The Fidelis Care prior authorization request form is the document providers submit to get advance approval before delivering certain covered services to a Fidelis Care member. It collects patient identifiers, requesting and servicing provider details, diagnosis and procedure codes, and the clinical justification for the service, then routes to Fidelis Care’s Utilization Management Department for a medical necessity review. Under New York rules, a complete standard request gets a decision within three business days, and an urgent request within 72 hours.1New York DFS. Minimum Process Requirements for Prior Authorization Utilization Review
Check First Whether the Service Needs This Form
Two things to confirm before you fill anything out. First, that the service actually requires prior authorization under the member’s plan. Fidelis Care publishes separate authorization grids for Medicaid and Child Health Plus, Essential Plan and Qualified Health Plan, and Wellcare by Fidelis Care (Medicare), and the codes that require approval differ across them. The current grids took effect April 1, 2026.2Fidelis Care. Fidelis Care Authorization Grids Effective April 1, 2026 Routine office visits, standard preventive screenings, and true emergency services don’t require authorization. Under the No Surprises Act, plans cannot require prior authorization for emergency screening, stabilization, or post-stabilization services, even out of network.3U.S. Department of Labor. Avoid Surprise Healthcare Expenses: How the No Surprises Act Can Protect You
Second, that Fidelis Care handles the review itself. Several categories are delegated to outside vendors with their own portals, and sending them to Fidelis Care’s fax lines is a common cause of delay:4Fidelis Care. Authorizations
- Evolent reviews radiology, cardiology, radiation oncology, musculoskeletal surgery, physical therapy, occupational therapy, and speech therapy.
- TurningPoint Healthcare Solutions reviews cardiac and ENT procedures.
- The Evolent Oncology Program reviews oncology services, with separate program rules by plan type.
If the service falls under one of those vendors, use the vendor’s portal rather than this form.
What the Form Asks For
The form has three required sections. Any field marked with an asterisk is required, and missing fields are a reliable way to have a request kicked back for additional information, which resets the decision clock.
Member Information
Enter the patient’s last name, first name, and middle initial exactly as they appear on the Fidelis Care member ID card. Add the Fidelis Care Member ID, the Medicaid or Medicare ID if applicable, and the date of birth.5Fidelis Care. Fidelis Care Prior Authorization Request Form Pull the number from the card or your practice management system; a transposed digit will stall the review.
Provider Information
Both the requesting provider and the servicing provider or facility go on the form. For each, enter the NPI, Tax ID, name, address, phone, and fax.6Liberty Dental Plan. Fidelis Care Prior Authorization Request Form Include an IPA affiliation if one applies.5Fidelis Care. Fidelis Care Prior Authorization Request Form The fax number you list is where the determination letter will be sent, so verify it.
Clinical Details and Documentation
This is where most denials start. Enter the ICD-10 diagnoses that justify the service, then list the specific CPT or HCPCS codes you are requesting. Include the number of units, the proposed date of service, and whether this is an initial request or an extension of a prior approval.
Attach records that tell the clinical story: recent office notes, lab results, imaging reports, and documentation of prior treatments that were tried and failed. Reviewers want to see what the diagnosis is, what has already been attempted, and why this service is the appropriate next step. A line like “patient needs MRI” with no rationale is a common reason for a request to be pended for more information.
Where to Submit
The provider portal at providers.fideliscare.org is the fastest route. It generates a tracking number on submission and lets you check status online.7Fidelis Care. Request Prior Authorization and Check Status Online via Provider Portal
If you fax, use the number that matches the service type. Fidelis Care maintains separate lines, and the wrong line adds processing time:8Fidelis Care. Reminder: New Fidelis Care Fax Numbers
- Outpatient procedures, elective inpatient admissions, DME, and surgery: 800-860-8720
- Inpatient ER admissions: 833-663-1602
- Inpatient rehab admissions: 833-663-1611
- Home care authorization and clinical documentation: 877-433-7085
- Behavioral health (excluding substance abuse): 833-561-0094
- Children’s behavioral health and plans of care: 833-663-1604
Phone submissions and questions go through the Provider Call Center at 1-888-FIDELIS (1-888-343-3547).7Fidelis Care. Request Prior Authorization and Check Status Online via Provider Portal Keep the fax confirmation page. It’s your proof of submission date if timeliness is ever disputed.
How Long a Decision Takes
Turnaround depends on urgency and whether the submission was complete. New York’s utilization review rules set the baseline:1New York DFS. Minimum Process Requirements for Prior Authorization Utilization Review
- Complete standard request: decision within three business days of receipt.
- Incomplete standard request: up to 15 days from receipt of the additional information, or from the end of the 45-day information window if nothing arrives.
- Complete urgent request: decision within 72 hours of receipt.
- Incomplete urgent request: decision within 48 hours of receiving the needed information, or within 48 hours of the end of the information-request window, whichever comes first.
For Wellcare by Fidelis Care Medicare members, federal CMS rules apply alongside state rules. Effective January 1, 2026, standard Medicare Advantage prior authorizations must be completed within seven calendar days, with a possible extension to 14 calendar days in certain circumstances. Expedited requests must be completed within 24 hours or the current business-day turnaround, whichever is shorter.9Fidelis Care. CMS Prior Authorization Change Summary: Effective 01/01/2026
To get expedited review, the attending provider must indicate on the request that applying the standard timeframe could seriously jeopardize the patient’s life, health, or ability to regain maximum function. With that certification, the plan has to apply the shorter deadline.
Inpatient Approvals and Concurrent Review
An initial inpatient authorization does not guarantee coverage for the full stay. As of November 2025, Fidelis Care begins concurrent review outreach when a member remains hospitalized beyond seven days, contacting the facility for updated clinical documentation and to start discharge planning. This replaces the prior 30-day trigger, and initial approvals for emergent and some elective admissions no longer reflect a 30-day authorization period.10Fidelis Care. Update to Concurrent Review Process for Hospitalized Members If a longer stay is likely, prepare the continued-stay documentation early.
If the Request Is Denied
The denial letter includes the clinical rationale and the appeal instructions. The path and deadlines depend on who’s appealing.
Provider Appeals
Providers file disputes using Fidelis Care’s Provider Appeal form. All claim requests for reconsideration and disputes must be received within 60 calendar days from the date of the remittance, or per your contract terms.11Fidelis Care. Provider COB / Resubmission / Appeal / Reconsideration Form Include documentation that wasn’t part of the original request: new test results, specialist notes, or peer-reviewed literature supporting medical necessity.
Medicare Member Appeals
Wellcare by Fidelis Care Medicare members or their authorized representatives can file an appeal within 65 days of the denial notice by calling Member Services at 1-800-247-1447. A written response is issued within 60 calendar days, with a possible 14-day extension if the member requests it or the plan demonstrates a need.12Fidelis Care. Rights, Appeals, and Disputes
External Review
If the internal appeal fails, the member can request an independent external review. It’s available for denials involving a medical judgment disagreement, a determination that a treatment is experimental, or a rescission of coverage. The request must be filed in writing within four months of the final internal denial. Standard external reviews are decided within 45 days, expedited reviews within 72 hours or less, and the cost is either nothing (under the federal HHS-administered process) or no more than $25.13HealthCare.gov. External Review A patient can also appoint the treating provider as an authorized representative to file on their behalf.