CurrentFidelis CarePolicy N/A

Authorization Grid Detail, Effective February 1, 2026

Defines which inpatient, outpatient, behavioral health, diagnostic, DME, therapy, pharmacy and other services require prior authorization, lists many specific CPT/HCPCS/J-codes and delegated vendors, and outlines special rules for OMH/OASAS facilities and carve-ins. This part is the first of two and contains authorization rules, delegated reviewers, code lists, and operational notes.

Policy Summary

PayerFidelis Care

PolicyAuthorization Grid Detail, Effective February 1, 2026

Policy CodePolicy N/A

Change TypeOperational authorization grid (no material coverage changes)

Effective DateFebruary 1, 2026

Next Review DateN/A

Key ActionProviders must obtain authorization for all inpatient admissions (except emergent stabilization); use inpatient ER fax 833-663-1602 for notifications.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — this authorization grid does not introduce material clinical or coverage changes.

1Inpatient admissions require authorization

3Delegated review vendors noted

MultipleCode lists included

2023-01-01Behavioral Health carve-in effective

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

HCPCS/CPT/J-codes listed

Policy summary and scope

This grid defines Fidelis Care's prior authorization requirements across inpatient, outpatient, behavioral health, durable medical equipment, therapy and pharmacy services. All inpatient admissions require authorization (emergent stabilization services excepted until post-stabilization), and specific outpatient and behavioral health procedures and tests are listed with authorization needed. The grid documents delegation of prior authorization to third-party reviewers (notably Evolent and TurningPoint, and Davis Vision for vision), includes oncology/pharmacy PA processes, and lists code groups (CPT/HCPCS/J-codes) requiring authorization. It also outlines special rules for New York State OMH-licensed mental health hospitals (age-based carve-outs and two-day notification to avoid concurrent review) and OASAS-licensed in-state inpatient SUD facilities (no prior authorization and no concurrent review for the first 28 days if notification and LOCADTR submission occurs within 2 business days).

Top-level thresholds & metadata

OB ultrasound countFirst 4 OB ultrasounds without authorization; five or more for a normal pregnancy require authorization

MNT visitsUp to 12 visits per year covered without authorization (97802/97803 or G0270/G0271)

DSMT unitsMembers allowed 10 hours (20 units) in a continuous 12‑month period; DSMT no longer requires authorization

Effective DateEffective February 1, 2026

PayerFidelis Care

Policy TitleAuthorization Grid Detail

Policy NumberN/A

StatusCURRENT

Coverage & utilization criteria (inpatient, rehab, transplants, OMH/OASAS)

Inpatient Admissions

All inpatient admissions require an authorization. Fidelis Care does not require authorization of emergency room services or any emergent service required to provide stabilization of an emergent condition. Fidelis Care does require authorization of post-stabilization services and inpatient admissions, after emergency room services are completed. All facility admissions are reviewed for medical necessity. Note: New fax number for Inpatient ER is 833-663-1602 (formerly 347-868-6411).

ALL of the following

All inpatient facility services - Medical, Substance Abuse, and Behavioral Health admissions require authorization.
Fidelis Care does not require authorization of emergency room services or any emergent service required to provide stabilization of an emergent condition; authorization is required for post-stabilization services and any inpatient admission after ER services are completed.
All facility admissions are reviewed for medical necessity.

Delegated prior-authorization and vendor contacts

Delegated Prior Authorization — Specific Service Areas

Certain specialty areas have prior authorization delegated to external vendors; when delegated, associated device HCPCS are also reviewed by the delegate.

Orthopedic and Spinal Surgical Procedures: Prior authorization required and delegated to Evolent as of 1/1/24 (Musculoskeletal Management Program transitioned to Evolent).
If a CPT code is delegated to Evolent, associated devices (HCPCS) will also be reviewed by Evolent.
ENT Surgical Procedures: Prior authorization delegated to TurningPoint Healthcare Solutions, LLC (some ENT delegation references to Evolent in other sections; see code groups).
Associated HCPCS reviewed by delegate.
Cardiac Surgical Procedures: Prior authorization delegated to TurningPoint Healthcare Solutions, LLC.

Required provider actions, submission rules, and billing notes

Prior Authorization

Obtain authorization for inpatient admissions

Obtain authorization for all inpatient admissions (emergent stabilization care is excluded until post-stabilization). Notify Fidelis using the new Inpatient ER fax (833-663-1602).

Emergent/stabilization services do not require authorization until post-stabilization
Use fax 833-663-1602 for inpatient ER notifications

Prior Authorization

Transplant authorization at evaluation

Authorization required at time of transplant evaluation for all solid organ and bone marrow/tissue transplants. Refer to the Transplant CPT list in the code_groups for the full set of CPT codes requiring authorization.

Authorization required at time of transplant evaluation
Transplant CPT list located in code_groups (see document code tables)

Code lists (grouped by category)

Transplant procedure CPTs (require authorization)CPTCovered

32850
32851
32852
32853
32854
32855
32856
33930
33931
33932

1–10 of 73

1/8

Outpatient surgery codes requiring authorization (representative groups)CPTCovered

43770	Bariatric
43772
43773
43774
43888
15820	Blepharoplasty
15821
15822
15823
11920-11971	Breast reconstruction/mammoplasty range

1–10 of 46

1/5

Behavioral Health codes requiring authorizationmixedCovered

96116	Psychological testing
96121
96130-96133	Neuropsych testing range
96136-96139
96146
96112	Developmental pediatric testing
96113
96110	Non-covered service (explicitly non-covered)
90870	Outpatient ECT
H0035	Partial hospitalization HCPCS

1–10 of 15

1/2

DME codes that do NOT require authorization (representative list)HCPCS

A4239
A4271
A4287
A4288
A4341
A4342
A4438
A4457
A4468
A4541

1–10 of 65

1/7

Orthotic codes that do NOT require authorizationHCPCS

L8480
L8485
L8505

OB ultrasound authorization rules (diagnosis driven)ICD-10Covered

Z32.01	Encounter for pregnancy test and childbirth
Z33.1	Pregnant state, incidental
Z34.00-Z34.03	Encounter for supervision of normal first pregnancy
Z34.80-Z34.83	Encounter for supervision of other normal pregnancy
Z34.9-Z34.93	Encounter for supervision of pregnancy, unspecified
O09.00-O09.03	Supervision of pregnancy with history of infertility
O09.1-O09.13	Supervision of pregnancy with grand multiparity
O09.211-O09.213	Supervision of pregnancy with history of previous caesarean delivery
O09.219
O09.291-O09.293-O09.299-O09.33	Various high-risk pregnancy codes listed

Therapy initial evaluation CPTs (do not require prior authorization)CPT

92610	Initial speech evaluation — does not require prior authorization
92611	Initial speech evaluation — does not require prior authorization

MNT and DSMT codesCPT|HCPCSCovered

97802	MNT initial
97803	MNT follow-up
G0270	MNT group code
G0271	MNT group code
G0108	DSMT - individual
G0109	DSMT - group

Listed J-codes (drug HCPCS) and associated productsHCPCS

J2778	multiple mappings in grid (see document rows)
J2779	multiple mappings in grid
J2781	multiple mappings in grid
J2782	multiple mappings in grid
J2786	multiple mappings in grid
J2787	multiple mappings in grid
J2799	multiple mappings in grid
J2801	multiple mappings in grid
J2802	multiple mappings in grid
J2804	multiple mappings in grid

1–10 of 82

1/9

Listed Q-, S-, and miscellaneous codes (facility/pharmacy/others)HCPCS|Other

J9308	ramucirumab (Cyramza) / polatuzumab mapping noted
J9311	rituximab and hyaluronidase (Rituxan Hycela)
J9312	rituximab (Rituxan)
J9313	moxetumomab pasudotox (Lumoxiti)
J9314	pemetrexed
J9316	pertuzumab/trastuzumab/hyaluronidase (Phesgo)
J9317	sacituzumab govitecan and hyaluronidase mapping
J9318	romidepsin
J9319	romidepsin lyophilized
J9321	epcoritamab and pemetrexed mappings

1–10 of 54

1/6

Specific oncology J-codes groupHCPCS

J9308	ramucirumab (Cyramza) / polatuzumab mapping noted
J9311	rituximab and hyaluronidase (Rituxan Hycela)
J9312	rituximab (Rituxan)
J9313	moxetumomab pasudotox (Lumoxiti)
J9314	pemetrexed
J9316	pertuzumab/trastuzumab/hyaluronidase (Phesgo)
J9317	sacituzumab govitecan and hyaluronidase mapping
J9318	romidepsin
J9319	romidepsin lyophilized
J9321	epcoritamab and pemetrexed mappings

1–10 of 31

1/4

Not otherwise classified / descriptive product listmixed

J9999

Not otherwise classified, antineoplastic drugs - Miscellaneous chemotherapy

Not otherwise classified / facility Q-codesHCPCS|Other

Q0138	pharmacy supply fee for initial immunosuppressive drug(s)
Q0155	pharmacy supply fee for oral anti-cancer/anti-emetic/immunosuppressive (first 30 days)
Q2041	cell therapies mapping (listed group)
Q2042	cell therapies mapping
Q2053	brexucabtagene autoleucel (Tecartus)
Q2054	lisocabtagene maraleucel (Breyanzi)
Q2055	idecabtagene vicleucel (Abecma)
Q2056	ciltacabtagene autoleucel (Carvykti)
Q2058	cell therapy / CAR-T related
Q9991	misc Q-codes and Q9998/Q9999 mappings

Listed J-codes (pharmacy/pharmacy-team PA) - quick referenceHCPCS

J2778	ranibizumab and related intravitreal agents (see grid)
J2779	ranibizumab variants / mappings
J2781	intravitreal implants / pegcetacoplan related
J2782	pegcetacoplan / related
J2840	sebelipase alfa and related mappings
J2998	unclassified drugs/biologics mappings
J7313	intravitreal/ocular implants
J7321	hyaluronan family
J7325	Synvisc and related
J7642	Ozurdex implant mapping

1–10 of 12

1/2

Pharmacy/oncology submission codes and feesHCPCS|Other

Q0138	pharmacy supply fee for initial immunosuppressive drug(s)
Q0155	pharmacy supply fee for oral anti-cancer/anti-emetic/immunosuppressive (first 30 days)
Q0510	pharmacy dispensing fee inhalation, per 30 days
Q0511	pharmacy dispensing fee inhalation, per 90 days
Q0512	pharmacy supplying fee for HIV PrEP
Q2041	cell therapy mapping
Q2053	Tecartus
Q2054	Breyanzi
Q2055	Abecma
Q2056	Carvykti

Not otherwise classified list (J9999 and misc)mixed

J9999	Not otherwise classified, antineoplastic drugs - Miscellaneous chemotherapy
Q9991	misc Q-codes
Q9998	ustekinumab (Selarsdi) mapping
Q9999	ustekinumab-aauz (Otulfi) mapping

Outpatient, DME, imaging and therapy rules

Outpatient and DME Services

Lists of CPT/HCPCS codes that require prior authorization in outpatient settings with place-of-service qualifiers and exceptions.

Diagnostic Testing: Sleep studies (including home sleep studies) require authorization; CPT 95805 and 95806 do not require authorization; wireless capsule endoscopy codes 91110-91113 require authorization; certain GI procedures require auth in POS 19/22 but not POS 11/24; infectious agent detection by DNA/RNA 87483 requires authorization.
BRCA/genetic testing exceptions: CPT 81220, 81329, 81336, 81420 do not require authorization; CPT 81220 lifetime limit 1; 81329/81336 combined limit 1 per lifetime.
Durable Medical Equipment: Many listed HCPCS DME codes do not require authorization (representative lists provided); other DME and orthotic codes require authorization; orthotic codes L8480, L8485, L8505 do not require authorization.
Home Health Care:

Behavioral health — outpatient authorization rules

Behavioral Health — Outpatient

Authorization removed for most outpatient behavioral health services except listed items which continue to require authorization.

Services that continue to require authorization: Psychological/Neuropsychological testing, Developmental Pediatric testing, Outpatient ECT, Partial Hospitalization, Intensive Outpatient, Transcranial Magnetic Stimulation (TMS) continue to require authorization.
Testing codes: 96116,96121,96130-96133,96136-96139,96146; Developmental 96112-96113 (96110 non-covered); Outpatient ECT 90870; Partial hospitalization revenue 912,913,944,945 and H0035; Intensive outpatient bill type 131, revenue 905 or 912, CPT 90899, S9480, H2013; TMS CPT 90867-90869 authorization required; requests via qhcmbh@fideliscare.org, fax 833-561-0098, or 1-888-FIDELIS ext 16072.
General note: Many outpatient behavioral health services no longer require authorization except the listed items above.
Behavioral Health carve-in effective 1/1/2023 referenced elsewhere.

Pharmacy, Part B drugs, injectables and mappings

Pharmacy / Part B Drugs and Injectables

Pharmacy benefit rules and prior authorization requirements for Part D and Part B drugs; many J-codes and HCPCS entries listed with associated drugs and mapping notes.

Part D / Part B rules: All covered Medicare Part D drugs must be prescribed for medically accepted indications; formulary, prior authorization, and step therapy criteria are available on Fidelis website links.
Enteral therapy HCPCS B4035-B4162 require authorization as Part B services.
Oncology medication delegation: Oncology medications and supportive agents require prior authorization from Evolent for participating providers before dispensing or administration.
Injectable PA submission:

Definitions

OASASNew York State Office of Addiction Services and Supports (licensing/certification body for SUD facilities)

OMHNew York State Office of Mental Health (licensing/certification body for mental health hospitals)

POSPlace of Service

Operational and administrative rules

Operational notes and submission endpoints:

Voicemail and reasonable-effort: Provider voicemail must be HIPAA-compliant (greeting identifies mailbox owner and organization and states PHI may be left) to receive detailed UM messages; otherwise a generic message will be left and a callback requested. A second direct attempt to reach the provider will be made as required by the Department of Health Reasonable Effort Policy.

Key contact/fax/email endpoints called out across the grid:

- Inpatient ER notifications: fax 833-663-1602 (new inpatient ER fax).

- Therapy (inpatient POS 31 & 32) prior auth: fax 833-663-1611.

- OASAS Appendix A and LOCADTR submissions: fax 833-663-1608 or LOCADTR@fideliscare.org.

- OMH Two-Day Notification (minors): fax 833-561-0094 or Mental_Health_Admission@fideliscare.org.

- Behavioral Health prior auth submissions (partial hospitalization / IOP / TMS): email qhcmbh@fideliscare.org, fax 833-561-0098, or call 1-888-FIDELIS and follow Behavioral Health prompts (ext 16072).

- Pharmacy/injectable PA e-fax (effective 10/1/2023): 1-844-235-5090 (also used for oncology requests by non-participating providers routed to Wellcare By Fidelis Care).

Other operational notes: outpatient/home therapy prior authorizations are routed through Evolent for dates of service on/after 10/1/2021 (timing: send request to Evolent within 1 business day for outpatient setting or 2 business days for home health; inpatient requests to Fidelis within 1 business day), and facilities must notify Fidelis within required windows to avoid concurrent review per OMH/OASAS rules.

Policy revision timeline

Policy Summary

PayerFidelis Care

PolicyAuthorization Grid Detail, Effective February 1, 2026

Policy CodePolicy N/A

Change TypeOperational authorization grid (no material coverage changes)

Effective DateFebruary 1, 2026

Next Review DateN/A

Key ActionProviders must obtain authorization for all inpatient admissions (except emergent stabilization); use inpatient ER fax 833-663-1602 for notifications.

SourceLink

On This Page

Providers must use new fax for Inpatient ER notifications: 833-663-1602 (formerly 347-868-6411).

Inpatient Rehabilitation Services

Inpatient Rehabilitation Services (acute, sub-acute, and skilled nursing rehabilitation) require authorization.

ALL of the following

Acute and sub-acute rehabilitation are authorized only when skilled services are provided.
Skilled nursing rehabilitation requires prior authorization.

Transplants

All solid organ and bone marrow/tissue transplants require authorization at the time of the transplant evaluation.

ALL of the following

All solid organ and bone marrow / tissue transplants require authorization at the time of the transplant evaluation.
Includes, but is not limited to, the listed CPT codes; See code_groups for full code list.

Elective Surgical Procedures — Inpatient vs Outpatient

Many surgical and medical procedures completed within 24 hours will not be approved as an inpatient level of care. Such procedures, when billed as outpatient within the Fidelis Care network, do not require authorization. Review the authorization grid for exceptions.

ALL of the following

Services completed within 24 hours from the onset of surgery are generally not approved as inpatient; when billed outpatient (in-network) they typically do not require authorization.
Examples include certain laparoscopic procedures and thyroid surgery if completed within 24 hours of the onset of surgery.
Providers should review the auth grid for any exceptions and consult the List of Inpatient Only Procedures for Medicare where applicable.

OASAS Licensed Inpatient SUD Treatment

OASAS-licensed inpatient Substance Use Disorder (SUD) treatment rules differ by facility licensing, location, and network participation.

ANY of the following

In-state, OASAS-licensed, in-network facilities
- Inpatient detoxification, inpatient rehabilitation and inpatient residential treatment services provided by New York State facilities licensed/certified/authorized by OASAS and participating in Fidelis Care's network are not subject to prior authorization review by Fidelis Care (effective 01/01/2020).
- These services are not subject to concurrent utilization review during the first 28 days of the inpatient admission provided that the facility notifies Fidelis Care of the inpatient admission and the initial treatment plan within two (2) business days of the admission.
- Notification may be via fax or email using the OASAS Appendix A Notification Form and the OASAS LOCADTR Medical Necessity Tool to fax: 833-663-1608 (formerly 646-829-1421) or LOCADTR@fideliscare.org.
- Facilities must perform daily clinical review of the patient; this does not require completing a LOCADTR concurrent review module every day.
- Facilities must periodically consult with Fidelis Care starting on or just prior to the 14th day of treatment to ensure LOCADTR use to determine medical necessity.
- Inpatient SUD services may be subject to utilization review after the 28th day from admission or upon discharge using the LOCADTR clinical review tool. Prior to discharge, facilities must provide the member and Fidelis Care with a written discharge plan determined using LOCADTR, and indicate whether services in the discharge plan are secured or reasonably available.
- All services may be reviewed retrospectively to assess clinical necessity.
Out-of-state, not OASAS-licensed, or out-of-network facilities
- Facilities outside New York State, not licensed/certified/authorized by OASAS, or not participating in Fidelis Care's network are required to request prior authorization review for Inpatient SUD services.
- All Inpatient SUD services provided by such facilities are subject to concurrent review throughout the admission.

OMH Licensed Inpatient Mental Health Treatment

OMH-licensed inpatient mental health treatment rules differ by member age, facility licensing, location, and network participation.

ANY of the following

Members under 18 at OMH-licensed in-network hospitals in NY
- Inpatient mental health treatment for members under age 18 provided by OMH-licensed hospitals in New York State participating in Fidelis Care's network are not subject to prior authorization review by Fidelis Care (effective 01/01/2020).
- Fidelis Care will not conduct concurrent utilization review during the first 14 days of inpatient admission provided that the facility: (i) notifies Fidelis Care of both the admission and the initial treatment plan within two business days by completing the OMH 'Two-Day Notification and Initial Treatment Plan' form and submitting it by fax to 833-561-0094 (formerly 718-896-1784) or by email to Mental_Health_Admission@fideliscare.org; (ii) performs daily clinical review of the patient; and (iii) participates in periodic consultation with Fidelis Care to ensure use of evidence-based, peer-reviewed clinical review criteria approved by OMH and appropriate to the patient's age to ensure medical necessity.
- All services may be reviewed retrospectively using the plan's clinical review criteria approved by OMH.
Members age 18+ or Out-of-State/Out-of-Network providers
- Inpatient mental health services for members age 18 and older require prior authorization review by Fidelis Care and are subject to concurrent review throughout the admission.
- Out-of-State and Out-of-Network providers must request prior authorization review for inpatient mental health treatment for members of all ages; services provided by such facilities are subject to concurrent review throughout the admission.

Out-of-Network and Unlisted Codes Authorization Requirements

Out-of-Network coverage and unlisted/temporary codes: Certain MA plans permit out-of-network (OON) coverage and all unlisted/temporary codes require authorization.

ALL of the following

Out-of-Network coverage is available only for specified Medicaid Advantage plans per plan terms; providers must verify member plan coverage for OON benefits prior to rendering services.
All unlisted and temporary CPT/HCPCS codes require prior authorization. Plans that reimburse OON providers may still require pre-authorization of the service and related codes.
See relevant plan documents and the auth grid for which MA plans allow OON coverage and for process to obtain authorization for unlisted/temporary codes.

Outpatient Surgery — Codes Requiring Prior Authorization

Outpatient Surgery — Codes Requiring Prior Authorization: The document lists numerous CPT/HCPCS codes and code ranges that require prior authorization for outpatient settings (POS 11, 22, and ambulatory surgery POS 24 where noted). Providers must obtain authorization for listed outpatient surgery codes when performed in the specified place of service.

ALL of the following

Bariatric surgery codes require authorization: 43770, 43772, 43773, 43774, 43888. (Note: S2083 no longer requires authorization as of 8/1/22).
Blepharoplasty codes: 15820, 15821, 15822, 15823 require prior authorization.
Breast reconstruction/mammoplasty codes: 11920-11971, 19300, 19303, 19316-19342, 19355, 19370-19396 require prior authorization.
Skin surgery and dermatological procedures: 11900, 15011, 15012 require authorization. Code 11730 requires authorization when billed with REV codes 0360, 0361 and 0490. Many auth requirements for skin surgery treatments and repairs have been removed; verify current auth grid.
Ambulatory surgery (POS 24) codes that continue to require authorization include (but are not limited to): 10040, 11300-11313, 11400-11471, 11721.
Dermal injections for Facial Lipodystrophy Syndrome (LDS) require authorization; coverage limited to individuals with HIV and secondary diagnosis of depression. Codes that may be covered with authorization: Q2026, Q2027, G0429.
Codes that continue to require authorization for any place of service include: A2030-A2039, 11200, 11201, 11719, 15769-15829, 17340-17999, Q4354-Q4397 (series as listed).
Freestanding ambulatory surgery center (bill type 0831) preauthorization required for: 10060, 11100, 17000, 20600, 20605, 20610.
Ear repair and ear piercing codes 69300 and 69090 require authorization when applicable.
Eyelid & ocular surgery codes (65760-65775 series and listed codes) require authorization when performed outpatient; see list for full codes.
Abdominoplasty/lipectomy/panniculectomy codes (15830, 15832-15839, 15847, 15876-15879) require authorization.
Facial cosmetic, septoplasty, rhinoplasty codes (21120-21296, 30400-30450, 30465-30520, 30620-30802, 30999, 31298, Q2028) require authorization; for CPT codes delegated to TurningPoint, submit authorization requests to TurningPoint.
Vascular procedure codes (e.g., 36465-36483, 36482-36483, 37241-37244, 37718-37764, 37767-37785) require prior authorization.
Spinal surgery codes such as 20932-20934, 22867-22868 require prior authorization.
This list is consolidated from the policy; verify the auth grid and delegated vendor code lists (Evolent, TurningPoint) for current delegated codes and associated device HCPCS reviews.

Counseling Services — Medical Nutrition Therapy and DSMT

Counseling Services — Medical Nutrition Therapy (MNT) and Diabetes Self-Management Training (DSMT) require authorization or follow coverage rules as specified by plan.

ALL of the following

Medical Nutrition Therapy and DSMT counseling services require prior authorization when the codes fall under the outpatient services requiring prior auth per the auth grid or when the member's plan requires authorization.
Effective January 1, 2020, certain outpatient substance use services (IOP, clinic visits, OTP, outpatient rehab, office visits/therapy) provided in-network/in-state do not require authorization; this carve-out does not change MNT/DSMT authorization requirements—verify plan-specific coverage.
Providers should confirm whether MNT/DSMT codes are delegated to a vendor or listed on the auth grid; obtain authorization when required and document medical necessity.

Services Provided by Outside Vendors

Services provided by outside vendors (delegated medical management vendors) require authorization through the delegated vendor where applicable.

ALL of the following

Orthopedic and spinal surgical procedures prior authorization has been delegated to Evolent (effective 1/1/24). If a CPT code is delegated to Evolent, associated devices (HCPCS codes) will also be reviewed by Evolent for medical necessity.
ENT and Cardiac surgical procedure prior authorizations have been delegated to TurningPoint Healthcare Solutions, LLC. For CPT codes delegated to TurningPoint, send prior authorization requests to TurningPoint; associated device (HCPCS) codes will also be reviewed by TurningPoint.
Verify current delegated code lists on the auth grid and submit requests to the appropriate vendor when codes are delegated.

Utilization Management - Voicemail Requirements

Utilization Management - Voicemail Requirements: Providers must follow voicemail and notification procedures when contacting Fidelis Care for authorization or utilization review inquiries.

ALL of the following

Providers calling for Behavioral Health authorization questions may contact Fidelis Care during regular business hours at 1-888-FIDELIS (1-888-343-3547), extension 16072.
Where voicemail is used, providers should leave a clear message including member name, member ID, date of admission/service, facility name, contact number, and a brief reason for the call; allow adequate business time for callbacks as specified by the vendor or Fidelis Care.
Specific fax numbers and email addresses for notification (e.g., Inpatient ER fax 833-663-1602; OASAS LOCADTR fax 833-663-1608 or LOCADTR@fideliscare.org; OMH two-day notification fax 833-561-0094 or Mental_Health_Admission@fideliscare.org) should be used in lieu of voicemail where forms/structured notifications are required.

Associated HCPCS reviewed by TurningPoint.

Radiology and Radiation Therapy Services: Prior authorization delegated to Evolent for radiology and radiation therapy services.

Outpatient Home Therapy PT/OT/ST: Prior authorization through Evolent effective for services on/after 2021-10-01; initial evaluation requires authorization and ongoing therapy requires authorization.

Oncology medications/supportive agents: Prior authorization required from Evolent for participating providers prior to dispensing/administration.

Oncology requests by non-participating providers require review by Wellcare By Fidelis Care.

External vendors named for delegated prior authorization include Evolent (musculoskeletal, radiology, radiation therapy, outpatient/home therapy and oncology medication reviews), TurningPoint (ENT and cardiac surgical procedures and some orthopedic/spinal lists), and Davis Vision for vision PAs. When delegated, requests should be submitted to the delegated vendor via their channels (Evolent web portal or phone for oncology: my.newcenturyhealth.com or 1-888-999-7713 option 1; pharmacy/injectable PAs to the Fidelis Pharmacy Team e-fax at 1-844-235-5090 for non-oncology injectables; oncology requests by non-participating providers routed to Wellcare by Fidelis Care via the same e-fax).

Documentation Required

Delegated prior-authorization vendors — submit to delegate when CPT is delegated

If the CPT/HCPCS is on a delegated list, submit prior-authorization requests to the delegated vendor (Evolent or TurningPoint) rather than to Fidelis. Delegated review includes associated device HCPCS when applicable. See delegated-vendor notes for service areas (orthopedic/spinal, ENT, cardiac, radiology, radiation, outpatient home therapy, oncology medications).

Prior Authorization

Submit OASAS Appendix A and LOCADTR for in-state OASAS inpatient SUD

In‑state OASAS‑licensed inpatient SUD: facility must notify Fidelis within 2 business days and fax/email the OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool to fax 833-663-1608 or LOCADTR@fideliscare.org. Periodic consultation with Fidelis is required starting on or near day 14.

Fax or email OASAS Appendix A and LOCADTR to fax 833-663-1608 or LOCADTR@fideliscare.org
Facility must notify Fidelis within 2 business days of admission
Periodic consultation required on/near day 14 to ensure LOCADTR use

Prior Authorization

OMH Two-Day Notification for minors

For OMH‑licensed NYS in‑network hospitals treating members under 18: facility must notify Fidelis of admission and initial treatment plan within 2 business days using the OMH Two‑Day Notification form to fax 833-561-0094 or email Mental_Health_Admission@fideliscare.org to avoid concurrent review for the first 14 days.

Submit OMH Two‑Day Notification and Initial Treatment Plan to fax 833-561-0094 or Mental_Health_Admission@fideliscare.org
If requirements met, Fidelis will not conduct concurrent utilization review during the first 14 days

Prior Authorization

Send oncology medication PAs to Evolent

Oncology medication and supportive-agent prior authorizations for participating providers must be submitted to Evolent via their web portal (my.newcenturyhealth.com) or by phone at 1-888-999-7713 (option 1). Oncology requests from non‑participating providers are reviewed by Wellcare By Fidelis Care (fax 1-844-235-5090).

Evolent portal: my.newcenturyhealth.com; phone 1-888-999-7713, option 1
Non‑participating provider oncology reviews: Wellcare By Fidelis Care fax 1-844-235-5090

Prior Authorization

Submit injectable (non-oncology) PA to Pharmacy Team

Submit PA requests for non‑oncology injectable drugs to the Pharmacy Team via e-fax to 1-844-235-5090 (new fax effective 2023-10-01).

E-fax for injectable (non‑oncology) PA submissions: 1-844-235-5090
Note effective date for this e-fax: 2023-10-01

Documentation Required

Therapy authorization timing and submission windows

Therapy authorizations: for outpatient settings (after initial evaluation) send authorization to Evolent within 1 business day; for home health send within 2 business days. Inpatient therapy (POS 31 & 32) prior authorization requests must be sent to Fidelis within 1 business day and faxed to 833-663-1611. Initial office/facility-based evaluations do not require prior authorization, but other billed codes on the same date do.

Outpatient: authorization request to Evolent within 1 business day after initial-eval codes
Home health: authorization request to Evolent within 2 business days
Inpatient POS 31 & 32: send prior authorization to Fidelis within 1 business day; fax 833-663-1611
Initial PT/OT/ST evaluation CPTs (92610, 92611 and designated initial evaluation CPTs) do not require prior authorization

Documentation Required

Delegated prior-authorization vendors — submit to delegated vendor when CPT is delegated

If a CPT code is delegated to Evolent or TurningPoint, providers must submit the prior-authorization request to that delegated vendor. Delegation covers the CPT and associated HCPCS device codes, which will be reviewed by the delegate.

Submit to delegated vendor when CPT appears on delegate list (Evolent or TurningPoint)
Associated HCPCS/device codes will also be reviewed by the delegate

Billing Rule

OB ultrasound counts and diagnosis-driven rules

OB ultrasound rules: the first four OB ultrasounds may be performed without authorization. Five or more ultrasounds for a normal pregnancy require authorization. High‑risk pregnancy diagnosis codes are exempt from authorization. See the code group 'OB ultrasound authorization rules (diagnosis driven)' for the specific diagnosis codes.

First 4 OB ultrasounds allowed without authorization
Five or more ultrasounds for a normal pregnancy require authorization
High‑risk pregnancy diagnosis codes (listed in code_groups) do not require authorization

Prior Authorization

Partial Hospitalization and Intensive Outpatient submissions

Partial hospitalization (Revenue codes 912, 913, 944, 945; HCPCS H0035) and intensive outpatient (bill type 131, revenue 905 or 912, CPT 90899, S9480, HCPCS H2013) require authorization. Behavioral Health authorization channels: email qhcmbh@fideliscare.org, fax 833-561-0098, or call 1-888-FIDELIS and follow Behavioral Health prompts or dial extension 16072.

Partial Hospitalization revenue codes: 912, 913, 944, 945; HCPCS H0035
Intensive Outpatient: bill type 131, revenue 905 or 912, CPT 90899, S9480, HCPCS H2013
Submit BH auths: qhcmbh@fideliscare.org; fax 833-561-0098; or call 1-888-FIDELIS and follow BH prompts or dial ext. 16072

Prior Authorization

Authorization required for out-of-network and unlisted/temporary codes

Out-of-network services for certain Medicare Advantage plans require authorization and all 'Unlisted' or 'Temporary' codes require prior authorization before billing. Medicare Advantage Flex Plan (003) and Medicare Advantage without RX (001) require authorization for OON services.

Medicare Advantage Flex Plan (003) and MA without RX (001) require authorization for OON services
All Unlisted/Temporary codes (e.g., C-codes) require authorization prior to billing

Documentation Required

Voicemail HIPAA compliance for UM messages

UM voicemail requirements: Voicemail messages about Utilization Management will be left only if the provider's voicemail is HIPAA‑compliant and the greeting identifies the mailbox owner, organization, and states the mailbox is confidential and PHI can be left. If not HIPAA compliant, a generic message requesting a callback will be left.

Voicemail greeting must identify owner and organization and state confidentiality/PHI allowed
If voicemail is HIPAA compliant, a detailed UM message will be left; otherwise only a generic message will be left

Denial Risk

Reasonable Effort Policy second attempt requirement

Per the Department of Health Reasonable Effort Policy, the UM department will make a second attempt to reach the provider directly when notifying of a UM determination. Failure to be reached on the second attempt may affect communication of determinations.

UM will make a second attempt to reach the provider as required by the Reasonable Effort Policy
Failure to be reached may affect communication of determinations

Effective 2021-09-20 for DOS on/after 2021-10-01, outpatient home therapy PT/OT/ST require prior authorization through Evolent; initial evaluation requires authorization.

Hospice care is covered through original Medicare.

Imaging / OB Ultrasound: First 4 OB ultrasounds can be performed without authorization; five or more ultrasounds for a normal pregnancy require authorization (diagnosis-driven); OB ultrasounds for high-risk pregnancy do not require authorization using specified diagnosis codes.OB ultrasound count: first 4 without authorization; 5+ require authorization for normal pregnancy

Prior authorization for radiology delegated to Evolent; cardiac ultrasounds delegated to TurningPoint.

Outpatient Therapy PT/OT/ST: Effective 2021-09-20 for DOS on/after 2021-10-01, services after the initial evaluation require prior authorization through Evolent; initial office/facility-based evaluations do not require prior authorization, but other billed codes on same date require authorization prior to billing.

If submitting codes other than initial evaluation, authorization request to Evolent within 1 business day for outpatient or 2 business days for home health, or to Fidelis within 1 business day for inpatient settings; therapy in inpatient POS 31 & 32 send prior auth to fax 833-663-1611.

Submission routing: Non-therapy providers (MD/DO/DPM) should request prior authorization for all services after the initial evaluation directly through Fidelis Care.

Documentation Required

Therapy authorization timing and submission windows — cross‑reference

(Cross‑reference) See the therapy authorization callout for submission windows and vendor details; providers may duplicate this callout if additional prominence is needed.

Refer to therapy authorization timing: outpatient 1 business day (Evolent), home health 2 business days (Evolent), inpatient fax 833-663-1611

Prior Authorization

Partial Hospitalization and Intensive Outpatient submissions (Behavioral Health)

Behavioral Health-specific: Partial hospitalization and intensive outpatient require authorization (Revenue codes 912, 913, 944, 945; HCPCS H0035; bill type 131, revenue 905/912, CPT 90899, S9480, H2013). Submit BH authorizations to qhcmbh@fideliscare.org, fax 833-561-0098, or call 1-888-FIDELIS and follow BH prompts or dial extension 16072.

Partial Hospitalization: rev 912, 913, 944, 945; HCPCS H0035
Intensive Outpatient: bill type 131; revenue 905 or 912; CPT 90899, S9480, H2013
BH auth channels: qhcmbh@fideliscare.org; fax 833-561-0098; phone 1-888-FIDELIS (BH prompts) or ext. 16072

Providers should submit PA requests for listed injectable (non-oncology) codes to the Pharmacy Team via e-fax 1-844-235-5090 (effective 10/1/2023).

Self-administered drugs fall under the pharmacy benefit.

Pharmacy-specific J-code quick reference (non-oncology injectables/compound mappings)HCPCS

J2778	ranibizumab / intravitreal agents (multiple mappings)
J2779	ranibizumab variants / mappings
J2781	intravitreal implant / pegcetacoplan-related
J2782	pegcetacoplan / avacincaptad mappings
J2786	avacincaptad / reslizumab mappings
J2799	reslizumab / miscellaneous
J2801	risperidone injectables (mappings)
J2802	romiplostim / clotting factor mappings
J2804	romiplostim / related mappings
J2820	sebelipase alfa / enzyme mappings

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Pharmacy-specific J-code quick reference (hyaluronans, ocular, implantables)HCPCS

J7313	intravitreal/ocular implant mappings
J7314	intravitreal implant mappings
J7318	Durolane mapping
J7321	Hyalgan family
J7322	Hymovis and related
J7323	Euflexxa
J7324	Orthovisc
J7325	Synvisc
J7327	Monovisc
J7328	Gelsyn-3

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Pharmacy-specific oncology & specialty biologics (selected HCPCS J-codes)HCPCS

J9311	rituximab + hyaluronidase (Rituxan Hycela)
J9312	rituximab (Rituxan)
J9321	epcoritamab and pemetrexed mappings
J9331	sirolimus protein-bound particles (Fyarro)
J9332	efgartigimod (Vyvgart)
J9333	rozanolixizumab (Rystiggo)
J9341	thiotepa (tepylute)
J9345	retifanlimab (Zynyz)
J9355	trastuzumab (Herceptin)
J9356	trastuzumab hyaluronide (Herceptin Hylecta)

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Pharmacy-related Q-/S-/misc codes (fees, cell therapies, supplies)HCPCS|Other

Q0138	pharmacy supply fee for initial immunosuppressive drug(s)
Q0155	pharmacy supply fee for oral anti-cancer/anti-emetic/immunosuppressive (first 30 days)
Q0510	pharmacy dispensing fee inhalation, per 30 days
Q0511	pharmacy dispensing fee inhalation, per 90 days
Q0512	pharmacy supplying fee for HIV PrEP
Q2041	cell therapies mapping
Q2042	cell therapies mapping
Q2053	brexucabtagene autoleucel (Tecartus)
Q2054	lisocabtagene maraleucel (Breyanzi)
Q2055	idecabtagene vicleucel (Abecma)

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Pharmacy submission quick actionsOther

PHARM-PA	Oncology meds/supportive agents: PAs required from Evolent for participating providers prior to dispensing/administration (request via Evolent portal or 1-888-999-7713, opt 1)
PHARM-EFAX	Injectable (non-oncology) PA requests: e-fax to Pharmacy Team 1-844-235-5090 (effective 10/1/2023)
PHARM-STEP	Formulary/step therapy details available on Fidelis website and Part B Step Therapy Policy

Not otherwise classified / misc pharmacy listHCPCS|mixed

J9999	Not otherwise classified, antineoplastic drugs - Miscellaneous chemotherapy
Q9991	misc Q-codes
Q9998	ustekinumab (Selarsdi) mapping
Q9999	ustekinumab-aauz (Otulfi) mapping

Prior Authorization

Send oncology medication PAs to Evolent (pharmacy section)

Oncology medication PAs: participating providers must submit PAs to Evolent via the web portal (my.newcenturyhealth.com) or by phone at 1-888-999-7713 (option 1). Oncology requests from non‑participating providers are reviewed by Wellcare By Fidelis Care (fax 1-844-235-5090).

Evolent portal: my.newcenturyhealth.com; phone 1-888-999-7713, option 1
Non‑participating provider oncology reviews: Wellcare By Fidelis Care fax 1-844-235-5090