CurrentFidelis CarePolicy N/A

COVID-19 UPDATE

A payer appendix listing HCPCS/CPT/Q-codes that require prior authorization, mapping many J-/Q-/S-/Jxxx codes to related entries and occasionally listing brand/generic drug names and other adjunct codes. Also includes Utilization Management voicemail requirements.

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE

Policy CodePolicy N/A

Change TypeAppendix (codes listed)

Effective Date

Next Review Date

Key ActionClaims for the HCPCS/CPT/Q-codes listed in Appendix I require prior authorization before services/drugs are provided; providers must obtain authorization for those codes to avoid denials.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — appendix enumerates codes requiring prior authorization but has no listed policy changes.

120+Distinct HCPCS/Q Codes Listed (approx.)

1Voicemail UM Requirement

Policy Appendix Summary

This appendix enumerates HCPCS/CPT/Q/J/S codes that require prior authorization under the payer's utilization management program as part of the COVID-19 update package. It is presented as Appendix I and lists numerous J-, Q-, and S-series codes (and other HCPCS/CPT codes) that are subject to authorization requirements.

The file you are viewing is Part 2 of 2 of the appendix set and continues the comprehensive code mappings and listings. Many entries in the appendix map HCPCS codes (including J-, Q-, and S-series) to specific drug or biologic names, cross-referenced internal identifiers, and related codes.

Codes Requiring Prior Authorization

Codes Requiring Prior Authorization (HCPCS/Codes listed)mixedCovered

J1448	listed (multiple mappings in appendix)
J1453	listed
J1454	listed
J1456	listed
J1458	listed
J1459	listed
J1460	listed
J1551	listed
J1552	listed
J1554	listed

1–10 of 123

1/13

Many J-, Q-, and S-series codes in this appendix map directly to specific drug or biologic names or to internal cross-reference entries within Appendix I (for example, multiple J-codes are followed by named biologics or internal identifiers in the appendix listings).

This document is Part 2 of 2 of Appendix I; consult both parts of the appendix for the full set of required prior authorization codes and their mapped drug/biologic references.

Required Provider Actions & Documentation

Prior Authorization

Prior authorization required for listed codes

Claims for the HCPCS/CPT/Q-codes listed in Appendix I require prior authorization before services/drugs are provided; providers must obtain authorization for those codes to avoid denials.

Affected codes: see Coding section / Appendix I list.

Documentation Required

Voicemail HIPAA-compliant requirements for UM messages

Providers must have a HIPAA-compliant voicemail that identifies the mailbox owner, the owner's organization, and states the mailbox is confidential and PHI can be left; otherwise the UM department will leave a generic message and request a callback, and will make a second direct attempt as required by the Department of Health Reasonable Effort Policy.

Voicemail must identify mailbox owner, the owner's organization, and state the mailbox is confidential and that PHI can be left.
If voicemail is not HIPAA-compliant UM will leave a generic message and request a callback; a second direct attempt will be made per Department of Health Reasonable Effort Policy.

Coverage Stance & Scope

Coverage stance: the codes listed in Appendix I are marked as covered but are subject to the payer's utilization management requirements.

Billing rule: all HCPCS/CPT/Q/J/S codes enumerated in the appendix require prior authorization under the payer's utilization management program; although code_groups are labeled 'covered' in the appendix, authorization must be obtained prior to provision of the service or submission of a claim to avoid denial.

Statistics

Distinct HCPCS/Q Codes Listed (approx.)120+

Voicemail UM Requirement1