Fidelis Care Prior Auth Coverage & Policy Update | OpenPayer
CurrentFidelis CarePolicy N/A
Authorization and Coverage Guidance — Prior Authorization, Exceptions, and Coding
Governance of prior authorization, authorization exceptions, and coding/coverage direction for inpatient, outpatient, behavioral health, and selected procedures for Fidelis Care members (New York-focused). Affects providers submitting authorization requests and billing for services.
Policy Summary
PayerFidelis Care
PolicyAuthorization and Coverage Guidance — Prior Authorization, Exceptions, and Coding
Policy CodePolicy N/A
Change TypeNo material clinical or coverage changes
Effective DateJan 1, 2020
Next Review DateN/A
Key ActionObtain prior authorization for all inpatient admissions and for the listed outpatient, transplant, surgical, and selected DME services.
No material clinical or coverage changes in this revision.
Inpatient require PAInpatient auth
First 28 daysOASAS exception
First 14 daysOMH pediatric exception
Carve-in 1/1/2023Behavioral health change
NIA handles therapy PANIA delegated
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Coverage Criteria and Authorization Exceptions
Inpatient Admissions
Covered when authorization obtained and medical necessity established
Inpatient admissions: All inpatient admissions require an authorization and facility admissions are reviewed for medical necessity.
Emergency room services and emergent stabilization do not require prior authorization but post-stabilization services and inpatient admissions do.
OASAS Inpatient SUD authorization exception
Authorization exceptions with conditions
OASAS-licensed Inpatient SUD (in-state, in-network): Inpatient detoxification, inpatient rehabilitation and inpatient residential treatment services provided by OASAS-licensed, in-state, in-network facilities are not subject to authorization review and are not subject to concurrent utilization review during the first 28 days of admission provided the facility notifies Fidelis Care of the inpatient admission and the initial treatment plan within two business days using LOCADTR, performs daily clinical review, and provides a written discharge plan prior to discharge.28 days
Facilities outside NYS, not OASAS-licensed, or out-of-network remain subject to authorization and concurrent review.
OMH pediatric inpatient mental health authorization exception
Authorization exceptions with conditions
OMH-licensed inpatient mental health for members under 18: OMH-licensed hospitals in NYS participating in Fidelis Care's provider network are not subject to authorization review and Fidelis Care will not conduct concurrent utilization review during the first 14 days of inpatient admissions provided the facility notifies Fidelis Care of the admission and initial treatment plan within two business days using the OMH Two-Day Notification and Initial Treatment Plan, performs daily clinical review, and participates in periodic consultation with Fidelis Care.14 days
Inpatient mental health services for members age 18 and older require prior authorization and are subject to concurrent review throughout the admission; out-of-state or out-of-network providers remain subject to authorization.
Behavioral Health Carve-in
Behavioral health coverage changes
Behavioral Health Carve-In (effective 1/1/2023): Effective 1/1/2023, additional behavioral health services are carved into the Medicaid Advantage Plus (MAP) Plan benefit package; service-specific coverage changes and hospital vs freestanding status are detailed in the carve-in crosswalk tables.
Refer to the crosswalk charts for specifics on each OMH/OASAS service before and after January 1, 2023.
Outpatient and DME Prior Authorization
Outpatient and DME services requiring prior authorization
Selected outpatient/DME services: Sleep studies (including home sleep studies), specified diagnostic testing, wireless capsule endoscopy/motility capsule (91110–91113), certain gastroenterology procedures, infectious agent detection by DNA/RNA (87483), CPT 43290 when performed in any place of service, penile prosthesis (54405), and other listed services (e.g., 96547, 96548, 97037) require prior authorization.
Some genetic tests (CPT 81220, 81329, 81336, 81420) do not require authorization; limits apply as noted (CPT 81220 lifetime limit = 1; CPT 81329 and 81336 combined limit = 1 per lifetime).
Outpatient Home Therapy (PT/OT/ST)
Outpatient therapy coverage and authorization rules
Outpatient Home Therapy PA: Effective 10/1/2021, all outpatient home therapy services (PT/OT/ST) performed by a therapy provider require prior authorization through National Imaging Associates (NIA); the initial evaluation requires authorization and CPT 92610 and 92611 do not require authorization.
This requirement excludes PT/OT/ST performed in inpatient settings, emergency room, SNF/sub-acute rehabilitation, or during an observation stay; authorization submission timelines vary by setting.
Outpatient and Therapeutic Services
Therapeutic and other outpatient services coverage stance
Services requiring PA: Listed outpatient procedures, specified therapeutic services (including radiation therapy delegated to NIA), interventional pain management and certain phototherapy/chiropractic/hyperbaric services require prior authorization per the outpatient services list.
Some services are not covered (e.g., ambulatory continuous glucose monitoring 95249) and some therapy evaluation codes (92610, 92611; speech-language evals 92610/92611) do not require authorization as noted.
Counseling Services (MNT, DSMT)
Nutrition and DSMT coverage
Medical Nutrition Therapy: Medical nutrition therapy by a licensed nutrition provider is covered for members with a diagnosis of diabetes; eight visits per year are covered without authorization using codes 97802, 97803, G0270, and G0271.8 visits/year
Diabetes Self-Management Training (DSMT): DSMT is covered up to 10 hours / 20 units in a continuous 12-month period when provided by certified providers and no longer requires authorization.10 hours/20 units per 12 months
Pharmacy Drug Authorization
Pharmacy and Part D/Part B drug authorization rules
Oncology and select medications: Oncology medications and supportive agents require prior authorization from Evolent (formerly New Century Health) for participating providers prior to dispensing or administration; non-participating provider oncology requests require review by Wellcare By Fidelis Care and submission via fax to the plan.
PA contact information and submission instructions are provided on the Fidelis website and in the document.
Part D drug coverage: Covered Medicare Part D drugs must be prescribed for FDA-approved indications or uses supported by Medicare-approved compendia; formulary and prior authorization criteria are maintained on the Fidelis website.
CPT code 20610 is listed as non‑covered when billed for joint injection of hyaluronic acid for the treatment of osteoarthritis of the knee with diagnosis codes M17.0, M17.10–M17.12. This non‑coverage applies regardless of place of service when the code is used for that indication.
Ambulatory continuous glucose monitoring using CPT 95249 is specified in the policy extract as a not covered service.
The document contains multiple HCPCS/J‑code to product mappings and examples (for example entries in chunks showing mappings such as J0174, J1555, and others). These sections present mappings and related Medicare entries but do not state additional explicit exclusions within the cited excerpts.
The policy states that authorization is not required for ophthalmic indications for the mapped Medicare/HCPCS entries shown in this section.
CPT 96110 is identified in the behavioral health testing section as a non‑covered service.
The policy extract explicitly states that topical oxygen is not a covered service.
The cited J‑code listing and related prescription‑drug information chunks do not include language categorizing services as 'not medically necessary' in the provided excerpts.
Code Lists and Billing Status
Transplant and related procedure codesCPTCovered
32850
transplant-related code listed
32851
transplant-related code listed
32852
transplant-related code listed
32853
transplant-related code listed
32854
transplant-related code listed
32855
transplant-related code listed
32856
transplant-related code listed
33930
transplant-related code listed
33931
transplant-related code listed
33945
transplant-related code listed
1–10 of 64
1/7
Outpatient surgery, behavioral health, and related CPT/HCPCS codes requiring authorizationmixedCovered
15820
Blepharoplasty
15821
Blepharoplasty
15822
Blepharoplasty
15823
Blepharoplasty
11920-11971
Breast reconstruction range
19300
Breast procedure
19316-19342
Breast procedure range
19355
Breast procedure
19370-19396
Breast procedure range
43770
Bariatric surgery
1–10 of 45
1/5
Outpatient/DME and special procedure codesmixed
20610
Joint injection — specifically non-covered for hyaluronic acid for osteoarthritis of knee when diagnosis M17.0, M17.10-M17.12
91110
Wireless Capsule Endoscopy
91111
Wireless Capsule Endoscopy
91112
Wireless Motility Capsule
91113
Wireless Motility Capsule
87483
Infectious agent detection by DNA or RNA
43290
Procedure requiring authorization in any place of service
54405
Penile prosthesis
96547
Other service listed
96548
Other service listed
1–10 of 15
1/2
DME codes not requiring authorizationHCPCSCovered
L3100
DME code listed as not requiring authorization
L3221
DME code listed as not requiring authorization
L3762
DME code listed as not requiring authorization
L4350
DME code listed as not requiring authorization
L5991
DME code listed as not requiring authorization
L7360
DME code listed as not requiring authorization
L7362
DME code listed as not requiring authorization
L7364
DME code listed as not requiring authorization
L7366
DME code listed as not requiring authorization
L8695
DME code listed as not requiring authorization
1–10 of 14
1/2
Orthotic codes not requiring authorization (partial list)HCPCSCovered
mirvetuximab soravtansine (Elahere); J9311; rituximab and hyaluronidase
Oncology & specialty agents (continued)HCPCS
J9118
calaspargase pegol-mknl (Asparlas); J9316
J9144
daratumumab
J9203
gemtuzumab (Mylotarg)
J9223
lurbinectedin (Zepzelca)
J9255
methotrexate (Accord); J9350
J9258
paclitaxel protein-bound particles
Medicare HCPCS/Q/J code mappingsmixed
J9203
mapped to gemtuzuma (Mylotarg) and other entries in list
J9204
mapped to mogamulizumab-kpkc (Poteligeo) and related entries
J9210
mapped to emapalumab-Izsg (Gamifant) and other entries
J9216
mapped to interferon gamma-lb and related entries
J9223
mapped to lurbinectedin (Zepzelca)
J9225
mapped to histrelin implant (Vantas)
J9227
mapped to isatuximab-irfc (Sarclisa) and Imjudo reference
J9229
mapped to inotuzumab (Besponsa)
J9247
mapped to melphalan flufenamide and tafasitamab-cxix (Monjuvi)
J9255
mapped to methotrexate (Accord)
1–10 of 25
1/3
Authorization exceptionsmixed
ophthalmic
authorization not required for ophthalmic indications (note rather than a numeric code)
BRCA / Genetic testing lifetime limits
CPT 81220 lifetime limit1 lifetime
CPT 81329 + 81336 combined limitCombined limit of 1 per lifetime
Authorization requirement for BRCA/genetic testing
Provider Responsibilities, Authorization Routing, and Documentation
Prior Authorization
Inpatient Authorization Required
All inpatient admissions require prior authorization. Emergency services for stabilization do not require authorization, but post-stabilization services and inpatient admissions following ER services do. Unauthorized inpatient admissions may be denied; facility admissions are reviewed for medical necessity.
All solid organ and bone marrow transplants require authorization at time of transplant evaluation.
Prior Authorization
Specific CPTs Require Prior Authorization
Certain outpatient procedures and services listed by CPT require prior authorization. Providers should consult delegated vendors (TurningPoint, Evolent/NIA) where applicable and follow delegated routing for code-specific authorization. Examples include many ENT, cardiac, orthopedic, spinal, bariatric, cosmetic, dermatologic, and other surgical CPTs.
Background and Scope
This policy document provides authorization requirements and identifies specific coverage exceptions implemented during the COVID‑19 update. Inpatient admissions require prior authorization and are reviewed for medical necessity; however, limited authorization exceptions with conditions are described for OMH‑licensed pediatric inpatient mental health (first 14 days when notification and required documentation are provided) and OASAS‑licensed in‑state inpatient SUD facilities (first 28 days when LOCADTR notification, daily clinical review, and discharge planning requirements are met).
Key Definitions
LOCADTR (OASAS clinical tool)
LOCADTR purposeClinical medical necessity tool for OASAS inpatient SUD admissions to document level of care and guide treatment planning
LOCADTR use requirementFacilities must use LOCADTR and notify Fidelis Care of inpatient admission and initial treatment plan within two business days
Concurrent review exceptionInpatient SUD services at OASAS-licensed in-state, in-network facilities are not subject to authorization or concurrent review for the first 28 days when LOCADTR notification and daily clinical review are performed
Two-Day Notification and Initial Treatment Plan (OMH requirement)
Two-Day Notification requirementFacility must notify Fidelis Care of the admission and initial treatment plan within two business days using the OMH Two-Day Notification and Initial Treatment Plan email
Applies to
Policy Revision History
2023-01-01policy_changeLatest
Behavioral Health services were carved into the Medicaid Advantage Plus (MAP) Plan benefit package (Behavioral Health Carve-In effective 1/1/2023).
Policy Summary
PayerFidelis Care
PolicyAuthorization and Coverage Guidance — Prior Authorization, Exceptions, and Coding
Policy CodePolicy N/A
Change TypeNo material clinical or coverage changes
Effective DateJan 1, 2020
Next Review DateN/A
Key ActionObtain prior authorization for all inpatient admissions and for the listed outpatient, transplant, surgical, and selected DME services.
DSMT maximum coverage10 hours / 20 units in a continuous 12-month period
Provider requirementServices must be provided by certified providers
Authorization statusDSMT no longer requires authorization when billed within limits
Blepharoplasty: 15820-15823
Breast reconstruction: 11920-11971, 19300, 19316-19396, 19355, 19370-19396
Bariatric surgery: 43770-43774, 43888 (S2083 no longer requires authorization as of 8/1/22)
Selected skin surgery codes (e.g., 10040, 11300-11307 require auth if ambulatory surgery POS 24)
Spinal surgery codes: 20932-20934, 22867-22870, 62380
ENT/cardiac code lists delegated to TurningPoint (refer to vendor lists)
Orthopedic/spinal procedures delegated to Evolent (NIA) (refer to vendor lists)
Prior Authorization
Therapeutic Services Prior Authorization
Therapeutic services such as radiation therapy, hyperbaric oxygen, chiropractic, phototherapy, interventional pain management, and certain injections require prior authorization or are delegated to NIA for review. Radiation therapy prior authorization is delegated to NIA.
Radiation Therapy Services: PA delegated to NIA; see vendor code list.
Phototherapy and chiropractic services require authorization where listed.
Note
Prior Authorization Not Specified in Extract
Some listings in the source are code-to-drug or HCPCS mappings without explicit prior authorization rules stated in this extract. Where no PA statement appears, follow the general pharmacy/infusion and Part B guidance and check the formulary or specific program links.
Extensive J-/Q-code mappings are documented; many are associated with Medicare Part B drug programs — refer to Fidelis prescription drug information for PA requirements.
Authorization is not explicitly stated for many listed injectable mappings in these chunks; confirm via formulary or program pages.
Prior Authorization
Outpatient Home Therapy Requires Prior Authorization (NIA)
Outpatient Home Therapy — PT, OT, ST — requires prior authorization through National Imaging Associates (NIA) for services rendered on or after 10/1/2021. Initial evaluations in office or facility settings do not require authorization, but subsequent therapy visits and home-based services do and must be routed to NIA within the stated timelines.
Effective 10/1/2021, all outpatient home therapy (PT/OT/ST) requires PA through NIA.
Initial evaluations performed in office/facility do not require authorization; other billed therapy codes the same date still require PA.
Authorization requests for outpatient settings should be sent to NIA within 1 business day; for home health settings within 2 business days.
Therapy requests in inpatient settings (POS 31 & 32 SNF/Sub-Acute) to be sent to fax 833-663-1611.
Prior Authorization
Prior Authorization Required for Listed Outpatient Services
Certain outpatient and DME services explicitly require prior authorization. Examples include sleep studies, some genetic testing (with specified CPT exceptions), gastroenterology procedures, wireless capsule studies, penile prosthesis, and other listed procedures.
Sleep studies, including home sleep studies, require authorization.
Certain gastroenterology procedures and specified CPTs (e.g., 43235,43239,43248,45378,45380,45384,45385,46255,46260,46270) require authorization in POS 19/22 when office/ASC is available; not required in POS 11 or 24.
Genetic testing: BRCA and other tests require authorization except CPTs 81220, 81329, 81336, 81420 which are not required (lifetime limits noted).
Note
None Explicitly Stated in These Chunks — Verify via Vendor/Fidelis Sites
Some chunks contain statements indicating no explicit additional provider actions or requirements beyond general review and delegation notes. When the source states 'none explicitly stated' in these chunks, providers should verify via vendor portals or Fidelis program pages.
Where no explicit PA or step therapy rule is present for a code/program in this extract, confirm requirements on the Fidelis website or delegated vendor portals.
Examples include many oncology drug code mappings without a standalone PA statement in these chunks.
Denial Risk
Out-of-Network Authorization and Cost Risk
Out-of-network services for Medicare Advantage may be covered with authorization but can incur additional copays and deductibles. Providers should confirm member plan (e.g., Medicare Advantage Flex Plan 003, Medicare Advantage without RX 001) and advise members of potential financial risk.
Out-of-network services require an authorization for specified Medicare Advantage plans.
Additional co-pays and deductibles may apply for out-of-network services.
Prior Authorization
Authorization Routing and Timelines
Authorization routing and timelines: use delegated vendors where indicated (NIA, TurningPoint, Evolent). Therapy authorizations to NIA must be submitted within operational timelines (1 business day for outpatient, 2 business days for home health after initial evaluation). Specific fax numbers and vendor contact details are provided for inpatient and SNF/sub-acute settings.
Prior authorizations delegated to NIA for radiology and therapy services — use NIA portals per instructions.
Therapy authorization timing: outpatient settings—within 1 business day; home health—within 2 business days.
TurningPoint and Evolent delegated code lists require requests directed to those vendors per their instructions.
Documentation Required
Documentation and Submission Requirements (When Specified)
Documentation and submission requirements are variably specified; some services require notification and initial treatment plan submission (OMH/OASAS inpatient behavioral health/SUD), while other code lists lack submission details in this extract. Providers must follow the specific program instructions for documentation when stated.
OMH inpatient pediatric: facility must notify Fidelis and send initial treatment plan within two business days.
OASAS in-state/licensed inpatient SUD: facility must notify Fidelis and send initial treatment plan within two business days; daily clinical review and periodic consultation required.
Where no documentation or submission requirement is specified for a listed code in these chunks, verify via the vendor or Fidelis program pages.
Documentation Required
Voicemail / HIPAA-Compliant Mailbox Requirement
Voicemail requirements for Utilization Management: providers may receive detailed UM messages only if their voicemail is HIPAA-compliant and greetings identify the mailbox owner. Otherwise, generic messages will be left and a callback requested. UM will make a second direct attempt when required by the Department of Health Reasonable Effort Policy.
UM voicemail must be HIPAA-compliant to receive PHI-detailed messages.
Voicemail greetings must specifically identify the mailbox owner.
If not HIPAA-compliant, only a generic message will be left requesting a callback.
UM will make a second attempt to reach the provider directly as required.
Step Therapy
Step Therapy — No Rules Present in These Chunks
Step therapy: the document references Part B step therapy programs and links to Part B Step Therapy Policy, but no explicit step therapy rules are present in these chunks. Providers should consult the Part B Step Therapy Policy link for details.
Part B Step Therapy applies to a listed set of drugs—refer to the Part B Step Therapy Policy link for the drug list and rules.
No specific step therapy rules are described in these extract chunks; verify on Fidelis formulary/program pages.
OMH-licensed inpatient mental health admissions for members under age 18 in NYS participating in Fidelis network
Concurrent review exceptionFidelis Care will not conduct concurrent utilization review during the first 14 days of admission when notification and daily clinical review/consultation occur