Fidelis Care prior auth Coverage & Policy Update

Coverage Criteria and Limits

Inpatient admission authorization

Covered when ALL of the following are met

Inpatient admission authorization: All inpatient admissions require prior authorization and are reviewed for medical necessity; emergency room services or any emergent service required to provide stabilization do not require authorization, but inpatient admissions following emergency room stabilization do require authorization.

Failure to obtain authorization for an inpatient admission (except emergency stabilization) may result in services being reviewed for medical necessity and potentially denied.

OMH-licensed inpatient mental health (age <18)

Covered without prior authorization for initial period when ALL conditions met

OMH in-state youth inpatient: Inpatient mental health treatment for members under age 18 provided by OMH-licensed hospitals in New York State that participate in Fidelis Care's network are not subject to authorization review for the first 14 days provided the facility: (1) notifies Fidelis Care of the admission and initial treatment plan within two business days using the OMH Two-Day Notification and Initial Treatment Plan form, (2) performs daily clinical review of the patient, and (3) participates in periodic consultation with Fidelis Care using evidence-based, peer-reviewed clinical review criteria approved by OMH.14 days

After 14 days, services may be subject to concurrent or retrospective review.

OASAS-licensed inpatient SUD

Covered without prior authorization for initial period when ALL conditions met

OASAS in-state inpatient SUD: Inpatient detoxification, inpatient rehabilitation and inpatient residential SUD services provided by OASAS-licensed New York State facilities participating in Fidelis Care's network are not subject to authorization review and are not subject to concurrent utilization review for the first 28 days of the inpatient admission provided the facility: (1) notifies Fidelis Care of the inpatient admission and initial treatment plan within two business days (by fax or email) and submits the OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool, (2) performs daily clinical review, and (3) begins periodic consultation with Fidelis Care by about day 14 to ensure use of the LOCADTR tool.28 days

Services may be subject to utilization review after day 28 and all services may be reviewed retrospectively.

Outpatient therapy

Covered when ALL of the following are met

Outpatient therapy: The initial evaluation for physical, occupational, and speech therapy does not require authorization; all subsequent therapy visits (including swallow function and related therapy) require prior authorization.

Members enrolled in Fidelis Dual Advantage Flex have specified annual dollar limits for therapy services.

OB ultrasound limits

Covered with limits

OB ultrasound frequency: The first four OB ultrasounds may be performed without authorization. Five or more ultrasounds for a normal pregnancy require authorization. OB ultrasounds for a high-risk pregnancy do not require authorization.4 ultrasounds

Diagnosis codes distinguish normal versus high-risk pregnancy as listed in the policy (e.g., Z32.01 for pregnancy encounter; O09.611–O09.613 for high-risk pregnancy examples).

MNT and DSMT coverage

Coverage for nutrition and diabetes self-management services

MNT coverage: Medical Nutrition Therapy (MNT) provided by a licensed nutrition provider is covered for members with diabetes diagnoses when billed with MNT visit codes (97802, 97803, G0270, G0271) and is covered without prior authorization.

Providers should bill the listed MNT codes for covered visits.

DSMT coverage: Diabetes Self-Management Training (DSMT) services are covered when provided by certified providers up to 10 hours (20 units) in a continuous 12-month period and do not require authorization.10 hours / 20 units

Coverage applies per continuous 12-month period.

Topical oxygen is not a covered service. Providers should not bill Fidelis Care for topical oxygen therapy as a covered benefit.

Topical oxygen is not a covered service. This exclusion applies to all member populations covered under this policy.

For members with a diagnosis of Low Back Pain, certain services are not covered. Specifically, therapeutic injections of steroids into intervertebral discs and prolotherapy are listed as non-covered services. In addition, the policy lists various pain management and injection procedure codes that require prior authorization or are otherwise addressed elsewhere in the policy.

No additional miscellaneous coverage exclusions are explicitly listed in the referenced sections beyond those already noted in therapeutic services and the Medicare drug/code listings. Where specific exceptions are identified for drug authorizations (for example, oncology or ophthalmic indications), providers should follow the documentation guidance in the policy to support any authorization exemptions.

Code 96110 is identified in the policy as a non-covered service and should not be billed as a covered outpatient behavioral health service.

The referenced Medicare drug and HCPCS code listings do not contain explicit statements using the phrase 'not medically necessary' in the cited chunks. Where authorization exceptions are noted (for oncology or ophthalmic indications), the policy states authorization is not required for those indications and providers should document the indication accordingly.

Codes and Billing Rules

Outpatient surgery codes requiring authorization (examples)CPTCovered

15820-15823

Blepharoplasty

Bariatric surgerymixedCovered

43770-43888	Bariatric surgery codes
S2083	Bariatric related HCPCS

Behavioral health testing and ECTCPTCovered

96112	Psychological testing
96113	Psychological testing
96116	Neuropsychological testing (requires authorization)
96121	Neuropsychological testing (requires authorization)
96130-96139,96146	Various assessment/testing codes requiring authorization
90870	Electroconvulsive therapy (ECT) - requires authorization

OB ultrasound diagnosis codes referencedICD-10

Z32.01	Encounter for pregnancy test
O09.611-O09.613	High risk pregnancy codes (examples cited)

DME/orthotic codes exempt from authorization (examples)HCPCSCovered

L3650	Orthotic code (no authorization)
A4604	DME code (no authorization)

Diagnostic testing and therapeutic servicesCPTCovered

95249	Ambulatory continuous glucose monitoring (requires authorization)
91110-91112	Wireless capsule/motility endoscopy
87483	Infectious agent detection by DNA/RNA

Telehealth codes requiring authorizationCPTCovered

G2010	Remote evaluation of recorded video and/or images (telehealth) - authorization required
G2012	Brief communication technology-based service - authorization required

Therapeutic and procedure CPT codesCPT

96567	Phototherapy
96573-96574	Phototherapy
96900	Phototherapy
96910	Phototherapy
96912	Phototherapy
96913	Phototherapy
96920	Phototherapy
63622	Spinal procedure (no auth required for ortho specialties per note)
63688	Spinal procedure (no auth required for ortho specialties per note)
20526	Injection

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Telehealth codes requiring authorizationCPT

G2010	Telehealth/virtual check-in
G2012	Telehealth/virtual check-in

Counseling / MNT codesCPTCovered

97802	MNT initial assessment and intervention
97803	MNT re-assessment and intervention
G0270	MNT group or related
G0271	MNT individual

Enteral therapy HCPCS requiring authorizationHCPCS

B4034-B4162

Enteral formulas/disposable items requiring authorization

Pharmacy / HCPCS drug code listings (partial large list)HCPCS

J0587	Drug HCPCS mapping (listed among many injectables)
C9047	C9047 series mapping to specific biologics
C9399	Unclassified drugs/biologics
J0178	Various high-cost injectables listed
J7200-J7209	Factor and specialty drug HCPCS series
J7311-J7360	Various J-codes listed for specialty drugs and implants
Q2041-Q2053	CAR-T and cellular therapy codes
Q5103-Q5123	Biosimilar HCPCS codes listed
Q9991-Q9992	Buprenorphine ER (Sublocade) HCPCS
S4981-S4993	Contraceptive product HCPCS

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Medicare J-codesHCPCSCovered

J9313	moxetumomab pasudotox-
J9314	romidepsin (Istodax)
J9316	pertuzumab, trastuzumab and.
J9317	hyaluronidase-zzxf (Phesgo) sacituzumab govitecan-hziy (Trodelvy)
J9348	naxitamab-gggk (Danyelza)
J9349	tafasitamab-cxix (Monjuvi)
J9355	trastuzumab (Herceptin)
J9356	trastuzumab hyal (Herceptin Hylecta)

Medicare Q-codes (selected)HCPCSCovered

Q2041	axicabtagene (Yescarta)
Q2042	tisagenlecleucel (Kymriah)
Q2043	sipuleucel-T (Provenge)
Q2053	Brexucabtagene autoleucel (Tecartus)
Q5103	infliximab-dyyb (Inflectra)
Q5104	infliximab-abda (Renflexis)
Q5107	bevacizumab-awwb (Mvasi)
Q5108	pegfilgrastim-jmdb (Fulphila)
Q5109	infliximab-qbtx (Ixifi)
Q5110	filgrastim-aafi (Nivestym)

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Medicare Q and S codes and othersHCPCSCovered

Q5122	pegfilgrastim-apg (Nyvepria)
Q5123	rituximab-arrx (Riabni)
Q9991	buprenorphine ER < 100 mg (Sublocade)
Q9992	buprenorphine ER >100 mg (Sublocade)
S4981	levonorges intrauter system
S4993	Contraceptive pills for birth control
S0191	misoprotol, oral (Cytotec)
S0122	menotropins (Menopur)
S0126	follitropin alfa (Gonal-f)
S0128	follitropin beta (Follistim)

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OB ultrasound count — First 4 without authorization; 5+ require authorization

Allowed without prior authorizationFirst 4 OB ultrasounds may be performed without prior authorization.

Authorization thresholdFive or more ultrasounds for a normal pregnancy require prior authorization.

High-risk pregnancy exceptionOB ultrasounds for a high-risk pregnancy do not require authorization (high-risk diagnosis codes cited).

Provider Requirements and Authorization Actions

Prior Authorization

Therapeutic and Radiation Therapy Prior Authorization Required

Providers must obtain prior authorization for the listed therapeutic services, select procedures, and radiation therapy as specified below. Failure to obtain required authorizations may result in services being reviewed for medical necessity and potential denial.

Therapeutic services (see list) and most outpatient therapy visits require prior authorization; the initial evaluation for Physical, Occupational, and Speech Therapy does not require authorization, but all subsequent visits do.
Pain management procedures and related codes (including injections, TENS, therapeutic services) require prior authorization — examples listed in policy (e.g., 20526, 20550-20553, 21073, 27096, 62263-62264, 62273, 62280-62282, 62290).
Radiation therapy services require prior authorization through eviCore healthcare; a full list of CPT codes is available at evicore.com/healthplan/fideliscare.
Hyperbaric oxygen therapy, phototherapy (96567, 96573-96574, 96900, 96910, 96912, 96913, 96920), chiropractic services, and specified procedures (e.g., bronchial thermoplasty 31660, 31661; radiofrequency ablation of uterine fibroids 58674) are subject to authorization when indicated.
Certain procedure exceptions: CPTs 63622 and 63688 do not require authorization for requests from orthopedic specialties.

Background and Scope

This document provides administrative clinical-management rules for authorization and utilization review across inpatient, behavioral health, surgical, diagnostic, DME, therapy and pharmacy services. All inpatient admissions require prior authorization except for emergency room services for stabilization; admissions following ER care must be authorized and are subject to medical necessity review.

Special rules apply to state-licensed behavioral health facilities: in-network OASAS-licensed inpatient SUD facilities are exempt from prior authorization for the initial 28 days when required notifications and form submissions are timely and facility review/consultation requirements are met; OMH-licensed in-state inpatient mental health care for members under 18 is exempt for the initial 14 days if the facility notifies Fidelis Care and performs the required clinical review and consultation activities.

Prior authorization is required for a broad set of outpatient procedures and services identified in the policy (examples include specified outpatient surgery codes, therapeutic services and pain management codes, ambulatory continuous glucose monitoring 95249, and telehealth/virtual check-in codes G2010 and G2012). Enteral therapy HCPCS codes B4034-B4162 and many listed drug HCPCS/J/Q codes also require prior authorization per the policy lists.

Providers must follow the submission and vendor-specific procedures described in the policy: pharmacy injectable prior authorizations are submitted to the Pharmacy Team via e-fax; vision prior authorizations are handled by Davis Vision; and certain drug authorizations may be exempt for oncology or ophthalmic indications when supported by documentation.

Failure to obtain required prior authorization can result in services being reviewed for medical necessity and potentially denied. Facilities licensed by OMH/OASAS must notify Fidelis Care of admissions and initial treatment plans within specified timeframes and participate in required daily review and consultation to maintain initial authorization exemptions.

For radiation therapy, prior authorization must be obtained through eviCore as specified in the policy. Providers should consult the policy lists and procedural instructions for specific code-level requirements and any applicable delegation arrangements.

Definitions and Vendor Details

OASAS/OMH licensed facilities — Definition and special in‑network rules (NY)

DefinitionIn-state New York State facilities licensed, certified, or otherwise authorized by OASAS (substance use) or OMH (mental health) and participating in Fidelis Care's provider network.

OASAS special ruleIn-network OASAS‑licensed inpatient SUD facilities are not subject to authorization review and are exempt from concurrent utilization review for the first 28 days if the facility notifies Fidelis Care of admission and initial treatment plan within two business days and submits the OASAS Appendix A and LOCADTR forms; daily clinical review and periodic consultation are required.

OMH special ruleIn-network OMH‑licensed hospitals providing inpatient mental health care to members under 18 are not subject to authorization review and are exempt from concurrent review for the first 14 days if the facility notifies Fidelis Care within two business days using the OMH Two‑Day Notification form, performs daily clinical review, and participates in periodic consultation.

Medical Nutrition Therapy (MNT)

Covered diagnoses

OpenPayer

Authorization and coverage requirements for services (COVID-19 update)

Coverage Criteria and Limits

Codes and Billing Rules

Provider Requirements and Authorization Actions

Background and Scope

Definitions and Vendor Details