Fidelis Care Prior Auth & Coding Update | OpenPayer
ModifiedFidelis CarePolicy N/A
Authorization, Utilization Review, and Coding Guidance — Medicaid/CHP/HealthierLife (Part excerpt)
Updates to Fidelis Care authorization, utilization review, and coding guidance across inpatient, outpatient, behavioral health, substance use disorder, surgical, transplant, and delegated review programs affecting providers serving Fidelis Care Medicaid, CHP and HealthierLife members in New York State.
Policy Summary
PayerFidelis Care
PolicyAuthorization, Utilization Review, and Coding Guidance (Medicaid/CHP/HealthierLife)
Policy CodePolicy N/A
Change TypeMaterial revisions to authorization and coverage rules
Effective DateN/A
Next Review DateN/A
Key ActionObtain prior authorization for all inpatient admissions (post-stabilization) and for listed outpatient services and J/C codes before claim submission.
Authorization requirement has been removed from all outpatient behavioral health services except a specified list which will continue to require authorization.
Developmental screening CPT 96110 reimbursed in the first three years in addition to E&M, with limits per AAP/Bright Futures schedule and specific billing diagnosis codes required.
Applied Behavior Analysis (ABA) services included in Medicaid managed care benefit package for eligible members under age 21; prior authorization required and form provided.
Prior authorization not required for first seven days of Intensive Outpatient Treatment and Mental Health Continuing Day Treatment; additional days require authorization.
All inpatient admissionsrequire prior authorization (except ER emergent stabilization)
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OMH in-state inpatient MH
not subject to prior authorization when OMH-licensed (with notification requirements)
Inpatient SUDnot subject to prior authorization and first 28 days not subject to concurrent review with notification
First 7 daysno authorization required for Intensive Outpatient and Continuing Day Treatment initial period
Multiple listsnumerous procedures require prior authorization or are delegated
Coverage Criteria and Medical Necessity Rules
OMH inpatient mental health utilization review triggers
Utilization review for OMH-licensed inpatient mental health treatment is conducted only when ANY of the following triggers are met per NYS OMH Best Practice Manual:
OMH utilization review triggers: 1) Individuals subject to a current Assisted Outpatient Treatment (AOT) court order; 2) Individuals who had an AOT court order that expired within the past five years; 3) High utilization as evidenced by: (a) Three or more psychiatric inpatient hospitalizations in the prior 12 months OR (b) Four or more psychiatric emergency department visits in the prior 12 months OR (c) Three or more medical inpatient hospitalizations in the prior 12 months; 4) Readmission to any mental health inpatient unit within 30 days of discharge; 5) Length of stay exceeds 30 days for individuals not meeting other triggers (concurrent review from Day 31 onwards)as stated
Follow NYS OMH Best Practice Manual
OASAS inpatient SUD initial exemption criteria
OASAS-licensed in-state inpatient SUD services are exempt from prior authorization and concurrent review for the initial period when ALL of the following are met:
OASAS SUD initial review exemption: Facility is OASAS-licensed, located in New York State, participating in Fidelis Care's provider network; facility notifies Fidelis Care of the inpatient admission and the initial treatment plan within two business days and submits the OASAS Appendix A Notification Form and LOCADTR tool (fax 833-663-1608 or LOCADTR@fideliscare.org); facility performs daily clinical review and consults with Fidelis Care on or just prior to day 1428 days
Services may be subject to utilization review after day 28 or upon discharge; facilities must provide written discharge plan and may be subject to retrospective review
Partial Hospitalization (Mental Health) medical necessity
Partial Hospitalization Mental Health Treatment — Authorization/Concurrent Review is conducted only when ALL of the following OMH criteria apply or other specified triggers are met:
OMH-specific population triggers: Individuals subject to a current Assisted Outpatient Treatment (AOT) court order OR individuals whose AOT court order expired within the past five years
High utilization triggers: Evidence of high utilization defined as: (1) Three or more psychiatric inpatient hospitalizations in the prior 12 months OR (2) Four or more psychiatric ED visits in the prior 12 months OR (3) Three or more medical inpatient hospitalizations in the prior 12 monthssee thresholds
Readmission/Length of stay triggers: Individuals readmitted to any mental health inpatient unit within 30 days of prior discharge; OR individuals not meeting above triggers whose length of stay exceeds 30 days30 days
Intensive Outpatient Treatment coverage
Intensive Outpatient Treatment — Coverage without authorization applies ONLY for the initial period while continued service requires meeting OMH criteria or utilization review triggers:
Initial coverage: No prior authorization needed for the first seven days of service7 days
Additional days require authorization
OMH clinical triggers for continued IOP: Individuals subject to a current or recent (within five years) AOT order; high utilization as defined for PHP; readmission within 30 days; or length of stay >30 dayssee thresholds
Concurrent review applies as specified
TMS coverage criteria
Transcranial Magnetic Stimulation (TMS) — Covered with prior authorization when ALL of the following are met:
Age and device: Member is over 18 years of age and TMS is administered using an FDA-cleared device in accordance with labeled indications>18 yrs
Diagnosis and prior treatment failure: Confirmed diagnosis of Major Depressive Disorder (MDD) and documented failure to respond to multiple trials of medication and evidence-based psychotherapy during the current episode of illnessmultiple trials
Age and frequency: Reimbursed in the 'First Three Years of Life' of the child and may be reimbursed up to two times for ASD screening beginning at 18 months and up to once per year for global developmental delay screening per the Bright Futures/AAP schedule (ages 9, 18, 30 months for global delay; 18 and 24 months for ASD)ages 9, 18, 30 months for global delay; 18 and 24 months for ASD
When billed to Medicaid, CPT 96110 must be billed with diagnosis code Z13.41 (autism screen) OR Z13.42 (screening for global developmental delays)
Respite services limits
Short-term Planned and Crisis Respite Services — Coverage limitations:
Annual limit: Short-term Planned and Crisis Respite services may not exceed 14 days (1,344 15-minute units) per calendar year without medical necessity14 days / 1,344 units
Respite beyond limits requires LPHA attestation and NYS DOH Children's HCBS Authorization and Care Manager Notification before service
OB Ultrasound Criteria
OB ultrasound coverage rules
Normal pregnancy OB ultrasound: The first four OB ultrasounds can be performed without authorization; five or more ultrasounds for a normal pregnancy require authorization>=5 ultrasounds
Diagnosis codes for normal pregnancy (e.g., Z32.01, Z33.1, Z34.00-Z34.93) are listed in policy
High-risk pregnancy OB ultrasound: OB ultrasounds for a high-risk pregnancy with specified O09.xx and related diagnosis codes do not require authorizationpresence of listed high-risk diagnosis codes
High-risk diagnosis codes enumerated in policy
Therapy Authorization Criteria
Therapy services prior authorization rules
Home & Outpatient PT/OT/ST: After the initial evaluation, physical therapy (PT), occupational therapy (OT), and speech therapy (ST) performed by a therapy provider in office, home, or facility require prior authorization through Evolent (NIA); initial home therapy evaluation requires authorization; CPT codes 92610 and 92611 are exempt from authorizationpost-initial evaluation
If billing codes other than designated initial evaluation CPT codes, authorization request must be submitted within specified timeframes
Inpatient therapy: PT/OT/ST performed in inpatient settings, Emergency Room, Skilled Nursing Facility/Sub-Acute Rehab, or during an Observation stay are excluded from this outpatient authorization program; prior authorization processes and fax numbers differ for SNF/Sub-Acute settingsinpatient POS
Prior auth fax for SNF/Sub-Acute therapy: 833-663-1611
Therapeutic Services Coverage
Therapeutic services coverage and exclusions
Not covered for Low Back Pain: The following are not covered for members with a diagnosis of Low Back Pain: 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; continuous or intermittent tractiondiagnosis = Low Back Pain
These services are explicitly excluded when the diagnosis is low back pain
Radiation therapy prior authorization delegated to Evolent (NIA)
Enteral Therapy Criteria
Enteral therapy coverage conditions
Enteral therapy eligibility: Enteral formulas (HCPCS B4034-B4162) require authorization and apply to: (1) tube-fed individuals dependent on tube nutrition; (2) individuals with inborn metabolic disorders requiring specific formulas; (3) children under 21 who require medical formulas for growth/development; (4) certain adults with HIV/AIDS or related conditions meeting BMI and recent weight-loss criteria; pharmacy supplies generally do not require authorization (CHP exceptions noted)meets listed condition(s)
Authorization applicable to listed HCPCS codes; benefit specifics vary by plan (e.g., CHP)
Emergency room services or any emergent service required to provide stabilization of an emergent condition do not require prior authorization. However, post‑stabilization inpatient admissions and all other inpatient admissions do require prior authorization; failure to obtain authorization for inpatient admissions (except emergent ER stabilization) may result in claim denial.
In‑network, in‑state outpatient substance use disorder (SUD) services — including outpatient office visits, therapy/counseling visits, intensive outpatient programs (IOP), outpatient rehabilitation, and opioid treatment programs (OTP) — do not require provider notification, prior authorization, or concurrent review when performed by OASAS‑licensed, in‑state, in‑network providers. Out‑of‑state or out‑of‑network providers must continue to request authorization.
Developmental screening using CPT 96110 is not subject to prior authorization when billed for a child in the First Three Years of Life. Per Medicaid requirements, when billing 96110 include diagnosis code Z13.41 (autism screen) or Z13.42 (screening for global developmental delays). Screening frequency follows Bright Futures/AAP guidance (ASD screening up to two times beginning at 18 months; global developmental screening up to once yearly).
OB ultrasound rules: the first four OB ultrasounds for a pregnancy may be performed without authorization. For a normal pregnancy, five or more ultrasounds require prior authorization. Ultrasounds performed for a high‑risk pregnancy with the specified O09.xx and related diagnosis codes do not require authorization.
For members with a diagnosis of Low Back Pain, the policy identifies specific services that are not covered: (a) prolotherapy; (b) therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT fluoroscopic guidance); (c) therapeutic injections of steroids into intervertebral discs; and (d) continuous or intermittent traction.
Appendix I summarizes categories of services and drug groups that require prior authorization. Key categories listed include: Inpatient drug requests, iron preparations, pain medications, radiopharmaceuticals, and various surgeries/surgical procedures and diagnoses (for example, sickle cell). Appendix I maps these categories to specific HCPCS/J/C codes elsewhere in the document.
Procedure CPT 20610 (injection of tendon sheath; e.g., for certain joint/soft tissue injections) is explicitly identified as non‑covered when billed together with listed hyaluronic acid J‑codes (examples include J7318, J7320–J7332) for members with a diagnosis of osteoarthritis of the knee (ICD‑10 codes: M17 series). In other situations, authorization for 20610 is not required.
Within the excerpt provided there are no additional explicit 'not medically necessary' (NMN) blanket statements for services beyond the examples called out; instead, the document primarily lists services and HCPCS/CPT/J codes that require prior authorization (Appendix I and other sections).
Code 11719 is noted as a non‑covered code for Medicaid when rendered by a physician per the Medicaid Fee Schedule. When the same procedure is rendered by a facility using POS 11, it is covered but requires prior authorization.
Prior authorization is required for many provider actions described below. Submit authorization requests per the instructions for each service or delegated vendor. Failure to obtain prior authorization when required may result in denial or delayed payment.
Inpatient admissions require authorization; emergency department stabilization does not but post-stabilization inpatient admissions after ER services do require authorization. New fax for Inpatient ER: 833-663-1602.
Transplants require authorization at time of transplant evaluation (includes solid organ and bone marrow / tissue transplants — see policy code listing).
Outpatient surgery — many specified CPT/HCPCS codes require prior authorization; certain codes delegated to Evolent (NIA) or TurningPoint require requests to those vendors. See outpatient surgery code lists and POS-specific rules (e.g., some skin surgery codes require auth only if POS 24).
Psychological/Neuropsychological testing (96116, 96121, 96130-96139, 96136-96137, 96146): authorization required. Requests must be submitted on the Psychological/Neuropsychological testing request form.
Developmental Pediatric Testing: 96112, 96113 — authorization required. 96110 developmental screening does NOT require authorization (except CHP) but must be billed with Z13.41 or Z13.42 per Medicaid guidance and follows Bright Futures/AAP periodicity rules.
Partial Hospitalization (PHP) / Intensive Outpatient (IOP) — utilization review (admission and concurrent/continued stay) is conducted only for members who meet specified OMH clinical triggers (e.g., AOT status, high utilization thresholds, readmission within 30 days, length of stay >30 days). For Intensive Outpatient, no prior authorization needed for first seven days; additional days require authorization.
Background and Scope
This policy provides operational guidance for prior authorization and utilization review across levels of care. Key points: all inpatient admissions require prior authorization (ER stabilization itself does not); OMH‑licensed inpatient mental health treatment is generally exempt from prior authorization but is subject to notification and selective utilization review triggers per OMH Best Practice (for example, high‑utilization patterns or length of stay >30 days); OASAS‑licensed in‑state inpatient SUD care can be exempt from prior authorization/concurrent review for the initial period when notification and LOCADTR submission requirements are met; and many outpatient procedures, specific therapeutic services, and numerous HCPCS/J/C codes listed in Appendix I require prior authorization before reimbursement.
Definitions and Eligibility Criteria
inv-100: OASAS-licensed Inpatient SUD definition
DefinitionInpatient detoxification, inpatient rehabilitation and inpatient residential SUD services provided in New York State by facilities licensed, certified or otherwise authorized by OASAS and participating in Fidelis Care's provider network.
Prior authorizationNot subject to prior authorization review by Fidelis Care when facility meets notification and LOCADTR submission requirements.
Concurrent review exemptionNot subject to concurrent utilization review during the first 28 days of the inpatient admission provided facility notifies Fidelis Care within 2 business days and submits Appendix A Notification Form and LOCADTR tool.
Notification requirementFacility must notify Fidelis Care of the inpatient admission and initial treatment plan within two business days (fax 833-663-1608 or LOCADTR@fideliscare.org).
Ongoing review/consultationFacility must perform daily clinical review and periodically consult with Fidelis Care beginning on or just prior to day 14; services may be subject to utilization review after day 28 or upon discharge.
Policy Summary
PayerFidelis Care
PolicyAuthorization, Utilization Review, and Coding Guidance (Medicaid/CHP/HealthierLife)
Policy CodePolicy N/A
Change TypeMaterial revisions to authorization and coverage rules
Effective DateN/A
Next Review DateN/A
Key ActionObtain prior authorization for all inpatient admissions (post-stabilization) and for listed outpatient services and J/C codes before claim submission.
Transcranial Magnetic Stimulation (TMS) CPT 90867-90869: covered with authorization. Members over 18 require documented failure of multiple medication trials and evidence-based psychotherapy during current episode; TMS must use an FDA-cleared device and meet additional clinical criteria.
Outpatient diagnostic testing and imaging: many diagnostic tests require authorization (sleep studies, genetic testing, wireless capsule endoscopy, select gastroenterology procedures in POS 19/22 when office/ASC available, and others). Imaging: OB ultrasounds — first 4 are allowed without authorization for normal pregnancy; five or more ultrasounds for a normal pregnancy require prior authorization. OB ultrasounds for high-risk pregnancy do not require authorization. Radiology prior authorization has been delegated to Evolent (NIA); review delegated lists for codes requiring authorization.
Therapy services (Home & Outpatient PT/OT/ST): effective 10/1/2021, prior authorization is required through Evolent (NIA) for Home and Outpatient PT/OT/ST performed after the initial evaluation (home therapy requires authorization for the initial evaluation). CPT 92610 and 92611 do not require authorization. For outpatient settings, authorization requests for services other than designated initial evaluation CPTs must be sent to Evolent (NIA) within 1 business day (or within 2 business days for home health) — inpatient therapy requests should be sent to Fidelis within 1 business day. For therapy provided in SNF/Sub-Acute (POS 31 & 32), prior auth requests should be faxed to 833-663-1611.
Therapeutic services (phototherapy, hyperbaric oxygen, pain management injections and specified codes, interventional pain management, radiation therapy — delegated to Evolent (NIA) for auth, ambulatory continuous glucose monitoring, radiofrequency ablation of uterine fibroids, bronchial thermoplasty, vision therapy, etc.) require prior authorization per the listed codes and delegation notes. Some services are specifically non-covered for certain diagnoses (e.g., listed services for low back pain). Topical oxygen requires prior authorization.
Codes requiring prior authorization: Appendix I contains an extensive list of J-, Q-, C-, and other HCPCS/CPT codes (oncology and high-cost drugs/biologics) that require prior authorization. Oncology medications and supportive agents require prior authorization from Evolent (see Evolent portal or 1-888-999-7713 option 1) except where noted (e.g., certain exclusions). Pharmacy PA requests per Appendix I should be submitted electronically via e-fax to 1-844-235-5090. Review Appendix I for detailed code lists and inpatient drug / drug-category notes.
Applied Behavior Analysis (ABA): Prior authorization required from Behavioral Health. ABA authorization request form is available at: https://www.fideliscare.org/Portals/0/Providers/FormsApplications/Applied-BehavioralAnalysis-Treatment-Report.pdf
Respite services over annual limits: Short-term planned and crisis respite may not exceed annual limits (14 days / 1,344 15-minute units) without medical necessity. Requests beyond limits MUST be supported by medical necessity documentation including an LPHA Attestation form and NYS DOH Children's HCBS Authorization and Care Manager Notification form; submit by email to SM_Childrens_HCBS@fideliscare.org, fax 833-663-1604, or call 1-888-FIDELIS and follow prompts for Children's Medicaid. Submit prior to rendering service to avoid claims processing disruptions.
Timing and submission notes: submit authorizations as soon as frequency/scope/duration known and before end of existing authorization to avoid delays. For outpatient therapy (non-initial eval codes) send auth to Evolent within 1 business day (2 business days for home setting). Non-therapy providers should request auth for all services after the initial evaluation directly through Fidelis Care.
OMH notification (Two-Day Notification): For OMH licensed inpatient mental health treatment, facilities must notify Fidelis Care within 2 business days of admission by calling 1-888-FIDELIS ext. 16072 for Behavioral Health or by fax to 833-561-0094 (formerly 718-896-1784). For members under 18, facilities must complete OMH 'Two-Day Notification and Initial Treatment Plan' form and submit by fax (833-561-0094) or email Mental_Health_Admission@fideliscare.org to avoid concurrent review during the initial period as specified.
Voicemail requirements for Utilization Management communications: UM messages with PHI may be left only if the provider's voicemail is HIPAA-compliant (greeting identifies owner, organization, and confidentiality/PHI acceptance). If not HIPAA-compliant, UM will leave a generic message requesting a callback. When notifying providers of a UM determination, a second direct contact attempt will be made as required by NY Department of Health Reasonable Effort Policy.
Step therapy: step therapy programs and other step requirements may apply for certain services or medications; follow the specific program or vendor instructions (where detailed step therapy rules apply, refer to the delegated vendor or pharmacy program documentation).
inv-101: OMH-licensed inpatient mental health
DefinitionInpatient mental health treatment provided by OMH-licensed hospitals in New York State participating in Fidelis Care's network.
Prior authorization stanceGenerally not subject to prior authorization review by Fidelis Care per NYS OMH Best Practice Manual.
Notification requirementFacility must notify Fidelis Care within 2 business days of admission (call 1-888-FIDELIS ext.16072 or fax 833-561-0094) to avoid initial concurrent review.
Utilization review triggersUtilization review is conducted only when any listed triggers apply (AOT orders current/expired within 5 years; high utilization; readmission within 30 days; length of stay >30 days).
Pediatric exceptionFor members under age 18, no prior authorization and no concurrent review for first 14 days if facility submits OMH Two-Day Notification and Initial Treatment Plan and meets daily review and consultation requirements.
DefinitionDevelopmental screening using standardized, validated tools to identify developmental risk and document objective data on milestones and speech/language.
Coverage windowReimbursed in the 'First Three Years of Life' and may be reimbursed per Bright Futures/AAP schedule (ages 9, 18, 30 months for global delay; 18 and 24 months for ASD).
FrequencyASD screening may be reimbursed up to two times beginning at 18 months; global developmental delay screening up to once per year in the first three years.
Billing requirementWhen billing CPT 96110 for Medicaid, include diagnosis code Z13.41 (autism screen) OR Z13.42 (screening for global developmental delays).
Eligibility ageMembers under age 21 are eligible for ABA services.
DiagnosesMust have a DSM-5 diagnosis of autism spectrum disorder and/or Rett Syndrome.
Referring cliniciansMust be referred by a NYS licensed physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner, or physician assistant.
ProvidersServices provided by Licensed Behavior Analyst (LBA), Certified Behavior Analyst Assistant (CBAA) under LBA supervision, or other Article 167–specified individuals enrolled in NYS Medicaid.
Prior authorizationPrior authorization is required from Behavioral Health and requests must use the Fidelis Care Applied Behavioral Analysis Treatment Report form (link on Fidelis website).
inv-104: High risk pregnancy definition
DefinitionPregnancy classified as high-risk by specified diagnosis codes (O09.xx series and related codes) as enumerated in the policy.
OB ultrasound authorizationOB ultrasounds for high-risk pregnancy do not require prior authorization when a listed high-risk diagnosis code is present.
Normal pregnancy thresholdFor normal pregnancy diagnoses, the first 4 OB ultrasounds do not require authorization; five or more require prior authorization.
Diagnosis examplesPolicy lists specific normal and high-risk pregnancy ICD codes (e.g., Z32.01, Z33.1, Z34.00–Z34.03; O09.00–O09.93 and related codes).
inv-105: Enteral therapy eligibility
ScopeEnteral formulas and disposable items described by HCPCS codes B4034–B4162 that require authorization (applicable to Child Health Plus as of 4/1/2023).
Eligible populationsApplies to: tube-fed individuals; individuals with inborn metabolic disorders requiring specific formulas; children under 21 requiring medical formulas for growth/development concerns; certain adults with HIV/AIDS meeting BMI and weight-loss criteria.
Adult HIV/AIDS criteriaAdults with HIV/AIDS may qualify if they require supplemental nutrition, comply with a medical/nutritional plan, and have BMI <18.5 OR BMI <22 with ≥5% unintentional weight loss in prior 6 months; up to 1,000 calories/day.
Total nutritional supportApplies when there is a permanent structural limitation preventing chewing and placement of a feeding tube is medically contraindicated.
Pharmacy suppliesPharmacy supplies do not require authorization (supplies not covered for CHP; refer to benefit plan).
DefinitionAppendix I is a listing of HCPCS C-codes and J-codes (with product descriptors) that require prior authorization prior to reimbursement.
ExamplesIncludes specific C-codes such as C9047, C9145, C9166, C9167, C9168, C9293, C9305, C9306 mapped to drug/product descriptors.
Prior authorization requirementProviders must obtain prior authorization for services billed using the listed HCPCS/C and J-codes in Appendix I before claim submission.
Oncology/complex drugsAppendix I encompasses oncology medications, biologics, and other high-cost injectable products that require PA via Evolent or specified process.