Medicaid Managed Care, Child Health Plus, Medicare Advantage and Dual Advantage, Fully ...

213 Pages·2017·6.58 MB·English

Section One Introduction
INTRODUCTION TO FIDELIS CARE NEW YORK
Fidelis Care was founded in 1993 on the belief that all New Yorkers should have access to
affordable, quality health insurance. Today, Fidelis Care provides quality, affordable health
insurance coverage for children and adults of all ages and at all stages of life.
Quality, affordable coverage from Fidelis Care: NY State of Health, The Official Health Plan
Marketplace is where individuals and families shop for and buy health insurance. Individuals can
find the Fidelis Care product in the Marketplace that best meets their or their family's needs.
 Child Health Plus is a New York State-sponsored program for children under the age of
19 and provides free or low-cost comprehensive coverage. Almost every child in New
York State is eligible - regardless of family income.
 Medicaid Managed Care is a New York State-sponsored program for children and adults
who meet income, resource, age, and/or disability requirements.
 Essential Plan is a New York State-sponsored program for lower-income people who
don’t qualify for Medicaid or Child Health Plus.
 Qualified Health Plans are for New York State residents who are not eligible for Child
Health Plus, Medicaid, or Essential Plan. Monthly premiums vary based on the selected
plan.
 HealthierLife (HARP) is a managed care product that manages physical health, mental
health, and substance use services in an integrated way for adults with significant
behavioral health needs (mental health or substance use).
 Medicare Advantage and Dual Advantage products through Fidelis Care offer
enhanced benefits for those who are eligible for Medicare because of age or disability, or
who are eligible for Medicare and Medicaid based on age, disability, and income.
 Fully Integrated Duals Advantage (FIDA), (Medicare-Medicaid Plan [MMP]). Fidelis
Care FIDA Plan is a managed care plan that contracts with both Medicare and the New
York State Department of Health (Medicaid) to provide benefits of both programs to
Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration.
 Fidelis Care at Home is a managed long term care (MLTC) product for people who
need long term care services and have or are eligible for New York State Medicaid.
Fidelis Care is operational in all 62 counties of New York State.For a current listing of programs,
eligibility guidelines, and counties of operation, please visit our website at fideliscare.org.
With a mission to serve the poor and medically underserved and to ensure that residents have
access to quality coverage, care, and service, Fidelis Care is committed to working with providers
to achieve our mission.
Fidelis Care is a Prepaid Health Services Plan (PHSP).
Provider Manual Use and Interpretation
The Provider Manual is designed to help participating providers and their employees in
understanding Fidelis Care policies and procedures, and their role as network providers.
Information in this Manual is not intended to alter or modify the benefits to which the member is
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Section One Introduction

entitled. If and when operational policies change, the Manual will be updated accordingly and a
notice will be posted on Fidelis Care’s Provider Portal. The most current version is the operative
version that providers are required to follow, and it is always available on fideliscare.org.
Nothing contained in this Manual shall require or cause Fidelis Care to pay, reimburse, arrange,
or provide any service or participate in any activity that is not in accordance with the Ethical and
Religious Directives for Catholic Healthcare Services issued by the United States Catholic
Conference, as interpreted by the Bishop of the Diocese in which the provider renders services to
members. Providers may consult with Fidelis Care's Chief Medical Officer or his/her designee
with questions regarding which services are or are not included.
HOW FIDELIS CARE WORKS WITH PROVIDERS AND MEMBERS
Provider Relations Division
The Provider Relations Division is dedicated to fostering strong, long-term partnerships with all
contracted providers. This relationship begins with an initial orientation and is followed by
continuing education on policies, procedures, and issues that concern healthcare delivery within
the guidelines of Fidelis Care.
Quality Health Care Management Division
The Quality Health Care Management Division (QHCM) evaluates the quality and
appropriateness of health care services provided to Fidelis Care members. Our Case Managers
can assist you with authorizations and care coordination.
Member Services Division
Member Services is available 24 hours a day, 7 days a week, to help members and respond to
questions or concerns regarding their health care coverage. This includes information regarding
covered benefits, choosing or changing a primary care provider, orienting members to our Plan,
and member responsibilities. Member Services also solicits feedback from members as to their
satisfaction with services provided by Fidelis Care. The goal is always to address member
concerns or complaints quickly and efficiently.
Claims Division
The Claims Division processes and pays claims for covered services provided in accordance with
the provider’s contract and Fidelis Care policies and procedures. Working with QHCM, the Claims
Division also collects encounter data for services.

ASSESSING PROVIDER SATISFACTION

On an annual basis Fidelis Care conducts a Provider Satisfaction survey to assess provider
satisfaction with Fidelis Care. The survey includes questions that relate to satisfaction with
utilization management/authorization processes, administrative policies, network adequacy, Call
Center, and Provider Relations. The survey results are analyzed and reported in various forums
and actions are taken to address opportunities. Fidelis Care encourages providers to participate
in the Provider Satisfaction Survey.

HOW TO CONTACT FIDELIS CARE
The easiest and fastest way to access information regarding membership and eligibility, claims
information, and primary care physician assignment, is through Fidelis Care’s Provider Portal,
Provider Access Online, by visiting https://providers.fideliscare.orgProvider Access Online is
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easily accessible through the Provider section of the website. Providers and their staff members
can log in using a secure user name and password 24 hours a day, 7 days a week.
For all other information, including contacting your Provider Relations Representative, the
Quality Care Management Incentive (QCMI) Program, or authorizations and care
coordination, please call:
1-888-FIDELIS (1-888-343-3547).
REGIONAL OFFICES
As a Statewide health plan, Fidelis Care is committed to maintaining a local, regional presence
for members and providers. Regional and satellite office locations are as follows:
New York City Regional Office 95-25 Queens Boulevard
Rego Park, New York 11374

Fax: [phone]

Suffern Satellite Office
400 Rella Blvd
Suite 116
Suffern, New York 10901

Fax: [phone]
Albany Regional Office 31 British American Blvd.
Latham, NY 12110

Fax: [phone]

25 Market Street
Mid-Hudson Valley Satellite Office
Suite 100
Poughkeepsie, New York 12601

Fax: [phone]
Buffalo Regional Office 480 CrossPoint Parkway
Getzville, New York 14068

Fax: [phone]

100 WillowBrook Office Park
Rochester Regional Office
Fairport, NY

Fax: [phone]
Syracuse Regional Office 5010 Campuswood Dr.
East Syracuse, NY 13057

I Fax: [phone]

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HOW TO CONTACT FIDELIS CARE'S DENTAL, PHARMACY, AND VISION PROVIDERS
Fidelis Care provides certain benefits through third-party benefits management organizations.
Providers should contact the benefits managers below to obtain authorizations and arrange
treatment as indicated.
Dental (Medicaid* and Child Health Plus)
DentaQuest
[phone]
*Dental coverage varies by member’s county
Pharmacy (Child Health Plus)
Caremark
[phone]
Vision
Davis Vision
[phone]

HOW TO CONTACT eviCore healthcare
Fidelis Care has engaged eviCore healthcare* (eviCore) to implement a new prior authorization
program to manage outpatient high-technology Radiology services, non-Obstetrical
Ultrasounds, diagnostic Cardiology services, and Radiation Therapy services that are
rendered on or after October 1, 2017.
Authorization Program: Radiology, Cardiology, and Radiation Therapy
eviCore healthcare
[phone] – phone
(800)-540-2406 – fax
*https://www.evicore.com/healthplan/fideliscare

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OTHER USEFUL NUMBERS
New York State Child Abuse Reporting Hotline [phone]
Early Intervention Program (EIP) [phone]
I Early Childhood Direction Center [phone] (New York State)
Vaccines for Children (VFC) [phone] or (800) KID-SHOTS
[phone]
Women Infants and Children Program (WIC)
NYS HIV Counseling, Testing and Other [phone]
Services Hotline

I NYS AIDS Institute (800) 541-AIDS
[phone] (English)
Domestic Violence Hotline
I [phone] (Spanish)

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Section Two Member Rights and Responsibilities

MEMBER RIGHTS AND RESPONSIBILITIES
Member Rights
Members have rights pursuant to Federal and State law and the applicable program contract. These
rights are summarized below. Additionally, member rights and responsibilities are outlined in the Fidelis
Care Member Handbook provided to all members upon enrollment.
A Fidelis Care member has the right to:

 Receive information about Fidelis Care, our services, our practitioners and providers, and
member rights and responsibilities. For more information, please visit the Fidelis Care website at
https://www.fideliscare.org/ or contact Member Services 24 hours a day, 7 days a week: 1-888-
FIDELIS (1-888-343-3547) or fax us at 718-896-6832. TTY users should call 1-800-421-1220.

 Be treated with respect and recognition of your dignity and your right to privacy.

 Have your information remain confidential throughout the Fidelis Care organization. The
following are ways Fidelis Care keeps your information confidential:

o Fidelis Care staff members are prohibited from discussing confidential information in
public places, such as elevators or outside of Fidelis Care offices.
o When discussing your confidential information on the telephone, staff members are
required to use appropriate safeguards to confirm they are speaking with someone
who has the right to your confidential information.
o All electronic transmissions contain limited identifiable information and are protected
by encryption when sent outside of the organization.
o Paper documents are stored in secure locked areas and destroyed when no longer
needed.

 Participate with practitioners in making decisions about your health care.

 A candid discussion with your practitioners or providers about appropriate or medically
necessary treatment options for your condition(s), regardless of cost or benefit coverage.

 Voice complaints or appeals about Fidelis Care and the care or services we provide. Complaints
may be communicated by contacting Member Services 24 hours a day, 7 days a week: 1-888-
FIDELIS (1-888-343-3547) or fax us at 718-896-6832. TTY users should call 1-800-421-1220.

 Make recommendations regarding our Member Rights and Responsibilities Policy.

A Fidelis Care member has the responsibility to:

 Supply information (to the extent possible) that Fidelis Care and its practitioners and providers
need in order to provide care.

 Follow plans and instructions for care that you have agreed to with your practitioners.

 Understand your health problems and participate in developing mutually agreed-upon treatment
goals, to the degree possible.

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THE PROVIDER'S ROLES AND RESPONSIBILITIES
 Providers shall provide services that conform to accepted medical and surgical practice
standards in the community. These community standards include, as appropriate, the
rules of ethics and conduct as established by medical societies and other such bodies,
formal or informal, governmental or otherwise, from which physicians seek advice or
guidance or to which they are subject for licensing and control.
 Providers shall immediately notify Fidelis Care's Chief Medical Officer, in writing:
1. if their ability to practice medicine is restricted or impaired in any way, or
2. if their license to practice their respective profession is revoked, suspended,
restricted, requires a practice monitor or is limited in any way, or
3. if any adverse action is taken, or
4. an investigation is initiated by any authorized Local, State or Federal agency, or
5. of any new or pending malpractice actions, or
6. of any reduction, restriction or denial of clinical privileges at any affiliated
hospital.
 Providers shall comply with all Fidelis Care administrative, patient referral, quality
assurance, utilization management, and reimbursement procedures.
 Providers shall not differentiate or discriminate in the treatment of members on the basis
of race, sex, color, age, religion, marital status, veteran status, sexual orientation,
national origin, disability, place of residence, health status, or source of payment and
shall observe, protect, and promote the rights of members as members and any other
category protected by law.
 Providers shall cooperate and participate in all Fidelis Care peer review functions,
including quality assurance, utilization review, administrative, and grievance procedures
as established by Fidelis Care.
 Providers shall comply with all final determinations rendered by Fidelis Care peer review
programs, or external third party reviewers for grievance procedures consistent with the
terms and conditions of the provider's agreement with Fidelis Care and this Provider
Manual.
 Providers shall notify Fidelis Care in writing of any change in office address, telephone
number, or office hours. A minimum of thirty (30) calendar days advance notice is
requested.
 Providers shall notify Fidelis Care at least sixty (60) calendar days in advance, in writing,
of any decision to terminate their relationship with Fidelis Care or as required by the
provider's agreement with Fidelis Care.
 Providers shall not under any circumstances, including non-payment by or insolvency of
Fidelis Care, bill, seek or accept payment from Fidelis Care members for covered
services with the exception of any applicable copayments.
 Providers may freely communicate with members about all treatment options, regardless
of benefit coverage limitations.
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 In the event that an member requires or requests a service that is not covered or
authorized by Fidelis Care, and such service is also not covered by the program through
which the member is entitled to receive services, the provider is required to:
1. Inform the member that the member will be personally responsible for all fees
related to the service and the estimated fee for the service;
2. Obtain an executed acknowledgment of financial responsibility from the member
prior to the time such services are provided; and
3. Obtain express prior approval from the member and Fidelis Care.

Only if these steps have been taken shall provider be entitled to bill the member and
collect for such services.
 At provider sites where participating providers are sharing office space with non-
participating providers, a participating provider must treat Fidelis Care members.
 Providers agree to maintain standards for documentation of medical records and
confidentiality for medical records (as per Section 7 of this manual).
 Providers agree to retain medical records for ten (10) years for Medicare recipients and
six (6) years) for all other members after the last date of service or, in the case of a
minor, for six (6) years after the patient reaches the age of majority, or the length of time
required by applicable law.
 Providers will maintain appointment availability in accordance with New York State
standards (as defined in Section 4 of this manual)
 Providers will maintain twenty-four (24)-hour access in accordance with New York State
standards (as defined in Section 4 of this manual). Providers shall notify Fidelis Care of
any extended coverage arrangements for sick leave, vacation, etc.
ADDITIONAL HOSPITAL’S ROLES AND RESPONSIBILITIES
 Provide all contracted services that are within the scope of the facility’s operating
certificate
 Discuss discharge planning with Fidelis Care to coordinate the most appropriate care for
the member and to ensure services are in place prior to discharge
RESTRICTED RECIPIENT PROGRAM
The Restricted Recipient Program is a medical review and administrative mechanism that
restricts recipients to one or more health care providers due to a demonstrated pattern of abusing
or misusing the Medicaid program. Restricted recipients are Fidelis Care members whose care
must be coordinated and authorized through a provider assigned by Fidelis Care. This restriction
applies to all non urgent and non-emergent services. Failure to coordinate care with the
member’s Fidelis Care assigned provider may result in a denial of services. Restricted recipients
are clearly identified when checking member eligibility using Provider Access Online.
CULTURAL SENSITIVITY
Cultural sensitivity begins with recognition that there are differences between cultures. These
differences are reflected in the ways that different groups communicate and relate to one another,
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and they carry over into interactions with health care providers. Cultural sensitivity does not
mean, however, that a person need only be aware of the differences to interact effectively with
people from other cultures. If health care providers and their patients are to interact effectively,
they must move beyond both cultural sensitivity and cultural biases that create barriers.
Developing this kind of culturally competent attitude is an ongoing process.
A culturally competent clinician views all patients as unique individuals and realizes that their
experiences, beliefs, values, and language affect their perceptions of clinical service delivery,
acceptance of a diagnosis, and compliance.
The Language Barrier
Language differences between the clinician and the patient are a further barrier to optimum health
care. Where possible, professional translators should be used. It's not always in the client's best
interest to have a family member act as an interpreter. The client may feel uncomfortable
discussing personal matters in front of a relative. In addition the interpreter may lack a medical
vocabulary, or may reinterpret what the patient says in an effort to "help." Role conflicts may
further hinder translation. For example, a child or a person of the opposite sex may be
embarrassed by the information or feel it improper to convey the message intended.
When using an interpreter the clinician should:
• Try to find an unrelated interpreter of the same sex as the patient, who is able to translate
medical information clearly.
• Schedule more time for the appointment, if possible. Discuss the focus of the session
with the interpreter before the patient arrives; be clear about what the interpreter should
convey to the patient.
• Have the interpreter meet with the patient before the session to assess his or her
educational level. This will determine how complex the discussion can become. If the
patient has already met the clinician, the interpreter should be presented as a member of
the health care team.
• Speak in short sentences or phrases, to make translating easier for the interpreter. Make
sure the patient understands what he or she has been told by asking for him/her to repeat
the message in his/her own words.
• Remember who the patient is—keep the focus on the patient, not the interpreter.
• Be sensitive to cultural differences when using nonverbal communication. For example, a
touch has many cultural meanings. Clinicians must be aware that personal space has
different boundaries in different cultures.
Communication Access
Communication is an integral part of providing care to a patient. Communication may become an
issue if there are barriers based on physical, social, or language limitations. Fidelis Care
providers may bill translator services using Code T1013. If a translator is not available, a
language line or TTY line can be accessed by calling the Provider Call Center at 1-888-FIDELIS.

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Physical Access

An accessible examination room has features that make it possible for patients with mobility
disabilities, including those who use wheelchairs, to receive appropriate medical care. These
features allow the patient to enter the examination room, move around in the room, and utilize the
accessible equipment provided. Detailed diagrams can be found at:
http://www.ada.gov/medcare_mobility_ta/medcare_ta.htm
Informed Consent

The provider will adhere to all Federal and State law requirements for obtaining informed consent
for treatment. Properly executed consents must be included in the medical record for all
procedures that require informed consent.
Confidentiality

All Protected Health Information (PHI), as this term is defined by the Health Insurance Portability
and Accountability Act of 1996 (45 CFR § 164.501), related to services provided to members
shall be confidential pursuant to Federal and State laws, rules and regulations. PHI shall be used
or disclosed by the provider only for a purpose allowed by or required by Federal or State laws,
rules, and regulations.
Medical records of recipients enrolled in foster care programs shall be disclosed to local social
service officials in accordance with the New York State Social Service Law.
Medical records of all Fidelis Care members shall be confidential and shall only be disclosed to
and by the provider’s personnel as necessary to provide medical care and quality, peer, or
complaint and appeal review of medical care under the terms of the applicable program contract
as required in accordance with applicable laws and regulations.
You Can Help Protect Patient Confidentiality

Protecting your members' privacy is an essential part of building a physician/patient relationship.
You and your staff can help protect patient confidentiality by following these simple measures:
 Avoid discussing cases within earshot of other patients or visitors.
 If voices can be heard easily through exam room walls, consider adding soundproof
panels or piping in soft music.
 Arrange office space to allow privacy for members who are paying bills and making
appointments.
 Make sure computer screens that contain patient information are protected from general
view.
 Be sure all patient care is provided out of sight from other members (for example;
weighing, lab draws).
 Have an Office Confidentiality Policy for staff to read and keep in your office personnel
files.
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