Provider Manual - Fidelis SecureCare

Provider Manual
North Carolina

Fidelis SecureCare of North Carolina Contacts At A Glance
9300 Harris Corners Parkway Suite 100
Charlotte, North Carolina 28269
Telephone – (877) 372-8080
Facsimile – (877) 372-8081
CALL US FOR:
AUTHORIZATIONS (MEDICAL)……………….. (704) 307-4394
AUTHORIZATIONS (PHARMACY) ……………. (866) 878-4927
TO SCHEDULE TRANSPORTATION ………… (704) 307-4393
SCHEDULING APPOINTMENTS …………….... (704) 307-4393
BENEFIT INQUIRIES …………………………….. (877) 372-8085
CLAIM INQUIRIES ……………………………….. (877) 372-8085
ELIGIBILITY INQUIRIES ………………………… (877) 372-8085
FAX OUR HEALTH SERVICES TEAM ………… (866) 878-4927
Inpatient Care Manager ………..…………. (877) 372-8083
Outpatient Care Coordinator …………….. (877) 372-8083
PROVIDER PORTAL (Claim, Eligibility)……….
www.fidelissc.com
MAIL CLAIMS TO:
Fidelis SecureCare of North Carolina, Inc
P.O. Box 3597
Scranton, PA 18505
OR FOR ELECTRONIC CLAIM PROCESSING CONTACT:
Emdeon Business Services EDI solutions at 866-369-8805
Fidelis Payor ID is #77054

Acknowledgement of Receipt
I acknowledge that I have received a copy of this Provider Manual describing the
standards and requirements established by Fidelis SecureCare and have received an
in-service training session by a Fidelis representative.
Print Name and Title
Date
Signature
Provider / Group Name
Training Conducted by (Name of Fidelis Employee)
Staff Sign-in Sheet
1.
2.
3.
4.
5.
6.
7.
8.

Utilization Management Affirmative Statement Regarding Incentives
This statement is intended to comply with the 2004 National Committee for Quality
Assurance (NCQA) Utilization Management Standard 14, Element G and Code of
Federal Regulations 42 (CFR) 422.152 regarding Utilization Management Affirmative
Statement Regarding Incentives.
In accordance with the regulations above, Fidelis requires that all utilization-related
decisions regarding member coverage and/or services must be based on
appropriateness of care and service. Financial rewards or incentives must not influence
any utilization decision. To assure that the risks of underutilization are considered, no
rewards or incentives can be issued by Fidelis that will discourage appropriate care and
services to members.
Fidelis does not reward providers, employees, or other individuals for issuing denials of
coverage, service, or care. Denials for medical service requests are reviewed by
medical directors and are based strictly upon review of the available clinical information,
clinical judgment and plan benefits.

Introduction to Fidelis
Fidelis SeniorCare is a leader in the development of Medicare Advantage Special
Needs Plans for eligible individuals residing in nursing facilities and assisted living
communities. Fidelis contracts with the federal government under the Medicare
Advantage Program to provide Medicare benefits plus enhanced coverage specifically
designed for this special needs population.
Today the company administers Fidelis SecureCare
plans in three states, Michigan, North Carolina and
Texas. Fidelis SecureCare plans are available for those
qualified individuals who require more focused
coordination of clinical care than traditional Medicare
can provide. Our contracted physicians and their
extenders, nurse practitioners and care managers
provide the highest quality care while effectively
managing the medical and psychosocial needs of these
frail Members.
At Fidelis SecureCare, we firmly believe that the quality of life of our Members can be
significantly improved—and their rate of decline measurably reduced—through clinically
superior, consistently attentive care. In concert with nursing facility staff, our physician
partners and our network of expert healthcare professionals, we strive daily to achieve
improved health outcomes for every chronically ill Member we serve.
Our Vision
Fidelis SecureCare is committed to achieving the highest level of care for our frail and
more vulnerable senior population, one that is compassionate and focused on the
needs of the whole person.
Our Mission
To fundamentally improve the way healthcare is delivered for the long term care
resident by partnering with physicians to provide care in the most effective and efficient
clinical setting.
Introduction to Fidelis - 1 -

Important Customer Service Information
If you need to talk to us about Contact Phone Number
Claims, including:
• Claim status
• Claim denial
• Claim submission process
• Claims remittance address (verification
or change)
• Corrected claims or Resubmitted claims
• Remittance Advice (RA)
Customer Service
(877) 372-8085
Or go to the Fidelis
Provider Portal at
www.fidelissc.com
Credentialing and Re-credentialing Provider Relations (704) 307-4392
Contract Status, Terms, or Rates Provider Relations (336) 831-5441
Coding Provider Relations (336) 831-5441
Medicare Assignment Customer Service (877) 372-8085
(877) 372-8085
Member Eligibility and Coverage
Customer Service
Or go to the Fidelis
Provider Portal at
www.fidelissc.com
Regulatory, DOI, or CMS Requirements Provider Relations (336) 831-5441
Training and Orientation Provider Relations (336) 831-5441
Update Your Provider Information Provider Relations (336) 831-5441
Other Questions Customer Service (877) 372-8085
Customer Service Hours:
November through March - 8:00 a.m. to 8:00 p.m. seven days per week
March through October - 8:00 a.m. to 6:00 p.m. EST Monday through Friday
Introduction to Fidelis - 2 -

Regulations and Responsibilities
Compliance with the Contract, Regulations, and this Manual
Fidelis is subject to certain requirements as set forth by the Centers for Medicare and
Medicaid Services (CMS) for this health plan and will disclose to CMS all information
necessary to administer and evaluate the program, and establish and facilitate a
process for current and prospective beneficiaries to exercise choice in obtaining
Medicare services. The Fidelis provider contract requires compliance with the contract
and with federal regulations governing Medicare Advantage health plans and the plan’s
policies and procedures. Those requirements are set forth in the Fidelis provider
contract, this manual and from time to time in provider newsletters and other
communications and notices sent by Fidelis.
General Federal and Medicare Regulations
• A Fidelis provider is required not to contract with or employ individuals who have
been excluded from participation in the Medicare Program.
• If a Fidelis provider files an affidavit with CMS stating that they will furnish Medicarecovered
services to Medicare beneficiaries only through private (direct) contracts
with the beneficiaries under Section 1802(b) of the Social Security Act (i.e. they will
not accept payment from Medicare), then their contract with Fidelis will terminate
concurrently. A Fidelis provider must provide notice to Fidelis within five (5) days of
providing any notice with CMS.
• Fidelis providers must provide Covered Services to all Members, including those
with ethnic backgrounds, physical or mental disabilities, and limited English
proficiency, in a culturally competent manner.
• Fidelis providers must provide disabled covered persons with the assistance
necessary to effectively communicate with the participating provider and their staffs,
as required by the Americans with Disabilities Act.
• Fidelis monitors and reports on quality and performance including but not limited to:
member satisfaction, disenrollment, and health outcomes.
Synopsis of Important Contract Requirements
The Agreement with Fidelis contains numerous important provisions that are
synopsized below. In some situations, a Fidelis contracted provider may subcontract
with another provider to provide services to a Fidelis Member. In all cases, any such
subcontracts must include the following provisions:
Regulations and Responsibilities - 1 -

• Providers understand that Fidelis is responsible for overall administration of the
health plan including all final coverage determinations and monitoring of its
contracted provider’s compliance with state and federal regulations.
• Fidelis is responsible for all marketing of the health plan and providers are not
authorized to act as agents of Fidelis in marketing. Only Fidelis-approved marketing
materials may be provided to beneficiaries to explain the Fidelis program.
• Providers will comply with Fidelis Utilization/Medical Management Policies and
Procedures.
• Providers will comply with Fidelis Quality Management Programs. Fidelis requires
that all providers participate in periodic audits and/or site surveys for evaluating
compliance with Fidelis Quality Management standards and regulatory
requirements.
• Medical Records - Fidelis Providers must safeguard the privacy of any information
that identifies a particular Member and must maintain Member records in an
accurate and timely manner.
Contracted providers must provide a Fidelis Medical Director or designee access to
all Fidelis Members' charts and medical records for the purpose of determining or
resolving eligibility, liability or appropriate care issues. Provider, as prescribed by
State and federal law under HIPAA regulations, will maintain confidentiality of this
information.
Fidelis is concerned with protecting Member privacy and is committed to complying
with the HIPAA privacy regulations. Generally, covered health plans and covered
providers are not required to obtain individual Member consent or authorization for
use and disclosure of Protected Health Information (PHI) for treatment, payment and
health care operations. Activities such as care coordination, reviewing the
competence of health care professionals, billing/claims management, and quality
improvement fall into this category. If you have further concerns, please contact
your Provider Relations Representative.
• No Balance Billing of Members with the exception of applicable co-payments or
coinsurances.
A Fidelis contracted provider agrees not to impose any charges on any Fidelis
Member for Covered Benefits shown in the Evidence of Coverage. Further,
contracted providers agree to accept the Fidelis payment as payment in full and
agree not to seek compensation from a Fidelis Member for services provided to that
Member, even in the event of non-payment by Fidelis.
• Contracted providers agree to retain financial and medical records relating to Fidelis
Members for a period of ten (10) years from the termination of the contract or such
time as may be required by applicable state or federal law, regulation or customary
practice.
• Fidelis Providers must give the U.S. Department of Health and Human Services, the
U.S. Government Accounting Office and their designees the right to audit, evaluate,
and inspect their books, contracts, medical records, member documentation and
Regulations and Responsibilities - 2 -

other relevant records. These rights will extend for ten (10) years beyond termination
of the Fidelis Agreement and until the conclusion of any governmental audit that may
be initiated that pertain to such records.
• Fidelis Providers must not discriminate against Members based on their health
status. Further, Providers must ensure that Members are not unlawfully
discriminated against based on race, color, creed, national origin, ancestry, religion,
sex, marital status, age, physical or mental handicap, or in any other manner
prohibited by state or federal law.
• Fidelis Providers must provide all covered benefits in a manner consistent with
professionally recognized standards of health care.
• Fidelis Providers must cooperate with the plan’s grievance and appeals procedures
that protect beneficiary and member rights.
• Fidelis Providers have specific continuity of care obligations in the event that the
Fidelis Agreement terminates for any reason, including a provider’s de-participation
or if Fidelis becomes insolvent. In the event of insolvency, Fidelis Providers must
continue to provide care to Members through the period in which their CMS
payments have been made to Fidelis. Additionally, if the Member is hospitalized,
services must be provided until termination of CMS’ agreement with Fidelis or, in the
event of Fidelis’ insolvency, through the date of the Member’s discharge.
• Fidelis Providers may not encourage members to disenroll.
Review the Fidelis contract for any additional sections or provisions not discussed in
this section. In addition, the description of the contract provisions listed in this section
does not constitute the complete disclosure of all requirements placed on providers
contracted with Fidelis. Contracted providers should refer to their Fidelis contract for
further information.
Member Relationship and Communications
Participating Providers are responsible to maintain the provider-member relationship
with each Member. Nothing contained in the Fidelis Agreement or this Manual is
intended to interfere with such provider-member relationship, nor should any provision
be interpreted to discourage or to prohibit a participating physician or other provider
from discussing treatment options or providing other medical advice or treatment
deemed appropriate by the participating physician. The participating physician shall
have the sole responsibility for the medical care and treatment of Members.
In the event that a Fidelis Provider terminates their participation or relationship with the
Plan, Fidelis has the exclusive right and responsibility to communicate with its Members
regarding those changes; participating providers should not send independent notices
to Fidelis Members.
Regulations and Responsibilities - 3 -

THE HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT OF 1996
Fidelis is concerned with protecting Member privacy and is committed to complying with
the HIPAA privacy regulations. Generally, covered health plans and covered providers
are not required to obtain individual Member consent or authorization for use and
disclosure of Protected Health Information (PHI) for treatment, payment and health care
operations. Activities that fall into this category include care coordination, reviewing the
competence of health care professionals, billing/claims management, and quality
improvement. If you have further concerns, please contact your Fidelis Provider
Relations Representative.
All medical records must be maintained for up to ten (10) years.
Providing Access to Medical Records
Members may access their medical records at any time by contacting their provider
directly. Members shall be given the opportunity to review their medical records in a
timely fashion.
Regulations and Responsibilities - 4 -

Physician Responsibilities
Primary Care Physicians and Medical Team Members
Primary Care Physician (PCP’s) and Medical Team Members are defined as Family
Providers, General Practice Physicians, Geriatricians, Internal Medicine Physicians and
their associated nurse providers and physician assistants.
Fidelis PCP responsibilities include
• Provide access to medical services 7 days a week/24 hours a day either directly or
through call coverage.
• The management of medical care provided to Members who have chosen or been
assigned to the physician and team as their Primary Care Provider. A PCP is
expected to provide all necessary care required by a Member that is within the
scope of his or her practice and expertise. The PCP should refer a Member to a
specialist or other provider only when he or she is not able to provide the specialty
care.
• Coordinate the services a Member may need that can be effectively provided within
the nursing facility.
• Coordinate and obtain a referral or prior authorization from Fidelis’ Medical
Management team prior to directing a Member to receive care from another Fidelis
provider inside or outside the nursing facility.
• Coordinate a member’s care needed from specialty physicians or other healthcare
providers by referring to providers in the Fidelis network of providers. Except in
emergency and urgent situations and for renal dialysis services for those members
temporarily out of the service area, if services are not available within the Fidelis
network of providers, then the Primary Care Provider must contact Fidelis’ Medical
Management team to obtain prior authorization to refer a Member to a nonparticipating
provider prior to the care being rendered.
• Provide direction and follow-up care for those Members who have received
emergency services.
• PCP’s and their care team are responsible for all Members who select them,
including members whom the PCP has not yet seen.
Panel Closure
Occasionally PCPs will request closure of their panel to new Fidelis Members. Fidelis
requires a 90-day written notice to the Provider Relations department prior to the
proposed effective date of such closure. This panel closure must be in writing. During
the 90-day period between notification of closure and revision of the provider directories
Regulations and Responsibilities - 5 -

to reflect such closure, PCPs must continue to accept Members who select them.
Fidelis will continue to list closed PCPs in Fidelis’ provider directories with a notation
designating them as “Not accepting new members.”
Reopening of Panel
The Fidelis Provider Relations department will continuously monitor the membership of
all PCPs who have “closed” their panel to new members. When a PCP requests to reopen
their panel to new members, the PCP will send a written notice to the Provider
Relations department requesting re-opening of their panel and the effective date of the
re-opening.
Specialist Physicians
The role of a Fidelis participating specialist is to provide consulting expertise, as well as
specialty diagnostic, surgical and other medical care for Fidelis Members. Fidelis
expects a participating specialist to support the role of a PCP in coordinating and
managing a Member's health care by providing only those specific services for which a
referral has been issued and promptly returning the Member to the PCP as soon as
medically appropriate. (See section on referrals and authorizations for details.) Open,
prompt communication with the PCP concerning follow-up instructions, circumstances
of further visit requirements, medications, lab work, x-rays, etc. are essential to the
coordination of care.
The Fidelis Specialist’s responsibilities include:
• Specialists must provide access to medical services 7 days a week/24 hours a day
either directly or through call coverage.
• Specialists should order all laboratory testing, radiology studies or other diagnostic
testing through a contracted, in-plan facility unless an emergency situation clearly
indicates emergency lab or radiology services are indicated. Fidelis has specific,
contracted laboratory and radiology service providers in all regions. There are
specific Fidelis policies within each region that outline which of these services may
be rendered in an office setting. If you have any questions, please contact your
regional Provider Relations department.
• Specialists are encouraged to “Fast Track” the member through his/her office on the
day of their scheduled appointment. “Fast Track” is defined as such: when the
member gets to the office, the member will be escorted immediately back to an
exam room and be seen by the specialist. The transportation attendant will also wait
for the member during this “fast tracking” so the member will not have to wait in the
waiting area after the appointment and the office staff will not have to call for the
transportation company to return to pick-up the member.
Regulations and Responsibilities - 6 -

Access to Care
Fidelis has adopted the following standards for access:
Prompt access to providers is vital for care to Members. The Fidelis policy on
Provider/Plan Access Standards was developed with this core value in mind. The
standards listed in this policy support the value of service as it seeks to anticipate,
understand and respond to individuals, organizations, nursing facility and community
needs as Members access healthcare services.
Fidelis believes that our Members are entitled to care that is delivered in the appropriate
setting, appropriate timeframe and appropriate manner.
Fidelis requires health care providers to provide access to health care services without
excessive scheduling delays. Providers will have policies and procedures in place to
properly identify emergency conditions and appropriately triage such cases. Triage
involves identifying which cases can be managed in the office/nursing facility or making
alternative arrangements, e.g. immediate care service or emergency room for cases
which cannot be safely managed in the office/or nursing facility setting.
The maximum time period between a request for an appointment/or visit to the nursing
facility and the date offered will be:
Medical Appointments
• Life Threatening, Emergent problem: Immediate access
• Urgent Care: Same Day
Defined as services provided for the relief of acute pain, initial treatment of
acute infection, or a medical condition that requires medical attention, but a
brief time lapse before care is obtained does not endanger life or permanent
health. Urgent conditions include, but are not limited to, minor sprains,
fractures, pain, heat exhaustion and breathing difficulties, other than those of
sudden onset and persistent severity.
• Preventive Care: 30 days
Defined as a preventive health evaluation without medical symptoms for
existing members. i.e. routine exam, annual physical.
• Routine Care: 7-14 days or earlier based on the population
Defined as non-urgent symptomatic condition that is medically stable. Special
attention will need to be given based on the geriatric population and how
symptoms are presented.
Regulations and Responsibilities - 7 -

• If a provider’s schedule cannot accommodate the Member requesting an
Urgent Care or Routine Care appointment within these time intervals, an
appointment will be offered with an alternative provider, nurse provider,
physician assistant or certified nurse midwife at the same location, or if none
are available, at another location. Immediate Care Service (ICS) may also be
offered as an alternative to an Urgent Care appointment or a Routine Care
appointment request, which cannot be scheduled within the appropriate
timeframe. The Member may choose to decline alternatives and accept a
delayed appointment with the provider.
Behavioral Health Appointments
The maximum time period between a request for an appointment and the date
offered will be:
• Emergent, Life Threatening: Immediate access
• Emergent, Non-Life Threatening: 6 hours
• Urgent Care: 48 hours
• Routine Care: 10 working days
• If a provider’s schedule cannot accommodate the Member requesting an
appointment within these time intervals, an appointment will be offered with
an alternative provider at the same location, or if none available, at another
location. The Member may choose to decline alternatives and accept a
delayed appointment with the provider.
Office Hours/Office Wait Time
• Fidelis requires health care providers to have established hours that
accommodate the needs of Fidelis Members. These hours should be clearly
posted and communicated to Members, authorized representatives and
nursing staff at each facility. Wait time standards require members to be
seen within 30 minutes of the scheduled appointment.
Regulations and Responsibilities - 8 -

Credentialing
Credentialing Program
Fidelis has a comprehensive written credentialing program that has been established in
accordance with the standards of the National Committee for Quality Assurance
(NCQA) and applicable state and federal regulatory requirements. The program is
reviewed and revised at least annually.
All providers who fall under the scope of Fidelis Credentialing Program must meet the
minimum credentials, qualifications and criteria established by the Plan. The Fidelis
Credentialing Committee makes all decisions regarding provider participation in the
Fidelis Network in accordance with Fidelis credentialing criteria.
Getting Credentialed with Fidelis SecureCare
Once you have completed the Fidelis Provider Application and executed the Provider
Agreement, you may become credentialed with Fidelis in one of two ways:
1. CAQH
a. Fidelis works with CAQH, a national credentialing clearinghouse. Once
you provide your credentials confidentially to CAQH, they will facilitate the
credentialing process with all of the payors / networks with which you wish
to become affiliated. Once you execute an agreement with Fidelis, you will
receive a package from CAQH inviting you to participate with them. There
is no cost to providers to sign up with CAQH.
b. If you are already signed up with CAQH, then we will simply access your
credentials from them and begin the credentialing process.
2. If you prefer not to sign up with CAQH, then you must complete the
documentation identified in Appendix 2 and deliver it to Fidelis or your Fidelis
representative below. Documentation must be received within 60 days of contract
execution.
Network Development Manager
Fidelis SecureCare of North Carolina
9300 Harris Corners Parkway Suite 100
Charlotte, North Carolina 28269
Telephone – (877) 372-8080
Facsimile – (877) 372-8081
Credentialing - 1 -

Who Needs to be Credentialed?
Credentialing is required for:
• All physicians who provide services to Fidelis SecureCare members, including
members of physician groups; and
• All other types of health care professionals who provide services to Fidelis
SecureCare members, and who are permitted to practice independently under
state law.
Credentialing is not required for:
• Health care professionals who are permitted to furnish services only under the
direct supervision of another provider;
• Hospital-based health care professionals who provide services to members
incident to hospital services, unless those health care professionals are
separately identified in enrollee literature as available to members; or
• Students or fellows
Physicians who provide services to members and practice independently under state
law are defined as below:
• Doctor of Medicine (M.D.); Doctor of Osteopathic Medicine (D.O.); Doctor of
Dental Science (D.D.S.) who provide care under the medical benefit program;
Doctor of Podiatric Medicine (D.P.M.); Doctor of Chiropractic (D.C.); and Doctor
of Optometry (O.D.).
• Behavioral Health Care Providers to include Psychiatrists and Physicians who
are certified in Addiction Medicine; doctoral and/or master’s level Psychologists
(PhD, PsyD) who are state certified or state licensed; master’s level
Clinical Social Workers who are state certified or state licensed; master’s level
Clinical Nurse Specialists or Psychiatric Nurse Providers who are nationally or
state certified or state licensed; and other Behavioral Health Care Specialists
who are licensed, certified, or registered by the state to practice independently.
• Nurse Providers, Nurse Midwives, and Physician Assistants who work in primary
care and obstetric/gynecology settings and who provide direct patient care, make
referrals to specialists or have prescriptive duties. (Note: please see rule above
regarding mid-level providers under supervision of physician)
• Urgent care physicians and anesthesiologists who work outside the hospital
setting.
• Hospitalists who exclusively provide care for hospitalized members.
Credentialing - 2 -

Providers who practice exclusively within the inpatient hospital setting, Pathologists,
Radiologists, Anesthesiologists, Emergency Room Physicians, physicians practicing in
free-standing facilities (i.e. surgical centers) and physicians who provide care for Fidelis
SecureCare members only as a result of members being directed to the hospital/facility
do not need to be credentialed by Fidelis SecureCare unless otherwise noted.
Health delivery organizations are required to be credentialed prior to seeing members to
ensure organizational providers are meeting minimally acceptable standards of patient
care. They must be reviewed and approved by an appropriate accrediting body, or
meets the standards established by the health plan. Accrediting bodies include the
Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the
Accreditation Association for Ambulatory Health Care, the Commission on Accreditation
of Rehabilitation Facilities, the Council on Accreditation, the Community Health
Accreditation Program (CHAP), and the Continuing Care Accreditation Commission.
Health delivery organizations are defined as:
• Hospitals (either JCAHO accreditation or Medicare certification). Note that
Medicare also certifies organ procurement organizations (OPOs) and that organ
transplants must generally be performed in certified organ transplants centers;
• Home Health Agencies (HHAs);
• Hospices;
• Clinical laboratories (a CMS-issued CLIA certificate or a hospital-based
exemption from CLIA);
• Skilled Nursing Facilities (SNFs);
• Comprehensive Outpatient Rehabilitation Facilities (CORFs);
• Outpatient Physical Therapy and Speech Pathology Providers;
• Ambulatory Surgery Centers (ASCs);
• Providers of end-stage renal disease services;
• Providers of outpatient diabetes self-management training;
• Portable x-ray suppliers
Credentialing Criteria
Fidelis has adopted the following Credentialing Criteria and requirements for
Participating Providers:
• Submission of a signed completed application, including the consent and other
necessary releases. Submission of inaccurate or misleading information on the
application, or failure to disclose relevant information will be grounds for
termination from or denial into the network.
Credentialing - 3 -

• Possess a current, valid license to practice in the state(s) in which he/she
provides professional services as a contracted provider with Fidelis and certify
that his/her license to practice has never been revoked, suspended, or placed on
probation by any state licensing board.
• Medical staff appointment or a clinical privileges have not been denied, revoked,
terminated, and has not voluntarily terminated privileges in lieu of disciplinary
action by any health care facility or professional related organization.
• Agrees to notify Fidelis regarding any current or past limitations imposed upon
clinical privileges, or any change in appointment or clinical privileges during the
course of contract with Fidelis.
• Has never been excluded or precluded from participation in Medicare or
Medicaid or has been convicted of Medicare, Medicaid, or governmental or
private third party payer fraud or program abuse or has been required to pay civil
penalties for the same.
• Possess and maintain certification by a medical specialty board recognized by
the American Board of Medical Specialties or AOA; or, have completed a
residency-training program approved by the ACGME or AOA in the contracted
specialty.
• Possess malpractice history acceptable to Fidelis.
• Possess professional liability insurance coverage in such minimum amounts
required by Fidelis.
• Has no criminal felony convictions, criminal misdemeanor related to the practice
of their profession, other health care related matters, third party reimbursement,
controlled substances violations, child/adult abuse charges, or any other matter
that in the opinion of Fidelis would adversely affect the ability of the provider to
contract with Fidelis.
• Has no chemical dependency/substance abuse history; or, for those providers
who have such history, must provide evidence that the provider has completed a
prescribed monitored treatment program and that no current chemical
dependency or substance abuse exists.
• Has no current physical or mental health on condition that would impair or would
be likely to impair provider’s ability to adequately perform the professional duties
for which provider is contracted and that could not be accommodated without
undue hardship
• Has no history of quality issues as identified by Fidelis internal processes on
review, National Providers Data Bank / Health Integrity Protection Data Bank, or
from any other source.
• Possess verified, current state drug license and federal Drug Enforcement
Agency certificates (DEA numbers), dependent on state requirements.
Credentialing - 4 -

• Agree to actively participate in utilization review and quality improvement
activities of Fidelis and permit access by Fidelis representatives to his/her office
location for the purpose of gathering information relevant to those activities.
• Have no significant utilization issues and Member services issues or complaints
identified and documented by Fidelis during participation period.
• Agrees to follow Fidelis policies and procedures.
Provider Rights
As a network provider, you have the right to:
• Review information submitted to your credentialing application.
• Correct erroneous information collected during the credentialing process.
• Be informed of the status of your credentialing or re-credentialing application.
• Be notified of these rights.
Requests for Additional Information
If Fidelis receives information from an outside source that differs substantially from
information you have provided us, we will contact you directly as soon as the
discrepancy is noted and request your clarification in writing within 10 business days.
Appeals Process for Providers Terminated or Rejected from the Fidelis Provider
Network
A provider has the right to appeal a Quality and Peer Review Committee decision that
has negatively impacted the provider. Fidelis complies with all state and federal
mandates with respect to appeals for providers terminated or rejected from the Fidelis
Provider Network. Fidelis notifies the provider in writing of the reason for the denial,
suspension and termination. Terminated or rejected providers may submit a request for
an appeal as outlined in the letter of rejection/termination sent by Fidelis. In addition, the
request for appeal must be received by Fidelis within ten (10) days of the date of the
rejection/termination letter. Upon receipt of the letter by Fidelis, the appeal is forwarded
to the Fidelis Appeals Committee for review and further processing Fidelis will ensure
that the majority of the hearing panel members are peers of the affected physician.
Credentialing - 5 -

Fidelis Agreement with the National Practitioner Data Bank (NPDB) and other
Authorities for Providers Terminated from the Fidelis Provider Network
As a requirement of the participation agreement between Fidelis and the National
Practitioner Data Bank (NPDB) pursuant to the Health Care Quality Improvement Act of
1986, as amended and other authorities per state and federal regulations, Fidelis is
obligated to report the termination of a Provider if the termination resulted from a quality
of care issue resulting in harm to a member’s health and/or welfare. Any provider
subject to this reporting requirement is notified via a letter of termination from Fidelis.
Confidentiality
Fidelis maintains the confidentiality of all information obtained about providers in the
credentialing and re-credentialing process as required by law. Providers will have
access to such information. Fidelis will not disclose confidential provider credentialing
and re-credentialing information to any person or entity except with the written
permission of the provider or as otherwise permitted or required by law.
Non-Discrimination
Fidelis will not discriminate against providers based on race, age, religion, creed, color,
national origin, ancestry, sex, sexual orientation, gender identity, physical or mental
handicap or serious medical condition, spousal affiliation, the types of procedures
performed, or the members in which the provider specializes in determining a provider’s
qualifications to provide health care services to Fidelis members. Selection of
participating providers will be primarily based on, but not limited to, cost and availability
of covered services and the quality of services performed by the providers.
Site Visits and Medical Record Audit Reviews
Office site visits and medical/treatment record keeping reviews may be conducted on all
high-volume specialists and high-volume behavioral healthcare providers and those
providers on whom grievances have been filed. High-volume is defined as
seeing/treating 20 or more Fidelis members per year as indicated by claims data.
No site visits will be conducted on the Primary Care Providers (PCPs) (physicians,
certified nurse providers, and certified physician assistants who practice in Family
Practice, General Practice and Internal Medicine) as their office practice is based at the
nursing facility.
Credentialing - 6 -

Medical/treatment record keeping reviews may be conducted on all Primary Care
Providers (PCPs) (physicians, certified nurse practitioners, and certified physician
assistants who practice in Family Practice, General Practice, Geriatrics and Internal
Medicine) with more than 20 members within the first 12 months of seeing/treating
members and then no less than every three (3) years after that for all Primary Care
Providers.
Clinical documentation audits will include assessments of chart organization,
appropriateness of clinical care and preventive health care, coordination of care and
completeness and comprehensiveness of documentation.
All site visits must meet the threshold requirements for Fidelis.
• If the threshold score is not met at the time of the visit, a Corrective Action Plan
will be initiated, and a re-audit will be conducted with six (6) months of the visit.
• If the re-audit does not produce a passing score, the provider will be presented to
the Quality and Peer Review Committees with a recommendation from
Credentialing to terminate.
A provider who relocates or opens an additional office site after being initially
credentialed must notify Fidelis 60 days prior to the move.
Delegated Credentialing
Fidelis offers a delegated credentialing option for large groups of health care providers.
Fidelis delegates the credentialing function to groups that meet Fidelis and National
Committee for Quality Assurance (NCQA) standards and state and federal law. The
decision by Fidelis to delegate the credentialing function results from a review of the
group’s credentialing policies and procedures and an on-site audit of the group’s
credentialing files. The Fidelis Credentialing Committee reviews the resulting
delegation report and makes a determination to approve, defer or grant provisional
delegated status for the group. If provisional status is granted, this is followed by a
reassessment within a specified period of time and a final decision to approve or defer.
Groups granted delegated status are required to sign a delegated credentialing
agreement with Fidelis.
Credentialing - 7 -

Re-credentialing
• Providers: Fidelis re-credentials providers on a set schedule in accordance with
state and federal law and national accreditation standards. At a minimum of every
36 months, a re-credentialing application will be sent to the provider. Fidelis will
identify and evaluate any changes in the provider’s licensure, clinical privileges,
training, experience, current competence, or health status that may affect the
provider’s ability to perform the services they are providing to Fidelis Members. Recredentialing
activities may also be triggered as a result of quality investigations or
information received from state and/or federal agencies.
• Delegated Re-credentialing: On an annual basis, Fidelis conducts group audits and
may delegate the re-credentialing function to delegated groups using the same
process used to initially delegate the credentialing function.
All Primary Care Providers, OB/GYN providers and identified high-volume specialists
and high-volume behavioral health care providers are required to have performance
monitors considered by the Quality and Peer Review Committees at the time of Recredentialing.
Provider specific information considered at Re-credentialing will be:
• Quality activities
• Member complaints
• Utilization patterns
• Quality of Care issues
• Fraud and Abuse
• Pharmacy and Therapeutics patterns
• Member satisfaction survey results (optional)
Credentialing - 8 -

Eligibility
You may verify the eligibility of a Fidelis member in one of the following ways:
The Fidelis Identification Card
Each Fidelis Member is issued a Member Identification Card within 7 days of
enrollment. Members are instructed to present the Fidelis ID card as verification of
insurance when seeking health care services. The Member will also receive a letter that
will have the Member’s name, their Member identification number or “ID number”, and any
applicable cost sharing information. This card identifies the member as a Fidelis
SecureCare member.
Members may select from any of a number of health plans that Fidelis offers, and
benefits vary by plan.
The I.D. card does not guarantee eligibility. It is for identification purposes only.
Eligibility must be verified at each visit. Failure to verify eligibility may result in nonpayment
of claims.
Eligibility - 1 -

Customer Service (1-877-372-8085)
To determine eligibility when the Member does not have an identification card, you may
call Customer Service for verification. Members may have a copy of their enrollment
form as interim proof of Membership until a card is issued and mailed.
You will need the following information to verify member enrollment:
• Full name
• Date of Birth
• HICN (Medicare ID)
Online
Eligibility may also be verified by referencing a Medicare eligibility system or by using
the Fidelis Provider Portal at www.fidelissc.com.
The Fidelis Provider Portal now allows you to access Member Eligibility and Claims
Information online, 24 hours a day, seven days a week.
Logging In
To access the Provider Portal, go to the Fidelis Secure Care website and click in the link
for the Provider Portal.
http://www.fidelissc.com/home/index.asp
Once you reach the provider portal, you will see the Log In Screen:
Eligibility - 2 -

You can receive your Username and Password with the help of the Fidelis staff, or by
clicking the link under the “Not registered for the provider portal” section.
Once logged in, you may select from the menu of options at the top of the screen.
Member Eligibility Look-Up
You can access member eligibility by entering either the Subscriber ID or the member’s
First Name, Last Name and Date of Birth.
Eligibility - 3 -

When the member is retrieved, you will see all of the information required to determine
eligibility.
You may also select the option to view any claims related to the member.
Eligibility - 4 -

Please check
which plan you
wish to enroll in:
Fidelis Secure Comfort – 005
Fidelis Secure Comfort Plus – 006
Fidelis Secure Independence – 007
PERSONAL INFORMATION
Mr. Mrs. Ms. Last Name
First Name
Initial
Date of Birth Sex: Male Female Social Security #
Permanent Residence Street Address (No P.O. Box) Apt/Room #
City
Email Address (optional)
Mailing Address (if different from above) Street Address
City
State
Telephone
Apt #
State
Zip
Zip
Emergency Contact Relationship to You Telephone
Street Address
City
Apt #
State
Zip
MEDICARE HEALTH INSURANCE INFORMATION
Please take out your Medicare card to complete this section. You must have Medicare Part A and Part B to join a Medicare
Advantage Plan. Please fill in these blanks so they match your red, white and blue Medicare card, OR attach a copy of your
Medicare card or your letter from the Social Security Administration or Railroad Retirement Board.
Name:
Is Entitled to
Sex: Male Female Hospital (Part A)
Medicare Claim Number: __ __ __ - __ __ - __ __ __ __ __ Medical (Part B)
VERIFICATION INFORMATION
1. Do you have End Stage Renal Disease (ESRD)? If you answered “yes” to this question and you do not need
regular dialysis any more, or have had a successful kidney transplant, please attach a note or record from your
doctor showing you do not need dialysis or have had a successful kidney transplant.
2. Some individuals may have other drug coverage, including private insurance, TRICARE, Federal employee
health benefits coverage, VA benefits, or State pharmaceutical assistance programs. Will you have other
prescription drug coverage in addition to Fidelis SecureCare?
If “yes,” please list your other coverage and your identification (ID) numbers for this group:
Name of other coverage:
ID # for this coverage: Group # for this coverage:
3. Are you a resident in a long term care facility, such as a nursing home? If “yes,” please provide the
following information:
Name of Institution:
Admission Date to Institution:
Telephone:
4. Are you enrolled in your State Medicaid Program?
If yes, please provide your Medicaid Number:
5. Do you or your spouse work?
Effective Date:
________________
________________
6. Since you became eligible for Medicare, have you had any prescription drug coverage or any insurance that
included drugs? If you answer no, your premium may be increased because of a late enrollment penalty. If you
answer yes, we may ask you for proof that your previous prescription drug coverage was at least as good as
Medicare’s standard prescription drug coverage (creditable prescription drug coverage). You can send copies of
your proof with this form or you can wait until we ask for it. You don’t have to send your proof to enroll. However,
if we ask for your proof and you don’t provide it, your premium may be increased because of a late enrollment
penalty. For more information about the late enrollment penalty, visit www.medicare.gov or call 1-800-MEDICARE.
7. Please choose the name of a Primary Care Physician (PCP), clinic or health center:
Name: Specialty: Telephone:
Your Signature (Please read reverse for details before signing.)
Today’s Date
If you are an authorized representative, you must provide the following information: OFFICE USE ONLY
Name:
Telephone:
Address:
Relationship to Enrollee:
ICEP/IEP:
If you qualify for extra help with your Medicare prescription drug coverage
Plan ID #:
costs, Medicare may cover all or some portion of your plan premium. Please OEP:
answer verification question 8 if you want the remaining premium, if there is Effective Date of Coverage:
any, deducted from your monthly check.
AEP:
8. Would you like the premium for this plan deducted from your SSA
monthly benefit check? State:
Yes No
H5575, H2323, H5980 08_45 a MRT CMS Approved 10/04/07
Name of staff member (if assisted in enrollment)
SEP (type):
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

YOUR PLAN PREMIUM OPTION
You can have the monthly premium for this Medicare drug plan automatically deducted from your Social Security
check. If you don’t choose this option, we will send you a bill each month which you can pay by mail or by
Electronic Funds Transfer (EFT).
STOP – PLEASE READ THIS IMPORTANT INFORMATION
If you currently have health coverage from an employer or union, joining Fidelis SecureCare could affect
your employer or union health benefits. If you have health coverage from an employer or union, joining Fidelis
SecureCare may change how your current coverage works. Read the communications your employer or union sends you.
If you have questions, visit their website, or contact the office listed in their communications. If there is no information
on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.
PLEASE READ
By completing this enrollment application, I agree to the following:
Fidelis SecureCare is a Medicare Advantage plan and I will need to keep my Parts A and B. I can only be in one
Medicare Advantage plan at a time. It is my responsibility to inform you of any prescription drug coverage that I have
or may get in the future. Enrollment in this plan is only at certain times of the year. I may leave this plan only at certain
times of the year, or under certain special circumstances, by sending a request to Fidelis SecureCare or by calling
1-800-Medicare. TTY users should call 1-877-486-2048.
Fidelis SecureCare serves a specific service area. If I move out of the area that Fidelis SecureCare serves, I need to
notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of Fidelis SecureCare, I have
the right to appeal plan decisions about payment or services if I disagree. I will read the Evidence of Coverage
document from Fidelis SecureCare when I receive it to know which rules I must follow in order to receive coverage
with this Medicare Advantage plan.
I understand that beginning on the date Fidelis SecureCare coverage begins, I must get all of my health care from Fidelis
SecureCare, with the exception of emergency or urgently needed services or out-of-area dialysis services. Medicare
beneficiaries are generally not covered under Medicare while out of the country except for limited coverage in Canada
and Mexico. Services authorized by Fidelis SecureCare and other services contained in my Fidelis SecureCare Evidence
of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without
authorization, NEITHER MEDICARE NOR FIDELIS SECURECARE WILL PAY FOR THE SERVICES.
The plan’s contract with CMS is renewed annually. Availability of coverage beyond the end of the current contract year
is not guaranteed. Benefits may vary by county and plan.
The person that is discussing plan options with you is either employed by or contracted with Fidelis SecureCare. The
person may be compensated based on your enrollment in a plan.
RELEASE OF INFORMATION
By joining this Medicare heath plan, I acknowledge that the Medicare health plan will release my information to
Medicare and other plans as is necessary for treatment, payment and health care operations. The information on this
enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on
this form, I will be disenrolled from the plan.
I understand that my signature (or the signature of the person authorized to act on behalf of the individual under the laws
of the State where the individual resides) on this application means that I have read and understand the contents of this
application. If signed by an authorized individual (as described above), this signature certifies that: 1) this person is
authorized under State law to complete this enrollment and 2) documentation of this authority is available upon request
by Fidelis SecureCare or by Medicare.

Quality Program
Purpose
The purpose of the Quality Improvement (QI) Program is to promote and continuously
improve the quality of clinical care (medical and behavioral health) and service that is
provided by facilities, physicians, and other providers to our members. Integral to the QI
program is a commitment to provide appropriate care and resources to our members in
the most appropriate setting with minimal disruption to their routines and that of their
families and other caregivers.
Goals
• To promulgate the principles and commitment of continuous quality improvement
throughout the health plan, provider network, delegated entities, and contracted
vendors.
• To develop a comprehensive, meaningful, and soundly executed Quality
Improvement strategy.
• To integrate a quality improvement approach in all aspects of the health plan
management.
• To implement a standardized and comprehensive quality improvement program
which will address and be responsive to the health needs of the member
population.
• To create an effective quality improvement program that allows for early
detection and resolution to issues that affect the plans members, families, or
providers.
• To measure, monitor, and continually improve performance of medical care in
key aspects of clinical and service quality for members, providers, and
customers.
• To demonstrate improved outcomes in medical and behavioral health care and
service to its members.
• To foster a supportive environment to assist providers and providers to improve
the safety of their practice.
• To ensure that all state and federal regulatory requirements are met and that
policies and procedures support the requirements.
Quality Program - 1 -

Targeted Quality Programs
Fidelis is committed to ensuring the highest level of clinical care for our members. We
understand that, because residents of long term communities often have a higher
number of co-morbidities than any other group, our approach to their care must address
all of the disease states and conditions present in each individual.
To meet the challenge, our comprehensive medical panel of family practice, geriatric
and internal medicine physicians; pharmacists; nurses; psychologists; psychiatrists and
social workers has developed clinical programs that incorporate the latest research data
and best medical practices.
A description of Fidelis’ targeted quality programs follows:
• Medication Therapy Management
• Behavioral Health Services
Medication Therapy Management Program
Residents of a long-term care community utilize more medications for more disease
states and conditions than any other group. Our Medication Therapy Management
(MTM) program was developed to maximize the clinical benefits of drug treatment. The
program is designed to monitor for various drug interactions, disease interactions, and
age interactions, contraindications, prescribed drug toxicities, overdosing and
appropriateness of drugs in a continuous effort to improve the Member’s outcome.
Members are enrolled in the MTM program as their disease states/conditions make
them eligible.
This clinical program offers a multidimensional approach to medication management
that incorporates medical and lab value data to improve the Member’s health. Our nurse
case management team plays a vital role in administering the program, constantly
providing important clinical input into the medication management process to maximize
outcomes.
Our focused approach has made this clinical program key in improving the overall care
of the Member.
Members become eligible for the Fidelis Medication Therapy Management Program as
their medical conditions and prescription histories warrant. Enrollment is automatic.
Members may elect to opt-out of the Program if they do not wish to participate.
Quality Program - 2 -

Behavior Health Services Program (May not be available in all markets)
Fidelis believes in a strong proactive behavioral health service delivery system to
ensure that the needs of our resident membership and facility customers are met.
In cases where a facility has a relationship with a consulting psychiatrist or group,
Fidelis will offer programs to complement and supplement these services. Fidelis has
contracts to provide a full range of behavioral and psychiatric services to the facility.
Each facility will have a Behavioral Case Manager who will work closely with the staff to
facilitate and coordinate behavioral health services.
Inpatient Care within a structured 24-hour hospital program offering a full range of
psychiatric, therapeutic and nursing services. Fidelis collaborates and coordinates
services with several local hospitals when an inpatient stay is necessary to stabilize a
resident. Procedures and protocols are available to directly facilitate both voluntary and
involuntary hospitalizations. A 24-hour hotline has been established to assist your
facility when inpatient services are necessary.
Step-Down Care has been designed to provide intensive behavioral healthcare
services for those individuals with psychiatric and behavioral disturbances that do not
meet the criteria for inpatient care but still present a significant disruption in the facility
and/or a high risk of resident-to-resident violence.
Intensive On-Site Behavioral Care is available 24 hours a day seven days a week to
address a resident’s acute psychiatric distress. The Fidelis clinician will assist the
facility in developing, implementing a treatment plan, and training your care staff in its
use immediately. Follow-up services will continue until we are sure that the resident has
been adequately stabilized. When necessary, Fidelis will authorize 1:1 staffing to
ensure the safety of the resident and staff at the facility while the intensive services are
initiated and implemented.
Routine Mental Health Care is regularly provided on a schedule that meets the needs
of the facility and its residential population. The assigned Behavioral Case Manager will
work closely to identify the need for supplemental services to the current psychiatric
provider or regular direct services by a Fidelis approved provider group at your building.
Family Centered Services are offered as part of the Fidelis Behavioral Services
Program. Staff is available to provide educational presentations on a variety of topics
including Understanding Dementia, Facilitating Adjustment of the New Resident to the
Nursing Home, Depression, Caregiver Stress, and Understanding Psychiatric
Medications. In addition, Fidelis staff can assist with developing and/or participating in a
family support group to assist family members in exploring and coping with their own
feelings and frustrations regarding their “loved ones” condition and placement in a
facility. Staff is available to provide family therapy to residents and their family
members.
Quality Program - 3 -

Referral and Prior Authorization Procedures
Prior Authorizations
Prior authorization is designed to promote the utilization of medically necessary
services, to prevent unanticipated denials of coverage, to ensure that participating
providers are utilized, and that all services are provided at the appropriate level of care
for the member’s needs.
Please see Appendix 3 for a summary of services that require referral and prior
authorization. Criteria for authorizing skilled nursing intervention are also included in
Appendix 3.
Member benefit plans change annually, so we advise that providers review
benefit and authorization requirements or call local Fidelis resources prior to
providing services.
How to Obtain Prior Authorization
Fidelis Providers can call or fax all prior authorization requests into the Utilization
Management (UM) Department Care Coordinator 24 hours per day, 7 days per week
utilizing the Service Request form.
Telephone: (877) 372-8080
Fax: (877) 372-8083
The following information will be required for Prior authorization processing:
• Member Name
• Date of Birth and/or Social Security Number
• Facility Name
• Requesting Provider
• Referral Provider
• Diagnosis
• Requested Service with CPT code(s) and ICD-9 code(s)
• Clinical Information for medical necessity including patient progress notes, labs
and imaging as appropriate
Referral and Prior Authorization - 1 -

Referrals for Specialty Care
The primary care physician (PCP) initiates and coordinates the referral management
process to ensure that appropriate care is provided when medically necessary.
• The PCP can authorize an initial referral to a specialist in the Fidelis network
indicating the specific services to be provided to the member. When referring a
member to a specialist, the Primary Care Physician (PCP), Nurse Practitioner
(NP) and/or Physician Assistant (PA) will make sure all applicable clinical notes,
tests and other consultative reports related to the medical condition for which the
member is being referred will be faxed or mailed to the specialist office prior to
the member’s appointment date.
• The PCP will retain a copy of the referral form for his/her files or if the referral is
called into the UM Department, the PCP will note that information in the
member’s chart.
• The specialist must provide a report to the Member’s PCP within five (5) working
days of rendering care or as soon as possible, in the event that legitimate delays
result from lab tests, x-rays, pathology reports, etc.
• If further care is required beyond the scope of the original referral, the specialist
must contact the Member's PCP for an additional referral or authorization before
providing additional treatment. Follow up appointments with a specialist will
require Prior Authorization.
• If a specialist is consulted during an emergency room visit, a referral is not
required for providing that care; however, a referral is required for any follow-up
care provided after the emergency room visit.
• If a specialist is called in for consultation during an observation or in-patient
hospital stay, no referral is required for providing that care in the hospital.
However, for any follow-up care provided after that hospitalization, a referral from
the PCP is required.
• If a contracted specialist provides a service without a referral from the member’s
PCP or without prior authorization, the claim may be denied for payment.
• The UM Care Coordinator will schedule the appointment, arrange the
transportation, if needed, and provide a telephonic authorization followed by a
faxed authorization.
Referral and Prior Authorization - 2 -

Continued Coverage of Care with Terminated Providers
• Continuation of care with terminated providers is covered if a member is
undergoing an active course of treatment for an acute or serious chronic
condition.
• If a member is receiving specialized services or an active course of treatment
that should not be interrupted, the Care Manager (CM ) will authorize care and
services:
- Through the lesser of the current period of treatment or for up to 90
calendar days for ongoing active treatment of a chronic or acute medical
condition as long as the practitioner or provider agrees to provide on-going
care (i.e. chemotherapy or facility specializing in vent dependent member)
and the termination of the contract was not related to a professional
review action. These time periods may be extended if Fidelis, in
conjunction with the terminated provider, determines that safe transfer is
not appropriate
- The CM will conduct ongoing referral management throughout the course
of treatment to prevent unauthorized services that would result in denial of
claims payment.
- If the need to alter the transition plan is identified and the provider is
unwilling to transition the member back into the network, the CM will
forward the case to the Medical Director or designee who will make the
final determination.
• If the termination of the provider is a result of a professional review action, the
CM will work with the member or member’s representative to identify a new Care
Team, specialist or provider, and facilitate and coordinate the transitioning of the
member’s care immediately.
Referrals to Non-Participating Providers or Non-Contracted Facilities In-Area
Except in true emergencies, Fidelis provides coverage for only those services rendered
by contracted providers and facilities. The exceptions are:
• Fidelis is notified, approves and authorizes the referral in advance. In these
instances, the UM Department will issue an authorization for the services to be
provided. Prior approval must be obtained by the PCP/Provider recommending
an out-of plan referral before arrangements have been made for those services.
• The member’s medical needs require specialized or unique services available
only through a non-contracted provider or facility. In this case, Fidelis will assist
the referring Provider in identifying specialists or facilities with the needed
capabilities. Fidelis must authorize any such referral.
Referral and Prior Authorization - 3 -

Out-of-Area Outpatient Authorization
Members are sometimes directed from an out-of-area physician to return to the out-ofarea
physician for a non-urgent, non-emergent follow-up visit. Members must be
educated that such follow-up care is not covered unless authorized. Refer members to
their Fidelis Evidence of Coverage (EOC). In these specific situations, the Fidelis
Medical Director will be contacted to intervene and make applicable evaluations.
Out-of-Area Inpatient Authorization
Fidelis provides coverage to members if they require emergency or urgently needed
services, as well as any services needed subsequently to ensure that they remain
stabilized from the time a non-contracted medical provider or facility requests
authorization from Fidelis until one of the following occurs:
• The member is discharged.
• The contracting medical provider arrives and assumes responsibility for the
member’s care.
• The non-contracting medical provider and Fidelis agree to other arrangements.
In some cases, members may be directed from an out-of-area physician to return to the
out-of-area physician for a follow-up visit if prior approval is obtained by the Fidelis UM
Department.
Referral and Prior Authorization - 4 -

Denials and Letter Issuance
Denials related to medical necessity are made by licensed physicians or behavioral
health care providers. The Medical Director or licensed physician designee will review
and sign the denial based on medical necessity. Providers will have the opportunity to
discuss UM denial decisions with the Fidelis medical director, physician or behavioral
health provider.
Notification letters may include:
• The specific reason for the denial
• The alternative plan of treatment and provider (if applicable)
• A reference to benefit provision (EOC language) or criterion on which the
decision was based
• Citation of the Medicare coverage rule, as determined locally by the carrier or
nationally or the accepted clinical standards used
• A description of appeal rights and the appeal process
• The telephone number for contacting Fidelis with questions and the Plan Member
Services phone number and address.
• Language that informs the provider that a physician or reviewing provider is
available to discuss the denial and the telephone number of the reviewer making
the denial decisions
Referral and Prior Authorization - 5 -

Definitions:
Fidelis SecureCare
Referral and Authorization Requirements for Covered Services
1. Referral: A request (written order) made by the member’s PCP to receive a specified medical service that is not performed by the PCP.
A referral does not require prior authorization.
2. Prior Authorization: A medical service that requires Health Plan approval prior to receiving the service in order for it to be covered.
3. Emergency Services: Services provided after the sudden onset of a medical condition that manifests itself by acute symptoms of
sufficient severity (including severe pain) that, in the absence of immediate medical attention, could reasonably be expected to result in: a)
placing the patient’s health in serious jeopardy; b) serious impairment to bodily functions; or c) serious dysfunction of any bodily organ or
part.
Covered Services Not Requiring Referral or Prior Authorization
Requirements:
• Must be performed by a Contracted/In-
Network FSC Provider
Covered Services Requiring Referral
Requirements:
• Must be performed by a Contracted/In-
Network FSC Provider
• Does not require prior authorization
• Requires a written order by the
PCP/NP/PA
• Requires notification to the Care
Coordinator via phone or faxed copy
of written order
Covered Services Requiring Prior Authorization
Requirements:
• Must be performed by a Contracted/In-
Network FSC Provider (if none
available, FSC will contract with outof-network
provider for service)
• Requires prior authorization by Health
Plan before service is rendered for
benefit interpretation and clinical
review of medical necessity
• Requires copy of specialist consult
faxed to FSC prior to further
authorization of outpatient specialist
visits
List of Services:
• Services performed on-site at the Nursing Facility, as follows (written PCP/NP/PA order as
required by state licensing requirements):
‣ Labs (i.e. WBC, CBC, urine/blood cultures)
‣ Basic X-rays (i.e., Skeletal/chest x-rays, Doppler studies done on site)
• Emergency Room Services
• Emergency Ambulance Services dispatched through 911 or its local equivalent
• Urgently Needed Services
• Routine, yearly OB/GYN care, including mammogram screening, pap, pelvic, breast exams
• Routine yearly physicals – colorectal and prostate screening
• Routine yearly retinal eye exams for members with diabetes
• Influenza (yearly), Pneumococcal and Hepatitis B vaccines
• Renal Dialysis Services when temporarily out of service area
List of Services:
• Initial Outpatient Specialist Consultations Only
‣ Includes all specialist consults done on-site at the NF and at the specialist office
‣ Pertains to all specialists not seen for > 1 year
List of Services:
• Inpatient Admissions and Continuing Stays
‣ Elective Hospitalizations
‣ Emergent Hospitalizations – notification required within 1 business day
‣ Skilled Nursing Facility
‣ Hospital Observation Stays
• Outpatient Surgery
• Outpatient Specialist Visits (after initial consult)
• Services provided by non-contracted provider
• Major Diagnostic Tests (i.e. MRI, CT, Endoscopies, Angiography)
• All Part B Therapy Services – Evaluation included (PT/OT/ST)
• DME (outside of what NF is required to provide per State Medicaid Regulations)
• Orthotics and Prosthetics
• Wound and Ostomy Supplies
• Platelet Gel Wound Care Services
• Respiratory Supplies
• Home Health Care
‣ Includes IV insertion services performed by vendor
• Escort Services
• Sitter Services
• Transportation, except 911
‣ Elective (non-emergent) transportation
‣ All air ambulance transfers
• Dental Services
• Vision Services (exception is retinal eye exams for members with diabetes)
• Hearing Services
• Cosmetic Surgery/Procedures
Fidelis SecureCare
3/5/04
Not to be reproduced without permission

Fidelis SecureCare
Criteria for Authorizing Part A Skilled Interventions
General Criteria
1. Prior Authorization required for all Part A Skilled Nursing and Therapy Services.
2. Decisions based on medical necessity.
3. Documentation describing identified skilled needs and services present in medical record.
4. Services required on a daily basis.
5. Services necessitate skills of a trained and licensed professional.
6. Location of care based on safety and availability of required resources to administer services.
7. Services ordered by the physician.
8. Initial Authorization Period begins the day services start.
9. Members must make significant functional improvement towards their maximum potential for coverage to continue beyond initial
authorization period. Coverage determinations beyond the initial authorization period must be reviewed/approved by the health plan utilization
department.
‣ Members receiving skilled nursing interventions evaluated daily by FSC CM.
‣ Members receiving skilled therapy interventions evaluated at least weekly by FSC CM with input from the primary care and therapy
providers.
For this to be skilled…
…the following requirements and/or restrictions apply; exceptions
must be approved by utilization management department.
Initial Authorization
Period
Observation and
Assessment
(Attachment A)
Without Antecedent
Hospitalization
(3 day qualifying hospital
stay not required)
• Documented evidence of a significant change in baseline condition
that requires the following interventions outlined on Attachment A:
‣ Assessment/Monitoring of at least 2 parameters a minimum of
1X/shift.
‣ Monitoring response/titrating dose of medication over 24-48
hours.
‣ Diagnostic testing ordered and reported to the PCT; appropriate
follow-up interventions and adjustments to the plan of care
made in response.
Following Hospital Stay • Limited to post inpatient admissions and condition must require the
interventions outlined on Attachment A as noted immediately above.
Colostomy/Ileostomy
Care
• Limited to new stomas; focus on teaching care management
procedures to staff, as needed
Up to 3 days
Up to 5 days
Up to 5 days
IM Injections • Must be given more than 1 time per day Therapy duration
Specific Criteria
Skilled Nursing Services
Treatment
Interventions
IV Administration
• Medication therapy, e.g., antibiotics Therapy duration
• Hydration therapy Therapy duration
• TPN therapy; focus on teaching care management procedures to staff, Up to 10 days
as needed
• Limited to new PEG Tube feedings requiring stabilization:
Up to 7 days
PEG Tube Care
‣ Caloric count, formula and rate of administration have not
stabilized or,
‣ Enteral feeding has been initiated within the past 1-4 days
Suprapubic Catheter • Limited to sterile irrigation, if daily Therapy duration
Care
Tracheostomy Care/ • Limited to newly inserted trachs Up to 7 days
Naso-pharyngeal
Aspiration
Ventilator Dependency • Limited to new ventilator dependency Up to 7 days
Skilled
Therapy
Services
Wound Care
PT
OT
ST
• Stage 3 and 4 pressure ulcers; are not chronic and require:
‣ Debridement at least daily
‣ Sterile dressing changes at least daily
‣ Application of dressings involving prescription medications and
aseptic technique at least daily
• Complicated post-surgical or vascular lesions requiring a minimum of
daily dressing changes
• Two or more therapy modalities required for a minimum of at least I
hour per day (combined), 5 days per week plus one skilled nursing
modality
• Documentation of an acute change in condition that causes
deterioration in prior functional status
• Shows an ability to tolerate and meaningfully participate in therapy
• Documented progress toward goals
Fidelis SecureCare
Not to be reproduced without permission
2/10/08 Final
Therapy duration
Up to 7 days

Fidelis SecureCare
Criteria for Authorizing Part B Therapy Interventions
General Criteria
1. A referral is required for the first initial evaluation and 4 treatment visits.
2. Prior Authorization is required for all therapy services after the first initial evaluation and 4 visits have been completed.
3. Decisions based on medical necessity.
4. Documentation describing identified need for therapy services present in medical record.
5. Therapy services required on an intermittent basis (i.e. 3x/week for 2 weeks, 5x/week for 2 weeks).
6. Therapy services necessitate skills of a trained and licensed therapist.
7. Location of care based on safety and availability of required resources to administer services.
8. Therapy services must be ordered by the physician.
9. Members must make significant functional improvement towards their maximum potential for coverage to continue beyond
initial authorization period. Coverage determinations beyond the initial authorization period must be reviewed/approved by the
health plan utilization department.
‣ Members receiving skilled therapy interventions evaluated at least weekly by FSC CM with input from the primary care and therapy
providers.
Specific Criteria
For this to be approved…
Part B
Therapy
Services
PT
OT
ST
…the following requirements and/or restrictions apply;
exceptions must be approved by utilization management
department.
• Documentation of an acute change in condition that causes
deterioration in prior functional status
• Shows an ability to tolerate and meaningfully participate in
therapy
• Documented progress toward goals
• Member must not have reached therapy cap for the year*
‣ $1810 for PT/ST per member per year
‣ $1810 for OT per member per year
Initial
Authorization
Period
Up to 14 days
to include the
initial evaluation
and 4 visits
*If cap reached, member must meet criteria for therapy exceptions per CMS.
Fidelis SecureCare
Not to be reproduced without permission
2/8/08 Final

Referral Date:
SERVICE REQUEST FORM
Referral Type: Routine Urgent/Emergent (Same Day)
Member Name: DOB: Member ID #:
Facility Name:
Unit/Room Number/Name:
Facility Phone Number:
( ) -
Facility/Nurse Fax Number:
( ) -
Requesting Provider: PCP Midlevel Other (If other, name and specialty _______________________)
Mode of Transportation: Wheelchair Stretcher Ht:______ Wt: ______
Attendant: Yes No Responsible Party Notified Yes No Will Accompany Yes No Will Meet Yes No
Responsible Party Name:___________________________________
Phone Number:_________________________________
If yes, describe (special instructions, dates, times, etc.) ____________________________________________________________
Diagnosis/Severity of Illness: _______________________________________________________________________________
Requested Service(s): _____________________________________________________________________________________
Requested Provider: ______________________________________________________________________________________
Clinical Information: _____________________________________________________________________________________
For Internal Use Only: Approved Denied Modified
Date Processing Completed: __________
Authorization/Referral Number: _________________________
Transport Authorization Number: ________________________
Escort Authorization: __________________________________
Explanations/Comments: ___________________________________________________________________
________________________________________________________________________________________
_________________________________________________________________________________
Date and Time of Appt: _________________________
Address: _______________________________
Phone: ________________________
Fax: ________________________________
Transportation by: ___________________________ Time of Pick-up at Nursing Facility: _______________
Utilization Management Department: Phone No. 1-877-372-8080 Fax No. 1-877-372-8083

Billing and Payment
Claims
To submit a paper claim
Send claims to Fidelis at the following address:
Fidelis SecureCare
PO Box 3597
Scranton, PA 18505
To submit an electronic claim
If you presently submit your claims through an electronic clearinghouse, you may continue
to do so. Fidelis uses Emdeon as its clearinghouse for electronic claims. To set up
electronic claim submission with Fidelis please contact Emdeon at the number below.
Emdeon Business Services EDI solutions at 866-369-8805
Fidelis Payor ID is #77054
Fidelis Claim Payment Guidelines
• Fidelis will pay “Clean” Claims for health services provided to a Member in
accordance with the contractual agreement. Clean claims are defined by the
Medicare Claim Processing Manual (IOM) Chapter 1.
• Fidelis will pay clean claims within a maximum of 30 days of when they are
received. Providers should allow for an additional 3-5 days for processing and
mailing of checks.
• Fidelis will automatically deny “Unclean” claims submitted by contracted providers.
• Except as noted in the member’s annual benefit plan, Fidelis will follow Medicare
guidelines for claim adjudication and payment.
Billing and Payment - 1 -

Remittance Advice (RA)
Payments received from Fidelis will include multiple claims for multiple members who
received services from the physician/provider. Each check will be accompanied by an
RA. The RA may include any of the following:
• Members / claims to which the RA applies
• Submitted charges
• Contractual allowances
• Co-pays and deductibles
• Amount paid
• Denials and reason for denial
Provider Billing and Collecting Requirements
• Unless otherwise specified in the Fidelis contract, Fidelis providers must file
claims with the plan within forty five (45) days of the date of service or from the
date of notice of benefit determination rendered by a third party. Fidelis will not
be required to pay claims submitted after 180 days.
• Physicians and other health care providers should submit claims for health services
to Fidelis using the appropriate claim form (CMS 1500 Claim Form for outpatient
services; UB04 Claim Form for in-patient services).
• The physicians /other health care providers cannot bill the Member for covered
health services provided if the physician /other health care provider failed to
submit a claim.
• The Member cannot be balance billed for services covered under the contractual
agreement at a predetermined contracted rate.
• If there are any co-payments identified, the co-payment should be either billed to
the member’s secondary insurance or collected directly from the member if the
member does not have any secondary insurance.
• If a claim is filed within the time period allowed and the service is a Fidelis
liability, the claim must be paid by Fidelis even if the contract between the
provider and Fidelis is no longer in effect; or if the Member has terminated his/her
Fidelis membership, provided that the Member's eligibility was effective at the
time that the service(s) were rendered and that the service was a covered benefit
through Fidelis.
Billing and Payment - 2 -

Appealing a Claims Payment or Denial
(Note: This process should not be used for Appealing Services that were denied)
Providers needing adjustments on claims that were previously paid or denied in error
may contact the Fidelis Customer Service Department at 1-877-372-8085 or; submit
a copy of the claim along with a written request containing the following:
• Provider name, Provider ID number, and Provider billing address
• Claim number of original claim (from Provider Remittance Advice).
• Member name
• Member ID number
• Date(s) of service
• Indicate telephone number and name of contact person in your office if we have
questions or need additional information
Claims Information Online
The Fidelis Provider Portal now allows you to access Member Eligibility and Claims
Information online, 24 hours a day, seven days a week.
Logging In
To access the Provider Portal, go to the Fidelis Secure Care website and click in the link
for the Provider Portal.
http://www.fidelissc.com/home/index.asp
Once you reach the provider portal, you will see the Log In Screen:
You can receive your Username and Password with the help of the Fidelis staff, or by
clicking the link under the “Not registered for the provider portal” section.
Billing and Payment - 3 -

Claims Look-Up
Once logged in, you may select from the menu of options at the top of the screen.
Billing and Payment - 4 -

You can research claims status and history by member information or claims
information.
You may also go directly to claims history from the member eligibility screen. Please
see the Eligibility section.
Once you have entered your search criteria, the list of possible matches will appear.
Double click on the claim in question to review claims details.
Billing and Payment - 5 -

FIDELIS SECURECARE GUIDELINE FOR
STANDING ORDER INFLUENZA (FLU) VACCINATION
OF RESIDENTS, STAFF, AND VOLUNTEERS
I. GUIDELINE
The Advisory Committee on Immunization Practices recommends vaccinating
persons who are at high risk for serious complications from influenza, including
those 50 years of age and older, who are residents of nursing homes. The
Association for Professionals in Infection Control, the Centers for Disease
Control and Prevention, the Immunization Action Coalition and the National
Foundation for Infectious Diseases all recommend that healthcare workers be
immunized as well, because they work in close contact with residents.
Recognizing the major impact and mortality of influenza disease on residents of
nursing homes, and the effectiveness of vaccines in reducing healthcare costs
and preventing illness, hospitalization and death, Fidelis SecureCare has
adopted the following policy statements:
(1) All residents, staff and volunteers of our facility should receive the influenza
vaccine annually, unless there is a documented contraindication.
(2) These vaccines may be administered by any appropriately qualified personnel
who are following our facility procedures, without the need for an individual
physician evaluation or order.
Every year, a log documenting how many people (residents, staff, and
volunteers) received the vaccine, as well as the number who refused and did not
receive the vaccination, will be sent to the Fidelis SecureCare QIC for reporting
of immunization status of NH residents, staff and volunteers.
II.
ADMINISTRATION PROCEDURE
A. Current and newly admitted residents, all staff, and volunteers will be offered
the influenza vaccine from September of each year through the end of March
the following year.
B. Each resident’s, staff’s, and volunteer’s immunization status will be
determined prior to vaccination, and will be documented in either the
resident’s medical record or staff/volunteer’s immunization record.
C. Informed consent in the form of a discussion regarding risks and benefits of
vaccination will occur prior to vaccination. (In the case of residents, this may
- 1 -

e with their authorized representative when appropriate. If signed consent is
required according to state law, it would occur at this procedural step.)
D. Residents, staff, and volunteers may refuse vaccination. Vaccination refusal
and reasons why (e.g., allergic, contraindicated, did not want vaccine, etc.)
should be documented by the facility.
E. Ensure that the current year’s influenza vaccine is used. Discard old vaccine.
F. Vaccine will be administered according to the Standing Order: Administer
0.5ml IM of influenza vaccine to all residents, staff, and volunteers who meet
vaccination criteria. Any large muscle may be used as an injection site (e.g.,
deltoid or quadriceps).
G. Vaccine should not be administered to residents, staff, or volunteers who are
allergic to chicken eggs, the vaccine, or any of the vaccine’s components.
H. Check body temperature before giving the vaccine. Any changes in baseline
or anyone who is febrile (above baseline) or being treated for an infection will
not receive the vaccine until he/she has recovered.
I. Document the administration of the vaccine, including injection site, in the
medical record (e.g., medication sheet, nurses’ notes, immunization record, or
progress sheet) or staff/volunteer immunization record. Submit immunization
information to state entity, as required.
J. The vaccine may be given at the same time or at any time before or after a
dose of pneumococcal vaccine (PPV23). There are no minimal interval
requirements between doses of the flu and PPV. If given at the same time as
the PPV, the influenza vaccine must be given in a separate body site, using a
different syringe.
K. An epinephrine injection 1:1000 will be kept on hand for severe allergic
reactions (i.e., anaphylaxis). Should anaphylaxis occur, a dose of 0.5cc
epinephrine 1:1000 SC will be given, standing emergency treatment
procedures followed, and the event reported to the Vaccine Adverse Events
Reporting System at 1-800-822-7967 or at http://vaers.hhs.gov.
Medical Director
Date
- 2 -

FIDELIS SECURECARE GUIDELINE FOR
INFLUENZA (FLU) VACCINATION
OF RESIDENTS, STAFF, AND VOLUNTEERS
I. GUIDELINE
The Advisory Committee on Immunization Practices recommends vaccinating
persons who are at high risk for serious complications from influenza, including
those 50 years of age and ALL older who are residents of nursing homes. The
Association for Professionals in Infection Control, the Centers for Disease
Control and Prevention, the Immunization Action Coalition and the National
Foundation for Infectious Diseases all recommend that healthcare workers be
immunized as well, because they work in close contact with residents.
Recognizing the major impact and mortality of influenza on residents of nursing
homes and the effectiveness of vaccines in reducing healthcare costs and
preventing illness, hospitalization and death, Fidelis SecureCare with the advice
of the Covering Physician/Medical Director, will offer the influenza vaccine yearly
to all residents, staff, and volunteers, unless contraindicated. Vaccination will be
offered from September of each year through the end of March the following
year.
Every year, a log documenting to whom the vaccine was offered and how many
people (residents, staff, and volunteers) received the vaccine, as well as those
who refused, will be sent to the Fidelis SecureCare QIC for reporting of
immunization status of NH residents, staff and volunteers.
II.
ADMINISTRATION PROCEDURE
A. Current and newly admitted residents, all staff, and volunteers will be offered
the influenza vaccine from September of each year through the end of March
the following year.
B. Each resident’s, staff’s, and volunteer’s immunization status will be
determined prior to vaccination and will be documented in either the
resident’s medical record or staff/volunteer’s immunization record.
C. Informed consent in the form of a discussion regarding risks and benefits of
vaccination will occur prior to vaccination. (In the case of residents, this may
be with their authorized representative when appropriate. If signed consent is
required according to state law, it would occur at this procedural step.)
D. Residents, staff, and volunteers may refuse vaccination. Vaccination refusal
and reasons why (e.g., allergic, contraindicated, did not want vaccine, etc.)
should be documented by the facility.
- 3 -

E. An order from the resident’s physician, nurse practitioner, or physician
assistant must be obtained. If difficult to obtain, an order from the medical
director should be obtained to prevent delay in vaccine administration.
F. Ensure that the current year’s influenza vaccine is used. Discard old vaccine.
G. Make sure that resident does not have contraindications, then administer the
influenza vaccine, as ordered.
H. Vaccine should not be administered to residents, staff, or volunteers who are
allergic to chicken eggs, the vaccine, or any of the vaccine’s components.
I. Check body temperature before giving the vaccine. Anyone who is febrile
(above baseline) or being treated for an infection will not receive the vaccine
until he/she has recovered.
J. Document the administration of the vaccine, including injection site, in the
medical record (e.g., medication sheet, nurses’ notes, immunization record, or
progress sheet) or staff/volunteer immunization record. Submit immunization
information to state entity, as required.
K. The vaccine may be given at the same time or at any time before or after a
dose of pneumococcal vaccine (PPV23). There are no minimal interval
requirements between doses of the flu and PPV. If given at the same time as
the PPV, the influenza vaccine must be given in a separate body site, using a
different syringe.
L. An epinephrine injection 1:1000 will be kept on hand for severe allergic
reactions (i.e., anaphylaxis). Should anaphylaxis occur, a dose of 0.5cc
epinephrine 1:1000 SC will be given, standing emergency treatment
procedures followed, and the event reported to the Vaccine Adverse Events
Reporting System at 1-800-822-7967 or at http://vaers.hhs.gov.
Medical Director
Date
- 4 -

FIDELIS SECURECARE GUIDELINE FOR
STANDING ORDER PNEUMOCOCCAL VACCINATION (PPV)
OF RESIDENTS
I. GUIDELINE
The Advisory Committee on Immunization Practices (ACIP) recommends
vaccinating persons at high risk for serious complications from pneumococcal
pneumonia, including those 65 years and older and all residents of nursing
homes.
Recognizing the major impact and mortality of pneumococcal disease on
residents of nursing homes, and the effectiveness of vaccines in reducing
healthcare costs and preventing illness, hospitalization and death, Fidelis
SecureCare has adopted the following policy statements:
(1) All residents of our facility should receive the pneumococcal vaccine
if they are 65 years of age or older; or younger than 65 years with
underlying conditions that are associated with increased susceptibility
to infection or increased risk for serious disease and its
complications.
(2) Re-vaccination with the pneumococcal vaccine if 5 or more years
have passed since the previous dose and the person was less than
65, however, who is now 65 or older, and/or is considered high risk
for developing pneumococcal infection.
(3) These vaccines may be administered by any appropriately qualified
personnel who are following our facility procedures without the need
for an individual physician evaluation or order.
Every year, a log documenting the number of residents who received the
vaccine, as well as the number who refused, will be sent to the Fidelis
SecureCare QIC responsible for reporting of immunization status of NH
residents.
II.
ADMINISTRATION PROCEDURE
A. Each resident’s pneumococcal immunization status will be determined upon
admission or soon afterwards, and will be documented in the resident’s
medical record. Current residents will have their immunization status
determined by reviewing available past and present medical records.
- 5 -

B. All residents with undocumented or unknown pneumococcal vaccination
status will be offered the vaccine.
C. Informed consent in the form of a discussion regarding risks and benefits of
vaccination will occur prior to vaccination. (This may be with the resident’s
authorized representative when appropriate. If signed consent were required
according to state law, it would occur at this procedural step.)
D. Residents may refuse vaccination. Vaccination refusal and reasons why (e.g.,
allergic, contraindicated, did not want vaccine, etc.) should be documented by
the facility.
E. Check to make sure that the current Pneumococcal Vaccine vials have not
expired. Discard old vaccine.
F. Vaccine will be administered according to the Standing Order: Administer
0.5ml IM or SC of Pneumococcal Vaccine (PPV23) to all residents who meet
vaccination criteria. Any large muscle may be used as an injection site, (e.g.,
deltoid or quadriceps).
G. Vaccine should not be administered to residents who are allergic to the
vaccine or any of its components.
H. Check resident’s body temperature before giving the vaccine. Any resident
who is febrile (above baseline) or being treated for an infection will not
receive the vaccine until he/she has recovered.
I. Document administration of vaccine, including injection site, in the medical
record (e.g., medication sheet, nurses’ notes, immunization record, or
progress sheet). Submit immunization information to state entity as required.
J. The vaccine may be given at the same time or at any time before or after a
dose of influenza vaccine. There are no minimal interval requirements
between doses of the flu and pneumococcal vaccines. If given at the same
time as the influenza vaccine, the pneumococcal vaccine must be given in a
separate body site, using a different syringe.
K. An epinephrine injection 1:1000 will be kept on hand for severe allergic
reactions (i.e., anaphylaxis). Should anaphylaxis occur, a dose of 0.5cc
epinephrine 1:1000 SC will be given, standing emergency treatment
procedures followed, and the event reported to the Vaccine Adverse Events
Reporting System at 1-800-822-7967 or at http://vaers.hhs.gov.
Medical Director
Date
- 6 -

FIDELIS SECURECARE GUIDELINE FOR
PNEUMOCOCCAL VACCINATION (PPV)
OF RESIDENTS
I. GUIDELINE
The Advisory Committee on Immunization Practices (ACIP) recommends
vaccinating persons who are at high risk for serious complications from
pneumococcal pneumonia, including those 65 years of age and older, as well as
all residents of nursing homes.
Fidelis SecureCare, with the advice of the Covering Physician/Medical Director,
will offer the pneumococcal pneumonia vaccination (PPV) to all residents who
meet immunization criteria and who cannot provide documentation of a previous
vaccination. Given that there is no risk in re-vaccination, those who are unsure or
do not know their vaccination status will be offered the vaccine.
Every year, a log documenting to whom the vaccine was offered and how many
residents received the vaccine, as well as the number who refused, will be sent
to the Fidelis SecureCare QIC responsible for reporting of immunization status of
NH residents.
II.
ADMINISTRATION PROCEDURE
A. Each resident’s pneumococcal immunization status will be determined upon
admission or soon afterwards, and will be documented in the resident’s
medical record. Current residents will have their immunization status
determined by reviewing available past and present medical records.
B. All residents without a documented history of immunization or with unknown
pneumococcal vaccination status will be offered the vaccine.
C. Informed consent in the form of a discussion regarding risks and benefits of
vaccination will occur prior to vaccination. (This may be with the resident’s
authorized representative when appropriate. If signed consent is required
according to state law, it would occur at this procedural step.)
D. Residents may refuse vaccination. Vaccination refusal and reasons why (e.g.,
allergic, contraindicated, did not want vaccine, etc.) should be documented by
the facility.
E. An order from the resident’s physician, nurse practitioner, or physician
assistant must be obtained. If difficult to obtain, an order from the medical
director should be obtained to prevent delay in vaccine administration.
- 7 -

F. Check to make sure that the current Pneumococcal Vaccine vials have not
expired. Discard old vaccine.
G. Make sure that resident does not have contraindications, then administer
recommended dosage for the pneumococcal vaccine (PPV23), as ordered.
H. Vaccine should not be administered to residents who are allergic to the
vaccine or any of its components.
I. Check resident’s body temperature before giving the vaccine. Any resident
who is febrile (above baseline) or being treated for an infection will not receive
the vaccine until he/she has recovered.
J. Document administration of vaccine, including injection site, in the medical
record (e.g., medication sheet, nurses’ notes, immunization record, or
progress sheet). Submit immunization information to state entity, as required.
K. The vaccine may be given at the same time or at any time before or after a
dose of influenza vaccine. There are no minimal interval requirements
between doses of the flu and pneumococcal vaccines. If given at the same
time as the flu vaccine, the pneumococcal vaccine must be given in a
separate body site using a different syringe.
L. An epinephrine injection 1:1000 will be kept on hand for severe allergic
reactions (i.e., anaphylaxis). Should anaphylaxis occur, a dose of 0.5cc
epinephrine 1:1000 SC will be given, standing emergency treatment
procedures followed, and the event reported to the Vaccine Adverse Events
Reporting System at 1-800-822-7967 or at http://vaers.hhs.gov.
Medical Director
Date
- 8 -

FIDELIS SECURECARE GUIDELINES FOR
ADVERSE REACTION TO VACCINATION
FOLLOWING IMMUNIZATION*
Because of possible hypersensitivity to vaccine components, persons administering
biologic products or serum should be prepared to recognize and treat allergic reactions,
including anaphylaxis. The necessary medications, equipment, and staff competent to
maintain the patency of the airway and to manage cardiovascular collapse must be
immediately available. Vaccine providers must be in close proximity to a telephone so
that emergency medical personnel can be summoned immediately, if necessary.
Whenever possible, residents should be observed for an allergic reaction for 15-20
minutes after receiving immunization(s).
I. Treatment for Syncope
Syncope may occur after vaccination. Personnel should be aware of presyncopal
manifestations and take appropriate measures to prevent injuries if
weakness, dizziness, or loss of consciousness occurs. The relatively rapid onset
of syncope in most cases suggests that having resident sit or lie down for 15
minutes after immunization could avert many syncopal episodes and secondary
injuries.
A. If resident becomes pale and/or feels faint:
- Have resident lie flat or sit with head between knees for several
minutes
- Observe resident until asymptomatic
- Notify attending physician of incident
B. If resident loses consciousness, but has a steady pulse, normal blood
pressure and respirations:
- Place resident flat on back with feet elevated
- Have resident rest in a quiet area and observe for 30 minutes after
regaining consciousness
- Notify attending physician of incident
- Continue to monitor vital signs
- If resident regains consciousness within three minutes, observe for
at least 30 minutes
- CALL FOR AMBULANCE if resident remains unconscious for more
than three minutes
- 9 -

C. If vital signs are abnormal (e.g., decreased BP,
decreased/increased/irregular pulse),
- Place resident flat on back with feet elevated.
- If indicated and you have a physician’s order, administer IV fluids.
- Notify attending physician (if you have not already done so).
- Continue to monitor vital signs:
i. If normal, observe for at least 30 minutes
ii. If abnormal, CALL FOR AMBULANCE
II.
Treatment of a local reaction
Soreness of the arm is the most common side effect associated with vaccination
and affects 30%-50% of individuals vaccinated. However, this rarely interferes
with the individual’s ability to conduct daily activities, and subsides in about 24-48
hours. Symptoms of local reaction may include mild pain, redness, pruritis, or
swelling at the injection site.
A. Apply ice to site
B. If indicated, administer PO acetaminophen or ibuprofen
C. If indicated, administer PO diphenhydramine or hydroxyzine
D. Notify attending physician of incident
E. If resident has local reaction and symptoms subside, observe for at least 30
minutes
III.
Treatment for mild to severe symptoms of anaphylaxis
Symptoms of mild systemic anaphylaxis may include pruritus, erythema, urticaria
and angioedema.
A. Administer epinephrine 1:1000 0.5cc SC. Epinephrine may be repeated every
five to 15 minutes, up to a maximum number of three times. If the resident’s
condition improves with this management and remains stable, a physician
may also recommend that the resident take an oral antihistamine for the next
24 hours
B. Notify attending physician of incident
C. If symptoms subside, observe for at least 30 minutes
D. If symptoms do not subside after appropriate administration of medications,
CALL FOR AMBULANCE.
- 10 -

IV.
Treatment for more severe or potentially life-threatening systemic
anaphylaxis
Symptoms of more severe or potentially life-threatening systemic anaphylaxis
may include severe bronchospasm, laryngeal edema, shock, and cardiovascular
collapse.
A. CALL FOR AMBULANCE
B. Maintenance of the airway and oxygen administration should be instituted
immediately
C. If resident is wheezing, has generalized hives or is in respiratory distress,
have him/her sit
D. If resident has low blood pressure or pulse is weak, have resident lie down on
back and elevate feet
E. If cardiac and/or respirator arrest occur, start CPR
F. Administer epinephrine 1:1000 0.5cc SC. Epinephrine may be repeated every
five to 15 minutes, up to a maximum number of three times
G. Notify attending physician of incident
V. Document all adverse events
A. Document administration of all emergency medications according to
established MAR procedures
B. Document vital signs and other relevant clinical information and all adverse
events in the resident’s medical record
C. Report adverse event(s) to the Vaccine Adverse Event Reporting System 1-
800-822-7967 or at http://www.vaers.org
VI.
Emergency equipment and supplies to have on hand
A. Sphygmomanometer and stethoscope
B. Emergency medications:
1 Epinephrine 1:1000
2 Diphenhydramine hydrochloride – PO and injectible
C. Syringes:
1 1cc syringes with 5/8 –3/4 inch needles (for epinephrine injection)
2 1 and 2cc syringes with 1 – 1 ½ inch needles (for diphenhydramine
injection)
D. Oral airways (small, medium, large)
E. Alcohol wipes and Band-Aids
F. Paper and pen
Medical Director
Date
- 11 -

Claim Disputes and Appeals
Appealing an Organization Determination
The appeal process for contracted practitioners or providers applies to UM denial
determinations that are adverse for the practitioner or provider, but not adverse to the
member. The UM team assumes that the practitioner or provider is acting strictly on
his/her own behalf when requesting the appeal when the member has no financial risk
for the service denied.
Examples of UM denial determinations included in the scope of this policy include:
• Contracted provider appeal of denied standard pre-service request, member has
not received the requested service, therefore has incurred no financial risk
• Contracted provider appeal of denied post service request, member is not
financially at risk, i.e., denied inpatient admission at a contracted facility
The contracted provider must submit the appeal request in writing to the following
address:
Fidelis SecureCare of North Carolina Inc
Appeals and Grievance Department
9300 Harris Corners Parkway Suite 100
Charlotte, North Carolina 28269
The written request must include supporting medical documentation. This
documentation will be reviewed by the Medical Director and a written determination will
be mailed within 30 days of the receipt of the appeal. This determination will be final.
Claim Disputes
Providers have the right to dispute the manner in which the claim was processed or
paid. There are two levels to the provider dispute process:
1 st level Provider Dispute (Verbal)
The provider can contact the claim inquiry call center at 877-372-8085. The claims team
will review the provider dispute and either re-process the claim or uphold the claims
processing determination. The provider will be notified of the determination via returned
call or updated remittance advice report.
Claim Disputes and Appeals - 1 -

2 nd level Provider Dispute (Written Appeal)
The provider may appeal when the provider disagrees with the resolution provided to
the initial provider dispute. The provider must submit this appeal in writing to the
following address:
Fidelis SecureCare of North Carolina Inc
Appeals and Grievance Department
9300 Harris Corners Parkway Suite 100
Charlotte, North Carolina 28269
The appeal request will be reviewed and the provider will receive notification of the
determination within 30 days of the receipt of appeal. This determination will be final.
Claim Disputes and Appeals - 2 -

Frequently Asked Questions
1. How does Fidelis reimburse for Part A skilled nursing services?
Fidelis will reimburse facilities for Part A skilled services using Medicare PPS
(Prospective Payment System) rates. The facility may submit either charges or
contracted rates to Fidelis, but claims will be adjusted based on the contract
between Fidelis and the facility.
SNFs should also file a claim to the SNFs intermediary using Condition Code 04
(Information Only) to update the Common Working File
2. Can the nursing facility bill Fidelis for DME?
The decision to authorize payment for DME & oxygen is made based on several
factors. Medically necessary DME may be authorized; however, if the DME is
covered by Medicaid, then it will not be paid for by Fidelis. Also, DME provided
during the same Part A “spell of illness” as skilled services is included in the PPS
rate and cannot be billed separately to Fidelis.
Prosthetics and orthotics may be reimbursable when billed by the original
provider (i.e. not the nursing facility).
3. Do I need to place my Authorization Number on the claim form?
Yes, Authorization Numbers should be included on each claim form. They
should be added to Box 63 on the UB04 and Box 23 on the CMS 1500.
4. How do I bill for Therapy Services (Physical Therapy, Speech Therapy, and
Occupational Therapy)?
Outpatient therapy services are paid as Part B for a SNF skilled stay if the
member has exhausted or is ineligible for benefit days under Part A.
Outpatient therapy services may be furnished directly by the SNF or under
arrangements with another provider; however, they must be billed by the nursing
facility.
Charges must be billed on UB04 Form. The correct bill type for a SNF Part B
therapy claim is 22X. Use Revenue codes 0420 (PT) 0430 (OT) and 0440 (SLP)
FAQs - 1 -

Fidelis will reimburse the facility for authorized skilled services at Medicare rates
subject to therapy limits and member co-pays and deductibles. Providers may bill
for authorized therapy in excess of benefit limits using appropriate modifiers KX
(-Requirements specified in the medical policy have been met) and GP (services
delivered under outpatient therapy plan of care).
5. How do I bill for Transportation Services?
Unless otherwise specified in by the provider agreement, non-emergency
wheelchair transportation services require prior authorization. They should be
billed using HCPCS code A0130 for each round trip. When wait times are
included in contracts, they should be billed using HCPCS code A0170 for each
30-minute increment. HCPCS codes should be placed in Field 24 on the CMS
1500 form.
Use the standard Medicare ambulance transportation modifiers attached to the
A0130 to indicate the “To/From” information.
6. Why are residents / patients receiving and explanation of benefit when they
have Medicaid?
Many of Fidelis’ members are dual eligible. For those residents / patients who are
eligible for Medicaid, Medicaid will cover co-payments and deductibles.
CMS requires Medicare Advantage plans (like Fidelis) to notify all members
regarding co-payments and deductibles even if they will be paid for by Medicaid.
This is confusing to many members, as they have also been informed that they
will not be required to personally pay these expenses.
7. Does Fidelis do cross-over billing?
No, the provider must bill Medicaid as secondary showing the Fidelis payment
amount in order for Medicaid to receive and process any secondary payments.
FAQs - 2 -

8. Does Fidelis enroll hospice patients?
Yes, Fidelis SecureCare will enroll Hospice patients. However, the hospice
benefit is managed and paid for by Original Medicare.
It should be clear to the resident or Responsible Party that most of Fidelis clinical
benefits such as extra physician visits could be contrary to the hospice plan of
care.
9. Once a member elects hospice, how should professional services be
billed?
Physicians should add a modifier GV (Attending physician not employed or paid
under arrangement by the patient’s hospice provider) to CPT codes on the CMS
1500 form.
10. Can SNFs bill Traditional Medicare for a Part A skilled stay for a member
who was enrolled with Fidelis, then disenrolled, even though there was no
3-day qualifying hospital stay?
SNFs should bill claims to their Fiscal Intermediary using Condition Code 58 if
they are seeking Part A reimbursement for a former MA member, who
disenrolled, when there was no 3-day qualifying hospital stay
11. Does Fidelis cover routine Blood Glucose Testing?
Fidelis follows Medicare guidelines. Medicare does not pay for Blood Glucose
tests unless the physician is actively involved in analyzing the result of each test.
12. How does a SNF bill for Enteral and Parenteral Nutrition (ENT/PEN)?
Suppliers MUST have a supplier code. Some SNFs have their own supplier
codes and bill the DMERC directly using the CMS 1500 form. Sometimes the
outside supplier bills for the Nursing Facility using the supplier code that the
Nursing Facility has obtained.
If SNF is billing for PEN Therapy – nutrients must be billed in units as follows:
Number of Calories X Days Billed = Number of units / 100
FAQs - 3 -

Example:
Patient needs 1500 calories per day for 30 days
A 30-day date span is billed by SNF
1500 X 30 = 450 units
100
Bill 450 units for nutrients
Bill supply kit units per number of billed days
13. How is a benefit period calculated?
A benefit period begins on the first day a member goes to a Medicare-covered
inpatient hospital or a skilled nursing facility. The benefit period ends when the
member has not been an inpatient at any hospital or SNF for 60 days in a row. If
the member goes to the hospital (or SNF) after one benefit period has ended, a
new benefit period begins. There is no limit to the number of benefit periods a
member can have. The type of care members actually get during the stay
determines whether they are considered an inpatient for SNF stays, but not for
hospital stays.
FAQs - 4 -

Please complete and return this form in one of three ways:
1. Mail: Fidelis SecureCare of North Carolina, Inc., Attention: Provider Relations, 9300 Harris Corners Parkway,
Suite 100, Charlotte, NC 28269
2. Fax : (877) 372-8081 Attention: Provider Relations
3. Scan and E-Mail to: NCProv.Relations@fidelissc.com
1. Name: ________________________________________________________________
(First) (MI) (Last) (Degree: MD, DO)
2. Group Name (if different): ________________________________________________________________
3. Specialty: Primary___________________ Sub-Specialty: __________________________
4. Primary Care Physician? : Yes or No Board Certified? : Yes or No If Yes: ______________________
5. Social Security No.: ________________________________________________________________
6. Gender: ________________________________________________________________
7. Federal Tax ID #: ________________________________________________________________
8. Medicare Provider #: ________________________________________________________________
9. NPI # & DEA NPI: ___________________________ DEA: __________________________
10. Admitting Hospital(s)
Hospital
Privilege Type
11. Primary Office Address: ________________________________________________________________
Use for Remittance? : Yes or No
Office Phone: __________________ Office Fax: ________________________
12. Office contact: _____________________________ Email: _____________________________
13. Alternate Office Address: ________________________________________________________________
Office Phone:
Use for Remittance? : Yes or No
Office Fax: ________________________
14. Office contact: Email: _____________________________
Credentialing is required in order to participate in our network. You may submit your application in any of the following ways
Complete a State mandated
Credentialing Application
If you are signed up with CAQH,
your Provider ID ____________
If you are not signed up with CAQH,
check this box and we will have an
“Outreach Kit” sent to you. Please visit
www.caqh.org for more information.
Completed By: ___________________________________
(Please Print Name)
Date: ______________________
For answers to questions on how to complete this form please contact Provider Relations at 1-877-372-8080 or via email at
NCProv.Relations@fidelissc.com
Rev. 3/20/08

North Carolina Department of Insurance
Uniform Application
To Participate as a Health
Care Practitioner
Note: Please send completed applications directly to the
organizations with which you seek to contract.
The following application is a form approved by the North Carolina Department of Insurance,
in accordance with North Carolina General Statute 58-3-230. Every insurer that provides a
health benefit plan and credentials providers for its network is required to use this form and
the insurer may not require an applicant to submit information that is not required by this
form Only the Commissioner of Insurance is authorized to make changes, deletions or
additions to this form.
June 2005 Page 1

INSTRUCTIONS
Before submitting the Application, make sure you have completed the following:
Include an answer in all spaces. Indicate "N/A", if the question is not applicable.
The provider has signed and dated the last page of the Application.
Before submitting the Application, make sure you have enclosed the following, if applicable:
Copy of the provider's original state(s) license(s) and current registration.
Copy of current DEA certificate. (Must have a valid date and refer to current address.)
Copy of South Carolina Controlled Drug Substance Certificate and DEA information.
Copy of the face sheet of your current professional liability insurance policy, indicating by name, provider(s)
covered, coverage amounts, effective date, expiration date, and policy number. Attach previous carrier face
sheet.
Proof of professional liability insurance for non-physician providers who care for patients in your practice.
Copy of certificate from the Specialty Board.
Copy of Educational Commission of Foreign Medical Graduate Certificate- ECFMG.
Letter(s) of reference, recommendation, and/or oversight, if required.
Copy of Curriculum Vitae or work history after graduation from Medical, Dental or other professional school
(CV must account for any gaps of 90 days or more).
Copy of CLIA (Clinical Laboratory Improvement Amendments) /ACR (American College of Radiology).
Copy of W-9 Form.
Examples of documentation to attach to this application:
June 2005 Page 2

A. DEMOGRAPHIC AND PERSONAL DATA:
1. Name of Applicant:
(Last Name) (First Name) (Middle Name) (Maiden)
2. Date of Birth: xx/xx/xxxx Place of Birth:
Social Security Number: xxx-xx-xxxx Sex: Male Female
3. Type of Practice: Primary Care: Specialist:
(Primary Specialty)
Please Identify Areas of Clinical Expertise:
(Secondary Specialty)
What population(s) do you treat (e.g. geriatric, all ages):
4. Name of Practice:
5. Primary Office Address (If you maintain more than one office, list each office, address, and hours of operation)
Practice Name:
Address:
(Street) (City) (County) (State) (Zip)
Handicapped Accessible? YES NO Office Phone: xxx-xxx-xxxx/xxxx Fax: xxx-xxx-xxxx/xxxx
E-mail address:
Accepting New Patients? YES NO Restrictions:
(Please list or indicate none)
Office Hours:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Secondary Office Address
Practice Name:
Address:
(Street) (City) (County) (State) (Zip)
Handicapped Accessible? YES NO Office Phone: xxx-xxx-xxxx/xxxx Fax: xxx-xxx-xxxx/xxxx
E-mail address:
Accepting New Patients? YES NO Restrictions:
(Please list or indicate none)
Office Hours:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
June 2005 Page 3

A. DEMOGRAPHIC AND PERSONAL DATA (Continued)
Additional Office Address or Billing Address, if different (check one) Billing Office
Name:
Address:
(Street) (City) (County) (State) (Zip)
Handicapped Accessible? YES NO Office Phone: xxx-xxx-xxxx/xxxx Fax: xxx-xxx-xxxx/xxxx
Accepting New Patients? YES NO Restrictions:
(Please list or indicate none)
Office Hours:
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
6. Name other provider(s) in your practice (if not enough space, please attach additional sheet):
7. Do nurse practitioners, physician assistants, midwives, social workers, or other non-physician providers provide care to
patients in your practice? YES NO
(If yes, please attach proof of professional liability insurance and proof of employment for those individuals)
8. Name and address of provider(s) who share call with you (if not enough space, please attach additional sheet):
Name:
Name:
Address:
Address:
9. Arrangements for 24 hour/7 day coverage:
10. Administrative Contact:
(Name)
(Title)
xxx-xxx-xxx/xxxx
(Telephone)
11. IRS requires reimbursement be made payable to name of practice affiliated with Federal Tax ID Number:
Federal Tax ID Number:
Name (if different from practice name):
Billing Address (if different from practice address):
12. UPIN Number: Medicare/Medicaid Number: /
National Provider Identifier (NPI):
13. DEA Number:
(Attach copy to application)
Exp. Date:
June 2005 Page 4

A. DEMOGRAPHIC AND PERSONAL DATA (Continued)
COMPLETE ONLY IF LICENSED IN SOUTH CAROLINA
SC Controlled Drug Substance Certificate:
(Attach a copy to application)
Expiration Date:
14. Provide the following information for each state in which you are currently or were previously licensed to
Practice (If not enough space please attach additional sheet)
STATE DATE OF LICENSE LICENSE NUMBER STATUS
Active, Inactive, Suspended
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
EXPIRATION
DATE
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
xx/xx/xxxx
PLEASE ATTACH A COPY OF EACH STATE LICENSE CERTIFICATE
15. Certification of Specialty Boards as applicable:
a. If you are certified by a specialty board, indicate name of board and date of certificate.
Date Certified: xx/xx/xxxx
Exp. Date: xx/xx/xxxx
(Primary Specialty Board)
(Secondary Specialty Board)
Date Certified: xx/xx/xxxx
Exp. Date: xx/xx/xxxx
b.. Are you listed in the American Board of Medical specialists? YES NO
c. If you have applied to a specialty board for examination, give the name of board and the date of scheduled examination.
Date: xx/xx/xxxx
d. If you have not applied to a specialty board, please explain:
June 2005 Page 5

A. DEMOGRAPHIC AND PERSONAL DATA (Continued)
16. List the dates of all current professional memberships in societies, including state and county societies:
FROM
TO
17. List all hospitals where you currently have privileges and indicate the type and status of those privileges:
(Type: active, admitting, associate, consulting, courtesy. Status: pending, provisional, suspended, temporary, visiting)
Hospital Privilege and Status of Privilege Estimated % of Admission
(primary admitting facility)
18. If you do not have admitting privileges, who admits for you?
Name:
Address:
Name:
Address:
Phone: xxx-xxx-xxxx/xxxx
Phone: xxx-xxx-xxxx/xxxx
June 2005 Page 6

B. EDUCATION AND PRACTICE HISTORY
1. Medical, Dental, or other Professional School Attended:
Institution:
Address:
(Street) (City) (State) (Zip)
Degree: From: xx/xx/xxxx To: xx/xx/xxxx
Please attach Educational Commission of Foreign Medical Graduate Certificate – (ECFMG), if applicable.
2. Internship
Institution:
Address:
(Street) (City) (State) (Zip)
Specialty: From: xx/xx/xxxx To: xx/xx/xxxx
3. Residency
Institution:
Address:
(Street) (City) (State) (Zip)
Specialty: From: xx/xx/xxxx To: xx/xx/xxxx
4. Other Residency / Fellowship – (specify)
Institution:
Address:
(Street) (City) (State) (Zip)
Specialty: From: xx/xx/xxxx To: xx/xx/xxxx
June 2005 Page 7

B. EDUCATION AND PRACTICE HISTORY (Continued)
5. List work history since beginning of medical, dental, or other professional school; please be specific.
(If not enough space, please attach additional sheet)
(Current Practice)
(Previous Practice)
(Previous Practice)
(Previous Practice)
(Previous Practice)
FROM
mm/yyyy
mm/yyyy
mm/yyyy
mm/yyyy
mm/yyyy
TO
mm/yyyy
mm/yyyy
mm/yyyy
mm/yyyy
mm/yyyy
6. List other training and/or education (including CME) within the last three years, if applicable.
7. Have you involuntarily or voluntarily withdrawn or been suspended from any internship, residency or fellowship training
program? Please explain:
8. Please explain any incident(s) in which you have involuntarily or voluntarily withdrawn your application for appointment,
clinical privileges or reappointment before a decision was made by a hospital or healthcare facility’s governing board.
June 2005 Page 8

C. PROFESSIONAL INFORMATION
Please check yes or no for the following questions. Please complete the attached Supplemental Form for any questions to
which you answer “yes”. Also please sign and date this application. If this application does not have the provider’s signature, it
cannot be accepted.
1. Has your license to practice in any jurisdiction ever been limited, restricted, reduced, suspended,
voluntarily surrendered, revoked, denied or not renewed; have you ever been reprimanded by a state
licensing agency; or are any of these actions pending with respect to your license; are you under
investigation by any licensing or regulatory agency? (If yes, please complete Supplemental Question
No. 1.)
2. Has your professional employment or membership in a professional organization ever been subject
to disciplinary proceedings, denied, limited, restricted, reduced, suspended, revoked, not renewed,
or voluntarily relinquished during or under threat of termination for any reason? (If yes, please
complete Supplemental Question No.2.)
3. Has your Drug Enforcement Agency registration or other controlled substance authorization ever
been limited, restricted, reduced, suspended, revoked, denied, not renewed, or have you voluntarily
surrendered or limited your registration during or under the threat of an investigation or are any
such actions pending? (If yes, please complete Supplemental Question No.3.)
4. Have you ever been sanctioned or suspended by Medicare or Medicaid? (If yes, please complete
Supplemental Question No.4.)
5. To your knowledge, have you ever been reported to the National Practitioner Data Bank or the
North/South
Carolina Board of Medical Examiners? (If yes, please complete Supplemental Question No.5.)
6. Have you ever been convicted of a felony or misdemeanor, or are you under investigation with
respect to such conduct? (If yes, please complete Supplemental Question No.6.)
7. Has a professional liability claim been assessed against you in the past five years, or are there any
professional liability cases pending against you? (If yes, please complete Supplemental Question
No.7.)
8. Has any liability insurance carrier canceled, refused coverage, or rated up because of unusual risk or
have any procedures been excluded from your coverage? (If yes, please complete Supplemental
Question No. 8.)
9. Have you ever practiced without liability coverage? (If yes, please complete Supplemental Question
No.9.)
10. Do you currently have any medical, chemical dependency or psychiatric conditions that might
adversely affect your ability to practice medicine or surgery or to perform the essential functions of
your position? (If yes, please complete Supplemental Question No.10.)
11. Have your Hospital and/or Clinic privileges ever been limited, restricted, reduced, suspended,
revoked, denied, not renewed, or have you voluntarily surrendered or limited your privileges during
or under the threat of an investigation or are any such actions pending? (If yes, please complete
Supplemental Question No. 11).
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
N
N
N
N
June 2005 Page 9

Provider Name:
SUPPLEMENTAL FORM
Provider ID#
(if applicable)
1. License Limited, Reprimanded, etc.
List State(s) where action took place:
Date(s) License revoked, suspended, etc. From xx/xx/xxxx To xx/xx/xxxx
Please explain:
2. Employment/Membership Suspended, Limited, etc.
List State(s) where action took place:
List Professional Organization:
Please explain:
3. Drug Enforcement Agency (DEA) Explanation.
List State(s) where action took place:
Please explain:
June 2005 Page 10

Provider Name:
SUPPLEMENTAL FORM
Provider ID#
(if applicable)
4. Medicare/Medicaid Sanction Disciplinary Action(s)
Disciplined Action(s):
List State(s):
Date(s) of action. From xx/xx/xxxx To xx/xx/xxxx
Please explain:
5. National Practitioner Data Bank Report(s)
Please explain the NPDB report (if you have a copy please attach):
6. Felony or Misdemeanor
Did you serve a sentence: Y N If YES, check how many years: 1 2 3 4 5 6 Other:
List State(s):
Please explain charge and verdict:
June 2005 Page 11

SUPPLEMENTAL FORM
Provider Name:
Provider ID#
(if applicable)
7. Named in Professional Liability Judgment, Settlement, etc.
Please explain, include dates & amounts:
8. Cancelled, Refused Coverage, etc.
Please list Insurance Carrier(s):
Please explain:
9. Practiced Without Liability Coverage
Please explain:
June 2005 Page 12

Provider Name:
SUPPLEMENTAL FORM
Provider ID#
(if applicable)
10. Medical, Chemical Dependency, or Psychiatric Conditions
Please explain in detail:
11. Hospital or Clinic Privileges Revoked, Restricted, etc.
List Hospital(s):
Date privileges revoked, suspended, etc. From xx/xx/xxxx To xx/xx/xxxx
Please explain:
June 2005 Page 13

Attestation Statement
(IMPORTANT: Submit Original Only)
This application is to be signed by each individual provider submitting an application.
Fill in each space with the name of the Health Plan for which you are applying.
No Stamps or Copies Please
All information submitted by me in this application, as well as any attachments or supplemental information, is true, current,
and complete to my best knowledge and belief as of the date of signature below. I fully understand that any significant
misstatement in this application may constitute cause for denial of my application or termination of a resulting participation
agreement.
By application for membership in
, I signify my willingness to appear for interview in
regard to my application. I authorize
to consult with administrators and members of the
medical staffs of hospitals or institutions with which I have been associated and with others, including past and present
malpractice carriers, who may have information bearing on the questions in this application. Upon request, I will obtain and
provide to
materials pertaining to my qualifications and competence, including, materials
relating to complaints filed, any disciplinary action, suspension, or action to curtail my medical- surgical privileges. I further
consent to the inspection by representatives of
of all documents that may be material to an
evaluation of my professional qualifications and competence.
I understand and agree that I, as an applicant, have the burden of producing adequate information for proper evaluation of my
professional competence, character, ethics, and other qualifications and for resolving any doubt about such qualifications. I
release from liability all representatives of
for their acts performed in good faith and
without malice in connection with evaluating my application and my credentials and qualifications, and I release from any
liability, all individuals and organizations that provide information to
in good faith and
without malice concerning this application and I hereby consent to the release and verification of information relating to any
disciplinary action, suspension, or curtailment of medical-surgical privileges to .
I understand that if my application is rejected for reasons relating to my professional conduct or competence,
, may report the rejection to the appropriate state licensing board and/or National Practitioner
Data Bank. In the event I am accepted for participation in
, I hereby consent to
for inspection of my patient records relating to
enrollees
as necessary for its peer and utilization review purposes as permitted by state or federal law and regulation I further agree to
notify
in a timely manner (not to exceed 30 days) of any changes to the information
on the initial application.
d
________________________________
PRINT NAME OF PROVIDER
________________________________
SIGNATURE OF PROVIDER
________________________________
DATE
Please Sign and Complete this Application
June 2005 Page 14

Practitioner Credentialing Application
AUTHORIZATION AND RELEASE OF INFORMATION FORM
Modified Releases Will Not Be Accepted
By submitting this application I understand and agree as follows:
1. I understand and acknowledge that, as an applicant for medical staff membership and/or participation status with the Healthcare
Organization(s)** with whom I have, or wish to establish, a contractual relationship as a network provider, staff physician, or other
provider of professional medical services (initial credentialing/recredentialing), I have the burden of producing adequate information
for proper evaluation of my competence, character, ethics, mental and physical health status, and other qualifications. In this
application I have provided information on my qualifications, professional training and experience, prior and current licensure, Drug
Enforcement Agency registration and history, and certification of CPR training. I have provided peer references familiar with my
professional competence and ethical character if requested. I have disclosed and explained any past or pending professional
corrective action, licensure limitations or related matters, if any. I have reported my malpractice claims history, if any, and have
attached or will provide a copy of a current certificate of professional liability coverage.
2. I further understand and acknowledge that the Healthcare Organization(s) or designated agent will investigate the information in this
application. By submitting this application, I agree to such investigation and to the disciplinary reporting and information exchange
activities of the Healthcare Organization(s) as a part of the verification and credentialing process.
3. I authorize all individuals, institutions and entities of other hospitals or institutions with which I have been associated and all
professional liability insurers with which I have had or currently have professional liability insurance, who may have information
bearing on my professional qualifications, ethical standing, competence, and mental and physical health status, to consult with the
Healthcare Organization(s), their staffs and agents.
4. I consent to the inspection of records and documents that may be material to an evaluation of qualifications and my ability to carry
out the clinical privileges/services I request. I authorize each and every individual and organization in custody of such records and
documents to permit such inspection and copying. I am willing to make myself available for interviews if required or requested.
5. I release from any liability, to the fullest extent permitted by law, all persons for their acts performed in a reasonable manner in
conjunction with investigating and evaluating my application and qualifications, and I waive all legal claims against any
representative of the Healthcare Organization(s) or their respective agent(s) to include CredentialsOnLine who acts in good faith
and without malice in connection with the investigation of this application.
6. I understand and agree that the authorizations and releases given by me herein shall be valid so long as I am an applicant for or have
medical staff membership and/or clinical privileges/participation status at the Healthcare Organization(s), unless revoked by me in
writing.
7. For hospital or medical staff membership/clinical privileges, I acknowledge that I have been informed of, and hereby agree to abide
by, the medical staff bylaws, rules, regulations and policies.
8. I agree to exhaust all available procedures and remedies as outlined in the bylaws, rules, regulations, and policies, and/or contractual
agreements of the Healthcare Organization(s) where I have membership and/or clinical privileges/participation status before
initiating judicial action.
9. I further acknowledge that I have read and understand the foregoing Authorization and Release. A photocopy of this Authorization
and Release shall be as effective as the original and authorization constitutes my written authorization and request to communicate
any relevant information and to release any and all supportive documentation regarding this application.
Signature __________________________________________________________
Date _______________________
**Healthcare Organization (e.g. hospital, medical staff, medical group, independent practice association (IPA),
health plan, health maintenance Organization (HMO), preferred provider organization (PPO), physician hospital
organization (PHO), medical society, credentials verification organization (CVO), professional association,
medical school faculty position or other health delivery entity or system).

Fidelis Secure Care of Michigan
EXPLANATION OF PAYMENTS
Not all relevant claim processing information is contained in this statement. This report contains privileged and confidential
information of Fidelis Secure Care subscribers. If you are not intended recipient, please contact by telephone for Provider or Member
Inquiries at (1-866-795-7773).
Servicing Provider Name: Johnson, Sample (2000000000000)
Servicing Provider NPI:
Patient and Services Information
Account Number GC01XXX
Subscriber # 071XX00XX Fidelis Secure Care - Michigan
Patient Name: White, Sample
Claim Id
080XX0000
Payee Name:
Osteopathic M.O. & H., PC
(200000000000)
Dates of Service Proc/Rev Amount Amount Adjusted Primary
Patient Responsibility
Interest Plan Remarks
Code Billed Allowed
Payor Pmt Co Pay Co Ins Ded Amt Non Cvrd Owed Payment
2/28/08 2/28/08 99244 257.00 194.01 62.99 0.00 0.00 38.80 0.00 0.00 -- 155.21 900
Claim totals for: 080XX000 257.00 194.01 62.99 0.00 0.00 38.80 0.00 0.00
0.00
155.21
Current Payment Amount:
Prior Paid Amount:
Net Payment Amount:
$155.21
$0.00
$155.21
Provider total: 2000000000000
Amount
Billed
Amount
Allowed
Adjusted
257.00 194.01 62.99
Primary
Payor Pmt
Patient Responsibility
Co Pay Co Ins Ded Amt Non Cvrd
Interest
Owed
0.00 0.00 38.80 0.00 0.00 0.00
Plan Payment
155.21
Osteopathic M.O. & H., PC
42815 Fidelis Blvd., Suite 201
SecureCare, MI 48038
Explanation of Claims Handling
Payment Summary
Payment Date: 4/3/08
Total Charged:
Check # : 21III
1
Total Cons Charged :
Paid To: Osteopathic M.O. & H., PC
Total Denied:
Tax ID: 380000000
Total Allowed:
Reference Id: 2000000000000000
2
Non Paid :
Prior Paid:
1 - Larger of contracted amount and charges.
Interest Owed:
2 - Includes items such as COB and Patient Responsibility.
Gross Paid:
Reductions:
Automatic Recovery:
Other Recoveries:
Net Check Amount:
$257.00
$257.00
$62.99
$194.01
$38.80
$0.00
$0.00
$155.21
$0.00
$0.00
$0.00
$155.21
900 Provider contracted discount/writeoff - do not bill member for this amount.
Date printed: 4/3/2008 Page 1 of 1 2000000000000000

Fidelis Secure Care of Michigan
EXPLANATION OF PAYMENTS
Not all relevant claim processing information is contained in this statement. This report contains privileged and confidential
information of Fidelis Secure Care subscribers. If you are not intended recipient, please contact by telephone for Provider or Member
Inquiries at (1-866-795-7773).
Servicing Provider Name: Kanos, Sample (200000000000)
Payee Name:
Cardio A.S.C., PC (200000000000)
Servicing Provider NPI:
Patient and Services Information
Account Number 1020510XXXXX
Subscriber # 07XXX000X Fidelis Secure Care - Michigan
Patient Name Ejay, Jr, Sampler
Claim Id
080XX00X000
Dates of Service Proc/Rev Amount Amount Adjusted Primary
Patient Responsibility
Interest Plan Remarks
Code Billed Allowed
Payor Pmt Co Pay Co Ins Ded Amt Non Cvrd Owed Payment
12/27/07 12/27/07 9921325 70.00 64.10 5.90 0.00 0.00 0.00 0.00 0.00 -- 64.10 900
Claim totals for: 080XX00X000 70.00 64.10 5.90 0.00 0.00 0.00 0.00 0.00
0.00
64.10
Current Payment Amount:
Prior Paid Amount:
Net Payment Amount:
$64.10
$0.00
$64.10
Servicing Provider Name: Kanos, Sample (200000000000)
Payee Name:
Cardio A.S.C., PC (200000000000)
Servicing Provider NPI:
Patient and Services Information
Account Number 1020510XXXXX
Subscriber # 07XXX000X Fidelis Secure Care - Michigan
Patient Name
Ejay Jr, Sampler
Claim Id
080XX00X000
Dates of Service Proc/Rev Amount Amount Adjusted Primary
Patient Responsibility
Interest Plan Remarks
Code Billed Allowed
Payor Pmt Co Pay Co Ins Ded Amt Non Cvrd Owed Payment
12/27/07 12/27/07 93732 90.00 77.40 12.60 0.00 0.00 0.00 0.00 0.00 -- 77.40 900
Claim totals for: 080XX00X000 90.00 77.40 12.60 0.00 0.00 0.00 0.00 0.00
0.00
77.40
Current Payment Amount:
Prior Paid Amount:
Net Payment Amount:
$77.40
$0.00
$77.40
Servicing Provider Name: Kanos, Sample (200000000000)
Payee Name:
Cardio A.S.C., PC (200000000000)
Servicing Provider NPI:
Patient and Services Information
Account Number 8780XX00XX
Subscriber # 06XXX00X0 Fidelis Secure Care - Michigan
Patient Name
Johnson, Sampler
Claim Id
080XX00XX0
Dates of Service Proc/Rev Amount Amount Adjusted Primary
Patient Responsibility
Interest Plan Remarks
Code Billed Allowed
Payor Pmt Co Pay Co Ins Ded Amt Non Cvrd Owed Payment
2/15/08 2/15/08 93018 25.00 16.32 8.68 0.00 0.00 0.00 0.00 0.00 -- 16.32 900
2/15/08 2/15/08 93016 35.00 25.52 9.48 0.00 0.00 0.00 0.00 0.00 -- 25.52 900
Claim totals for: 080XX00XX0 60.00 41.84 18.16 0.00 0.00 0.00 0.00 0.00
0.00
41.84
Current Payment Amount:
Prior Paid Amount:
Net Payment Amount:
$41.84
$0.00
$41.84
Date printed: 4/3/2008 Page 1 of 2 2000000000000000

Fidelis Secure Care of Michigan
EXPLANATION OF PAYMENTS
Not all relevant claim processing information is contained in this statement. This report contains privileged and confidential
information of Fidelis Secure Care subscribers. If you are not intended recipient, please contact by telephone for Provider or Member
Inquiries at (1-866-795-7773).
Provider total: 200000000000
Amount
Billed
Amount
Allowed
Adjusted
220.00 183.34 36.66
Primary
Payor Pmt
Patient Responsibility
Co Pay Co Ins Ded Amt Non Cvrd
Interest
Owed
0.00 0.00 0.00 0.00 0.00 0.00
Plan Payment
183.34
Cardio A.S.C., PC
27177 Fidelis Road
STE. 100
SecureCare, MI 48034
Explanation of Claims Handling
Payment Summary
Payment Date: 4/3/08
Total Charged:
Check # : 2IIIII
1
Total Cons Charged :
Paid To: Cardiovascular Associates, PC
Total Denied:
Tax ID: 380000000
Total Allowed:
Reference Id: 2000000000000000
2
Non Paid :
Prior Paid:
1 - Larger of contracted amount and charges.
Interest Owed:
2 - Includes items such as COB and Patient Responsibility.
Gross Paid:
Reductions:
Automatic Recovery:
Other Recoveries:
Net Check Amount:
$220.00
$220.00
$36.66
$183.34
$0.00
$0.00
$0.00
$183.34
$0.00
$0.00
$0.00
$183.34
900 Provider contracted discount/writeoff - do not bill member for this amount.
Date printed: 4/3/2008 Page 2 of 2 2000000000000000

CMS FORM 1500 JOB AID B 2007
CMS Form 1500 (08/05)
Instructions for Submission to Medicare Carriers/MACs and
DMERCs/DME MACs
Block Information To Be Entered Notes
Patient and Insured Information
Block 1 Health
Insurance Coverage
Block 1a Insured’s
ID Number
Block 2 Patient's
Name
Block 3 Patient's
Birth Date and Sex
Block 4 Insured's
Name
Check the box next to the insurance option
applicable to this claim.
Enter the patient's Medicare Health
Insurance Claim Number (HICN)
Enter the patient's last name, first name,
and middle initial (if any).
Enter the patient's eight-digit birth date
(MM|DD|YYYY) and check the appropriate
box to indicate the sex of the patient.
If Medicare is secondary to other
insurance, either through a patient's or
spouse's employment or any other source,
list the name of the insured’s last name, first
name, and middle initial (if any).
If a Medicare claim is being filed,
check the Medicare box.
Enter the HICN whether Medicare
is the primary or secondary payer.
Be sure to enter exactly as shown
on the patient's Medicare card.
The following codes are used to
indicate the patient's sex: F =
Female; M = Male
When the patient and insured are
the same, enter “SAME”.
Block 5 Patient's
Address
Block 6 Patient's
Relationship to the
Insured
Block 7 Insured's
Address
Block 8 Patient
Status
Block 9 Other
Insured's Name
If Medicare is primary, leave blank.
Enter the patient's mailing address and
telephone number.
If block 4 was completed, check the
appropriate box to indicate the patient's
relationship to the insured (self, spouse,
child, other).
If blocks 4, 6 and 11 are completed, enter
the insured's address and telephone
number.
Check the appropriate box to indicate the
patient's marital status (single, married, or
other). Check the appropriate box to
indicate the patient's employment status
(employed, full-time student, or part-time
student).
Only participating physicians and
suppliers are to complete block 9 and its
subdivisions and only when the
beneficiary wishes to assign benefits
under a Medigap policy to the
participating physician or supplier.
If the Medigap enrollee's name is
different from the patient's name (as
entered in block 2), enter the Medigap
policy enrollee's last name, first name, and
middle initial (if any).
Otherwise, enter “SAME”. If no
Medigap benefits are assigned, leave
blank.
If this address is the same as the
patient's, enter “SAME”.
Participating physicians and
suppliers must enter
information required in block 9
and its subdivisions if
requested by the beneficiary.
(Participating physicians/suppliers
sign an agreement with Medicare
to accept assignment of Medicare
benefits for all Medicare patients.
A claim for which a beneficiary
elects to assign his/her benefits
under a Medigap policy to a
participating physician/supplier is
called a mandated Medigap
transfer.)
Otherwise, the Medicare
CMS Form 1500 (08/05) Job Aid B
Page 1 of 18

CMS FORM 1500 JOB AID B 2007
Block Information To Be Entered Notes
Patient and Insured Information
Block 9 (con’t)
Other Insured's
Name
carrier/MAC cannot forward the
claim information to the Medigap
insurer.
Block 9a Other
Insured's Policy or
Group Number
Block 9b Other
Insured's Date of
Birth and Sex
Block 9c Employer's
Name or School
Name
Block 9d Insurance
Plan Name or
Program Name
Block 10a-10C Is
Patient’s Condition
related to:
Employment
(Current or
Previous)?
Auto Accident?
Place (State)
Other Accident?
Block 10d Reserved
for Local Use
Enter the Medigap insured's policy and/or
group number, preceded by “MEDIGAP”,
“MG”, or “MGAP”.
Enter the Medigap insured's eight-digit birth
date (MM|DD|YYYY) and check the
appropriate box to indicate the insured's
sex.
If block 9d contains a Medigap PAYERID
number, leave blank.
Otherwise, enter the claims processing
address of the Medigap insurer. Use an
abbreviated street address, a two letter
postal abbreviation, and the ZIP Code
copied from the Medigap insured's Medigap
ID card.
If you entered a policy and/or group
number into block 9a, you must enter the
nine-digit PAYERID number of the
Medigap insurer. If no PAYERID number
exists, enter the Medigap insurance
program or plan name.
Check "YES" or "NO" to indicate whether
employment, auto liability, or other accident
involvement applies to one or more of the
services described in block 24. Enter the
State postal code.
If the patient is entitled to Medicaid, enter
the patient's Medicaid number, preceded by
“MCD”.
Do not list other supplemental
coverage in blocks 9a-d at the
time a Medicare claim is filed.
(If the private insurer contracts
with the carrier to send Medicare
claim information electronically,
other supplemental claims will be
automatically forwarded to the
private insurer. If the private
insurer has not contracted to
send claim information
electronically, the beneficiary
must file his/her own
supplemental claim. )
Block 9d must be completed if a
policy and/or group number was
entered in block 9a.
The following codes are used to
indicate the patient's sex: F =
Female; M = Male
Use abbreviated street address.
Example: 1257 Anywhere Street
Baltimore MD, 21204 would be
entered as “1257 Anywhere St.
MD 21204”.
If “Yes” is checked, this indicates
that Medicare may be secondary
to other insurance. Enter primary
insurance information in block 11.
CMS Form 1500 (08/05) Job Aid B
Page 2 of 18

CMS FORM 1500 JOB AID B 2007
Block Information To Be Entered Notes
Patient and Insured Information
Block 11 Insured's
Policy Group or
FECA Number
Block 11a Insured's
Date of Birth and
Sex
Block 11b
Employer's Name or
School Name
If there is insurance primary to Medicare
(i.e., Medicare is secondary), enter the
insured's policy or group number and
proceed to blocks 11a-c. (blocks 4, 6 and 7
must also be completed.)
If there is no insurance primary to
Medicare (i.e., Medicare is primary), enter
“NONE” and proceed to block 12.
If the insured reports a terminating event
with regard to insurance that had been
primary to Medicare (e.g., insured
retired), enter “NONE” and proceed to
block 11b.
Enter insured's eight-digit birth date
(MM|DD|YYYY) and sex if different than
block 3.
Enter the employer's name, if applicable. If
there is a change in the insured's insurance
status, enter either a six-digit (MM|DD|YY)
or eight-digit (MM|DD|YYYY) retirement
date, followed by the word “RETIRED”.
THIS BLOCK MUST BE
COMPLETED.
By completing this block, the
physician/supplier acknowledges
having made a good faith effort to
determine if Medicare is the
primary or secondary payer.
Enter the appropriate information
in block 11c if insurance primary
to Medicare is indicated in block
11.
If a lab has collected previously
and retained MSP information for
a beneficiary, the lab may use
that information for billing
purposes of the non-face-to-face
lab service. If the
lab has no MSP information for
the beneficiary, the lab will enter
the word “None” in block 11 of
Form CMS-1500 (08/05), when
submitting a claim for payment of
a reference lab service. Where
there has been no face-to-face
encounter with the beneficiary,
the claim will then follow the
normal claims process. When a
lab has a face-to-face encounter
with a beneficiary, the lab is
expected to collect the MSP
information and bill accordingly.
If a provider or supplier enters 8-
digit dates for blocks 11b, 14, 16,
18, 19, or 24a, he or she must
enter 8-digit dates for all these
fields. (The same applies for
those who submit 6-digit dates.)
Blocks 12 and 31 are exempt
from this requirement for paper
claims. Carriers must return all
electronic claims that do not
include an 8-digit date
(CCYYMMDD) when a date is
reported. (CR 5391)
CMS Form 1500 (08/05) Job Aid B
Page 3 of 18

CMS FORM 1500 JOB AID B 2007
Block Information To Be Entered Notes
Patient and Insured Information
Block 11c Insurance
Plan Name or
Program Name
Block 11d Is there
another health
benefit plan?
Block 12 Patient's or
Authorized Person’s
Signature
Block 13 Insured's
or Authorized
Person's Signature
Enter the nine-digit PAYER ID number of
the primary insurer. If no Payer ID number
exists, enter the complete primary payer's
program or plan name. If the primary
payer's Explanation of Benefits (EOB) does
not contain the claims processing address,
record the primary payer's claims
processing address directly on the EOB.
Leave blank. Not required by Medicare.
The patient or their authorized
representative must sign in block 12 unless
a signature and/or a computer-generated
signature is on file. If a signature is already
on file, enter “SOF” or “SIGNATURE ON
FILE”. Enter a date in either a six-digit
(MM|DD|YY), eight-digit (MM|DD|YYYY), or
alphanumeric (January 1, 1998) format.
*When an illiterate or physically
handicapped enrollee signs by mark (i.e.,
with an “X”), a witness must enter his or her
name and address next to the mark.
If block 9 contains Medigap information,
the patient or their authorized
representative must sign and date block 13
to authorize payment of mandated Medigap
benefits to the participating physician (or the
signature must be on file as a separate
Medigap authorization).
In lieu of signing the claim, the
patient may provide the provider,
physician, and/or supplier a
signed statement to keep on file.
If the patient is physically or
mentally unable to sign, an
authorized representative may
sign on the patient's behalf. After
the statement's signature line, the
representative must write “by”,
followed by their name, address,
relationship to the patient, and the
reason the patient cannot sign.
This authorization is effective
indefinitely unless the patient or
patient's representative revokes
the arrangement.
The signature authorizes release
of medical information necessary
to process the claim.
The Medigap assignment on file
in the participating provider of
service/supplier's office must be
insurer-specific. It may state that
the authorization applies to all
occasions of service until it is
revoked.
Block Information To Be Entered Notes
Provider of Service or Supplier Information
Block 14 Date of
Current: Illness (First
Symptom); Injury
(Accident); or
Pregnancy (LMP)
Enter either a six-digit (MM|DD|YY) or eightdigit
(MM|DD|YYYY) date of current illness,
injury, or pregnancy.
For chiropractic services, enter either a
six-digit (MM|DD|YY) or eight-digit
(MM|DD|YYYY) date of the initiation of the
course of treatment, then enter either a sixdigit
(MM|DD|YY) or eight-digit
(MM|DD|YYYY) date in block 19.
If a provider or supplier enters 8-
digit dates for blocks 11b, 14, 16,
18, 19, or 24a, he or she must
enter 8-digit dates for all these
fields. (The same applies for
those who submit 6-digit dates.)
Blocks 12 and 31 are exempt
from this requirement for paper
claims. Carriers must return all
electronic claims that do not
include an 8-digit date.
CMS Form 1500 (08/05) Job Aid B
Page 4 of 18

CMS FORM 1500 JOB AID B 2007
Block Information To Be Entered Notes
Provider of Service or Supplier Information
Block 14 (con’t)
Date of Current:
Illness (First
Symptom); Injury
(Accident); or
Pregnancy (LMP)
Block 15 If Patient
Has Had Same or
Similar Illness Give
First Date
Block 16 Dates
Patient Unable to
Work in Current
Occupation
Block 17 Name of
Referring Provider or
Other Source
Leave blank. Not required by Medicare.
If the patient is employed and unable to
work in current occupation, enter either a
six-digit (MM|DD|YY) or eight-digit
(MM|DD|YYYY) date range to indicate when
the patient is unable to work.
Enter the name of the referring or ordering
physician, if the service or item was ordered
or referred by a physician.
If a non physician practitioner (NPP)
extender or other limited licensed
practitioner performs services “incident
to” or refers a patient for consultative
services, see Notes.
When a patient is referred to a physician
who also orders and performs a
diagnostic service, a separate claim form
is required for the diagnostic service. Enter
the original ordering/referring physician's
name and NPI into blocks 17 and 17a of the
FIRST claim form. Enter the performing
physician's name and NPI into blocks 17
and 17a of the SECOND claim form.
Effective for dates of service on or after
January 3, 2006, Independent Diagnostic
Testing Facilities (IDTFs) are no longer
allowed to bill for diagnostic services using
a surrogate UPIN (OTH00000). The IDTF
(CCYYMMDD) when a date is
reported. (CR 5391)
An entry in this field may indicate
employment-related insurance
coverage.
If a provider or supplier enters 8-
digit dates for blocks 11b, 14, 16,
18, 19, or 24a, he or she must
enter 8-digit dates for all these
fields. (The same applies for
those who submit 6-digit dates.)
Blocks 12 and 31 are exempt
from this requirement for paper
claims. Carriers must return all
electronic claims that do not
include an 8-digit date
(CCYYMMDD) when a date is
reported. (CR 5391)
When a claim involves multiple
referring and/or ordering
physicians, a separate Form
CMS1500 (08/05) must be
submitted for EACH
ordering/referring physician.
The following services/situations
require the submission of the
referring/ordering provider
information:
• Parenteral and enteral nutrition;
• Immunosuppressive drug
claims;
• Hepatitis B claims;
• Diagnostic laboratory services;
• Diagnostic radiology services;
• Portable x-ray services;
• Consultative services;
• Durable medical equipment;
• When the ordering physician is
also the performing physician
(as often is the case with inoffice
clinical laboratory tests);
• When a service is incident to the
CMS Form 1500 (08/05) Job Aid B
Page 5 of 18

CMS FORM 1500 JOB AID B 2007
Block Information To Be Entered Notes
Provider of Service or Supplier Information
Block 17 (con’t)
Name of Referring
Provider or Other
Source
Block 17a ID
Number of Referring
Provider or Other
Source
must submit the UPIN/NPI assigned to the
ordering physician. Claims will be rejected
and must be resubmitted with the correct
information.
Enter the ID qualifier 1G, followed by the
CMS assigned UPIN of the
referring/ordering physician listed in item
17.
service of a physician or nonphysician
practitioner, the name
of the physician or nonphysician
practitioner who
performs the initial service and
orders the non-physician
service must appear in block
17;
• When a physician extender or
other limited licensed
practitioner refers a patient for
consultative service, submit the
name of the physician who is
supervising the limited licensed
practitioner.
The UPIN may be reported until
May 22, 2007, and must be
reported until this date if an NPI
is not available.
Block 17b
NPI
Until May 23, 2007, block 17a or 17b is
required when a service was ordered or
referred by a physician.
(It is recommended that, until May 23, 2007,
the UPIN be entered in 17a AND the NPI in
17b.)
From May 23, 2007 through May 23, 2008,
17a may continue to be reported as part of
the CMS allowed contingency.
Effective May 23, 2008 and later, 17a is not
to be reported but 17b MUST be reported
when a service was ordered or referred by a
physician.
Enter the NPI of the referring/ordering
physician listed in 17.
If the ordering/referring physician
has not been assigned an UPIN,
one of the following surrogate
UPINs must be used: RES00000
- for interns and residents who
have not been assigned an NPI;
‣ RET00000 - for retired
physicians who were not
issued an NPI;
‣ VAD00000 - for physicians
serving in the Veterans
Health Administration (VHA)
or the U.S. Armed Services;
‣ PHS00000 - for physicians
serving in the Public Health
or Indian Health Services;
‣ NPP00000 - for statelicensed
nurse practitioners,
clinical nurse specialists, or
any other non-physician
practitioner authorized to
order medical services or
refer patients without
approval or collaboration
from a supervising physician
‣ OTH00000 - for when the
ordering/referring physician
has not been assigned an
NPI and does not meet any
of the above criteria.
CMS Form 1500 (08/05) Job Aid B
Page 6 of 18

CMS FORM 1500 JOB AID B 2007
Block Information To Be Entered Notes
Provider of Service or Supplier Information
Block 18
Hospitalization Dates
Related to Current
Services
Block 19 Reserved
for Local Use
Enter either a six-digit (MM|DD|YY) or eightdigit
(MM|DD|YYYY) date range to indicate
when a medical service is furnished as a
result of, or subsequent to, a related
hospitalization.
Enter either the six-digit (MM|DD|YY) or an
eight-digit (MM|DD|YYYY) date the patient
was last seen, and the UPIN (NPI when it
becomes effective) of his or her attending
physician when a physician providing
routine foot care submits claims.
For physical therapy, occupational
therapy or speech-language pathology
services, the date last seen and the
UPIN/NPI of an ordering/referring
/attending/certifying physician or nonphysician
practitioner are not required. If
this information is submitted voluntarily it
must be correct or it will cause rejection or
denial of the claim. However when the
therapy service is provided incident to the
services of a physician or non physician
practitioner then incident to policies
continue to apply. For example, for
identification of the ordering physician who
provided the initial service, see block 17
and 17a, and for the identification of the
supervisor, see block 24j.
For physical and occupational
therapists, entering this information
certifies that the required physician
certification (or recertification) is being kept
on file (see Chapter 15 of the Medicare
Benefits Policy Manual).
When submitting for chiropractic
services (if an X-ray, rather than a
physical examination was the method
used to demonstrate the subluxation),
enter either a six-digit (MM|DD|YY) or an
eight-digit (MM|DD|YYYY) X-ray date for
chiropractor services. By entering an X-ray
date and the initiation date for course of
chiropractic treatment in block 14, the
If a provider or supplier enters 8-
digit dates for blocks 11b, 14, 16,
18, 19, or 24a, he or she must
enter 8-digit dates for all these
fields. (The same applies for
those who submit 6-digit dates.)
Blocks 12 and 31 are exempt
from this requirement for paper
claims. Carriers must return all
electronic claims that do not
include an 8-digit date
(CCYYMMDD) when a date is
reported. (CR 5391)
If a provider or supplier enters 8-
digit dates for blocks 11b, 14, 16,
18, 19, or 24a, he or she must
enter 8-digit dates for all these
fields. (The same applies for
those who submit 6-digit dates.)
Blocks 12 and 31 are exempt
from this requirement for paper
claims. Carriers must return all
electronic claims that do not
include an 8-digit date
(CCYYMMDD) when a date is
reported. (CR 5391)
Block 19 can contain up to three
conditions per claim. Additional
conditions must be reported on a
separate Form CMS-1500.
CMS Form 1500 (08/05) Job Aid B
Page 7 of 18

CMS FORM 1500 JOB AID B 2007
Block Information To Be Entered Notes
Provider of Service or Supplier Information
Block 19 (con’t)
Reserved for Local
Use
chiropractor is certifying that all the relevant
information requirements (including level of
subluxation) of Pub.100-02, Medicare
Benefits Policy Manual, chapter 15, are on
file, along with the appropriate X-ray and all
are available for carrier/MAC review.
When submitting a Not Otherwise
Classified (NOC) drug claim, enter the
drug's name, strength and dosage.
Enter a concise description of an “unlisted
procedure code” or a NOC code if one
can be given within the confines of this box.
Otherwise, an attachment must be
submitted with the claim.
When modifier -99 (multiple modifiers) is
entered in block 24d, enter all applicable
modifiers.
If modifier -99 is entered on multiple line
items of a single claim form, all applicable
modifiers for each line item containing a -99
modifier should be listed as follows:
1=(mod), where the number 1 represents
the line item and “mod” represents all
modifiers applicable to the referenced line
item.
When an independent laboratory renders
an EKG tracing or obtains a specimen
from a homebound or institutionalized
patient, enter the statement "Homebound".
(See Pub. 100-02, Medicare Benefit Policy
Manual, Chapter 15, "Covered Medical and
Other Health Services," and Pub. 100-04,
Medicare Claims Processing Manual,
Chapter 16, "Laboratory Services From
Independent Labs, Physicians and
Providers," and Pub. 100-01, Medicare
General Information, Eligibility, and
Entitlement Manual, Chapter 5,
"Definitions," respectively for the definition
of "homebound" and a more complete
definition of a medically necessary
laboratory service to a homebound or an
institutional patient.)
When the beneficiary absolutely refuses
to assign benefits to a non-participating
provider, enter the statement, “Patient
refuses to assign benefits”. In this case,
payment can only be made directly to the
CMS Form 1500 (08/05) Job Aid B
Page 8 of 18

CMS FORM 1500 JOB AID B 2007
Block Information To Be Entered Notes
Provider of Service or Supplier Information
Block 19 (con’t)
Reserved for Local
Use
beneficiary.
When billing services involving the
testing of a hearing aid(s) are used to
obtain intentional denials when other
payers are involved, enter the statement,
“Testing for hearing aid”.
When dental examinations are billed,
enter the specific surgery for which the
exam is being performed. Enter the specific
name and dosage amount when low
osmolar contrast material is billed, but
only if Health Care Common Procedure
Coding System (HCPCS) codes do not
cover them.
When providers share postoperative
care, enter a six-digit (MM|DD|YY) or an
eight-digit (MM|DD|YYYY) assumed and/or
relinquished date for a global surgery claim.
Also include the total number of global
surgery days the provider was responsible
for care if not given in the units field of the
claim (block 24G).
If submitting a national emphysema
treatment trial claim, enter Demonstration
ID number “30”.
If the physician is performing a
purchased interpretation of a diagnostic
test, enter the PIN (or NPI when effective)
of the physician who is performing a
purchased interpretation of a diagnostic
test. (See Pub.100-04, chapter 1, section
30.2.9.1 for additional information.)
Block 20 Outside
Lab and $ Charges
Method II suppliers shall enter the most
current HCT value for the injection of
Aranesp for ESRD beneficiaries on dialysis.
(See Pub. 100-04, chapter 8, section
60.7.2.)
When billing for diagnostic tests subject
to purchase price limitations, check the
“Yes” box.
Enter the purchase price under charges.
If no purchased tests are included on the
claim, check the “No” box.
Effective for dates of service on or after
April 1, 2004, independent laboratories are
not required to report the purchase price of
“Yes” indicates that an entity
other than the entity billing for the
service performed the diagnostic
test and block 32 must be
completed. When billing for
multiple purchased diagnostic
tests, each test shall be submitted
on a separate claim Form CMS-
1500 (08/05). Multiple purchased
tests may be submitted on the
ASC X12 837 electronic format as
CMS Form 1500 (08/05) Job Aid B
Page 9 of 18

CMS FORM 1500 JOB AID B 2007
Block Information To Be Entered Notes
Provider of Service or Supplier Information
Block 20 (con’t)
Outside Lab and $
Charges
Block 21 Diagnosis
or Nature of Illness
or Injury
purchased diagnostic tests. Report the
service(s) with modifier 90 in item 24D, the
reference laboratory's name, address, and
PIN in block 32, and the reference
laboratory's CLIA number in block 23.
Independent laboratories will receive the
lower of the submitted charge or the fee
schedule amount (based on the zip code in
block 32) for the technical component of
purchased diagnostic tests.
Enter the patient's diagnosis /condition
using up to four codes in priority order
(primary, secondary condition).
long as appropriate line level
information is submitted when
services are rendered at different
service facility locations.
“No” indicates that no diagnostic
tests are included on the claim.
All narrative diagnoses for nonphysician
specialties must be
submitted on an attachment.
Block 22 Medicaid
Resubmission Code
and Original Ref. No.
Block 23 Prior
Authorization
Number
CR 5441 announced that for claims
processed July 1, 2007 and later CMS will
capture up to eight diagnoses.
With the exception of claims submitted by
ambulance suppliers (specialty type 59),
use an ICD-9-CM code number and code to
the highest level of specificity.
Leave blank. Not required by Medicare.
For procedures requiring Quality
Improvement Organization (QIO) prior
approval, enter the prior QIO authorization
number.
When an investigational device is used
in a Food and Drug Administration
(FDA)-approved clinical trial, enter the
Investigational Device Exemption (IDE)
number. Post Market Approval number
should also be placed here when
applicable.
For physicians performing care plan
oversight services, enter the six-digit
Medicare provider number (NPI when
available) of the home health agency (HHA)
or hospice when Health Care Common
Procedure Coding System (HCPCS) code
G0181 (HH) or G0182 (Hospice) is billed.
For laboratory services billed by an entity
performing Clinical Laboratory
Improvement Act (CLIA) covered
procedures, enter the ten-digit CLIA
certification number.
When a physician provides services to a
An independent laboratory must
enter a diagnosis only for limited
coverage procedures.
Block 23 can contain only one
condition. Any additional
conditions should be reported on
a separate Form CMS-1500.
CMS Form 1500 (08/05) Job Aid B
Page 10 of 18

CMS FORM 1500 JOB AID B 2007
Block Information To Be Entered Notes
Provider of Service or Supplier Information
Block 23 (con’t)
Prior Authorization
Number
Block 24
Block 24A Date(s)
of Service
beneficiary residing in a SNF and the
services were rendered to a SNF
beneficiary outside of the SNF, the
physician shall enter the Medicare facility
provider number of the SNF.
The six service lines in section 24 have
been divided horizontally to accommodate
submission of both the NPI and legacy
identifier during the NPI transition and to
accommodate the submission of
supplemental information to support the
billed service. The top portion in each of the
six service lines is shaded and is the
location for reporting supplemental
information. It is not intended to allow the
billing of 12 service lines. At this time, the
shaded area in 24a through 24h is not used
by Medicare. Future guidance will be
provided on when and how to use this
shaded area for the submission of Medicare
claims.
Enter a 6-digit or 8-digit (MMDDCCYY) date
or each procedure, service, or supply.
When "from" and "to" dates are shown for a
series of identical services, enter the
number of days or units in column G.
For visits/consultations, if a span of dates is
used in block 24a with units greater than 1
in block 24g, the number of days in the
span date range must equal the total
number of days in block 24g or the claim
will reject. Non-consecutive visits/consults
should be billed as separate lines of
service.
If a provider or supplier enters 8-
digit dates for blocks 11b, 14, 16,
18, 19, or 24a, he or she must
enter 8-digit dates for all these
fields. (The same applies for
those who submit 6-digit dates.)
Blocks 12 and 31 are exempt
from this requirement for paper
claims. Carriers must return all
electronic claims that do not
include an 8-digit date
(CCYYMMDD) when a date is
reported. (CR 5391)
Effective with claims received on
or after May 23, 2007 unless a
contingency plan is in place,
block 24A must be reported as
one continuous number (i.e.,
MMDDCCYY), without any
spaces between month, day, and
year. By entering a continuous
number, the date(s) in block 24A
will penetrate the dotted, vertical
lines used to separate month,
day, and year. Carrier claims
processing systems will be able to
process the claim if the date
penetrates these vertical lines.
However, all 8-digit dates
reported must stay within the
confines of block 24A; do not
compress or change the font of
CMS Form 1500 (08/05) Job Aid B
Page 11 of 18

CMS FORM 1500 JOB AID B 2007
Block Information To Be Entered Notes
Provider of Service or Supplier Information
Block 24A (con’t)
Date(s) of Service
the “year” item in block 24A.
(CR 5391)
Block 24B Place of
Service
Enter the appropriate Place of Service
(POS) code for each item used or service
performed.
01-Pharmacy
03 School
04 Homeless Shelter
05-Indian Health Service Free-standing
Facility
06-Indian Health Service Provider-based
Facility
07-Tribal 638 Free-standing Facility
08-Tribal 638 Provider-based Facility
09-Prison-Correctional Facility
11 Office
12 Patient's home
13-Assisted Living Facility
14-Group Home
15 Mobile unit
20 Urgent Care Facility
21 Inpatient hospital
22 Outpatient hospital
23 Emergency Room
24 Ambulatory surgery center
25 Birthing center
26 Military treatment facility
31 Skilled nursing facility
32 Nursing facility
33 Custodial care facility
34 Hospice
41 Ambulance, land
42 Ambulance, air or water
49-Independent Clinic
50 Federally Qualified Health Center
51 Inpatient psychiatric facility
52 Psychiatric Facility-Partial
Hospitalization
53 Community Mental Health Center
54 Intermediate care facility/mentally
retarded
55 Residential substance abuse treatment
facility
56 Psychiatric residential treatment facility
57-Non-residential Substance Abuse
Treatment Facility
60 Mass immunization center
61 Comprehensive inpatient rehab facility
62 Comprehensive outpatient rehab facility
65 ESRD treatment facility
71 State or local public health clinic
72 Rural health clinic
81 Independent laboratory
99 Other unlisted facility
The claim will return as
unprocessable if a date of service
extends more than 1 day and a
valid "to" date is not present.
When a service is rendered to a
hospital inpatient, use the
inpatient hospital code.
Paper claims with more than one
place of service code should be
split and submitted as separate
claims (one claim per place of
service code). This is because
the pricing is based on the zip
code in item 32, and, if there are
other places of service that do not
coincide with the address in item
32, pricing would not be accurate.
Claims will be rejected entirely if
filed with more than one place of
service code.
CMS Form 1500 (08/05) Job Aid B
Page 12 of 18

CMS FORM 1500 JOB AID B 2007
Block Information To Be Entered Notes
Provider of Service or Supplier Information
Block 24C
EMG
Medicare providers are not required to
complete this block.
Block 24D
Procedures,
Services, or Supplies
Block 24E
Diagnosis Pointer
Block 24F Charges
Enter the procedures, services, or supplies
using the Health Care Common Procedure
Coding System (HCPCS) or the Current
Procedural Terminology (CPT) code that
applies. When applicable, show HCPCS
modifiers or CPT modifiers with the HCPCS
code or CPT code.
Enter the specific procedure code without a
narrative description. However, when
reporting an "unlisted procedure code" or a
"not otherwise classified" (NOC) code,
include a narrative description in block 19 if
a coherent description can be given within
the confines of that box. Otherwise, an
attachment shall be submitted with the
claim. (The claim will be returned as
unprocessable if an “unlisted procedure
code” or a “not otherwise classified” (NOC)
code is indicated in block 24d, but an
accompanying narrative is not present in
block 19 or on an attachment.)
If modifier “-99” is entered on multiple
line items of a single claim form, all
applicable modifiers for each line item
containing a “-99” modifier should be listed
in block 19 as follows: 1=(mod), where the
number 1 represents the line item and
“mod” represents all modifiers applicable to
the referenced line item.
Enter the diagnosis code reference number
as shown in block 21 to relate the date of
service and the procedures performed to
the primary diagnosis. Enter only one
reference number per line item.
When multiple services are performed,
enter the primary reference number for
each service (either 1, 2, 3, or 4).
If two or more diagnoses are required for
a procedure code (e.g., pap smears),
reference only one of the diagnoses in block
21.
Enter the charge for each listed service.
The Form CMS-1500 (08-05) has
the ability to capture up to four
modifiers.
CMS Form 1500 (08/05) Job Aid B
Page 13 of 18

CMS FORM 1500 JOB AID B 2007
Block Information To Be Entered Notes
Provider of Service or Supplier Information
Block 24G Days or
Units
Enter the number of days or units.
If only one service is performed, the
numeral 1 must be entered.
This field is most commonly used
for multiple visits, units of
supplies, anesthesia minutes, or
oxygen volumes.
Some services require that the actual
number or quantity billed be clearly
indicated on the claim form (e.g., multiple
ostomy or urinary supplies, medication
dosages, or allergy testing procedures).
When multiple services are provided, enter
the actual number provided.
This field should contain at least
1day or unit.
Block 24H EPSDT
Family Plan
Block 24I ID. QUAL.
Block 24J
Rendering Provider
ID. #
Block 25 Federal
Tax I.D. Number
For anesthesia, show the elapsed time
(minutes) in block 24g. Convert hours into
minutes and enter the total minutes required
for this procedure. Enter the anesthesia
start and stop times in block 19 of the claim
form.
For instructions on submitting units for
oxygen claims, see chapter 20, section
130.6 of Pub. 104.
Leave blank. Not required by Medicare.
Enter the ID qualifier 1C in the shaded
portion.
Prior to May 23, 2007, enter the rendering
provider’s PIN in the shaded portion.
Enter the rendering provider’s NPI number
in the lower portion.
Effective May 23, 2007 and later, do not use
the shaded portion unless a contingency
plan is in place, then block 24J may
continue to be used until May 23, 2008.
Enter the provider of service or supplier
Federal Tax I.D. Number (Employer
Identification Number or Social Security
Number) and check the appropriate check
box.
Prior to May 23, 2007, in the case
of a service provided incident to
the service of a physician or nonphysician
practitioner, when the
person who ordered the service is
not supervising, enter the PIN of
the supervisor in the shaded
portion. (Enter the NPI in the
lower portion.)
Medicare providers are not
required to complete this item for
crossover purposes since the
Medicare contractor will retrieve
the tax identification information
from their internal provider file for
inclusion on the COB outbound
claim. However, tax identification
information is used in the
determination of accurate
National Provider Identifier
reimbursement. Reimbursement
of claims submitted without tax
identification information will/may
CMS Form 1500 (08/05) Job Aid B
Page 14 of 18

CMS FORM 1500 JOB AID B 2007
Block Information To Be Entered Notes
Provider of Service or Supplier Information
Block 25 (con’t)
Federal Tax I.D.
Number
be delayed.
Block 26 Patient's
Account Number
Block 27 Accept
Assignment?
Block 28 Total
Charge
Block 29 Amount
Paid
Block 30 Balance
Due
Block 31 Signature
of Physician or
Supplier Including
Degrees or
Credentials
OPTIONAL: Enter the patient's account
number assigned by the provider of
service's or supplier's accounting system to
assist in patient identification.
Check the appropriate item to indicate that
the provider of service/supplier accepts
assignment of Medicare benefits.
If Medigap is indicated in block 9 and
Medigap payment authorization is given in
block 13, the provider of service/supplier
must also be a Medicare participating
provider and accept assignment of
Medicare benefits for all covered charges
for all patients.
Enter the total charges for the services (i.e.,
total of all charges in block 24f).
Enter the total amount the patient paid on
covered services only.
Leave blank. Not required by Medicare.
Enter the signature of the provider of
service or supplier, or his or her
representative, and either the six-digit
(MM|DD|YY), eight-digit (MM|DD|YYYY), or
alphanumeric (e.g., January 1, 2003) date
the form was signed.
In the case of a service that is provided
incident to the service of a physician or
non-physician practitioner, when the
The following providers of
service/suppliers can only be paid
on an assignment basis:
‣ Clinical diagnostic laboratory
services;
‣ Physician services to
individuals dually entitled to
Medicare and Medicaid;
‣ Participating physician/supplier
services;
‣ Services of physician
assistants, nurse practitioners,
clinical nurse specialists, nurse
midwives, certified registered
nurse anesthetists, clinical
psychologists, and clinical
social workers;
‣ Ambulatory surgical center
(ASC) services for ASC
procedures;
‣ Home dialysis supplies and
equipment paid under Method
II.
‣ Ambulance services;
‣ Drugs and biologicals; and
‣ Simplified billing roster for
influenza virus vaccine and
Pneumococcal vaccine.
This block is only to be used to
show that a patient paid the
provider at the time of service.
This is a required field; however
the claim can be processed if the
following is true. If a physician,
supplier, or authorized person's
signature is missing, but the
signature is on file; or if any
authorization is attached to the
claim or if the signature field has
"Signature on File" and/or a
computer generated signature.
CMS Form 1500 (08/05) Job Aid B
Page 15 of 18

CMS FORM 1500 JOB AID B 2007
Block Information To Be Entered Notes
Provider of Service or Supplier Information
Block 31 (con’t)
Signature of
Physician or Supplier
Including Degrees or
Credentials
Block 32 Service
Facility Location
Information
ordering physician or non-physician
practitioner is directly supervising the
service as in 42 CFR 410.32, the signature
of the ordering physician or non-physician
practitioner shall be entered in block 31.
When the ordering physician or nonphysician
practitioner is not supervising the
service, then enter the signature of the
physician or non-physician practitioner
providing the direct supervision in block
31.
Enter the name, address, and ZIP code of
the facility if the services were furnished in
a hospital, clinic, laboratory, physician's
office, or facility other than the patient's
home.
Only one name, address and zip
code may be entered in the block.
If additional entries are needed,
separate claim forms shall be
submitted.
Providers of service (namely physicians)
shall identify the supplier's name, address,
and ZIP code when billing for purchased
diagnostic tests.
When more than one supplier is used, a
separate Form CMS-1500 (08/05) should
be used to bill for each supplier.
For durable medical, orthotic, and
prosthetic claims, the name and address
of the location where the order was
accepted must be entered (DMERC/DME
MAC only). This block is completed whether
the supplier's personnel performs the work
at the physician's office or at another
location.
9-digit ZIP code required for
services paid under Medicare
Physician Fee Schedule (MPFS)
and anesthesia services when
rendered in payment locality that
crosses ZIP code areas effective
for dates of services on or after
October 1, 2007 (refer to CR
5208 for further information)
For foreign claims, only the
enrollee can file for Part B
benefits rendered outside of the
United States.
If a modifier is billed, indicating the service
was rendered in a Health Professional
Shortage Area (HPSA) or Physician
Scarcity Area (PSA), the physical location
where the service was rendered shall be
entered if other than home.
If the supplier is a certified mammography
screening center, enter the 6-digit FDA
approved certification number.
Complete this block for all laboratory work
performed outside a physician's office. If
an independent laboratory is billing, enter
the place where the test was performed.
CMS Form 1500 (08/05) Job Aid B
Page 16 of 18

CMS FORM 1500 JOB AID B 2007
Block Information To Be Entered Notes
Provider of Service or Supplier Information
Block 32a NPI
Block 32b
Enter the NPI of the service facility as soon
as it is available.
Effective May 23, 2008, and later, 32b is
not to be reported.
Enter the ID qualifier 1C followed by one
blank space and then the PIN of the service
facility. Providers of service (namely
physicians) shall identify the supplier's PIN
when billing for purchased diagnostic
tests.
If the supplier is a certified mammography
screening center, enter the 6-digit FDA
approved certification number.
The NPI may be reported on the
Form CMS-1500 (08-05) as early
as January 1, 2007, and must be
reported May 23, 2008, and later.
Block 33 Billing
Provider Info & Ph #
Block 33a NPI
For durable medical, orthotic, and
prosthetic claims, enter the PIN (of the
location where the order was accepted) if
the name and address was not provided in
block 32 (DMERC/DME MAC only).
Enter the provider of service/supplier's
billing name, address, ZIP Code, and
telephone number.
Enter the NPI of the billing provider or
group.
Effective May 23, 2007, and later, you
MUST enter the NPI of the billing provider
or group unless a contingency plan is in
place then you have until May 23, 2008.
Block 33b
Effective May 23, 2007, and later, 33b is
not to be reported unless a contingency
plan is in place. If a contingency plan is
in place then 33b may continue to be
reported through May 23, 2008.
Enter the ID qualifier 1C followed by one
blank space and then the PIN of the billing
provider or group. Suppliers billing the
DMERC/DME MAC will use the National
Supplier Clearinghouse (NSC) number in
this block. Enter the PIN for the performing
provider of service/supplier who is not a
member of a group practice. Enter the
group PIN for the performing provider of
service/supplier who is a member of a
group practice.
Enter the group UPIN, including the 2-digit
location identifier, for the performing
CMS Form 1500 (08/05) Job Aid B
Page 17 of 18

CMS FORM 1500 JOB AID B 2007
Block Information To Be Entered Notes
Provider of Service or Supplier Information
Block 33b (con’t) practitioner/supplier who is a member of a
group practice.
CMS Form 1500 (08/05) Job Aid B
Page 18 of 18