Fidelis Care (Centene/NY) Letter of Medical Necessity Guide
How to write an LMN and overturn a prior authorization denial with Fidelis Care (Centene/NY). Includes denial reasons, turnaround times, appeals address, and clinician tips.
Quick Facts
- Avg Turnaround: 30 days standard, 72h expedited (NY DOH rules)
- Appeals Address: Fidelis Care Appeals, PO Box 4900, Kingston, NY 12402
- Provider Portal: https://www.fideliscare.org/providers
Why Fidelis Care Denies Prior Authorizations
- 1. NY Medicaid PDL restriction
- 2. PA required
- 3. Step therapy
- 4. Quantity limit
- 5. Age/diagnosis restriction
Clinician Tips for Fidelis Care
- ✓ Fidelis Care is Centene's New York Medicaid MCO — covers Medicaid Managed Care, CHIP (Child Health Plus), and qualified health plans
- ✓ NY State PDL governs formulary; Fidelis Care adds its own PA layer
- ✓ Submit PA via Availity or fax; check provider.fideliscare.org for state-specific PA forms
- ✓ NY DOH requires timely determinations — cite NY Medicaid regulations in appeal letters
Acquired by Centene in 2018. One of the largest Medicaid MCOs in NY. Envolve Pharmacy Solutions is the PBM.
Fidelis Care Prior Authorization FAQ
Why does Fidelis Care deny prior authorizations?
The most common Fidelis Care denial reasons are: NY Medicaid PDL restriction; PA required; Step therapy; Quantity limit; Age/diagnosis restriction.
How long does Fidelis Care take to review a prior authorization?
Fidelis Care typically responds in 30 days standard, 72h expedited (NY DOH rules).
What should a Letter of Medical Necessity for Fidelis Care include?
An LMN for Fidelis Care (Centene/NY) should reference the specific medical policy or coverage bulletin, document failed first-line therapies with dates, include current labs and ICD-10 codes, and cite supporting clinical guidelines. Acquired by Centene in 2018. One of the largest Medicaid MCOs in NY. Envolve Pharmacy Solutions is the PBM.