ModifiedFidelis CarePolicy N/A

Authorization, Prior Authorization Delegations, and Service-Specific Coverage Rules (Medicaid/CHP)

Guidance on authorization, prior authorization delegations, and service-specific coverage/notification rules for Fidelis Care Medicaid/CHP members in New York State.

Policy Summary

PayerFidelis Care

PolicyAuthorization, Prior Authorization Delegations, and Service-Specific Coverage Rules (Medicaid/CHP)

Policy CodePolicy N/A

Change TypeMultiple material revisions (authorization timing, delegation, and benefit clarifications)

Effective DateN/A

Next Review DateN/A

Key ActionSubmit authorization requests for services requiring prior authorization (e.g., transplants, TMS, oncology drugs, continued intensive outpatient days) to the specified vendor or Fidelis channel per service instructions.

SourceLink

POLICY UPDATE CHANGES

No authorization is required for the first seven days of intensive outpatient and continuing day treatment services; additional days require authorization.

Effective dates and prior-authorization changes for multiple programs: PROS (no prior auth effective 2/1/22), ACT services available to CHP members (effective 1/1/23) and no authorization for ACT using H0040 effective 6/1/23.

CORE and HCBS services eligibility and some services no longer require prior authorization (e.g., IPRT intake/service delivery not requiring prior auth effective 1/1/23).

Children and Family Treatment & Support Services (CFTSS) utilization management requirements discontinued and moved into CHP benefit package for 1/1/23.

Short-term Children's Respite Services must be in-person and are limited to 14 annual days (1,344 15-minute units) without medical necessity beyond that.

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.

Coverage and Medical Necessity Criteria

OMH Inpatient Mental Health - Utilization Review Triggers

Utilization review for OMH-licensed inpatient mental health treatment will be conducted only for members who meet ONE OR MORE of the following triggers per NYS OMH Best Practice Manual:

OMH triggers: Individuals who had an AOT court order that expired within the past five years; OR Individuals subject to a current Assisted Outpatient Treatment (AOT) court order; OR Individuals with high utilization of inpatient or emergency department services in the past year as evidenced by: (1) three (3) or more psychiatric inpatient hospitalizations in the prior 12 months; OR (2) four (4) or more psychiatric ED visits in the prior 12 months; OR (3) three (3) or more medical inpatient hospitalizations in the prior 12 months; OR Individuals whose length of stay exceeds 30 days (concurrent review from day 31 onwards); OR Individuals readmitted to any mental health inpatient unit within 30 days of discharge.see text

Per NYS OMH Best Practice Manual and Fidelis Care policy

Partial Hospitalization - Utilization Review Triggers

Utilization review for partial hospitalization mental health treatment will be conducted only for members who meet ONE OR MORE of the following triggers:

Partial hospitalization triggers: Individuals with an AOT court order that expired within the past five years; OR Individuals subject to a current AOT court order; OR Individuals with high utilization in the prior 12 months as evidenced by: three (3) or more psychiatric inpatient hospitalizations; OR four (4) or more psychiatric ED visits; OR three (3) or more medical inpatient hospitalizations; OR Individuals readmitted to any mental health inpatient unit within 30 days of discharge; OR Individuals whose length of stay exceeds 30 days (concurrent review from day 31 onwards).see text

Per NYS OMH Best Practice Manual

Intensive Outpatient Treatment - Authorization Timing

Intensive outpatient treatment authorization rules:

IOP auth timing: No authorization is required for the first seven (7) days of intensive outpatient services; additional service days require prior authorization.7 days

Per Fidelis Care policy for revenue codes 905/906/912 and codes H2013, 90899, S9480

OMH Inpatient (under 18) - Initial Non-Review Conditions

For OMH-licensed inpatient mental health treatment for members under 18 who are in-network:

Under-18 OMH non-review conditions: The admission is not subject to authorization review and Fidelis Care will not conduct concurrent utilization review during the first fourteen (14) days of the inpatient admission provided that the facility: (i) 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 (fax or email); (ii) performs daily clinical review of the patient; and (iii) participates in periodic consultation with Fidelis Care.14 days

Applies only to in‑network OMH‑licensed hospitals; out‑of‑network facilities remain subject to concurrent review

Intensive Outpatient Utilization Review Criteria

Concurrent/continued stay utilization review for intensive outpatient mental health treatment will be conducted only for members who meet ONE OR MORE of the following triggers per NYS OMH Best Practice Manual:

Intensive Outpatient Review Triggers: Individuals subject to a current Assisted Outpatient Treatment (AOT) court order; OR Individuals who had an AOT court order that expired within the past five years; OR Individuals with high utilization in the prior 12 months as evidenced by: three (3) or more psychiatric inpatient hospitalizations OR three (3) or more medical inpatient hospitalizations OR four (4) or more psychiatric ED visits; OR Individuals readmitted to any mental health inpatient unit within 30 days of discharge; OR Individuals whose length of stay exceeds 30 days (concurrent review from day 31 onwards).as stated

Per NYS OMH Best Practice Manual

TMS Medical Necessity Criteria

Covered for members over 18 when ALL of the following are met:

TMS Eligibility: (1) TMS is administered using an FDA‑cleared device consistent with FDA‑labeled indications; AND (2) there is a confirmed diagnosis of Major Depressive Disorder (MDD); AND (3) the member has failed to respond to multiple trials of medication and evidence‑based psychotherapy during the current episode of illness.age > 18

Authorization required for CPT codes 90867, 90868, 90869

CORE / HCBS Eligibility and Submission Requirements

CORE and HCBS services available if member is eligible through HealthierLife plan enrollment and completed evidence-based eligibility assessment and/or LPHA recommendation:

CORE/HCBS Access: Member must be determined eligible through enrollment and appropriate evidence‑based eligibility assessment; where applicable, the Service Initiation Form or LPHA Recommendation Form must be submitted to Fidelis Care within required timeframes; certain CORE/HCBS services do not require prior authorization (see policy for effective dates and service‑specific rules).Service Initiation Form submitted within 3 business days for CORE services

Per Fidelis Care HCBS/CORE program requirements

DXA Scan Coverage Criteria

Covered when ALL of the following are met for the specified age/diagnosis groups:

Women >65: One DXA scan (CPT 77080 or 77081) every two years when accompanied by diagnosis code Z13.820.every two years

Authorization not required when criteria met

Men >=70: One DXA scan (CPT 77080 or 77081) every two years when accompanied by diagnosis code Z13.820.every two years

Authorization not required when criteria met

Women 51–64: One DXA scan (CPT 77080 or 77081) every two years when accompanied by any of the specified diagnosis codes on the policy list.every two years

Therapy Authorization Criteria

Authorization required for therapy services after initial evaluation when performed in outpatient/home settings:

Therapy after initial evaluation: Home and outpatient Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) provided after the initial evaluation require prior authorization through Evolent (NIA); home therapy requires authorization for the initial evaluation. CPT codes 92610 and 92611 are exempt from authorization. If billing codes other than designated initial evaluation CPT codes, an authorization request must be submitted 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).timely prior auth submission as stated

Program excludes PT/OT/ST performed in Inpatient, ER, SNF/Sub‑Acute Rehab, or Observation settings

Behavioral Health and Self-Management Coverage

Coverage limits for counseling and self-management training:

Counseling services: Members are allowed up to 10 hours (20 units) of counseling services in a continuous six‑month period; services must be provided by certified providers and do not require authorization.10 hours/6 months

Per Fidelis Care counseling services policy

Asthma self‑management training (ASMT): Members with newly diagnosed or medically complex asthma may receive up to 10 hours of ASMT during a continuous six‑month period; medically stable members may receive up to 1 hour during a continuous six‑month period. Codes S9441, S9445, S9446 do not require authorization when billed with appropriate asthma diagnosis codes.10 hours or 1 hour depending on clinical status

Per ASMT policy

Smoking cessation counseling is reimbursed for up to 8 visits per calendar year using CPT codes 99406 and 99407 and must be billed with diagnosis code F17.200; no authorization is required for Medicaid members.

Pharmacy Coverage and Authorization

Pharmacy benefit transition and oncology medication authorization routing:

Pharmacy transition: Effective April 1, 2023, Fidelis Medicaid Managed Care and HARP members receive pharmacy benefits through NYRx (Medicaid FFS); physician‑administered drugs listed on the Medicaid Pharmacy List are available through NYRx. Providers should consult NYRx for current guidance.effective 4/1/2023

See Fidelis Care pharmacy notices and NYRx resources

Oncology medications and supportive agents require prior authorization (PA) from Evolent before being dispensed at a pharmacy or administered in a physician office, outpatient hospital, or ambulatory setting for Medicaid Managed Care and HARP members (excludes Child Health Plus); requests are submitted via Evolent's web portal or phone per the Evolent Oncology Program.prior auth required

Per Fidelis Care and Evolent guidance

In-network, in‑state OASAS‑licensed inpatient substance use disorder (SUD) facilities and OMH‑licensed inpatient mental health hospitals (members under age <18 in‑network) are exempt from prior authorization for specified initial periods when the facility complies with notification and documentation requirements. For OASAS inpatient SUD, services are not subject to authorization review and are not subject to concurrent utilization review for the first 28 days of admission provided the facility notifies Fidelis Care and uses the LOCADTR clinical tool as described. For OMH‑licensed inpatient mental health admissions for members under 18, Fidelis Care will not conduct concurrent utilization review for the first 14 days of the admission if the facility: (1) notifies Fidelis Care of the admission and initial treatment plan using the OMH Two‑Day Notification form within two business days; (2) performs daily clinical review; and (3) participates in periodic consultation with Fidelis Care.

Per New York State guidance, short‑term Children’s Respite Services must be delivered in‑person; telehealth or telephonic delivery for individual or group respite is not allowable. Short‑term Planned and Crisis Respite are limited to 14 days (1,344 15‑minute units) per calendar year without additional documented medical necessity. Services beyond these limits require submission of an LPHA Attestation and the NYS DOH Children’s HCBS Authorization and Care Manager Notification form prior to rendering the service.

Authorization is no longer required for podiatric services generally; however, authorization requirements still apply to specific podiatric procedures when indicated. Note that code 11719 is non‑covered for Medicaid when rendered by a physician but is covered when rendered by a facility using POS 11 and in that facility setting it requires authorization.

For members with a diagnosis of Low Back Pain, certain therapeutic procedures are not covered. Excluded services include therapeutic facet joint steroid injections in the lumbar/sacral regions (with or without CT/fluoroscopic guidance), therapeutic injections of steroids into intervertebral discs, and continuous or intermittent traction. These services should not be billed for members whose primary diagnosis is Low Back Pain.

Several categories of services and medication requests are managed outside of or excluded from routine prior‑authorization routing. Examples include certain antibiotics, transplant and CAR‑T therapies, controlled substances, hemophilia factor products, inpatient drug requests, and other categories identified on the Medicaid Pharmacy List; these items may be excluded from standard Evolent review and require separate handling. In addition, specific therapeutic procedure groups (for example, selected pain management injections and other items listed in the Therapeutic Services section) have distinct coverage rules or prior‑authorization requirements as noted.

HCPCS codes for medications that are not FDA‑approved are considered a benefit exclusion and may be denied. For example, non‑FDA‑approved drug HCPCS codes such as J1726 are listed as benefit exclusions in Appendix I and are not covered under the pharmacy/drug benefit.

Authorization requirements vary by product line. Where specified in Appendix I and other pharmacy guidance, authorization is required for NYM and HARP members for listed drugs; conversely certain authorizations are not required for CHP members. Pharmacy benefit routing also changes effective 4/1/2023 (transition to NYRx/FFS) and oncology or physician‑administered drugs may require review by delegated vendors (Evolent) per the guidance — providers should follow the product‑line‑specific instructions when submitting authorization requests.

Procedures and medical/surgical interventions that are completed within 24 hours will not be approved at an inpatient level of care; when those same procedures are billed as outpatient within the Fidelis network they generally require authorization. Claims billing an inpatient level of care for procedures finished within 24 hours are not considered medically necessary as inpatient admissions.

Reiterating NYS guidance: short‑term Respite delivered via telehealth or telephone is not allowable and must be provided in‑person. Providers must follow the HCBS Manual‑based requirements and submission steps for any respite beyond the annual limits.

Codes and Billing Guidance

Covered HCPCS CodesHCPCSCovered

J0207	amifostine (Ethyol) injection - requires prior authorization as listed in Appendix I
J0208	sodium thiosulfate injection - requires prior authorization as listed in Appendix I

Transplant / Selected Procedure ExamplesmixedCovered

32850	Transplant related procedure (example list)
33930	Transplant related procedure (example list)

Provider Responsibilities and Authorization Processes

Prior Authorization

Inpatient Admissions Require Authorization

All inpatient admissions require prior authorization and are reviewed for medical necessity. Emergency room services or emergent stabilization do not require prior authorization; however, authorization is required for inpatient admissions after stabilization when applicable. For inpatient behavioral health and substance use disorder (SUD) admissions there are specific notification and concurrent review exceptions (see OMH/OASAS rules). New fax numbers: Inpatient ER admissions 833-663-1602.

Facility admissions reviewed for medical necessity
Emergency services for stabilization do not require prior authorization
Fax for Inpatient ER: 833-663-1602

Prior Authorization

Transplants Require Authorization

All solid organ and bone marrow transplants require authorization at the time of transplant evaluation. This includes a broad list of transplant-related CPT codes and associated procedures; providers must obtain authorization before the transplant evaluation proceeds.

Policy Background and Scope

This policy references clinical program rules and New York State standards for behavioral health and substance use disorder care, including OMH and OASAS licensed services and rehabilitation/transplant processes. It relies on tools such as LOCADTR for SUD inpatient medical necessity and OMH Best Practice Manual utilization review triggers (including Assisted Outpatient Treatment/AOT status and high‑utilization thresholds). The guidance describes both facility‑level notification requirements and the clinical review expectations that support utilization management and discharge planning for inpatient behavioral health and SUD services.

Key Terms and Abbreviations

LOCADTR

LOCADTR toolLOCADTR is the referenced medical necessity tool for OASAS inpatient SUD concurrent review and discharge planning

Notification timingOASAS facilities must notify Fidelis Care of inpatient admission and initial treatment plan within two business days and may fax/email the OASAS Appendix A Notification Form and LOCADTR to the specified contacts

Concurrent review windowInpatient SUD services are not subject to concurrent review for the first 28 days if facility notifies Fidelis and performs daily clinical review; otherwise subject to concurrent review throughout admission

AOT

AOT as triggerAssisted Outpatient Treatment (AOT) court orders (current) are referenced as a utilization review trigger for inpatient, partial hospitalization, and intensive outpatient services

Prior AOT consideration

Policy Summary

PayerFidelis Care

PolicyAuthorization, Prior Authorization Delegations, and Service-Specific Coverage Rules (Medicaid/CHP)

Policy CodePolicy N/A

Change TypeMultiple material revisions (authorization timing, delegation, and benefit clarifications)

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Prior Authorization

Outpatient Surgery Prior Authorization

Many outpatient surgical procedures require prior authorization. Specific categories include bariatric, blepharoplasty, breast reconstruction, dermatologic procedures, abdominoplasty/ lipectomy, reduction mammoplasty, facial cosmetic procedures, vascular procedures, speech processor implants, spinal surgery, CAR-T, and others. Some code-specific authorizations have been removed (e.g., S2083). For certain CPT codes delegated to TurningPoint or Evolent, authorization requests must be submitted to those delegates as directed.

Bariatric surgery: 43770–43775 (S2083 no longer requires authorization as of 8/1/22)
Dermatology: many codes removed for POS 11/22; remaining require auth (e.g., 11200,11201,15769–15829,17340–17999)
Delegation: Musculoskeletal codes delegated to Evolent; ENT/Cardiac surgical delegations to TurningPoint — submit auths to delegated vendor when applicable

Prior Authorization

Delegated Prior Authorization

Certain prior authorization responsibilities have been delegated to external vendors. Authorization for musculoskeletal (orthopedic/spinal) procedures is delegated to Evolent (NIA). Some ENT and cardiac surgical procedure authorizations have been delegated to TurningPoint Healthcare Solutions. When a CPT code appears on a delegate's list, submit authorization requests to the delegated vendor per the vendor instructions.

Evolent (NIA): Musculoskeletal Management Program — authorization and associated device (HCPCS) review
TurningPoint: ENT and Cardiac surgical procedure authorizations — follow TurningPoint submission instructions
Check delegated CPT code lists and submit to the appropriate delegate

Prior Authorization

ABA Prior Authorization (Members <21)

Applied Behavior Analysis (ABA) services for members under age 21 require prior authorization from Behavioral Health. Members must meet diagnosis and referral requirements (e.g., ASD or Rett Syndrome, referred by a NYS licensed provider). Authorization requests must use the Fidelis ABA authorization forms and be submitted to Behavioral Health.

ABA eligibility: member <21 with diagnosis of autism spectrum disorder and/or Rett Syndrome
Referral required from NYS licensed physician/qualified provider
Prior authorization required from Behavioral Health using the ABA authorization request form

Prior Authorization

Intensive Outpatient — Prior Authorization

Intensive Outpatient (IOP) mental health treatment: no authorization is required for the first seven days of service. Authorization is required for additional service days beyond the first seven. Utilization review for OMH-licensed programs follows NYS OMH Best Practice Manual clinical criteria and concurrent review triggers.

Revenue codes 905, 906, 912; CPT 90899; S9480; HCPCS H2013
No authorization required for first 7 days; additional days require prior authorization
Concurrent review triggers per NYS OMH Best Practice Manual (e.g., high utilization, AOT status, readmission within 30 days)

Prior Authorization

Continuing Day Treatment / IPRT Prior Authorization

Continuing Day Treatment / Intensive Psychiatric Rehabilitation Treatment (IPRT) (H2012): The first seven service days do not require authorization; additional days require prior authorization. For IPRT and related Home & Community Based Services (HCBS), follow health plan submission requirements and concurrent review timelines.

H2012: first 7 days no authorization; thereafter authorization required
IPRT and HCBS services have specific enrollment and submission requirements

Prior Authorization

TMS Prior Authorization and Clinical Criteria

Transcranial Magnetic Stimulation (TMS) for adults requires prior authorization for CPT codes 90867, 90868, and 90869. Members must meet clinical criteria including confirmed MDD diagnosis and failure of multiple medication and evidence-based psychotherapy trials during the current episode.

CPT codes: 90867, 90868, 90869
Authorization submission: email ghcmbh@fideliscare.org, fax 833-561-0098, or call 1-888-FIDELIS and follow Behavioral Health prompts
Clinical criteria include FDA-cleared device use, confirmed MDD, and prior medication/psychotherapy trial failures

Prior Authorization

DXA and TBS Scan Prior Authorization

DXA and TBS scans: Specific age and diagnosis groups are permitted without authorization; all other requests require prior authorization. DXA frequency rules apply (e.g., women >65: one scan every 2 years). TBS scan CPT codes are listed among services requiring authorization.

DXA CPTs: 77080, 77081 — women >65 and men >70 one every 2 years when accompanied by diagnosis Z13.820; other age/diagnosis groups listed require authorization
TBS CPTs: 77089–77092 require prior authorization when not meeting exception

Prior Authorization

Pain Management Prior Authorization and Coverage Notes

Pain management procedures (including injection codes and select interventional pain CPTs) and certain therapeutic services require prior authorization. Some procedures are not covered for specific diagnoses (e.g., certain facet injections for low back pain). Verify authorization requirements and coverage exclusions prior to performing services.

Pain management CPTs include 62325–62327, 64600–64640 series, 63685, 63688 and related HCPCS (C1778,C1787,C1883,C1897)
Certain therapies (e.g., continuous traction, intradiscal steroid injections) are not covered for Low Back Pain diagnoses
Topical oxygen and some phototherapy/hyperbaric oxygen therapies require prior authorization

Prior Authorization

Drug Codes Requiring Prior Authorization

Many pharmacy HCPCS/J-codes require prior authorization per Appendix I. Oncology medications and supportive agents require prior authorization and are reviewed by Evolent for Medicaid members (Child Health Plus oncology requests remain with Fidelis). Submit pharmacy PA requests electronically via e-fax to the Pharmacy Team.

Submit authorization requests to Pharmacy Team e-fax: 1-844-235-5090
Oncology meds/supportive agents: Evolent portal or 1-888-999-7713 for Medicaid/HARP (Child Health Plus exceptions apply)
Appendix I lists numerous HCPCS/J-codes that require prior authorization — providers must submit PA prior to dispensing/administration

Denial Risk

Appendix I — Prior Authorization, Exclusions, and Unit Limits

Appendix I contains an extensive list of HCPCS/J-codes that require prior authorization. HCPCS codes for non–FDA-approved medications are considered benefit exclusions and may be denied. Maximum unit edits apply to all HCPCS codes regardless of authorization status; requests exceeding unit limits risk claim denials.

HCPCS codes not FDA-approved (e.g., J1726 examples) are benefit exclusions
Maximum unit edits policy applies regardless of authorization — verify allowable units before submitting claim
Refer to Appendix I for full code-to-drug mapping and PA requirements

Note

Outpatient SUD Authorization and Oversight

Outpatient SUD: As of 1/1/2020, Fidelis Care does not require provider notification, authorization, or concurrent authorization review for in-network, in-state outpatient SUD services (including office visits, clinic visits, IOP, OTP, outpatient rehab). Out-of-state or out-of-network providers must continue to request authorization. Fidelis will use quality and case management oversight for outpatient SUD outliers.

In-network, in-state outpatient SUD services are not subject to authorization as of 1/1/2020
Out-of-state/out-of-network providers must request authorization
Fidelis conducts oversight and outlier management for outpatient SUD

Prior Authorization

Timing and Routing for Authorization Submission

Providers must follow specific submission timing and routing rules: therapy services after the initial evaluation require authorization through Evolent (NIA); if submitting claims using non-initial-evaluation CPT codes, send the authorization request to Evolent within 1 business day for outpatient or 2 business days for home health settings, or to Fidelis within 1 business day for inpatient settings. For inpatient therapy POS 31 & 32, fax prior authorization requests to 833-663-1611. Non-therapy providers (MD/DO/DPM) should request authorizations directly through Fidelis Care.

Therapy authorization routing: Evolent (NIA) for outpatient/home therapy after initial eval
Timing: authorization request within 1 business day (outpatient) or 2 business days (home health); inpatient within 1 business day
Inpatient therapy (POS 31/32) prior auth fax: 833-663-1611
Non-therapy providers must request authorizations directly through Fidelis

Documentation Required

OMH and OASAS Two-Day Notification Requirements

OMH/OASAS inpatient notification rules — providers must notify Fidelis Care within specified timeframes to qualify for authorization/concurrent review exceptions. OMH: notify within two business days of admission and submit the OMH Two-Day Notification and Initial Treatment Plan form to the new fax 833-561-0094 or email to MentalHealthAdmission@fideliscare.org. OASAS: notify within two business days using Appendix A Notification Form and LOCADTR to fax 833-663-1608 or LOCADTR submission as directed.

OMH two-day notification: fax 833-561-0094 or email MentalHealthAdmission@fideliscare.org
OASAS notification: fax 833-663-1608 or LOCADTR submission to Fidelis
Failure to notify may result in concurrent review from admission and removal of first-day exceptions

Documentation Required

CORE and HCBS Submission Timelines

CORE Services and HCBS workflows: CORE Service Initiation Form must be submitted within 3 business days of the first service visit to the designated email (QHCMHARPBH@fideliscare.org) or fax 833-561-0089. C-YES and Health Home providers must submit Plan of Care and request concurrent review as needed; do not wait until initial authorization expiration to request concurrent review to avoid claims delays.

CORE Service Initiation Form due within 3 business days to QHCMHARPBH@fideliscare.org or fax 833-561-0089
C-YES/Health Home: submit Plan of Care and request concurrent review before existing authorization ends

Documentation Required

Respite Medical Necessity and Submission Requirements

Children's Respite (CFTSS): Short-term planned and crisis respite services are limited to 14 days (1,344 15-minute units) per calendar year unless supported by medical necessity. Respite beyond annual limits requires LPHA Attestation and the NYS DOH Children's HCBS Authorization and Care Manager Notification Form submitted prior to service delivery to avoid claim processing disruptions. Submit forms by email to SM_Childrens_HCBS@fideliscare.org or fax 833-663-1604.

Short-term respite must be in-person; telehealth delivery is not allowed
Annual limit: 14 days (1,344 units) — beyond this requires medical necessity documentation (LPHA Attestation + NYS DOH HCBS form)
Submit HCBS Authorization and Care Manager Notification Form prior to service delivery; fax 833-663-1604

Documentation Required

Voicemail HIPAA-compliant Requirements for UM Messages

Voicemail messages from Utilization Management may include detailed UM information only if the provider's voicemail is HIPAA-compliant (greeting identifies mailbox owner, organization, and confidentiality/PHI statement). Otherwise, only a generic message will be left requesting a callback.

HIPAA-compliant voicemail must identify owner, organization, and confidentiality statement to allow detailed UM messages
If not HIPAA-compliant, UM will leave a generic message and request callback