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  • Outpatient Treatment Report Otr - Fideliscare

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OUTPATIENT TREATMENT REPORT (OTR) Mental Health Clinical Summary Authorization Reference #: Most recent Auth Start date: Patient name: Gender: Male Female Date of Birth: Address: If a minor, name.

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All claims must be submitted within ninety (90) days from the date of service. Claim are processed within thirty (30) days after receipt of a clean claim submitted electronically and forty-five (45) days after receipt of a clean paper claim.

Fidelis Care offers free online claims submission through Ability's claims portal. To learn more about Ability, call 1-888-499-5465 or visit .mdon-line.com/fideliscare. You also have the option to contact another clearinghouse to initiate 837-claim submission to Fidelis Care.

IMPORTANT – Corrected claims and claim appeals must be submitted within 60 (sixty) days from the claims remittance. Fidelis Care offers secure electronic delivery of remittance advices. You may receive these either through your claims clearinghouse or directly from Fidelis Care.

Varicose Vein treatments are covered by most insurance plans, and Locastro Vein Center participates with most of them, including BC/BS, Medicare, Medicaid, Fidelis etc. Our office staff will help guide you through the insurance process to try and get covered services paid for.

I have received several denials from Fidelis stating "Patient does not meet coverage guidelines" (Y52). One representative said it was a denial error and sent back for reprocessing.

NOTE: All claim requests for reconsideration and claims disputes must be received within 60 calendar days, or per your contract terms, from the date of the remittance.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate WorkFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232