General Authorization Requirements / Exceptions
Covered when ALL of the following general authorization requirements and exceptions are met; preserve listed exceptions.
All inpatient admissions require prior authorization and are reviewed for medical necessity.
Emergency room services and emergent stabilization do not require prior authorization; however, authorization is required for inpatient admissions that follow ER services when admission is indicated.
High‑volume breast cancer surgery rule: Fidelis Care Medicaid members must receive mastectomy and lumpectomy procedures associated with a breast cancer diagnosis at high‑volume facilities per NYS policy.
Transplants (solid organ and bone marrow) require authorization at the time of the transplant evaluation. (Representative CPT/HCPCS ranges listed in source must be submitted with request.)
OASAS‑licensed inpatient SUD facilities in‑network/in‑state: not subject to authorization review and not subject to concurrent utilization review for the first 28 days provided the facility notifies Fidelis Care within 2 business days using the OASAS Appendix A Notification Form/LOCADTR tool (fax 833‑663‑1608 or LOCADTR@fideliscare.org). Facilities outside NYS or out‑of‑network must request authorization and remain subject to concurrent review.
OMH‑licensed inpatient mental health hospitals in NYS: not subject to authorization review per OMH Best Practice Manual; facility must notify Fidelis Care within 2 business days (fax 833‑561‑0094 or Mental_Health_Admission@fideliscare.org). For members under age 18 in participating network hospitals, no concurrent utilization review during first 14 days if notification and initial treatment plan submitted within 2 business days; periodic consultation and daily clinical review required.
Note: New inpatient/ER fax numbers — Inpatient ER: 833‑663‑1602; OASAS LOCADTR fax: 833‑663‑1608; OMH fax: 833‑561‑0094.
Delegated Authorization Programs
Delegations for prior authorization and associated device/code review.
Evolent (Musculoskeletal Management Program) delegated to review specified musculoskeletal CPT codes effective 1/1/24. If a CPT code is delegated to Evolent, associated device HCPCS codes are also reviewed by Evolent.
TurningPoint Healthcare Solutions, LLC is delegated to review specified ENT and Cardiac surgical CPT codes. If a CPT code is delegated to TurningPoint, associated HCPCS device codes are also reviewed by TurningPoint.
Radiology/Radiation Therapy prior authorization is delegated where indicated; when CPT is delegated, associated HCPCS will be mapped and reviewed by the delegated organization.
Outpatient Surgery - Services That Require Prior Authorization
Outpatient surgical procedures that require prior authorization. Preserve nested examples and the S2083 note.
Bariatric surgery (examples): 43770, 43771, 43772, 43773, 43774, 43775.
Blepharoplasty: 15820, 15821, 15822, 15823.
Breast reconstruction: 11920-11971, 19300, 19316-19342, 19355, 19370-19396.
Skin surgery / dermatologic examples: 15011, 15012, (other skin excision/repair codes as applicable).
Ear repair / related ENT outpatient procedures — see TurningPoint delegated list where applicable.
Reduction mammoplasty, abdominoplasty, and other cosmetic/reconstructive procedures require prior authorization as listed.
Behavioral Health Outpatient - Authorization Exceptions and Requirements
Behavioral Health outpatient authorization exceptions and requirements; include testing and program rules.
Psychological and neuropsychological testing require prior authorization per behavioral health policy when indicated.
Partial hospitalization (PHP) and intensive outpatient program (IOP) services follow program‑specific authorization rules; certain outpatient SUD services (in‑network/in‑state) do not require authorization effective 01/01/2020.
Applied Behavior Analysis (ABA): authorization and eligibility follow program criteria; providers should submit required documentation to the behavioral health intake team.
PROS/ACT/IPRT rules: Program‑specific timing exceptions apply (e.g., initial notification/time windows) and periodic consultation with Fidelis Care is required for OMH/OASAS licensed programs.
Transcranial Magnetic Stimulation (TMS): coverage requires meeting clinical eligibility and documented prior authorization for TMS series; associated CPT codes 90867, 90868, 90869 apply and must be submitted with clinical documentation.
Therapies, PT/OT/ST and Podiatry
Therapies (PT/OT/ST) and podiatry authorization routing and timing rules.
Outpatient PT/OT/ST prior authorization routing and program management may be handled by Evolent where delegated; check delegated-code lists.
Home health therapy vs outpatient timing: home health therapy authorization and approval basis follow home health policy and are separate from outpatient authorization timing; inpatient therapy services follow inpatient authorization rules.
Podiatry: selected podiatry procedures may require prior authorization; exceptions exist for urgent/emergent care and certain site‑of‑service scenarios.
Place of service and bill type notes: ambulatory surgery centers commonly bill using bill type 0831; ensure correct POS/bill type mapping when submitting authorization and claims.
Imaging and Diagnostic Services
Imaging and diagnostic services rules, delegation, frequency and no‑auth exceptions.
Radiology prior authorization is delegated to Evolent where indicated; delegated CPT lists include mapping of associated HCPCS for device/supplies review.
OB ultrasound frequency rules: routine OB ultrasound frequency limits apply per policy and billing guidelines; additional ultrasounds require clinical justification.
DXA bone density: no prior authorization required for routine DXA when age/diagnosis meet coverage rules; Trabecular Bone Score (TBS) rules referenced with DXA.
Sleep studies: authorization required per clinical criteria; home vs facility sleep testing follows program rules.
Capsule endoscopy and select advanced diagnostic procedures require prior authorization.
DME, Home Health Care, Hospice, CDPAS
DME, home health, hospice and CDPAS authorization and program adherence.
DME: prior authorization follows the DME program manual; submit medical justification and required documentation per DME policy. Maximum unit edits and HCPCS coverage rules apply.
MLTC/CHP specific supply codes: follow the referenced MLTC/CHP supply code list for coverage and authorization requirements.
Home health approvals are based on clinical documentation of homebound status and skilled need; authorization determinations follow home health policy.
Consumer Directed Personal Assistance Services (CDPAS) require authorization per program rules and documentation.
Hospice: authorization/submission rules for hospice services and transition notes must be followed; hospice election and transition timing affect authorization and claims processes.
Other Service-specific Rules
Other service‑specific rules, exclusions and vendor exceptions.
Elective vs inpatient‑only guidance: inpatient only procedures and elective surgical procedures performed within 24 hours are not approved at an inpatient level if appropriately billed as outpatient; verify network status and authorization requirements.
Therapeutic services such as hyperbaric oxygen therapy (HBOT) and topical oxygen require prior authorization per coverage criteria.
Excluded pain management treatments are identified in program exclusions; review policy for specific non‑covered modalities.
ADHC rules: Adult Day Health Care program authorization and billing limits apply; providers must follow program guidance.
Counseling limits: program‑specific counseling visit limits and documentation requirements apply.
Adult Day Health Care (ADHC) initial assessment
ADHC initial assessment, grandfathering and continuation review rules.
Adult Day Health Care (ADHC) initial assessment: members grandfathered under prior program may continue services for up to 90 days from plan change; initial assessments and continuation medical necessity reviews are required per program timelines.
Continuation review: ADHC services require periodic medical necessity review; providers must submit documentation to support continued need at required intervals.
Erectile dysfunction services exclusion and code list
Erectile dysfunction (ED) services are excluded as noted; associated codes listed.
Erectile dysfunction services are excluded from coverage under this policy (cosmetic / non‑covered treatment for ED).
Associated codes excluded include relevant HCPCS/CPT and supply codes used for ED devices and procedures — providers should refer to the ED exclusion code list in the program appendix when validating claims.
Counseling Services limits and billing
Counseling services limits, provider requirements and billing exceptions.
Counseling (non‑behavioral health outpatient counseling described elsewhere) is subject to a maximum of 10 hours (20 units) per six‑month period. Providers must be appropriately certified/licensed to bill counseling services.
Billing codes G0108 and G0109 (diabetes outpatient self‑management training group/one‑on‑one) do not require prior authorization when billed with appropriate diagnosis and documentation per program rules.
Providers must track the six‑month period and cumulative units; claims exceeding limits may be denied without prior authorization.
Asthma Self-Management Training (ASMT)
Asthma Self‑Management Training rules.
ASMT hour limits are stability‑based: number of hours authorized depends on clinical stability and documented need.
Group size limit: group education sessions must meet the policy group size requirements.
No prior authorization required when ASMT is billed on the same claim with an asthma diagnosis code (J45.x series) per billing guidance.
Smoking Cessation Counseling (SCC)
Smoking cessation counseling coverage and billing rules.
Smoking Cessation Counseling (SCC) does not require prior authorization.
Reimbursement limited to up to 8 visits per year for counseling services.
Required diagnosis codes include F17.x entries for tobacco use disorder (ensure correct ICD‑10 coding on claim).
Vision and Orthodontic vendor authorization
Vision and orthodontic vendor routing and contact information.
Davis Vision: vision benefits and authorizations are routed to Davis Vision (vendor handles routine vision services).
DentaQuest: orthodontic services and prior authorization requests are routed to DentaQuest for dental/orthodontic benefits.
Providers should contact the respective vendor for authorization requirements and claims processing; vendor contact numbers and portals are maintained in the provider resources.
Enteral Therapy criteria (Child Health Plus applicability)
Enteral nutrition therapy criteria, HCPCS ranges, CHP applicability and documentation requirements.
Covered enteral therapy HCPCS range: B4034–B4162; prior authorization required per enteral nutrition program when not meeting no‑auth exceptions.
Eligibility criteria include medical conditions such as inborn errors of metabolism, severe malabsorption, or other documented clinical indications; BMI/weight‑loss criteria apply per clinical policy.
Caloric caps and supply limits: enteral formulas and supplement caps apply; documentation of caloric needs and justification must be submitted.
Documentation requirements: clinical assessment, nutrition plan, goals, and monitoring documentation must accompany prior authorization requests.
Child Health Plus (CHP) applicability: CHP members are subject to enteral therapy criteria where specified; certain CHP‑specific rules may apply — verify CHP routing and submission instructions.
Oncology medication prior authorization routing
Oncology medication prior authorization routing, exclusions and contact guidance.
Oncology medications and supportive oncology agents are routed to Evolent for prior authorization where the oncology medication program is delegated.
Exclusions from oncology medication routing include: routine antibiotics, medications administered as part of bone marrow transplant (BMT) / CAR‑T inpatient therapy, hemophilia factor products, and other specified exclusions — refer to the oncology drug routing appendix for full list.
For questions or submissions related to delegated oncology medications/supportive agents, contact the Evolent oncology review line: 1‑888‑999‑7713. Note: Child Health Plus oncology medication requests should be sent to Fidelis Care per CHP exception guidance.
Medicaid pharmacy benefit transition and PA submission
Medicaid pharmacy benefit transition and PA submission instructions.
NYRx pharmacy benefit transition effective 4/1/2023: providers must check NYRx formulary and PA requirements for medications transitioned to the Medicaid pharmacy benefit.
For Appendix I codes requiring PA submission to the Pharmacy Team, submit via e‑fax to 1‑844‑235‑5090 (Pharmacy Team).
Verify pharmacy PA routing and prior authorization requirements on NYRx before submitting pharmacy PA requests.
S codes and HCPCS exclusions
S‑codes and HCPCS exclusions and examples.
S‑codes: certain S‑codes are excluded from coverage or handled separately; providers should reference the S‑code exclusion list in the program appendix when submitting claims.
HCPCS non‑FDA approved medication exclusions: HCPCS codes for medications not FDA‑approved for the indicated use or lacking clinical evidence are excluded — examples are provided in the HCPCS exclusions appendix.
Maximum unit edits
Maximum unit edits and how they apply to HCPCS regardless of authorization.
Maximum unit edits apply to all HCPCS codes regardless of prior authorization status.
Refer to the Maximum Units of Service policy for details on per‑code unit limits and claim adjudication behavior.
Prior Authorization Requirement Statements
Plan‑specific prior authorization requirement statements and alternates (CHP vs NYMMHARP).
Child Health Plus (CHP) members: certain services and medications (e.g., oncology medications per appendix) may have CHP‑specific routing or exceptions — when CHP exception applies, send requests to Fidelis Care as noted.
NYMMHARP / Medicaid Managed Care: follow the Medicaid/NYMMHARP prior authorization requirements as specified; where program delegations exist, submit to delegated vendor per routing table.
Providers must verify member product (Medicaid vs CHP vs NYMMHARP) prior to submission as authorization routing and exceptions differ by product.
Utilization Management Voicemail Requirements
Utilization Management voicemail and reasonable effort requirements for provider notifications.
HIPAA‑compliant voicemail greeting requirement: when leaving voicemails with member PHI, the voicemail greeting must be HIPAA‑compliant and cannot disclose protected health information.
Second‑attempt requirement: per DOH Reasonable Effort Policy, if initial contact attempt fails, a second attempt must be made and documented before denial for failure to cooperate or reach member.
Providers must follow Fidelis Care voicemail and reasonable effort procedures when conducting utilization management outreach; document attempts in the medical record and authorization file.