Scope: This authorization grid defines prior authorization requirements and exceptions for Fidelis Care (Policy: Authorization Grid Detail; Effective May 1, 2026) across inpatient admissions, outpatient surgeries, behavioral health carve-ins, delegated vendor review programs, outpatient therapy and DME, and pharmacy injectable/J-code handling.
Inpatient: All inpatient admissions (medical, substance use disorder, behavioral health) require authorization; emergency room stabilization does not require prior authorization but post-stabilization inpatient admissions do. All facility admissions are reviewed for medical necessity. Transplants require authorization at the time of transplant evaluation (extensive CPT list applies). OASAS-licensed in-state, in-network inpatient SUD facilities are exempt from prior authorization and concurrent review for the first 28 days if the facility notifies Fidelis Care within 2 business days and follows LOCADTR processes; OMH-licensed in-state, in-network inpatient mental health for members 18 are exempt from prior authorization and concurrent review for the first 14 days if the facility submits the Two-Day Notification and Initial Treatment Plan within 2 business days and follows required clinical review processes. Out-of-state or out-of-network facilities continue to require authorization.
Delegated Programs: Certain specialty prior authorizations are delegated to vendor partners: Musculoskeletal/orthopedic and spinal program to Evolent (effective 1/1/24) and ENT/cardiac surgical and some radiology/radiation services to TurningPoint or TurningPoint/Evolent as noted. Outpatient PT/OT/ST prior authorization (post-initial evaluation) is delegated to Evolent (effective 10/1/2021) with specified submission timelines.
Outpatient surgeries & other codes: The grid enumerates outpatient CPT/HCPCS/revenue code groups that require prior authorization (including bariatric, blepharoplasty, breast reconstruction, eyelid/ocular surgery, abdominoplasty/panniculectomy, facial cosmetic, vascular, spinal, CAR-T, selected urology and other procedure codes) and notes specific ASC/bill-type and place-of-service authorization rules.
Behavioral Health outpatient carve-in: Most outpatient behavioral health services no longer require authorization except specific services which continue to require authorization (e.g., psychological/neuropsych testing codes, developmental testing, outpatient ECT, partial hospitalization/intensive outpatient revenue and HCPCS codes, and TMS CPTs 90867–90869 under clinical criteria).
Pharmacy & injectables: Oncology medications and supportive agents require prior authorization via Evolent for participating providers before dispensing or administration. A broad list of injectable J-/C-/Q- codes require authorization; non-oncology injectable prior authorizations are submitted to the Pharmacy Team via e-fax (new fax effective 10/1/2023: 1-844-235-5090). Ophthalmic indications are noted as not requiring authorization.
Operational notes: Out-of-network services for specified Medicare Advantage plans require authorization; all unlisted/temporary codes require authorization; utilization management voicemail must be HIPAA-compliant for detailed messages and Fidelis will make a second direct contact attempt per Department of Health policy.