Governs prior authorization, inpatient/outpatient admission and service authorization rules, and special handling for behavioral health and substance use services during the COVID-19 update period for Fidelis Care members in New York State.
Key ActionObtain prior authorization for all inpatient admissions and for specified outpatient services (imaging via eviCore, outpatient therapy via NIA, most DME and listed procedures) before providing non-emergent care.
No material clinical or coverage changes in this revision.
AllInpatient authorization requirement
NoneOut-of-network benefits
4 freeOB ultrasound threshold
40Home health max (visits/yr)
210
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Hospice max (days)
10 hrsDSMT allowance (12 mo)
Coverage and Service Limits
Outpatient Therapy (PT/OT/ST)
Covered when ALL of the following are met:
Therapy authorization and visit limits: Services rendered on or after 10/1/2019 require prior authorization for all PT/OT/ST services after the initial evaluation via National Imaging Associates (NIA); initial evaluations do not require prior authorization. Non-therapy providers (MD, DO, DPM, etc.) should request prior authorization for all services after the initial evaluation directly through Fidelis Care.effective 10/1/2019
Benefit limited to 60 visits per condition per plan year for rehabilitation and 60 visits per condition per plan year for habilitation; visit limit applies to all therapies combined.
Durable Medical Equipment / Supplies
Covered when ALL of the following are met:
DME authorization: A listed set of DME HCPCS codes do not require authorization; other DME codes require authorization. Specific supplies require authorization: compression garments/gradient stockings; electric breast pumps; electric heat pads and hot water bottles; surgical stockings; protective helmets; wigs; insulin pumps; and insulin infusion pumps. Codes for blood glucose monitors and testing supplies (A4253, A9275, E0607, E2100, E2101) are covered through the member's prescription drug benefit.
Orthotics are not covered.
Imaging Studies
Covered when the following imaging authorization rules are met:
OB ultrasound rules: The first 4 OB ultrasounds for a normal pregnancy may be performed without authorization; five or more ultrasounds for a normal pregnancy require prior authorization. OB ultrasounds for a high-risk pregnancy do not require authorization.first 4 without PA
Specific ICD-10 codes define normal versus high-risk pregnancy as listed in the policy (e.g., Z32.01, Z33.1, Z34.00-Z34.03; high-risk codes O09.xx and O36.80x0-O36.80x5, etc.).
Radiology services require prior authorization through eviCore Healthcare. A full list of CPT codes subject to authorization is available on the eviCore Fidelis Care webpage.
Podiatry Services
Podiatry authorization: Podiatric services rendered to members with a confirmed diagnosis of Diabetes Mellitus do not require authorization (the diabetes diagnosis must be included on the claim). Podiatric services to members without a diagnosis of diabetes require authorization. Podiatrists require authorization for all DME codes supplied in the office regardless of member diagnosis. Routine foot care for non-diabetics is not covered.
Diabetes Self-Management Training
DSMT coverage: Diabetes Self-Management Training (DSMT) services billed with codes G0108 (individual) and G0109 (group) are covered when provided by certified providers and do not require authorization.10 hours / 20 units per 12 months
Members are allowed 10 hours (20 units) in a continuous 12-month period.
Home Health and Hospice
Home health: Home care approvals are based on medical need for skilled services; the home health benefit maximum is 40 visits per plan year.40 visits per plan year
Hospice care must be provided as part of a Hospice Care program certified pursuant to Article 40 of the N.Y. Public Health Law; when medically necessary, coverage is available for up to 210 days.210 days
The policy explicitly states that orthotics are not covered. This exclusion applies to orthotic devices billed as DME and is listed under the Durable Medical Equipment/Supplies section; related DME authorization rules and exception lists in the same section do not change this coverage stance.
CPT code 20610 is designated as non-covered when billed with the following osteoarthritis diagnosis codes: M17.0, M17.10–M17.12, M17.2, M17.20–M17.32, M17.4, M17.5, and M17.9. This non-coverage note appears within the outpatient surgery section and applies when 20610 is billed in the circumstances described (e.g., certain ambulatory surgery center billing scenarios).
For members with a diagnosis of Low Back Pain, the following procedures and services 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.
The policy states that routine foot care for non-diabetics is not covered. Podiatric services for members without a diabetes diagnosis require authorization, whereas services for members with a confirmed diagnosis of Diabetes Mellitus do not require authorization (provided the diabetes diagnosis is included on the claim).
As reiterated elsewhere in the DME section, orthotics are not covered. This duplication in the DME/Supplies section confirms orthotics are excluded from coverage regardless of other listed DME authorization rules.
Code Lists and Billing Identifiers
Behavioral health CPT/HCPCS codes requiring authorizationmixedCovered
96112
Developmental testing
96113
Developmental testing
90870
Outpatient ECT
90899
Intensive outpatient unspecified
H0035
Partial hospitalization behavioral health
S9480
Intensive outpatient
H2013
Intensive outpatient
DME Codes Not Requiring Authorization (excerpt)HCPCSCovered
Authorization, Notification, and Documentation Requirements
Prior Authorization
Outpatient surgery prior authorization list
The services listed below require prior authorization. Review setting- and code-specific notes (place of service, delegated review vendors) before submitting requests.
Bariatric surgery: CPT 43770-43775, S2083
Blepharoplasty: CPT 15820-15823
Breast reconstruction: CPT 11920-11971, 19300, 19316-19342, 19355, 19370-19396
Skin surgery/dermatologic procedures: Many do not require auth when performed in POS 11 or 22; the following require auth if completed as ambulatory surgery (POS 24): 10040, 11300-11313, 11400-11471, 11721. Only the following require authorization for any place of service: 11200-11201, 11719, 15769-15829, 17340-17999
ASC bill type 0831 codes requiring auth: 10060, 11100, 11900, 17000, 20600, 20605, 20610 (Note: CPT 20610 is non-covered when billed with specified M17.x diagnosis codes)
This policy summarizes operational authorization and utilization management requirements applicable to Fidelis Care providers. Key operational rules include: all inpatient admissions require prior authorization (emergency stabilization is an exception for initial emergency care, but subsequent inpatient admissions require authorization); all solid organ and bone marrow/tissue transplants require authorization at the time of transplant evaluation; listed DME HCPCS codes do not require authorization while other DME and specified supplies require prior authorization; outpatient PT/OT/ST services after the initial evaluation require prior authorization through National Imaging Associates (effective 10/1/2019); and radiology/imaging and certain diagnostic procedures require prior authorization through eviCore. In addition, OMH- and OASAS-licensed inpatient facilities have specific notification and documentation obligations (e.g., OMH two-day notification and OASAS LOCADTR reporting) that must be followed for admissions and concurrent review.
Key Terms and Forms
LOCADTR
Tool definitionLOCADTR is a medical necessity assessment tool used by OASAS‑licensed inpatient SUD facilities for concurrent review and discharge planning.
Use in reviewInpatient SUD services may be subject to utilization review after the 28th day from admission or upon discharge using the LOCADTR clinical review tool.
Facility obligationsFacilities must periodically consult with Fidelis Care starting on or just prior to the 14th day of treatment to ensure use of LOCADTR for medical necessity assessment.
OMH Two-Day Notification
Form purposeOMH Two‑Day Notification is the OMH‑developed form used to notify Fidelis Care of admission and the initial treatment plan for certain inpatient mental health admissions.
Timing and submission
Policy Revision History
2020-12-01effective_dateLatest
Policy content (including OASAS inpatient SUD notification procedures and inpatient/authorization rules) became effective on 2020-12-01.
2020-10-01policy_change
Outpatient PT/OT/ST services (after the initial evaluation) require prior authorization effective 10/01/2019, reiterated in this policy language for services rendered on or after 10/01/2019.
Key ActionObtain prior authorization for all inpatient admissions and for specified outpatient services (imaging via eviCore, outpatient therapy via NIA, most DME and listed procedures) before providing non-emergent care.
Spinal surgery and related: 20932-20934, 22867-22870, 62380
Esophageal sphincter augmentation: 43284
Certain outpatient orthopedic and spinal surgical procedures require prior authorization (dates of service from 10/1/2019); TurningPoint Healthcare Solutions, LLC delegated for dates on/after 12/23/2019 (see orthopedic/spinal delegation). If a CPT code is delegated to TurningPoint, associated devices (HCPCS) will also be reviewed by TurningPoint for medical necessity.
Prior Authorization
Behavioral health prior authorization
Outpatient behavioral health services and certain behavioral health-related items require authorization. Follow form and attestation requirements where noted.
Psychological/Neuropsychological Testing (CPT 96116, 96121, 96130-96133, 96136-96139, 96146) — authorization required; requests must be submitted using the Psychological/Neuropsychological Testing request form.
Applied Behavior Analysis (ABA) for Autism Spectrum Disorder — authorization required from Behavioral Health. At time of request, attestation of ASD diagnosis by a licensed physician or psychologist is required.
DME speech generation equipment for ASD — authorization required.
Inpatient SUD and OMH inpatient notification and documentation requirements: facilities must notify Fidelis Care within two business days using the appropriate forms and follow OASAS/OMH reporting (see provider notification procedures).
Prior Authorization
Diagnostic and radiology prior authorization
Certain diagnostic tests, imaging, and GI procedures require prior authorization; authorization vendor and place-of-service rules apply.
Diagnostic testing requiring auth: Sleep studies (including home sleep studies), Breast cancer/genetic testing (BRCA and other genetic tests) — note exceptions: CPT 81220, 81329, 81336 do NOT require authorization (lifetime limits apply as noted).
Wireless capsule endoscopy and motility capsules: 91110-91112 — authorization required.
Gastroenterology procedures require authorization when performed in POS 19 or 22 (office/ASC) if an office-based or ambulatory surgery center is available: 43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270. These procedures do NOT require authorization when performed in POS 11 or 24.
Radiology and advanced imaging require prior authorization through eviCore Healthcare. A full list of CPT codes is available at https://www.evicore.com/healthplan/fideliscare.
Radiation therapy services require prior authorization through eviCore Healthcare.
Prior Authorization
Outpatient therapy prior authorization
Outpatient therapy (PT/OT/ST) performed after the initial evaluation requires prior authorization through National Imaging Associates (NIA). Initial evaluations do not require authorization, but all subsequent billed therapy procedure codes (even if on same date as the eval) do.
Effective 10/1/2019, PT/OT/ST after the initial evaluation require PA through NIA.
Initial evaluations are exempt from PA but any other billed therapy codes on the same date still require authorization prior to billing.
Non-therapy providers (MD, DO, DPM, etc.) should request authorization for therapy services after the initial evaluation directly through Fidelis Care.
Rehabilitation visit limits: 60 visits per condition per plan year (applies to all therapies combined). Habilitation: 60 visits per condition per plan year.
Denial Risk
DME and supplies authorization risk / HCPCS benefit applicability
Durable medical equipment and certain supplies have mixed authorization rules — some HCPCS/HCPCS-like items are listed as no-auth while others require prior authorization.
Supplies requiring authorization include compression garments/gradient stockings, electric breast pumps, electric heat pads/hot water bottles, 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 (do not require DME auth).
Some HCPCS-listed specialty drug J-codes and biologics are noted in the benefits list; check pharmacy/medical benefit rules for prior authorization requirements and applicable vendors.
Prior Authorization
Auth required by place of service
Place-of-service affects authorization requirements for specific procedures — confirm POS when requesting authorization.
GI procedures listed require authorization if performed in POS 19 or 22 when an office/ASC alternative exists; no auth required in POS 11 or 24.
Many skin surgery treatments do not require auth when performed in POS 11 (office) or POS 22 (outpatient hospital); the listed skin surgery codes require authorization when performed as ambulatory surgery in POS 24.
Certain outpatient orthopedic/spinal procedures and associated devices are delegated to TurningPoint for dates on/after 12/23/2019 — submission must follow the delegated vendor's process.
Radiology authorization is vendor-specific (eviCore) — prior auth applies regardless of place of service as specified by eviCore rules.
Provider billing and documentation notes to avoid denials and ensure correct processing.
Podiatry services: Authorization is NOT required for podiatric services rendered to members with a confirmed diagnosis of Diabetes Mellitus. The diabetes diagnosis must be included on the claim when services are billed. Podiatric services for non-diabetic members require authorization.
CPT 20610 non-coverage trigger: CPT 20610 is non-covered when billed with specified M17.x diagnosis codes (see outpatient surgery list for exact diagnosis code ranges).
Submit prior authorization requests to the correct delegated vendor or Fidelis Care depending on service type (e.g., TurningPoint for delegated orthopedic/spinal, eviCore for radiology, NIA for outpatient therapy, New Century Health for oncology medications, Pharmacy Team e-fax for certain pharmacy codes).
Telehealth: Authorization is required for G2010 and G2012.
The facility must notify Fidelis Care of admission and initial treatment plan within two business days using the OMH Two‑Day Notification and Initial Treatment Plan form and submit by fax or email to specified contacts.
Age and scopeEffective 01/01/2020, this applies to OMH‑licensed inpatient mental health treatment for members under age 18 to avoid prior authorization and concurrent review during the first 14 days, provided form and requirements are met.
OMH-licensed inpatient mental health treatment for members under age 18 was updated to not require prior authorization and concurrent review during the first 14 days effective 01/01/2020.
2019-12-23delegation_change
Prior authorization for certain orthopedic and spinal procedures was delegated to TurningPoint Healthcare Solutions, LLC effective for dates of service on or after 12/23/2019.