Governs prior authorization, utilization review, and network/access rules for a range of inpatient, outpatient, behavioral health, and DME services for Fidelis Care members (New York State). Affects providers requesting authorization and conducting inpatient/behavioral health services.
No material clinical or coverage changes in this revision.
Allinpatient authorization requirement
28OASAS SUD exemption (days)
14OMH MH exemption (days)
40Home health max (visits/yr)
60Rehab visit limit
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20+
Appendix I J‑code group
Coverage and Medical Necessity Criteria
Inpatient Admissions
All inpatient admissions and certain facility services require authorization and review for medical necessity.
Inpatient authorization: All inpatient admissions require prior authorization; emergency room services or emergent services required to provide stabilization do not require prior authorization, but post-stabilization services and inpatient admissions after ER services are completed do require authorization. All facility admissions are reviewed for medical necessity. Inpatient rehabilitation services (acute, sub-acute and skilled nursing rehabilitation) require prior authorization.
Providers should use the inpatient/ER fax contact as noted in the policy for notifications.
Inpatient SUD (OASAS licensed, in-network NYS facilities)
Inpatient SUD services coverage when provided by in-network, in-state OASAS licensed facilities:
OASAS in-network in-state SUD: Inpatient detoxification, inpatient rehabilitation and inpatient residential treatment services provided by New York State facilities that are licensed, certified or otherwise authorized by OASAS and participating in Fidelis Care's provider network are not subject to prior authorization review. These services are not subject to concurrent utilization review during the first 28 days of the inpatient admission if the facility notifies Fidelis Care of the inpatient admission and the initial treatment plan within two business days and performs daily clinical review; the facility must periodically consult with Fidelis Care starting on or just prior to day 14.28 days
Facilities outside NYS, not OASAS-licensed, or out-of-network must request prior authorization and remain subject to concurrent review throughout the admission. Services may be reviewed after 28 days or upon discharge; discharge planning and documentation requirements apply.
OMH inpatient mental health utilization review triggers
OMH-licensed inpatient mental health treatment coverage rules:
Triggers for utilization review: Utilization review will be conducted only for individuals meeting specified triggers (e.g., current or recent Assisted Outpatient Treatment orders, high utilization defined by prior hospital/ED utilization, readmission within 30 days, or length of stay exceeding 30 days).See policy for trigger definitions
For members under 18, inpatient mental health treatment provided by OMH-licensed, in-network NYS hospitals is not subject to prior authorization and is exempt from concurrent utilization review during the first 14 days provided 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, (ii) performs daily clinical review, and (iii) participates in periodic consultation with Fidelis Care.
Home Health Care authorization criteria
Covered when ALL of the following are met
Home health approval conditions: Home care approvals are based on the medical need for skilled services.40 visits per plan year
Benefit maximum: 40 visits per plan year.
Hospice Care authorization criteria
Covered when ALL of the following are met
Hospice care criteria: 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
NY certification requirement applies.
Rehabilitation/Habilitation visit limits
Coverage limited subject to visit caps and authorization
Rehabilitation therapy limits: Rehabilitation and habilitation benefits are limited to 60 visits per condition per plan year; the visit limit applies to all therapies combined.60 visits
Applies to PT, OT, ST and habilitation services; prior authorization required for services after initial evaluation per delegated processes.
OB Ultrasound authorization
Imaging authorization rules
OB ultrasound authorization: For a normal pregnancy, the first four OB ultrasounds can be performed without authorization; five or more ultrasounds for a normal pregnancy require authorization. OB ultrasounds for listed high-risk pregnancy diagnosis codes do not require authorization.4 ultrasounds
High-risk pregnancy diagnosis codes enumerated in policy (see policy for full list).
Fidelis Care does not provide out-of-network benefits. However, authorization will be provided for medically necessary services not available in-network; providers should submit prior authorization requests when a needed service cannot be obtained from an in-network provider so coverage can be reviewed and approved.
Orthotics are expressly not covered under the DME benefit. Certain HCPCS S-codes are benefit exclusions except for S0013, S0190, S0191, and S9435, which are exceptions. In addition, HCPCS medication codes for drugs that are not FDA-approved (for example, J1726 cited in the policy) are considered benefit exclusions. A list of DME HCPCS codes that do not require prior authorization is provided in the policy, and updates to DME PA status (including new codes effective 4/1/24) are noted.
The policy specifies that CPT 20610 is non-covered when billed together with hyaluronic acid J‑codes listed (for example J7318, J7320–J7329, J7331–J7332 as enumerated) and when the claim includes an osteoarthritis of the knee diagnosis from the M17 series. In other circumstances (i.e., when those J‑codes and M17 diagnoses are not present), no authorization is required for 20610.
For members with a diagnosis of Low Back Pain, the policy lists specific services that are not covered: prolotherapy;therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT fluoroscopic guidance);therapeutic steroid injections into intervertebral discs; and continuous or intermittent traction. These exclusions apply when the listed Low Back Pain diagnosis is the clinical indication.
Prior authorization is required for certain outpatient diagnostic procedures and select durable medical equipment/supplies. Lack of an approved prior authorization for these services may result in claim denials. Providers must follow the documented submission routes and supply required documentation to avoid retrospective denials.
Outpatient diagnostic testing requiring prior authorization includes: sleep studies (including home sleep studies); select genetic and breast cancer testing (BRCA) — authorization not required for CPT 81220, 81329, 81336, 81420 (note lifetime limits apply to some codes); wireless capsule endoscopy (91110-91111) and wireless motility capsule (91112-91113); selected gastroenterology procedures when performed in POS 19 or 22 where an office or ASC is available (e.g., 43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270); 43290 requires authorization in any place of service; penile prosthesis 54405; other listed diagnostic/therapy codes such as 97037.
Imaging: First four OB ultrasounds for normal pregnancy do not require authorization; five or more require authorization. OB ultrasounds for high-risk pregnancy do not require authorization. Many radiology authorizations have been delegated to Evolent (NIA); however, a full CPT list of radiology services requiring authorization should be consulted.
Durable Medical Equipment/Supplies: Some DME is NOT subject to prior authorization (selected HCPCS/HCPCS-like codes listed below). Other DME codes do require prior authorization — verify each item prior to ordering/billing.
This document defines Fidelis Care’s requirements for prior authorization and utilization review across a broad set of services for New York members. It covers authorization rules for inpatient and outpatient admissions, behavioral health, transplant evaluations, outpatient surgery, therapeutic services, and durable medical equipment and supplies. The policy also describes special New York State exceptions for OMH and OASAS licensed in‑state, in‑network facilities, delegated review arrangements for certain surgical and specialty services, pharmacy and HCPCS/J‑code prior authorization lists (Appendix I), and provider notification and documentation obligations.
Definitions and Clarifying Rules
OASAS / OMH licensed facilities — definitions and coverage implications
Definition of OASAS/OMH licensed facilitiesFacilities licensed, certified or otherwise authorized by New York State OASAS (substance use disorder) or OMH (mental health) and participating in Fidelis Care's NY provider network.
Coverage implication — OASAS facilitiesWhen in‑network and in‑state, OASAS‑licensed inpatient SUD facilities are not subject to prior authorization or concurrent review for the first 28 days if notification and documentation requirements are met.
Coverage implication — OMH facilities for minorsWhen in‑network and in‑state, OMH‑licensed inpatient mental health hospitals providing care to members under 18 are not subject to prior authorization and are exempt from concurrent review for the first 14 days if notification and documentation requirements are met.
Normal vs. high‑risk pregnancy — OB ultrasound authorization
Normal pregnancy OB ultrasound policyThe first 4 OB ultrasounds for a normal pregnancy may be performed without prior authorization; five or more require authorization.
Non-covered pairing trigger: CPT 20610 is non-covered when billed with intra-articular hyaluronic acid J‑codes (e.g., J7318, J7320–J7332, J733? series as listed) and a diagnosis of osteoarthritis of the knee (ICD-10 codes beginning with M17 variants). In all other situations CPT 20610 does not require authorization.
Denial risk when PA not obtained: Submitting claims for the outpatient diagnostic procedures, selected gastroenterology procedures, imaging beyond allowed OB ultrasounds, wireless capsule endoscopy, select DME that require authorization, and the HCPCS J‑codes listed in Appendix I without an approved prior authorization may lead to denial or retrospective review and non-payment.
Prior authorization for J‑codes/medications: Many HCPCS J‑ and Q‑codes (see Appendix I) require prior authorization before administration or billing. Oncology medications and supportive agents also require prior authorization and review by Evolent/New Century Health per the pharmacy/oncology process. Appendix I enumerates numerous specific J/Q codes; providers must obtain authorization prior to claim submission for those codes.
Required documentation and submission routes: For enteral therapy (HCPCS B4034–B4162) and many pharmacy items, a written order stating the enteral formula or item is medically necessary is required. Submit prior authorization requests to the appropriate review entity: Pharmacy prior authorizations (including Appendix I codes) via e-fax to 1‑844‑235‑5090; oncology/supportive oncology requests through Evolent/New Century Health portal or contact; therapy and radiology requests delegated to Evolent (NIA) follow Evolent submission procedures. For inpatient/ER notifications and certain program-specific faxes, use the updated fax numbers listed in the policy (e.g., inpatient ER: 833‑663‑1602; Inpatient SUD notifications: 833‑663‑1608; OMH two‑day notification fax: 833‑561‑0094; therapy inpatient fax: 833‑663‑1611).
Voicemail HIPAA-compliance requirements: Utilization Management (UM) messages may be left only if the provider's voicemail is HIPAA-compliant. Voicemail greetings must identify the mailbox owner, the owner's organization, and state the mailbox is confidential and that PHI may be left. If voicemail is not HIPAA-compliant, only a generic message will be left requesting a callback; UM will make a second direct attempt as required by Department of Health Reasonable Effort Policy.
High‑risk pregnancy ruleOB ultrasounds for listed high‑risk pregnancy diagnosis codes do not require authorization.
Relevant diagnosis codes referencedPolicy enumerates specific normal and high‑risk pregnancy diagnosis codes (e.g., Z32.01, Z33.1, Z34 series for normal; O09 and O36 series for high‑risk).
Therapy initial evaluation and subsequent authorization rules
Initial therapy evaluation ruleOffice or facility‑based initial PT/OT/ST evaluations do not require prior authorization.
Subsequent procedure authorizationAll other billed therapy procedure codes after the initial evaluation require prior authorization through Evolent (NIA) or Fidelis per the setting and timing rules.
Timing for authorization submissionsFor outpatient settings, authorization requests for non‑initial codes must be sent to Evolent within 1 business day (outpatient) or within 2 business days (home health); inpatient settings use Fidelis submission routes.