Coverage and review rules apply as follows depending on service type, facility licensure, network status and specific procedure codes:
Inpatient admissions: All inpatient admissions require authorization except emergency room services and emergent stabilization; post-stabilization inpatient admissions after ER services require authorization.
All facility admissions are reviewed for medical necessity; new fax for Inpatient ER: 833-663-1602.
OASAS licensed in-state Inpatient SUD: In-network OASAS-licensed inpatient SUD facilities in New York State are not subject to prior authorization or concurrent utilization review for the first 28 days provided the facility notifies Fidelis Care of the admission and initial treatment plan within two business days, performs daily clinical review, and begins periodic consultation near day 14; utilization review may occur after day 28 or on discharge.28 days
Out-of-state, unlicensed, or out-of-network SUD facilities must request prior authorization and are subject to concurrent review throughout admission; fax/LOCADTR submission instructions available.
OMH licensed inpatient mental health: OMH-licensed in-state inpatient mental health treatment for members under 18 in-network is not subject to prior authorization and will not have concurrent utilization review during the first 14 days if the facility notifies Fidelis Care of the admission and initial treatment plan within two business days, performs daily clinical review, and participates in periodic consultation; utilization review triggers (AOT status, recent AOT, high utilization, readmission within 30 days, or length of stay >30 days) apply as specified.14 days; concurrent review from Day 31 for stays >30 days
Out-of-network facilities are subject to concurrent review throughout the admission; use OMH Two-Day Notification form and send to Fidelis as instructed.
Specified outpatient procedures and delegated review: Certain outpatient surgical, dermatologic, vascular, spinal, cardiac, ENT, transplant evaluation, CAR-T and other listed procedures require prior authorization per the code lists in sections III.A–III.S; some code groups and device HCPCS codes are delegated to external reviewers (e.g., Evolent (NIA), TurningPoint) and should be submitted to the delegate when indicated.
Refer to the specific code lists and delegated-review instructions; failure to obtain required prior authorization may result in claim denial.
Transplant evaluations: All solid organ and bone marrow/tissue transplants require authorization at the time of transplant evaluation.
Submit prior authorization at transplant evaluation to avoid denial for listed transplant procedures.
Codes requiring prior authorization (drugs/biologics): Prior authorization is required for the HCPCS/J/Q and listed Q-/S- code groups and their mapped products as enumerated in Appendix I; submissions without prior authorization are subject to denial.
Oncology medications and supportive agents require prior authorization via Evolent for Medicaid Managed Care and HARP (excludes Child Health Plus); see Appendix I and Evolent auth grid.