How to Fill Out and Submit the Fidelis Care Provider Appeal Form

The Fidelis Care provider appeal form, formally the Resubmission/Appeal/Reconsideration Form, is a one-page document used to challenge a claim denial, dispute a payment amount, or resubmit a claim with corrected information. You have 60 calendar days from the remittance date to file it, and you can send it through the Fidelis Care Provider Portal or by mail to one of three Farmington, Missouri PO boxes keyed to the member’s plan type.

Pick the Right Request Type

The top of the form asks you to check one of three boxes. The choice matters, because each type routes the request differently.

  • Appeal. A formal request to reconsider a medical, payment, or contractual adverse decision. Authorization denial disputes, invoice and claim pricing disputes, clinical edit reviews, denials requiring medical records, and timely filing disputes all fall here.
  • Reconsideration. Use this when the original claim went in with incorrect or insufficient information, or when you are self-disclosing an overpayment. It is not a disagreement with the decision; it is an acknowledgment that something was wrong on your end.
  • COB Resubmission. Use this when resubmitting a claim related to coordination of benefits, with the supporting COB data attached.

The form explicitly states it should not be used for corrected claims or utilization review appeals. Medical necessity denials follow a different process with a different address, covered further down.

Fields You Have to Complete

Every field on the form is required, and incomplete submissions can be delayed or denied outright. Gather these before you start:

  • Member name and member ID, both from the patient’s insurance card.
  • Claim number, the identifier Fidelis Care assigned to the original claim, shown on the remittance advice.
  • Date of service.
  • Provider name and NPI or TIN.
  • Name of requestor and date of request.

Below the checkboxes is a required free-text field for the reason behind your appeal, reconsideration, or COB resubmission. Keep it specific. Reference the denial reason code, explain why the original decision was incorrect, and point to the attached documentation that supports your position.

What to Attach

The form instructs you to “include relevant information and any supporting medical or clinical documentation.”1Fidelis Care. Fidelis Care Provider Appeal Form What counts as relevant depends on the dispute:

  • Authorization denial disputes: the original authorization approval, or a copy of the authorization request showing it was submitted before the service.
  • Clinical edit or medical records denials: the clinical notes, lab results, or imaging reports that justify the service billed.
  • Pricing disputes: the relevant fee schedule, contract rate sheet, or Explanation of Benefits showing the discrepancy between expected and actual payment.
  • Timely filing disputes: proof of original submission — clearinghouse confirmation, electronic acknowledgment, or certified mail receipt — showing the claim was filed within the contractual window.

When attaching clinical records, send only what pertains to the dates of service and diagnosis codes in dispute. A whole patient chart in place of the operative notes the insurer actually needs adds processing time without strengthening the case.

Where to Download the Form

The fillable PDF is posted on the Fidelis Care website under the Manuals, Forms, Policies and Tip Sheets page.2Fidelis Care. Manuals, Forms, Policies and Tip Sheets Look for “Provider Reconsideration/Appeals Form” in the forms list. Because it is a fillable PDF, you can complete it on screen before printing or uploading.

How to Submit

Through the Provider Portal

Submitting online is the fastest route. You need either the Claims Information Viewer or Account Administration user role to reach the claims function.3Fidelis Care. New! Claims Appeal Function Now Available on the Fidelis Care Provider Portal Once you are in:

  • Select Claims from the left-side menu.
  • Search for the claim by Subscriber ID, Claim ID, Medicaid ID, Medicare ID, Patient Account Number, or Provider NPI, with a date range.
  • Click the Claim ID, then Dispute Claim under the Payment heading.
  • Choose the dispute type (COB Resubmission, Appeal, or Reconsideration), write a brief explanation in the notes field, and upload supporting documents.
  • Click Submit Request. A confirmation message appears, and a tracking number generates under Submitted for Appeal.

Only one dispute per claim can be open at a time. The status will show Open or Pending during review and change to Resolved once a decision is reached.3Fidelis Care. New! Claims Appeal Function Now Available on the Fidelis Care Provider Portal

By Mail

If you mail the form, the PO box depends on the member’s plan type. All three are in Farmington, Missouri, not New York.1Fidelis Care. Fidelis Care Provider Appeal Form

  • Medicaid Managed Care, Child Health Plus, Fidelis Care at Home (MLTC), HealthierLife (HARP), or Fidelis Medicaid: PO Box 10500, Farmington, MO 63640-5001.
  • Qualified Health Plans, Essential Plan, or Fidelis MarketPlace: PO Box 10600, Farmington, MO 63640-5002.
  • Medicare Advantage, Dual Advantage, or Medicaid Advantage Plans (Fidelis Medicare): PO Box 10700, Farmington, MO 63640-5003.

Use certified mail or another method with a delivery receipt. If the deadline is ever questioned, you will need proof of the submission date.

The 60-Day Deadline

All claim requests for reconsideration and disputes must be received within 60 calendar days from the remittance date, or within the timeframe set by your provider contract if different.1Fidelis Care. Fidelis Care Provider Appeal Form The clock runs from the remittance date, not the date you opened the notice. Missing the window generally forfeits the right to challenge the denial through Fidelis Care’s internal process.

Check your participation agreement. The 60-day standard is the default, but the “per your contract terms” language on the form means a contractual deadline controls when it differs.4Fidelis Care. Required Request Form for Administrative Reviews and Provider Appeals

When This Is the Wrong Form

Two common dispute types do not belong on the Resubmission/Appeal/Reconsideration Form.

Medical necessity denials. These go to the Fidelis Care Medical Appeals Unit, not the Farmington PO boxes. Submit within 60 calendar days of the denial notice, in writing, with the member’s medical records for the treatment at issue, a summary from your utilization management department, and a copy of the original denial letter.5Fidelis Care. Provider Manual – MMC, CHP, MADA, MLTC, HARP The channels are:

  • Mail: Fidelis Care Medical Appeals Unit, PO Box 1208, Amherst, NY 14226.
  • Phone: 1-888-343-3547.
  • Fax: 1-833-710-2226.
  • Online: Fidelis Care Provider Portal.

Verbal appeals are accepted by phone, but Fidelis Care requires a signed written follow-up.5Fidelis Care. Provider Manual – MMC, CHP, MADA, MLTC, HARP

Pharmacy appeals. These have their own fax lines, separate from both the Farmington PO boxes and the medical appeals fax.6Fidelis Care. New Fidelis Care Fax Numbers

  • Medicaid/Exchange pharmacy benefit appeals: 888-865-6531.
  • Medicaid/Exchange pharmacy medical benefit appeals: 844-235-5091.
  • Medicare pharmacy benefit appeals: 866-388-1766.
  • Medicare pharmacy medical benefit appeals: 833-757-0611.
  • MLTC member appeals: 833-710-1658.

Check the member’s plan type before sending. A pharmacy appeal faxed to the general medical line or mailed to Farmington will land in the wrong queue.

After You Submit

Fidelis Care will make reasonable efforts to resolve a standard appeal within 30 calendar days of receipt.1Fidelis Care. Fidelis Care Provider Appeal Form Expedited appeals, typically for situations where delay could seriously harm the patient, are processed within two business days and no later than 72 hours from receipt.5Fidelis Care. Provider Manual – MMC, CHP, MADA, MLTC, HARP

Two outcomes are possible. If the original decision is overturned, any additional payment due will appear on your remittance advice. If the decision is upheld, you will receive a letter explaining why.1Fidelis Care. Fidelis Care Provider Appeal Form On the portal, a Resolved status means either the claim will be adjusted or the original decision stands.

If the Internal Appeal Is Denied

New York law gives healthcare providers the right to file an external appeal with the Department of Financial Services when health care services are denied concurrently or retrospectively.7Department of Financial Services. New York State External Appeal An independent external appeal agent reviews the case, and the decision is binding on the plan.

Providers appealing on their own behalf must submit the external appeal within 60 days of receiving the final adverse determination from Fidelis Care.7Department of Financial Services. New York State External Appeal The same deadline is set out in New York Insurance Law Section 4914.8New York State Senate. New York Insurance Law ISC 4914 – Procedures for External Appeals Health plans may charge providers a $50 fee per external appeal, refunded if the external agent overturns the denial. Standard external reviews are completed within 30 days; expedited reviews are decided within 72 hours and can be filed alongside an internal appeal when the situation is urgent.

External appeals can be filed online through the DFS Portal, by email to earesponse@dfs.ny.gov, by fax to 800-332-2729, or by certified mail to the Department of Financial Services at 99 Washington Avenue, Box 177, Albany, NY 12210.7Department of Financial Services. New York State External Appeal A signed patient consent for release of medical records is required, and depending on the appeal type, a physician attestation form as well. DFS will not complete eligibility screening without all required documents.