Managed Long Term Care (MLTC) eligibility and billing for Fidelis Care FCAH and MAP
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Governance of eligibility requirements, covered services, prior authorization and claims/billing rules for Fidelis Care Homecare (FCAH) and Medicaid Advantage Plus (MAP) MLTC members in New York State; affects providers delivering home- and community-based long‑term care services to Fidelis MLTC/MAP members.
New minimum functional eligibility standards for MLTC/MAP effective September 1, 2025 requiring applicants to have community‑based long term services >120 days and either limited assistance in 2+ ADLs or dementia diagnosis with supervision need in 1+ ADL.
Coverage criteria and member eligibility
Covered services and eligibility
Covered when ALL of the following are met:
ALL of the following
ONE of
- Limited assistance in two or more Activities of Daily Living (ADLs).
- A diagnosis of dementia or Alzheimer’s disease with need for supervision in one or more ADLs.
Billing codes, units, and claim submission
| T1019U1 | PCA Level 2 — billed per 15 minutes |
| T1019U3 | PCA Level 2 shared case (multiple), billed per 15 minutes |
| T1019U2 | PCA Level 2 shared assistance (up to two clients), billed per 15 minutes |
| T1019U4 | PCA Level 2 — high service needs, billed per 15 minutes |
| T1019U6 | Consumer-directed personal assistance (direct to consumer), 1 client, billed per 15 minutes |
| T1019U7 | Consumer-directed personal assistance (direct to consumer), 2 clients, billed per 15 minutes |
| T1019U8 | Consumer-directed personal assistance, 1 client — enhanced, billed per 15 minutes |
| T1019U9 | Consumer-directed personal assistance, 2 clients — enhanced, billed per 15 minutes |
| T1020 | Home care level 2 — billed daily |
| T1020U2 | Home care level 2 shared case (multiple), billed daily |
| T1019U1 | Second level PCA — billed per 15 minutes |
| T1019U2 | Second level shared assistance (up to two clients) — billed per 15 minutes |
| T1019U3 | Second level shared case (multiple) — billed per 15 minutes |
| T1019U4 | Second level — high service needs — billed per 15 minutes |
| T1019U6 | Direct to consumer, 1 client — billed per 15 minutes |
| T1019U7 | Direct to consumer, 2 clients — billed per 15 minutes |
| T1019U8 | Direct to consumer, 1 client — enhanced — billed per 15 minutes |
| T1019U9 | Direct to consumer, 2 clients — enhanced — billed per 15 minutes |
| T1020 | Home care level 2 — billed daily |
| T1020U2 | Home care level 2 shared case (multiple) — billed daily |
Provider responsibilities: referrals, authorization, and EVV
Referral & Authorization Submission: email/fax, network verification, separate transport auth
Submit referrals for covered services via email to mltcauthreq@fideliscare.org or fax to 833-710-1772. Verify that the ordering/provider is in-network prior to referral by checking the Fidelis Find-a-Doctor site (https://www.fideliscare.org/Find-a-Doctor#/search). Non‑emergency transportation requires a separate prior authorization request and must be submitted separately from other referrals.
- Email referrals to: mltcauthreq@fideliscare.org
- Fax referrals to: 833-710-1772
- Confirm provider network participation at: https://www.fideliscare.org/Find-a-Doctor#/search
- Submit a separate authorization for arranging non‑emergency transportation (including adult social day transportation)
HHAeXchange: required portal for authorizations, scheduling and EVV
Use the HHAeXchange portal to receive Fidelis authorizations, schedule visits, manage care plans and perform electronic visit verification (EVV). Providers not using HHAeXchange must obtain portal access; use of HHAeXchange has been required since February 14, 2022 to avoid claim denials.
- Receive new member assignments and Fidelis authorizations through HHAeXchange
- Schedule and confirm visits and record electronic visit confirmations (EVV) in HHAeXchange
- Obtain access to the HHAeXchange portal if not currently using it
- For questions or access issues email Support@hhaexchange.com and see https://hhaexchange.com/fideliscare/
Definitions and assessment requirements
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.