Fidelis Medication Prior Authorization Form: Submission and Appeals

A Fidelis medication prior authorization form is the request your prescriber submits to Fidelis Care to justify coverage of a drug that needs clinical review before the plan will pay. Which form you use and where it goes depends on your plan: Child Health Plus, Essential Plan, Ambetter, and Medicare members use forms from the Fidelis Care Provider Resources page, while Medicaid and HARP pharmacy requests go through the state’s NYRx program instead.¹² Fidelis prefers electronic submission through CoverMyMeds or Surescripts, but fax and the provider portal are also accepted.

Finding the Right Form for Your Plan

Fidelis Care doesn’t use one universal form. CHP, EP, Ambetter, and Medicare enrollees pull the authorization form from the “Authorizations” section of the Fidelis Care website.¹ Medicaid and HARP members are on a different track entirely. Since April 2023, their pharmacy benefits have been administered by the New York State NYRx program, so those prior authorization requests go to NYRx, not Fidelis.² If you’re a Medicaid member and your prescriber sends a drug request to Fidelis, it won’t be processed there.

Your prescriber’s office usually handles the submission. Knowing which form and channel apply to you still matters, because it lets you follow up intelligently if the pharmacy says the request hasn’t come through.

What Goes on the Form

The form has four parts. Mistakes in any of them, especially mismatched member IDs or thin clinical detail, cause denials that have nothing to do with whether the drug is actually appropriate for you.

Member Information

Your full legal name, date of birth, and Fidelis Care member ID go at the top.³ The NYRx version also asks for sex, height, weight, and allergies.⁴ Check every field against your insurance card. A single wrong digit in the member ID is enough to get the request bounced before anyone looks at the medicine.

Prescriber Information

The prescribing physician fills in their name, National Provider Identifier, specialty, office address, phone, and fax number.³ The fax number is where the decision letter goes, so an error here means the response never reaches the office that needs it.

Medication Details

This section lists the drug name, strength, formulation, dosing frequency, quantity, day supply, and route of administration.⁴ The prescriber also notes whether the drug is new, a renewal, or continued from another insurer. Blank fields, especially day supply or route, usually come back as a request for more information, and that resets the decision clock.

Clinical Justification

This is where approvals and denials are decided. The prescriber lists the diagnosis and ICD-10 code and answers specific clinical questions:⁴

Whether the drug is being prescribed for an FDA-approved use. If not, medical literature supporting off-label use should be attached.
Whether preferred alternatives were tried first, and if so, which drugs, when, and why each failed or caused problems.⁵
Whether the prescriber is willing to prescribe a preferred formulary agent, and if not, the clinical reasons the preferred drugs don’t work for you.
Whether supporting lab results, diagnostic studies, or clinical notes are attached.

Vague reasoning rarely survives review. The requests that get approved describe a concrete treatment history: which drugs were tried, at what doses, for how long, and what went wrong, whether that was poor symptom control, side effects, or a drug interaction.

How to Submit the Form

Electronic prior authorization is the preferred route. CoverMyMeds and Surescripts are integrated into most electronic health record systems, so the form can be sent and tracked without printing anything.¹ Prescribers can also submit through the Provider Access Online portal at providers.fideliscare.org.⁶

For fax, the right number depends on your plan and whether you’re submitting an initial request or an appeal:²

Medicare initial requests: 844-235-5021
CHP, EP, and Ambetter initial requests: 844-235-4852
Medicare appeals: 866-388-1766
CHP, EP, and Ambetter appeals: 888-865-6531

Medicaid and HARP pharmacy requests go to NYRx by fax at 1-800-268-2990.⁴ Faxing to the wrong line is one of the most common reasons a request seems to disappear. If the prescriber’s office hasn’t heard back within a few days, confirm the fax went where it was supposed to go, and keep the transmission confirmation.

How Long the Decision Takes

New York Insurance Law Section 4903 sets the clock. For a standard pre-authorization of a new drug, Fidelis Care must decide within three business days of receiving all necessary clinical documentation.⁷ The phrase “all necessary” is doing real work. If the file is missing lab results or a required field, the three days don’t start until the plan has everything.

Two faster tracks apply. A request to override step therapy must be decided within 72 hours. A request involving continued or extended treatment for someone already on a drug must be decided within one business day.⁷ Both you and your prescriber get written notice of the outcome.

Emergency Supply for Medicaid Members

If you need a medication urgently and the prior authorization hasn’t gone through, Medicaid members have a bridge. When the pharmacist cannot reach the prescriber and there’s an emergency, the pharmacist can call 1-877-309-9493 to get a three-day emergency supply authorized.⁸ After that three-day supply is dispensed, the original prescription is no longer valid for any remaining quantity. The pharmacist and prescriber have to arrange ongoing coverage separately.

If the Request Is Denied

A denial has several layers of review above it, and the first one usually isn’t even a formal appeal.

Peer-to-Peer Call

At any point in the process, the prescriber can request a peer-to-peer phone call with a Fidelis Care clinical reviewer who has experience in the relevant specialty.⁹ This gives your doctor a chance to explain the clinical picture directly. Denials that stem from ambiguous paperwork often reverse at this stage without any formal appeal paperwork.

Internal Appeal

If the peer-to-peer doesn’t resolve it, you have at least 45 days from the date of the denial notice to file a formal internal appeal under New York Public Health Law Section 4904. A different clinical reviewer, one not involved in the original decision, examines the case. Standard appeals must be decided within 30 days of receiving all information needed to evaluate them.¹⁰

If a delay could seriously harm your health, your prescriber can request an expedited appeal, which must be decided within two business days.¹⁰ If the plan misses any of these deadlines, the statute treats the denial as reversed.

Medicare members follow slightly different rules. Fidelis Care’s Medicare plans allow 60 calendar days for a standard appeal decision and 72 hours for an expedited one, and the appeal has to be filed within 65 days of the denial notice.¹¹

External Appeal

If the internal appeal upholds the denial, you can take the case outside Fidelis entirely. An external appeal is reviewed by an Independent Review Organization, a panel of outside clinical experts with no connection to the plan, whose decision binds Fidelis.¹² You can also request an external appeal if coverage was denied because the plan considers the drug experimental or investigational.¹³

You have four months from the final internal denial to file.¹⁴ The application goes to the New York Department of Financial Services, which randomly assigns the reviewing organization. Filing fees cap at $25 per appeal and $75 per plan year, and the fee is waived for Medicaid, Child Health Plus, and Family Health Plus enrollees, or anyone facing financial hardship.¹² If the review overturns the denial, the fee is refunded.

Expedited external appeals are decided within 72 hours, or within 24 hours when the dispute involves a non-formulary drug.¹³

Medicare Formulary Exception Requests

If you’re on a Fidelis Care Medicare plan and the drug you need isn’t on the formulary, or you want to pay a lower copay tier, that’s a separate process from standard prior authorization. Your prescriber completes the Request for Medicare Drug Coverage Determination form with a supporting statement about why the formulary alternatives won’t work for you, whether due to failed trials, adverse reactions, or contraindications.¹⁵

Exception requests cover drugs not on the formulary, drugs removed mid-year, requests to bypass step therapy or quantity limits, and requests for a lower copay tier. Submit by mail to Medicare Pharmacy Prior Authorization Department, P.O. Box 31397, Tampa, FL 33631-3397, or by fax to 1-866-226-1093.¹⁵ You can also start the process by calling Member Services at 1-800-247-1447.

1
Fidelis Care. Authorizations
2
Fidelis Care. Pharmacy Benefits and Authorizations
3
Fidelis Care. NYS Medicaid Prior Authorization Request Form
4
NYRx, the Medicaid Pharmacy Program. Prescription Prior Authorization Request Form
5
Fidelis Care. Medication Prior Authorization – Step Therapy Clinical Policy
6
Fidelis Care. Provider Access Online
7
New York State Senate. New York Insurance Code 4903 – Utilization Review Determinations
8
NYRx, the Medicaid Pharmacy Program. Mandatory Generic Drug Program
9
Fidelis Care. Frequently Asked Questions – Physical Medicine Services
10
New York State Senate. New York Public Health Code 4904 – Utilization Review Appeals
11
Fidelis Care. Rights, Appeals, and Disputes
12
New York State Senate. New York Public Health Code 4910 – Right to External Appeal Established
13
Department of Financial Services. New York State External Appeal
14
New York State Senate. New York Insurance Code 4914 – Procedures for External Appeals of Adverse Determinations
15
Fidelis Care. Request for Medicare Drug Coverage Determination