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Prior Authorization Request Form Form Must Be Filled Out Completely And Legibly Submission of request form required for NYS of Health Managed Medicaid CHP FHP and Medicare Advantage Fax 800 860-8720 Fidelis Care Member Name Last First M. I. Questions 888 343-3547 Patient / Member Information Services CPT/Procedure Code s and Description ICD- 10 Diagnosis Dx Code s Date of Birth mm/dd/yyyy Check if applicable Medicare No-Fault Workers Comp Date of Injury mm/dd/yyyy Date of Procedure if applicable mm/dd/yyyy Provider Name Phone Tax ID or NPI Include area codes Fax IPA Affiliation if applicable Inpatient Facility Name and Tax ID or NPI Outpatient/Ambulatory/23 Hour This Request is Urgent/Emergent Additional Information Pre-service Please Submit the following clinical information with this form as appropriate for this request circle all included History Physical Current Symptoms and Functional Impairment Treatment history Lab/Radiology testing results Pictures Medical record chart notes Th....

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Fidelis Care offers new Medicare Advantage plans in 2022. Dual Advantage plans are also available for people who qualify for both Medicare and Medicaid coverage.

Prior authorization (also called “preauthorization” and “precertification”) refers to a requirement by health plans for patients to obtain approval of a health care service or medication before the care is provided. This allows the plan to evaluate whether care is medically necessary and otherwise covered.

Starting in 2022, our Medicare Advantage and Dual Advantage plans have a new name: Wellcare By Fidelis Care.

Local Department of Social Services. Your Local Department of Social Services (LDSS) may be able to assist you in obtaining your health insurance coverage and/or provide you with information about other programs and benefits you may qualify.

Requests for administrative review must be sent to the following address: Attn: Claims Reconsideration, Fidelis Care, 480 CrossPoint Parkway, Getzville, NY 14068.

Fidelis Care is the business name for the New York State Catholic Health Plan, Inc., a nonprofit 501(c)(3) managed care organization for members who receive health insurance from Medicaid, Child Health Plus, Family Health Plus, Family Health Plus Employer Buy-in, and some categories of Medicare.

Fidelis Care, a leading health insurer that serves all of New York State, offers free or low-cost comprehensive health coverage, including Medicaid Managed Care, Medicare Advantage, Child Health Plus, and plans available through NY State of Health, The Official Health Plan Marketplace.

Your insurance is accepted at the following Gotham Health Centers/Clinics: NYC Health + Hospitals/Gotham Health, Belvis. NYC Health + Hospitals/Gotham Health, Cumberland. NYC Health + Hospitals/Gotham Health, East New York.

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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