of treatment to prevent unauthorized services that would result in denial of claims payment. - If the need to alter the transition plan is identified and the provider is unwilling to transition the member back into the network, the Care Coordinator will forward the case to the Medical Director or designee who will make the final determination. • If the termination of the provider is a result of a professional review action, the Care Coordinator will work with the member or member’s representative to identify a new Care Team, specialist or provider, and facilitate and coordinate the transitioning of the member’s care immediately. Referral and Prior Authorization
Referrals to Non-Participating Providers or Non-Contracted Facilities In-Area Except in true emergencies, Fidelis provides coverage for only those services rendered by contracted providers and facilities. The exceptions are: • Fidelis is notified and approves and authorizes the referral in advance. In these instances, the UM Department will issue an authorization for the services to be provided. Prior approval must be obtained by the PCP/provider recommending an out-of plan referral before arrangements have been made for those services. • The member’s medical needs require specialized or unique services available only through a non-contracted provider or facility. In this case, Fidelis will assist the referring provider in identifying specialists or facilities with the needed capabilities. Fidelis must authorize any such referral. Out-of-Area Outpatient Authorization Members are sometimes directed from an out-of-area physician to return to the out-ofarea physician for a non-urgent, non-emergent follow-up visit. Members must be educated that such follow-up care is not covered unless authorized. Refer members to their Fidelis Evidence of Coverage (EOC). In these specific situations, the Fidelis Medical Director will be contacted to intervene and make applicable evaluations. Out-of-Area Inpatient Authorization Fidelis provides coverage to members if they require emergency or urgently needed services, as well as any services needed subsequently to ensure that they remain stabilized from the time a non-contracted medical provider or facility requests authorization from Fidelis until one of the following occurs: • The member is discharged. • The contracting medical provider arrives and assumes responsibility for the member’s care. • The non-contracting medical provider and Fidelis agree to other arrangements. In some cases, members may be directed from an out-of-area physician to return to the out-of-area physician for a follow-up visit if prior approval is obtained by the Fidelis UM Department. Referral and Prior Authorization
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 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: Referral and Prior Authorization Pr
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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