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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyFidelis Care Prior Auth & Coverage Rules | OpenPay…
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    CurrentFidelis CarePolicy N/A

    Authorization and Utilization Review Requirements (Coverage Criteria)

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    Governs prior authorization, utilization review, and related authorization/coding guidance for a range of inpatient, outpatient, behavioral health, diagnostic, and DME services for Fidelis Care members in New York State. Affects providers requesting authorization or notification for these services.

    Policy Summary
    PayerFidelis Care
    PolicyAuthorization and Utilization Review Requirements (Coverage Criteria)
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateSep 1, 2021
    Next Review DateN/A
    Key ActionObtain prior authorization for all inpatient admissions and for listed outpatient procedures, imaging, therapies, DME and J-code medications as specified; notify Fidelis Care within two business days for certain inpatient behavioral health and SUD admissions and submit required forms.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    AllInpatient authorization requirement
    28 daysSUD concurrent review exemption
    14 daysOMH minor concurrent review exemption
    40
    Home health max / yr
    210Hospice max (days)
    60Rehab visit limit

    Coverage criteria and clinical authorization rules

    Inpatient Admission Authorization

    Covered when ALL of the following are met for inpatient admissions

    Inpatient admission authorization: All inpatient admissions require an authorization.

    Emergency room services that stabilize an emergent condition do not require authorization; post-stabilization inpatient admissions do require authorization and all facility admissions are reviewed for medical necessity.

    Inpatient SUD Authorization/Review

    SUD inpatient utilization review rules

    Inpatient SUD notification and review: In-network OASAS‑licensed inpatient SUD services are not subject to prior authorization and are exempt from concurrent utilization review for the first 28 days of the inpatient admission provided the facility notifies Fidelis Care of the admission and initial treatment plan within two business days and submits the OASAS Appendix A Notification Form and LOCADTR tool.28 days; notification within 2 business days

    Facilities must perform daily clinical review, consult periodically with Fidelis Care starting on or just prior to day 14, and services may be subject to utilization review after day 28 or retrospectively. Out‑of‑state, non‑OASAS‑licensed, or out‑of‑network facilities remain subject to prior authorization and concurrent review throughout the admission.

    Behavioral Health Utilization Review Triggers

    Behavioral health utilization review triggers per NYS OMH Best Practice Manual

    Triggers for utilization review (examples): Utilization review for OMH‑licensed inpatient, partial hospitalization, and intensive outpatient programs will be conducted only for members who meet clinical triggers such as: current or recent AOT order (including expired within past 5 years); high utilization defined as three or more psychiatric inpatient hospitalizations in the prior 12 months OR four or more psychiatric ED visits in the prior 12 months OR three or more medical inpatient hospitalizations in the prior 12 months; readmission to any mental health inpatient unit within 30 days of discharge; or length of stay exceeding 30 days (concurrent review from Day 31 onward).3 psychiatric inpatient hospitalizations OR 4 psychiatric ED visits OR 3 medical inpatient hospitalizations in prior 12 months; readmission within 30 days; LOS > 30 days

    For members under 18 at participating OMH‑licensed hospitals, no prior authorization is required and concurrent review is not conducted for the first 14 days if the facility notifies Fidelis Care within two business days, performs daily clinical review, and participates in periodic consultation per the OMH Two‑Day Notification requirements.

    Outpatient/Dx Authorization

    Outpatient and diagnostic procedures requiring authorization

    Outpatient procedures requiring prior authorization: Specific outpatient surgery and diagnostic procedure codes listed in the policy (see coding sections) require prior authorization when performed in the specified places of service or circumstances (examples include bariatric surgery, blepharoplasty, breast reconstruction, specified skin surgery codes when performed as ambulatory surgery, select free‑standing ambulatory surgery center procedures, and specified spinal, vascular, and other procedural codes).See code lists in the policy

    Some skin surgery codes do not require authorization when performed in POS 11 or 22; certain codes always require authorization regardless of POS. Some outpatient orthopedic and spinal procedures require authorization and delegation to TurningPoint applies for specified dates of service.

    DME Authorization and Coverage

    DME and supplies coverage rules

    DME authorization rules: Orthotics are not covered. A set of specific DME HCPCS codes listed in the policy do not require authorization; other DME codes require prior authorization. Certain supplies require authorization including compression garments/stockings, electric breast pumps, electric heat pads, surgical stockings, protective helmets, wigs, insulin pumps, and insulin infusion pumps. Blood glucose monitors and testing supplies (A4253, A9275, E0607, E2100, E2101) are covered through the member's prescription drug benefit.

    Providers should reference the specific DME code lists in the policy for which codes do not require authorization and which require prior authorization.

    Authorization-dependent coverage and limits

    Covered when authorization requirements and program limits are met as specified below

    Diagnostic testing and genetic testing: Sleep studies (including home sleep studies), wireless capsule endoscopy/motility (91110–91112), and other listed diagnostic tests require authorization as indicated. Genetic testing CPT 81220, 81329, and 81336 do not require authorization but have lifetime limits (CPT 81220: 1 per lifetime; CPTs 81329 and 81336: combined limit of 1 per lifetime).See diagnostic code thresholds and lifetime limits

    Certain GI procedures require authorization when performed in POS 19 or 22; authorization is not required when performed in POS 11 or 24.

    Durable Medical Equipment/Supplies: Specific DME HCPCS codes listed do not require authorization; other DME codes require authorization. Listed supplies (compression garments, electric breast pumps, electric heat pads, surgical stockings, protective helmets, wigs, insulin pumps/infusion pumps) require authorization. Blood glucose monitors/testing supplies covered through pharmacy benefit.N/A

    Refer to DME code lists in policy for details.

    Orthotics are not covered. See the Durable Medical Equipment/Supplies section for the list of DME codes that do not require authorization and other DME authorization rules.

    For members with a diagnosis of Low Back Pain, the following therapeutic procedures are not covered: prolotherapy; therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT fluoroscopic guidance); therapeutic injections of steroids into intervertebral discs; and continuous or intermittent traction.

    Orthotics are not covered. This exclusion is stated in the DME and supplies section; providers should reference the specific DME code lists for items that do not require authorization and those that do.

    Authorization is not required for medications when used for oncology indications in members under 18. Authorization is also not required for medications when used for ophthalmic indications, per the benefit applicability notes.

    The therapeutic procedures listed as exclusions for members with Low Back Pain (prolotherapy; therapeutic lumbar/sacral facet joint steroid injections; intradiscal steroid injections; continuous or intermittent traction) are considered not covered when the member’s diagnosis is Low Back Pain.

    Code lists, limits, and coding-related notes

    Transplant codes requiring authorizationCPTCovered
    32850-32856Included transplants (solid organ) examples
    33930-33945Included transplant-related codes
    38204-38215Bone marrow/transplant codes
    38230-38242Transplant codes
    44133-44136Transplant/related codes
    47133-47147Transplant/related codes
    48160Transplant code
    48550-48556Transplant codes
    50300-50380Transplant/related codes
    50547Transplant code
    1–10 of 11
    1/2
    Transplant codes requiring authorization (flat list) - alternate groupingCPTCovered
    32850-32856Included transplants (solid organ) examples
    33930-33945Included transplant-related codes
    38204-38215Bone marrow/transplant codes
    38230-38242Transplant codes
    44133-44136Transplant/related codes
    47133-47147Transplant/related codes
    48160Transplant code
    48550-48556Transplant codes
    50300-50380Transplant/related codes
    50547Transplant code
    1–10 of 11
    1/2
    Outpatient surgery codes requiring authorizationmixedCovered
    43770-43775Bariatric surgery
    S2083Bariatric related HCPCS
    15820-15823Blepharoplasty
    11920-11971Breast reconstruction
    19300Breast surgery
    19316-19342Breast reconstruction
    19355Breast reconstruction
    19370-19396Breast reconstruction
    10040Skin surgery ambulatory
    11300-11313Skin surgery ambulatory
    1–10 of 16
    1/2
    Behavioral health and testing codesmixedCovered
    96116Psychological testing
    96121Psychological testing
    96130-96133Neuropsychological testing
    96136-96139Psych testing/assessment
    96146Testing admin
    96112-96113Developmental pediatric testing
    96110Non-covered service (note)
    90870Outpatient ECT
    Revenue: 912, 913, 944, 945Partial hospitalization revenue codes
    HCPCS H0035Partial hospitalization HCPCS
    1–10 of 15
    1/2
    DME codes not requiring authorization; blood glucose supplies covered via drug benefitHCPCS
    E0130DME not requiring authorization (listed)
    E0135DME not requiring authorization (listed)
    E0168DME not requiring authorization (listed)
    E0182DME not requiring authorization (listed)
    E0184DME not requiring authorization (listed)
    E0235DME not requiring authorization (listed)
    E0274DME not requiring authorization (listed)
    E0305DME not requiring authorization (listed)
    E0310DME not requiring authorization (listed)
    E0424DME not requiring authorization (listed)
    1–10 of 55
    1/6
    Diagnostic testing codesCPTCovered
    91110-91111Wireless Capsule Endoscopy
    91112Wireless Motility Capsule
    Diagnostic and GI codes requiring authorization in specific settingsCPTCovered
    91110Wireless Capsule Endoscopy
    91111Wireless Capsule Endoscopy
    91112Wireless Motility capsule
    43235GI procedure
    43239GI procedure
    43248GI procedure
    45378GI procedure
    45380GI procedure
    45384GI procedure
    45385GI procedure
    1–10 of 16
    1/2
    DME codes not requiring authorizationHCPCSCovered
    E0130DME code not requiring authorization
    E0135DME code not requiring authorization
    E0168DME code not requiring authorization
    E0182DME code not requiring authorization
    E0184DME code not requiring authorization
    E0235DME code not requiring authorization
    E0274DME code not requiring authorization
    E0305DME code not requiring authorization
    E0310DME code not requiring authorization
    E0424DME code not requiring authorization
    1–10 of 50
    1/5
    Therapeutic and pain management codesCPTCovered
    96567Phototherapy
    96573Phototherapy
    96574Phototherapy
    96900Phototherapy
    96910Phototherapy
    96912Phototherapy
    96913Phototherapy
    96920Phototherapy
    96921Phototherapy
    96922Phototherapy
    1–10 of 30
    1/3
    Ambulatory CGMCPTCovered
    95249Ambulatory continuous glucose monitoring
    Other therapeutic procedures requiring authorizationCPTCovered
    58674Radiofrequency Ablation of Uterine Fibroids
    Chiropractic codes requiring authorizationCPT|RevenueCovered
    98940Chiropractic service
    98941Chiropractic service
    98942Chiropractic service
    98943Chiropractic service
    0940Revenue code associated with chiropractic services
    Glucose monitors/testing suppliesHCPCSCovered
    A4253Blood glucose testing supplies (covered through pharmacy benefit)
    A9275Blood glucose supplies (covered through pharmacy benefit)
    E0607Blood glucose monitor (covered through pharmacy benefit)
    E2100Blood glucose testing supplies (covered through pharmacy benefit)
    E2101Blood glucose testing supplies (covered through pharmacy benefit)
    Pharmacy/provider-administered drug HCPCS/C codes and mappings (listed as benefits requiring authorization or review)CPT|HCPCS|C-codes|J-codes|G-codesCovered
    C9054Unclassified/assigned drug-related codes (multiple mappings listed)
    C9055Unclassified/assigned drug-related codes (multiple mappings listed)
    C0965Romidepsin and related mappings
    C9074Lumasiran and related mappings
    C9076Miscellaneous mappings
    C9077Cabotegravir/rilpivirine and related mappings
    C9078Trilaciclib and related mappings
    C9079Evinacumab and related mappings
    C9080Melphalan flufenamide and related mappings
    C9399Unclassified drugs/biologics
    1–10 of 19
    1/2
    Benefit applies - group excerptHCPCS
    J0490listed mappings (e.g., belimumab (Benlysta) and others) as shown
    J0897appears as mapping target in list
    J1071appears as mapping target in list
    J1572appears as mapping target in list
    J1575appears as mapping target in list
    J0517benralizumab (Fasenra) and other mappings
    J0565bezlotoxumab (Zinplava) and other mappings
    Benefit applies - group excerptHCPCS
    J1628guselkumab (Tremfya) and related mappings
    J1632brexanolone (Zulresso) and related mappings
    J1740ibandronate (Boniva) and related mappings
    J1742ibutilide (Corvert) and related mappings
    J1743idursulfase (Elaprase) and related mappings
    J1744icatibant and related mappings
    J1745infliximab (Remicade) and related mappings
    Benefit applies - group excerptHCPCS
    J1930lanreotide (Somatuline) and related mappings
    J2326nusinersen (Spinraza) and related mappings
    J2350ocrelizumab (Ocrevus) and related mappings
    J2505pegfilgrastim (Neulasta) and related mappings
    Benefit applies - group excerptHCPCS
    J3031fremanezumab-vfrm (Ajovy) and related mappings
    J3110taliglucerase alfa (Elylyso) and related mappings
    J3241teprotumumab and related mappings
    J3304triamcin acet PF ER mic and related mappings
    Benefit applies - group excerptHCPCS
    J7518mycophenolic acid 180 mg and related mappings
    J7520sirolimus (Rapamune) and related mappings
    J7599immunosuppress Drug Noc and related mappings
    J7637filgrastim-aafi (Nivestym) and related mappings
    Benefit applies - group excerptHCPCS
    J7677revefenacin inh and related mappings
    J7999misc compounded drug and related mappings
    J8499rx drug oral non-chemo and related mappings
    J8655netupitant palonosetron and related mappings
    Benefit applies - group excerpt continuedHCPCS
    J8700temozolomide (Temodar) and related mappings
    J8999rx oral chemo and related mappings
    J9035bevacizumab (Avastin) and related mappings
    S0156exemestane oral and related S-code mappings
    Inpatient SUD concurrent review exemption — First 28 days of admission (no concurrent review if facility notifies Fidelis Care within 2 business days)
    PolicyIn-network OASAS-licensed inpatient SUD services are not subject to concurrent utilization review for the first 28 days of admission if the facility notifies Fidelis Care of the inpatient admission and initial treatment plan within 2 business days.
    Notification methodFacility may fax or email the OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool to 646-829-1421 or LOCADTR@fideliscare.org.

    Authorization pathways, submission instructions, and billing responsibilities

    Prior Authorization

    Obtain prior authorization for listed procedures and codes

    Prior authorization is required for the listed outpatient surgery, diagnostic, transplant, and other procedure codes; providers must request authorization before performing these services when the codes/conditions listed apply.

    • See outpatient surgery code lists (e.g., 43770-43775, 15820-15823, 11920-11971, 10040, 11300-11471, 11200-11201, 15769-15829, 17340-17999, and many others) which require PA (chunk 11–12).
    • All solid organ and bone marrow/tissue transplants require authorization at the time of transplant evaluation (chunk 2).
    • Diagnostic testing and certain GI procedures require authorization in specific settings (chunk 18).
    • Some DME and supplies require authorization as listed (chunk 19).
    Prior Authorization

    Authorize diagnostic and selected GI procedures (as specified)

    Obtain authorization for specified diagnostic procedures and wireless capsule/motility studies when performed in subject settings; authorization is not required when those services are performed in POS 11 or 24.

    Policy background and scope

    This document provides administrative rules for authorization and utilization review rather than clinical disease background. It requires prior authorization for all inpatient admissions except for emergency services that stabilize the member; facilities must notify Fidelis Care and submit required documentation for certain inpatient behavioral health and substance use disorder (SUD) admissions to qualify for limited concurrent review exemptions (e.g., SUD: first 28 days if facility notifies within two business days; OMH inpatient minors: first 14 days if notification requirements met). The policy references NYS OMH Best Practice Manual criteria and tools such as LOCADTR for SUD review, and directs providers to the coding and authorization modules for specific procedure, DME, and medication authorization requirements.

    Key definitions and terms

    LOCADTR — medical necessity tool used for inpatient SUD utilization review and discharge planning
    Tool nameLOCADTR (Level of Care Determination and Transfer) is the clinical review tool used for inpatient SUD utilization review and discharge planning
    PurposeLOCADTR is used to assess medical necessity, conduct utilization review after day 28 or at discharge, and to determine discharge planning needs
    SubmissionFacilities may fax or email the LOCADTR Medical Necessity Tool to Fidelis Care as part of the two‑day notification process
    OMH Best Practice Manual triggers — clinical criteria specified by NYS OMH that trigger utilization review
    Trigger sourceOMH Best Practice Manual clinical criteria trigger utilization review for OMH‑licensed inpatient, partial hospitalization, and intensive outpatient programs
    Example triggers
    Policy Summary
    PayerFidelis Care
    PolicyAuthorization and Utilization Review Requirements (Coverage Criteria)
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateSep 1, 2021
    Next Review DateN/A
    Key ActionObtain prior authorization for all inpatient admissions and for listed outpatient procedures, imaging, therapies, DME and J-code medications as specified; notify Fidelis Care within two business days for certain inpatient behavioral health and SUD admissions and submit required forms.
    SourceLink
    On This Page
    Coverage criteria and clinical authorization rulesCode lists, limits, and coding-related notesAuthorization pathways, submission instructions, and billing responsibilitiesPolicy background and scopeKey definitions and terms
    Home health and hospice: Home health approvals are based on medical need for skilled services with a benefit maximum of 40 visits per plan year. Hospice care, when medically necessary and provided by a certified Hospice Care program, is available up to 210 days.40 visits per plan year; hospice up to 210 days

    Home care approvals contingent on demonstration of skilled need.

    Imaging and radiology: Radiology and radiation therapy services require prior authorization through eviCore Healthcare; the full CPT lists are maintained on the eviCore website. OB ultrasound exceptions: the first four OB ultrasounds for a normal pregnancy do not require authorization; five or more require authorization. OB ultrasounds for defined high‑risk pregnancy diagnoses do not require authorization.Per eviCore list; first 4 OB ultrasounds without PA for normal pregnancy

    Providers should follow eviCore and policy guidance for specific CPTs and OB diagnosis codes.

    Outpatient therapy (PT/OT/ST): Effective 10/1/2019, all therapy services after the initial evaluation require prior authorization through National Imaging Associates (NIA). Initial PT/OT/ST evaluations do not require prior authorization but all other billed therapy procedure codes (even if same date as evaluation) require authorization. Rehabilitation and habilitation benefits are limited to 60 visits per condition per plan year (all therapies combined).60 visits per condition per plan year

    Excludes PT/OT/ST in inpatient setting, ER, SNF, or during an observation stay.

    Therapeutic services: Phototherapy, hyperbaric oxygen (99183, C1300), specified pain management and injection codes, cardiac and pulmonary rehabilitation, ambulatory CGM (95249), radiofrequency ablation of uterine fibroids (58674), bronchial thermoplasty (31660, 31661), and other listed therapeutic procedures require authorization as indicated.See code groups

    Neuromodulation codes 63622 and 63688 do not require authorization when requested by orthopedic specialties. Cardiac and pulmonary rehab require authorization when delivered outpatient.

    Pharmacy and specialty medications: Oncology medications and supportive agents for members 18 and over require prior authorization from New Century Health (NCH) via NCH web portal or phone. Certain drug requests (e.g., CAR T‑cell therapy, immune globulins, sickle cell disease therapy, radiopharmaceuticals) are reviewed directly by Fidelis Care and should not be submitted to NCH. HCPCS/J‑code mappings and listed provider‑administered drugs require authorization per the policy and listed mappings.Per NCH and Fidelis Care lists

    PA submission instructions and lists of drugs requiring NCH review are available on the Fidelis Care provider resources site.

    Services not requiring authorization in certain circumstances: Initial PT/OT/ST evaluations, the first four OB ultrasounds for a normal pregnancy, and OB ultrasounds for defined high‑risk pregnancy diagnoses do not require prior authorization.Initial evaluation; first 4 OB ultrasounds; specified high‑risk OB ICD‑10 codes

    See policy for the list of high‑risk pregnancy diagnosis codes and other exceptions.

    Facility obligations during exemptionFacility must perform daily clinical review and periodically consult with Fidelis Care starting on or just prior to day 14 to ensure LOCADTR use and medical necessity.
    Post-exemption reviewInpatient SUD services may be subject to utilization review after the 28th day from admission or upon discharge using the LOCADTR clinical review tool.
    Exclusions to exemptionFacilities outside NY, not OASAS‑licensed, or out-of-network remain subject to prior authorization and concurrent review throughout the admission.
    OMH inpatient mental health concurrent review exemption for minors — First 14 days of admission for members under age 18 if facility notifies Fidelis Care within 2 business days
    PolicyFor members under age 18 at OMH‑licensed hospitals in-network, Fidelis Care will not conduct concurrent utilization review during the first 14 days of inpatient admission if the facility notifies Fidelis Care of the admission and initial treatment plan within 2 business days.
    Notification methodComplete OMH Two-Day Notification and Initial Treatment Plan form and submit by fax to 718-896-1784 or email to Mental_Health_Admission@fideliscare.org.
    Facility obligations during exemptionFacility must perform daily clinical review and participate in periodic consultation with Fidelis Care to ensure use of approved evidence‑based clinical review criteria appropriate to the patient age.
    Exclusions to exemptionAll inpatient mental health services provided by out‑of‑network facilities are subject to concurrent review throughout the admission.
    Home health visits benefit maximum — 40 visits per plan year
    Benefit maximumHome health care benefit maximum is 40 visits per plan year.
    Approval basisHome care approvals are based on the medical need for skilled services.
    Related coverage noteHospice coverage is available up to 210 days when medically necessary and provided by a certified program.
    OB ultrasounds without authorization — First 4 OB ultrasounds for a normal pregnancy
    OB ultrasound allowanceThe first 4 OB ultrasounds for a normal pregnancy may be performed without prior authorization.
    Additional ultrasoundsFive or more ultrasounds for a normal pregnancy (dx Z32.01, Z33.1, Z34.00–Z34.03, Z34.80–Z34.83, Z34.9–Z34.93) require authorization.
    High‑risk pregnancyOB ultrasounds for specified high‑risk pregnancy diagnoses (listed ICD‑10 codes) do not require authorization.
    BRCA/Genetic testing lifetime limits — CPT 81220: 1 per lifetime; CPT 81329 and 81336: combined limit of 1 per lifetime
    CPT 81220Limit: 1 per lifetime (authorization not required).
    CPT 81329 and 81336Combined limit: 1 per lifetime between CPT 81329 and CPT 81336 (authorization not required).
    Policy contextGenetic/BRCA testing CPT exceptions noted in diagnostic/GI authorization list — these CPTs do not require authorization but have lifetime limits.
    Rehabilitation visit limit — 60 visits per condition per plan year (all therapies combined)
    Visit limitRehabilitation benefit limited to 60 visits per condition per plan year (all therapies combined).
    Applies toLimit applies to Physical Therapy, Occupational Therapy, and Speech Therapy combined per condition.
    HabilitationHabilitation services are also limited to 60 visits per condition per plan year.
    DSMT allowance — 10 hours / 20 units in continuous 12-month period
    DSMT allowanceMembers are allowed 10 hours / 20 units in a continuous 12‑month period for Diabetes Self‑Management Training (codes G0108, G0109).
    Provider requirementServices must be provided by certified providers and no longer require authorization.
    Related codeEducation and Training for patient self‑management: 98960 (referenced in policy).
    Authorization exceptions — Authorization not required for oncology indications in members <18; authorization not required for ophthalmic indications
    Oncology exceptionAuthorization is not required for J‑code medications when used for oncology indications in members less than 18 years of age.
    Ophthalmic exceptionAuthorization is not required for J‑code medications when used for ophthalmic indications.
    General ruleAuthorization is generally required for medications on the J‑code list except where specific exceptions apply.
    J-code — definition and use for injectable/biologic drugs
    DefinitionJ‑codes are HCPCS procedure codes used to bill for injectable and biologic drugs listed in the policy (mapped to specific drug names/benefit applicability).
    Billing guidanceProviders must bill using the listed J‑codes corresponding to the drug supplied; benefit applicability is tied to specific J‑code mappings shown in the policy.
    Authorization contextAuthorization is generally required for medications billed with J‑codes unless a listed exception (e.g., oncology <18, ophthalmic) applies or specific review pathways (e.g., New Century Health) are in place.
    • Wireless Capsule Endoscopy (91110–91111) and Wireless Motility Capsule (91112) require authorization (chunk 18).
    • GI procedures 43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270 require authorization when performed in POS 19 and 22 if an office or ASC is available; no auth required in POS 11 or 24 (chunk 18).
    • BRCA/genetic CPT 81220, 81329, 81336 are noted as not requiring authorization (chunk 18).
    Prior Authorization

    Request radiology prior authorization via eviCore

    Radiology services require prior authorization through eviCore Healthcare; providers must use eviCore's Fidelis Care list of CPT codes when requesting authorization.

    • A full list of radiology CPT codes subject to eviCore review is maintained at https://www.evicore.com/healthplan/fideliscare (chunk 20).
    • Radiation therapy services also require prior authorization through eviCore (chunk 23).
    Prior Authorization

    Obtain NIA prior authorization for outpatient PT/OT/ST after initial evaluation

    All outpatient PT, OT, and ST procedure codes billed after the initial evaluation require prior authorization through National Imaging Associates (NIA); initial evaluations do not require prior authorization.

    • Effective 10/1/2019, services after the initial evaluation require PA through NIA; initial evaluations do not require PA but other billed codes—even on the same date—do (chunks 21, 20).
    • Non-therapy providers should request authorization for therapy services after the initial evaluation directly through Fidelis Care (chunk 21).
    • Benefit limit: 60 visits per condition per plan year (all therapies combined) (chunk 21).
    Prior Authorization

    Authorize outpatient cardiac and pulmonary rehabilitation

    Obtain authorization for outpatient cardiac and pulmonary rehabilitation services prior to delivery of those outpatient services.

    • Cardiac rehab codes include S9472, 93797, 93798, G0422, G0423, rev code 0943 (chunk 23).
    • Pulmonary rehab codes include G0237–G0239, G0424, S9473, rev code 0943 (chunk 23).
    Prior Authorization

    Prior authorization required for hyperbaric oxygen therapy

    Obtain prior authorization for hyperbaric oxygen therapy codes before providing treatment.

    • Hyperbaric oxygen therapy is listed with codes 99183 and C1300 and requires prior authorization (chunk 23).
    Prior Authorization

    Secure authorization for chiropractic services

    Obtain prior authorization for the listed chiropractic services (98940–98943 and revenue code 0940) before providing care.

    • Chiropractic services codes 98940–98943 and rev code 0940 require authorization (chunk 24).
    Prior Authorization

    Obtain New Century Health prior authorization for oncology medications (members ≥18)

    For outpatient oncology medications and supportive agents for members age 18 and over, obtain prior authorization from New Century Health (NCH) before dispensing or administering the medication.

    • PA requests to NCH can be submitted via NCH's web portal (my.newcenturyhealth.com) or by calling 1-888-999-7713, option 1 (chunk 29).
    • This requirement applies to Medicaid Managed Care, Essential Plan, and Qualified Health Plan (excluding Child Health Plus) for members 18+ (chunk 29).
    • Certain requests (e.g., CAR T-cell therapy, Cablivi, immune globulins, sickle cell therapy, radiopharmaceuticals, etc.) are reviewed directly by Fidelis Care and should not be sent to NCH (chunk 29).
    Prior Authorization

    Follow J-code authorization requirements and exceptions

    Authorization is generally required for medications billed with J-codes unless a specific exception applies; providers must follow the J-code mapping and exception guidance in the policy.

    • Authorization is not required for oncology indications for members under 18 and is not required for ophthalmic indications where noted (chunk 55).
    • Multiple J-code mappings and benefit-applicability notes are provided in the policy and determine whether authorization is required (chunks 36–37).
    Prior Authorization

    Request authorization for DME/supplies and document home health skilled need

    Obtain authorization for DME and supplies that require it; for home health approvals ensure the request documents medical need for skilled services and respects the benefit maximum.

    • Some DME HCPCS codes do not require authorization (list provided in chunk 19); other DME codes and specific supplies (compression garments, electric breast pumps, insulin pumps, infusion pumps, wigs, protective helmets, surgical stockings, etc.) require authorization (chunk 19).
    • Home health approvals are based on medical need for skilled services; the home health benefit maximum is 40 visits per plan year (chunk 19).
    • Blood glucose monitors and testing supplies (A4253, A9275, E0607, E2100, E2101) are covered through the member's prescription drug benefit (chunk 19).
    Note

    Follow the oncology medication review pathway (NCH vs Fidelis)

    Use the New Century Health pathway for oncology-related drug reviews when required; do not send to NCH requests that Fidelis Care reviews directly.

    • PA for outpatient oncology medications/supportive agents for members 18+ must be requested via NCH's portal or phone (chunk 29).
    • Requests such as CAR T-cell therapy, immune globulins, radiopharmaceuticals, and specified categories are to be reviewed directly by Fidelis Care and not sent to NCH (chunk 29).
    Step Therapy

    Step therapy: not specified in this policy fragment

    No step therapy rules are specified in this fragment; the section provides mapping of J-codes to drug names and benefit applicability rather than step therapy protocols.

    • Policy content lists J-code mappings and benefit-applicability entries (chunks 36–37, 54) but does not define step therapy requirements in this fragment.
    Documentation Required

    Notify Fidelis Care within 2 business days and submit required forms for certain inpatient BH/SUD admissions

    Notify Fidelis Care within two business days for certain inpatient behavioral health and SUD admissions and submit the required forms to qualify for the concurrent-review exemptions.

    • For inpatient SUD: fax or email the OASAS Appendix A Notification Form and LOCADTR tool to 646-829-1421 or LOCADTR@fideliscare.org within two business days to be exempt from concurrent review for the first 28 days (chunk 5).
    • For OMH-licensed inpatient mental health admissions of members under 18: submit the OMH 'Two-Day Notification and Initial Treatment Plan' form by fax to 718-896-1784 or email to Mental_Health_Admission@fideliscare.org within two business days to be exempt from concurrent review for the first 14 days (chunk 10).
    Documentation Required

    Submit oncology medication PA to New Century Health (members ≥18)

    For outpatient oncology-related medications for members 18+, submit prior authorization requests to New Century Health via their web portal or phone to support approval.

    • PA can be requested at my.newcenturyhealth.com or by calling 1-888-999-7713, option 1 (chunk 29).
    • This is required before dispensing at a pharmacy or administering in physician office, outpatient hospital, or ambulatory setting for members 18+ (chunk 29).
    Billing Rule

    Submit pharmacy PA requests via e-fax to Fidelis Pharmacy Team

    Submit certain pharmacy prior authorization requests electronically via e-fax to the Fidelis Care Pharmacy Team at 1-877-533-2405 as directed.

    • The policy instructs that specific pharmacy authorization requests must be submitted electronically via fax (e-fax) to 1-877-533-2405 (chunk 30).
    • This e-fax submission process applies to pharmacy PA requests not routed through NCH (chunk 30).
    Billing Rule

    Bill with the appropriate J-code and follow mapping for benefit applicability

    Bill using the J-code that corresponds to the drug supplied and follow the policy's J-code mapping to determine benefit applicability and authorization requirements.

    • The policy contains numerous J-code mappings indicating specific drugs and benefit applicability; providers must bill the J-code that matches the drug supplied (chunks 36–37).
    • These mappings determine whether authorization is required or which pathway (NCH vs Fidelis) will review the request (chunks 36–37).
    Denial Risk

    Risk of denial if authorization not obtained for inpatient/post-stabilization services

    Failure to obtain required authorization for inpatient admissions or post‑stabilization inpatient services may lead to medical necessity review and potential denial or nonpayment of services.

    • All inpatient admissions require authorization; post-stabilization inpatient admissions require authorization after emergent ER services (chunk 1).
    • Failure to obtain authorization may result in services being subject to medical necessity review and potential denial (planner denial risk summary; chunk 56 supports risk language derived from chunk 1).
    Denial Risk

    Obtain authorization for certain GI procedures in POS 19/22 or risk denial

    When GI procedures listed are performed in POS 19 (off-campus outpatient) or 22 (outpatient hospital) and an office or ASC is available, obtain prior authorization; lack of authorization in these circumstances may trigger denial.

    • GI procedures 43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270 require authorization in POS 19 and 22 when an office or ASC is available (chunk 18).
    • Authorization is not required when these services are performed in POS 11 or 24 (chunk 18).
    Denial Risk

    Radiology services require eviCore authorization — failure risks denial

    Radiology services must be authorized through eviCore; failing to obtain eviCore authorization before performing radiology/imaging may result in denial.

    • Radiology and radiation therapy services require prior authorization through eviCore; a full CPT list for Fidelis Care is available on eviCore's website (chunks 20, 23).
    • Providers must request authorization from eviCore prior to performing the radiology service to avoid potential denial (chunks 20, 23).
    Denial Risk

    Secure NIA authorization for outpatient therapy after initial evaluation or risk claim denial

    Outpatient PT/OT/ST services (all billed codes after the initial evaluation) require prior authorization through NIA for services on/after 10/1/2019; billing without required authorization may be denied.

    • Initial evaluations do not require prior authorization, but all other billed therapy procedure codes—even if on the same date—require authorization prior to billing (chunks 21, 20).
    • Providers should secure PA through NIA for post-evaluation therapy services to avoid denial; the benefit is limited to 60 visits per condition per plan year (chunk 21).
    Documentation Required

    Confirm J-code authorization requirements and exceptions before billing

    Authorization may be required for medications billed with J‑codes; follow the policy's J‑code mapping and noted exceptions to determine when PA is required.

    • The policy states authorization is not required for oncology indications in members under 18 and not required for ophthalmic indications where noted (chunk 55).
    • Check the J-code mappings and benefit-applicability entries in the policy to determine whether a specific J-code requires authorization (chunks 36–37).
    High utilization (3+ psych inpatient hospitalizations OR 4+ psych ED visits OR 3+ medical inpatient hospitalizations in prior 12 months), readmission within 30 days, or length of stay >30 days
    ApplicabilityThese triggers guide when Fidelis Care will conduct admission and concurrent utilization review for OMH‑licensed programs
    Genetic testing authorization exceptions — CPT 81220, 81329, 81336 exceptions and lifetime limits
    CPT 81220Authorization not required for CPT 81220; lifetime limit = 1
    CPT 81329 & 81336Authorization not required for CPT 81329 and 81336; combined lifetime limit = 1
    Policy noteGenetic testing CPT exceptions and lifetime limits are specified in the diagnostic testing section
    Therapy initial evaluation — initial PT/OT/ST evaluations do not require prior authorization; subsequent billed therapy codes require authorization
    Initial evaluation ruleInitial PT/OT/ST evaluations do not require prior authorization
    Subsequent service ruleAll other billed therapy procedure codes after the initial evaluation require prior authorization (even if on same date)
    Visit limitsRehabilitation and habilitation benefits limited to 60 visits per condition per plan year (applies to all therapies combined)