Authorization Grid Detail, Effective June 1, 2026
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Part 2 of Fidelis Care Authorization Grid Detail describes services that require prior authorization or are exempt (imaging, DXA/TBS, therapy authorizations, podiatry, therapeutic services, long-term home health, ADHC, certain DME/ED items, counseling limits, outside vendor prior auths) and provides Appendix I: extensive list of HCPCS/J-codes requiring prior authorization.
No material clinical/coverage changes
Policy overview and scope
This Authorization Grid covers which imaging, therapy and therapeutic services, certain DME and a large set of pharmacy/HCPCS/J-codes require prior authorization. Imaging items include OB ultrasounds, DXA (77080/77081), TBS scans (77089-77092), other imaging (G0680, 75577) and related CPT/HCPCS codes. Therapy and therapeutic services covered include home & outpatient PT/OT/ST (post-evaluation), phototherapy, hyperbaric oxygen, interventional pain and other listed procedure codes. DME and procedure codes for erectile dysfunction and select supplies are included. Pharmacy/physician-administered drugs and many HCPCS/J/C/G codes are listed in Appendix I and require prior authorization.
Prior authorization for radiology reviews and oncology medication reviews has been delegated to Evolent (NIA). Therapy prior authorization for home and outpatient PT/OT/ST (after the initial evaluation) is also handled through Evolent (NIA); certain cardiac ultrasounds and other specific delegations are noted separately. Pharmacy and oncology-related PA routing and exclusions are addressed in the pharmacy section and Appendix I.
Appendix I provides an extensive, itemized list of HCPCS/J/C/G/Q/S and related codes mapped to specific high-cost drugs and biologics that require prior authorization (representative/sample entries are shown in the Appendix). Providers should consult the Appendix I list when determining PA requirements for medications and related HCPCS codes.
Policy metadata: Payer = Fidelis Care; this document is the Authorization Grid Detail policy describing imaging, therapies, DME and pharmacy/HCPCS/J-codes requiring prior authorization (Appendix I).
Authorization requirements and coverage criteria
OB Ultrasound Authorization Rules
Authorization requirements for obstetric ultrasounds
Codes requiring prior authorization (grouped lists)
| 96567 | Phototherapy |
| 96573 | Phototherapy |
| 96574 | Phototherapy |
| 96900 | Phototherapy |
| 96910 | Phototherapy |
| 96912 | Phototherapy |
| 96913 | Phototherapy |
| 96920 | Phototherapy |
| 96921 | Phototherapy |
| 96922 | Phototherapy |
| 11719 | Toenail debridement — non-covered when rendered by physician for Medicaid; covered with prior auth when facility POS 11 |
| 37788 | Pudendal or penile arterial procedure |
| 37790 | Erectile dysfunction procedure |
| 54400 | Penile implant insertion |
| 54401 | Penile implant insertion revision |
| 54405 | Penile implant removal |
| 54408 | Penile implant other |
| 54410 | Other penile prosthesis procedure |
| 54411 | Other penile prosthesis procedure |
| 54416 | Other penile procedure |
| 54417 | Other penile procedure |
| C9047 | Caplacizumab-yhdp (Cablivi) mapping entries and related J-codes |
| C9166 | Secukinumab IV mapping and related J-codes |
| C9309 | Onasemnogene abeparvovec and related J-codes |
| C9399 | Unclassified drugs/biologics mapping |
| C9818 | Insertion of implant mapping |
| G0516 | Insertion of implant / alpha-1 related mappings |
| G0517 | Removal of implant mappings |
| J0013 | Esketamine nasal spray and related mappings |
| J0139 | Adalimumab (Humira) and related mappings |
| J0174 | Donanemab (Kisunla) and related mappings |
| ophthalmic indications | authorization is not required for ophthalmic indications (general note) |
| CHP marker ^ | authorization is required for CHP members; it is not required for NYM or HARP members |
| NYM/HARP marker ~ | authorization is required for NYM/HARP members; it is not required for CHP members |
What providers must do (prior auth submissions, documentation, and billing rules)
Radiology prior authorization delegated to Evolent
Prior authorization for radiology services has been delegated to Evolent (NIA). Consult Evolent’s authorization grid and use Evolent submission channels (portal or phone) per their process. Note: cardiac ultrasound reviews are delegated to TurningPoint per policy.
- Consult Evolent auth grid for codes delegated to Evolent (NIA).
- Submit requests via Evolent’s portal or phone per Evolent process.
- Cardiac ultrasounds are delegated to TurningPoint per policy.
Therapy prior authorization via Evolent
Home and outpatient PT/OT/ST provided after the initial evaluation require prior authorization through Evolent (NIA). For outpatient services, submit authorization within 1 business day; for home health, submit within 2 business days. Home therapy initial evaluations require authorization. For inpatient settings, follow Fidelis submission rules (see inpatient fax guidance).
- Outpatient: authorization to Evolent within 1 business day.
- Home health: authorization to Evolent within 2 business days; initial home evaluations require authorization.
- Inpatient submissions follow Fidelis timelines and fax processes.
DXA age/diagnosis documentation
When billing DXA (CPT 77080 or 77081) include the member’s age and the appropriate diagnosis to qualify for no-authorization benefit. Examples: women >65 or men >70 with diagnosis Z13.820 are eligible for one 77080 or 77081 every two years; women 51–64 and men 51–69 qualify every two years when accompanied by the listed diagnosis codes. Requests outside these age/diagnosis combinations require authorization.
Appendix I PA submission
Appendix I lists HCPCS/J-codes that require prior authorization. Submit prior authorization requests for Appendix I codes to the Pharmacy Team electronically via e-fax to 1-844-235-5090. Note: outpatient oncology-related requests are handled by Evolent per the pharmacy section; refer to that section for oncology submission routing.
- Submit Appendix I PA requests via e-fax: 1-844-235-5090.
- Appendix I is separate from Evolent oncology program; oncology outpatient requests route to Evolent as described in the pharmacy section.
Therapy fax for inpatient SNF/Sub-Acute
For therapy services provided in inpatient Skilled Nursing Facility/Sub-Acute settings (POS 31 & 32), prior authorization requests must be faxed to 833-663-1611.
- Fax prior authorization requests for inpatient SNF/Sub-Acute (POS 31 & 32) to: 833-663-1611.
Oncology medication prior authorization
Oncology medications and supportive agents require prior authorization from Evolent before being dispensed at a pharmacy or administered in a physician’s office, outpatient hospital, or ambulatory setting for members of all ages. Child Health Plus oncology requests continue to require prior authorization to Fidelis. Follow Evolent submission channels for oncology requests.
- Evolent PA required prior to dispensing/administration for oncology meds/supportive agents (all ages, excludes Child Health Plus).
- Child Health Plus oncology requests continue to be submitted to Fidelis.
- Submit oncology outpatient requests via Evolent’s portal or phone per instructions in the pharmacy section.
Submit non-therapy provider auths to Fidelis
Non-therapy providers (MD, DO, DPM, etc.) should submit prior authorization requests for services rendered after the initial therapy evaluation directly to Fidelis Care (not to Evolent).
- MD/DO/DPM and other non-therapy providers must request PAs through Fidelis Care for services after the initial therapy evaluation.
Prior authorization required for listed codes
Claims for the HCPCS/J/Q/S codes listed in the Appendix require prior authorization per Fidelis Care policy. Check the pharmacy and appendix notes for member-type exceptions (e.g., CHP, NYM/HARP markers) before submission.
- Appendix I codes require PA prior to billing.
- Review special member-type exception markers (CHP, NYM/HARP) for applicability.
Voicemail HIPAA compliance for UM messages
UM voicemail messages may include detailed utilization management information only if the provider voicemail greeting is HIPAA-compliant. The greeting must identify the mailbox owner and organization and state that the mailbox is confidential and that PHI may be left. If not compliant, only a generic message will be left and a callback requested.
- Voicemail greeting must identify owner and organization and state confidentiality/PHI may be left to be HIPAA-compliant.
- If mailbox is not HIPAA-compliant, UM will leave a generic message and request a callback.
Reasonable Effort Policy callback
When notifying a provider of a utilization management determination, Fidelis will make a second attempt to reach the provider directly as required by the Department of Health Reasonable Effort Policy.
- A second direct contact attempt will be made when notifying providers of UM determinations per Dept. of Health Reasonable Effort Policy.
Key terms and abbreviations
Special notes and member-type exceptions
Special notes: authorization is not required when services are billed for ophthalmic indications as noted in the Appendix.
Member-type markers: the caret marker ^ indicates authorization is required for CHP members and not required for NYM/HARP members; the tilde marker ~ indicates authorization is required for NYM/HARP members and not required for CHP members.
Other member-type exceptions and routing: oncology medication and supportive agent PAs are delegated to Evolent for Medicaid Managed Care and HARP (excludes Child Health Plus which continues to route to Fidelis); Appendix I also flags S-code exclusions and non‑covered HCPCS medication codes per the pharmacy section.
Document changes and history
Authorization Grid Detail effective; major delegations to Evolent (NIA) and NYRx transition noted.
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