Ambetter from Fidelis Care Prior Authorization

Ambetter from Fidelis Care prior authorization rules are often service-specific rather than universal, so the safest workflow is to confirm the requirement in the payer's provider resources before scheduling or submitting care. The notes below summarize the most actionable provider-side guidance captured in the research set for this payer.

At a glance

• For Ambetter from Fidelis Care QHP members, prior authorization is service-specific and should be checked against the current authorization grid / lookup tool. The provider manual states most outpatient services do not require prior authorization, but inpatient services generally do except emergencies. Some categories are delegated to vendors (for example, certain radiology/radiation therapy and some surgical services in historical QHP guidance), so the exact requirement depends on the service and current authorization grid.
• Prior authorization rules vary by service and may change; the live authorization lookup tool is the best source.
• The provider manual sections captured are for QHP/EP and may not apply to non-QHP Fidelis Care lines of business.
• Some historical manual language references external delegates (eviCore, TurningPoint); verify current delegation in the live lookup tool.

Where to verify prior authorization requirements

• Verification resource 1
• Verification resource 2

How to submit prior authorization requests

• Telephone to Fidelis Care authorization/case management team

• Provider portal / authorization tools

• Vendor-specific prior authorization processes where delegated

• Submission resource 1

• Submission resource 2

Information commonly required

• Clinical information needed to determine medical necessity
• Member identification information
• Service details and date(s) of service
• Provider/facility information
• For urgent situations, notification as soon as practical / next business day handling

Turnaround notes and caveats

• Non-urgent requests received after 5:00 PM are processed the next business day.
• The manual says Fidelis Care will make at least two attempts to obtain necessary clinical information.
• For urgent situations that cannot wait until the next business day, providers should call 1-888-FIDELIS.
• Prior authorization rules vary by service and may change; the live authorization lookup tool is the best source.
• The provider manual sections captured are for QHP/EP and may not apply to non-QHP Fidelis Care lines of business.
• Some historical manual language references external delegates (eviCore, TurningPoint); verify current delegation in the live lookup tool.

Provider resources

• Provider Access Online (Provider Portal) (official)
• Electronic Transactions (official)
• Authorization Grids / Authorization Lookup Tool (official)
• Manuals, Forms and Policies (official)
• Ambetter from Fidelis Care Provider FAQ (official)

Sources