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  • Fidelis Section Thirteen Forms

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Section Thirteen A Provider Appeals Form REQUEST FOR ADMINISTRATIVE REVIEW OF PREVIOUSLY PROCESSED CLAIM MEMBER NAME: MEMBER ID: CLAIM NUMBER: DOS: PROVIDER NAME: NATIONAL PROVIDER IDENTIFIER or TAX.

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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.

You can access this application by calling 1-‐888-‐ FIDELIS (1-‐888-‐343-‐3547) and following the prompts for “claim status”. From here, you can obtain basic information about your claim such as claim status, paid amount, member responsibility, etc.

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.

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

You can call our Member Services Department or by fax to: 716-393-6779.

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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
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
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 workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
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