OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentFidelis CarePolicy N/A

Authorization and Utilization Review Coverage Criteria

Customize your policy alerts

Sign up for all Fidelis Care policy alerts

Know when Fidelis Care releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Governs prior authorization, utilization review, and notification requirements for a range of inpatient, outpatient, surgical, and behavioral health services for Fidelis Care members in New York State (NC not applicable here).

Policy Summary

PayerFidelis Care

PolicyAuthorization and Utilization Review Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionObtain prior authorization for all inpatient admissions and for procedures and services specified in the policy before scheduling or providing non-emergent care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All inpatientrequire authorization

28 daysOASAS SUD exemption

14 daysOMH pediatric exemption

60therapy visit limit

ONCOLOGYNCH routed oncology UM

Coverage and Medical Necessity Criteria

OMH Inpatient Mental Health Utilization Review Criteria

Utilization review (admission and concurrent/continued stay) for OMH licensed inpatient mental health treatment will be conducted only for members who meet the following clinical criteria per NYS OMH Best Practice Manual:

OMH review triggers: Individuals subject to a current Assisted Outpatient Treatment (AOT) court order; OR Individuals who had an AOT court order that expired within the past five years; OR Individuals with high utilization of inpatient or ED services in the prior 12 months (3 or more psychiatric inpatient hospitalizations OR 4 or more psychiatric ED visits OR 3 or more medical inpatient hospitalizations); OR Individuals readmitted to any mental health inpatient unit within 30 days of discharge; OR Individuals not meeting any of the above whose length of stay exceeds 30 days (concurrent review from Day 31 onwards)see node text

Applies to OMH licensed hospitals in New York State; facility must notify Fidelis Care within 2 business days of admission

OASAS Inpatient SUD Coverage Conditions

Inpatient SUD services provided by in-state OASAS-licensed and in-network facilities are not subject to prior authorization review and are exempt from concurrent utilization review for the initial period provided conditions are met:

OASAS inpatient SUD initial conditions: Facility notifies Fidelis Care of the inpatient admission and initial treatment plan within two business days; facility performs daily clinical review of the patient (daily LOCADTR module not required); facility periodically consults with Fidelis Care starting on or just prior to Day 14 to ensure use of the LOCADTR tool; facility provides a written discharge plan prior to discharge and indicates whether discharge services are secured or reasonably available; services may be subject to utilization review after Day 28 or upon discharge; all services may be reviewed retrospectively to assess clinical necessity.initial 28-day exemption

Out-of-state, non-OASAS licensed, or out-of-network facilities remain subject to prior authorization and concurrent review

Partial Hospitalization / IOP Utilization Review Criteria

Utilization review for partial hospitalization and intensive outpatient mental health treatment provided by OMH licensed programs will be conducted only for members who meet the following clinical criteria per NYS OMH Best Practice Manual:

Partial/IOP review triggers: Individuals subject to a current Assisted Outpatient Treatment (AOT) court order; OR Individuals who had an AOT court order that expired within the past five years; OR Individuals with high utilization of inpatient or ED services in the prior 12 months (3 or more psychiatric inpatient hospitalizations OR 4 or more psychiatric ED visits OR 3 or more medical inpatient hospitalizations); OR Individuals readmitted to any mental health inpatient unit within 30 days of discharge; OR Individuals not meeting any of the above whose length of stay exceeds 30 days (concurrent review from Day 31 onwards)see node text

Applies to OMH licensed partial hospitalization and intensive outpatient programs in New York State

Outpatient Therapy (PT/OT/ST) Coverage & Authorization

Covered when ALL of the following are met

Therapy services coverage: Rehabilitation and habilitation outpatient therapy services (PT/OT/ST) are covered when provided within the visit limits; the benefit is limited to 60 visits per condition per plan year (applies to rehabilitation and habilitation combined); office or facility initial evaluations do not require prior authorization but all subsequent therapy services after the initial evaluation require prior authorization through National Imaging Associates (NIA) effective 10/1/2021; initial home evaluation requires authorization. CPT codes 92610 and 92611 (speech/language evaluation) do not require prior authorization.60 visits

Visit limit applies to all therapies combined; prior authorization requests per NIA process

Home Health Care

Covered when ALL of the following are met

Home Health Coverage: Home health (home care) approvals are based on the medical need for skilled services; coverage is subject to the benefit maximum of 40 visits per plan year.40 visits

Visits counted per plan year

Hospice Care

Covered when ALL of the following are met

Hospice Coverage: 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

Per NY Public Health Law Article 40

Autism Spectrum Disorder (ASD) Benefits

Covered when ALL of the following are met

ASD services: Members with Autism Spectrum Disorder (ASD) have expanded benefits including increased case management services, certain DME items to assist speech performance, and Applied Behavior Analysis (ABA); authorization is required for DME speech generation equipment; authorization from Behavioral Health is required for ABA; attestation of the ASD diagnosis by a licensed physician or psychologist must be provided at the time of request.

Authorization requirements apply to DME speech generation equipment and ABA

Imaging - OB Ultrasounds

Covered when criteria met; authorization rules apply as specified

OB ultrasound authorization: For a normal pregnancy, the first four (4) OB ultrasounds can be performed without authorization; five (5) or more ultrasounds for a normal pregnancy require authorization; OB ultrasounds for high-risk pregnancy do not require authorization. Specific diagnosis codes define normal versus high-risk pregnancies.First 4

Authorization delegated to NIA for many imaging services effective 10/1/2021; see diagnosis code lists for normal vs high-risk

Low Back Pain - Not Covered Procedures

Low back pain exclusions: The following services 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; and continuous or intermittent traction.

These items are listed as not covered when the diagnosis is Low Back Pain

Benefit-applicability list

Covered when the listed J-code/product is present in the benefit list

Listed items: Items explicitly enumerated under the repeated heading 'Benefit applies to' (specific HCPCS/J- and Q-codes paired with product mappings) are applicable to the benefit as listed; this section is a catalog-style applicability list and contains no additional clinical criteria in these excerpts.

Use the enumerated code-to-product mappings when preparing authorization requests and billing

In-network, in-state outpatient substance use disorder (SUD) services (including outpatient office visits, therapy/counseling visits, outpatient clinic visits, intensive outpatient programs, outpatient rehabilitation, and Opioid Treatment Programs) do not require prior authorization or concurrent utilization review when provided by in-network, in-state providers. Out-of-state or out-of-network providers remain subject to authorization requirements and must request authorization. Fidelis Care retains the right to manage outlier utilization through quality and case management oversight.

For inpatient mental health care provided to members under age 18 at OMH-licensed hospitals in New York State that participate in the Fidelis network, prior authorization and concurrent utilization review are not required for the first 14 days of an admission provided the facility: (1) 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; (2) performs daily clinical review of the patient; and (3) participates in periodic consultation with Fidelis Care to ensure use of OMH‑approved evidence‑based clinical review criteria. All out‑of‑network inpatient mental health admissions remain subject to concurrent review throughout the admission.

Orthotics are explicitly listed as not covered. Separately, several therapeutic procedures commonly used for low back pain are identified as not covered for members with a diagnosis of Low Back Pain (see Low Back Pain not‑covered list): 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. Claims for orthotics may therefore be denied as non‑covered.

The provided 'Benefit applies to' sections enumerate many HCPCS/J‑code product mappings and include entries described as unclassified or generic product descriptors. Within the excerpt there are no explicit blanket exclusions attached to those lists; instead the lists function as a catalog of products for which the benefit applies. The presence of entries referencing unclassified drugs/biologics indicates that not all items in the catalog are fully specified in this excerpt.

Oncology‑related outpatient medication and supportive agent requests are routed for prior authorization and utilization management review by New Century Health (see Section B). In addition, the policy instructs that all services billed with 'Unlisted' or 'Temporary' codes (such as C‑codes) require authorization. When requesting authorization for oncology outpatient services, include the specific HCPCS/J/Q code and product information as required by the New Century Health process.

CPT code 20610 (joint injection) is identified as non‑covered when billed with any of the specified osteoarthritis diagnosis codes (for example, M17.0; M17.10‑M17.12; M17.2; M17.20‑M17.32; M17.4; M17.5; M17.9). Providers should ensure diagnosis coding does not combine 20610 with these osteoarthritis codes if seeking coverage for a hyaluronic acid joint injection.

The policy lists specific therapeutic injection procedures that are not covered for members with a diagnosis of Low Back Pain. These exclusions include therapeutic facet joint steroid injections in the lumbar and sacral regions, steroid injections into intervertebral discs, prolotherapy, and continuous or intermittent traction. These items are identified as not medically necessary for Low Back Pain in the Low Back Pain section.

Within the excerpted catalog-style 'Benefit applies to' lists and related J‑code groupings there are no explicit statements formatted as 'not medically necessary' beyond the separate Low Back Pain and 20610 items noted elsewhere. The J‑code lists operate as applicability/benefit listings rather than indication‑specific coverage rules in the provided text.

Codes and Code Groupings Requiring Prior Authorization or Notation

Transplant CPT codesCPTCovered

32850-32856	solid organ transplant related codes
33930-33945	transplant related codes
38204-38215	bone marrow/tissue transplant related codes
38230-38242	transplant related codes
44133-44136	transplant related codes
47133-47147	transplant related codes
48160	transplant related code
48550-48556	transplant related codes
50300-50380	transplant related codes
50547	transplant related code

1–10 of 11

1/2

Outpatient surgery CPT codes requiring prior authCPTCovered

43770-43775	bariatric surgery
15820-15823	blepharoplasty
11920-11971	breast reconstruction
19300	breast procedure
10040	skin surgery (ambulatory POS 24 require auth)
11300-11313	skin surgery codes
11400-11471	skin surgery codes
11721	skin surgery code
11200-11201	skin procedure requiring auth any POS
11719	skin procedure requiring auth any POS

1–10 of 26

1/3

Facial/ENT CPT and HCPCS codesmixedCovered

21120-21296	facial cosmetic, septoplasty, rhinoplasty
30400-30520	rhinoplasty and nasal surgery codes
30620-30802	facial/nasal procedure codes
30999	unlisted craniofacial code
31298	nasal/sinus procedure code
C9749	HCPCS/CPT crosswalk code listed
Q2028	HCPCS code listed

Vascular procedure CPT codesCPTCovered

36465-36479	vascular vein procedures
36482-36483	vascular procedure codes
37718-37785	vascular procedure codes
37241-37244	endovascular venous codes

Gender reassignment surgery codesCPTCovered

55970	gender reassignment surgery
55980	gender reassignment surgery

Speech processor implant CPT codesCPTCovered

69716	speech processor implant procedures
69719	speech processor implant procedures
69726	speech processor implant procedures
69727	speech processor implant procedures

Spinal surgery CPT codesCPTCovered

20932-20934	spinal surgery related codes
22867-22870	spinal fusion/fixation codes
62380	spinal injection code

Esophageal procedure CPT codesCPTCovered

43284	esophageal procedure
43497	esophageal procedure

Behavioral health CPT/HCPCS codesmixedCovered

96116	psychological testing
96121	psychological testing
96130-96133	neuropsych testing
96136-96139	testing and interpretation
96146	testing code
96112	developmental testing
96113	developmental testing
90870	outpatient ECT
H0035	partial hospitalization mental health HCPCS
90899	intensive outpatient CPT (listed as 90899)

1–10 of 12

1/2

Residential treatment codes (covered)mixedCovered

1001-1002	residential treatment CPT codes
H0017-H0019	residential treatment HCPCS codes
H2036	residential treatment HCPCS code

Residential treatment codes (neutral)mixed

1001	residential treatment CPT code 1001
1002	residential treatment CPT code 1002
H0017	HCPCS residential treatment
H0018	HCPCS residential treatment
H0019	HCPCS residential treatment
H2036	HCPCS residential treatment

GI and related procedure codes with POS-based PACPT

43235	Esophagoscopy with ultrasound
43239	Esophagoscopy with dilation
43248	Esophagogastroduodenoscopy
45378	Colonoscopy therapeutic
45380	Colonoscopy with biopsy
45384	Colonoscopy with removal of lesion
45385	Colonoscopy with polypectomy
46255	Hemorrhoid banding
46260	Anoscopy with biopsy
46270	Other anorectal procedures

1–10 of 12

1/2

DME codes not requiring authorization (partial list shown)HCPCSCovered

E0130	Crutch/cane accessory
E0135	Crutch/cane accessory

TBS scan CPT codesCPTCovered

77089	TBS Scan
77090	TBS Scan
77091	TBS Scan
77092	TBS Scan

Speech therapy initial evaluation exceptionCPTCovered

92610	Evaluation of speech and language
92611	Speech/language evaluation

Therapeutic service codes requiring authorizationmixedCovered

99183	Hyperbaric oxygen service
C1300	Hyperbaric oxygen therapy HCPCS
95249	Ambulatory continuous glucose monitoring

Cardiac rehab codesCPT/HCPCSCovered

S9472	Cardiac rehabilitation HCPCS
93797	Cardiac stress test
93798	Cardiac stress test
G0422	Cardiac rehab, per session
G0423	Cardiac rehab, per session

Chiropractic codes requiring PACPTCovered

98940	Chiropractic manipulation
98941	Chiropractic manipulation
98942	Chiropractic manipulation
98943	Chiropractic manipulation

Education/DSMT codesCPT/HCPCSCovered

G0108	Diabetes self-management training, individual
G0109	Diabetes self-management training, group
98960	Education and training for patient self-management

Other therapeutic procedure codes listedCPT

61736	Stereotactic radiosurgery
61737	Stereotactic radiosurgery

Pharmacy/infusion J- and C-codes (extensive list present across chunks)HCPCS

J0172	Multiple biologic/infusion drug mapping listed
J0205	Alglucerase / assorted mappings
J0222	Patisiran and related mappings

Listed J-codes (partial group)HCPCS

J1559	immune glob (Hizentra) and multiple other mappings listed
J1560	immune glob over 10cc; other mappings listed
J1561	immune glob (Gamunex-C/Gammaked/Vivaglobin) and other mappings

Additional immune globulin J-codesHCPCS

J1566	immune glob powder; IVIG (Octagam) mappings
J1569	IVIG (Gammagard) mappings
J1572	immune glob / hyaluronidase mappings

J174x groupHCPCS

J1740	brexanolone (Zulresso) and multiple mappings
J1742	plasminogen, human (Ryplazim) and other mappings
J1743	idursulfase (Elaprase) and other mappings

J193x groupHCPCS

J1930	lanreotide (Somatuline) and related mappings
J1931	laronidase (Aldurazyme) and related mappings
J1932	lanreotide (Cipla), aripiprazole lauroxil (Aristada) and related

J235x groupHCPCS

J2356	tezepelumab-ekko (Tezspire) / omalizumab (Xolair) etc.
J2357	paired entries with J2356; nasal vaccine inhalation referenced

J24xx groupHCPCS

J2406
J2425	palifermin (Kepivance) and other mappings
J2426	paliperidone pal ER (Invega) and ESRD reference

J2440 groupHCPCS

J2440

papaverin; Andexxa; intravitreal implant (Retisert) and other mappings

Selected specialty J-codes referenced laterHCPCS

J3304	aripiprazole lauroxil (Aristada) mapping
J3355	triptorelin ER (Triptodur) mapping
J3380	mecasermin (Increlex) / other mappings

Benefit applies - mixed J-codes (partial)HCPCSCovered

J3355	triptorelin ER (Triptodur)
J3357	urofollitropin (Bravelle)
J3358	ustekinumab SC (Stelara)
J3380	ustekinumab IV (Stelara)
J1932	multiple mappings listed (see chunk)
J3304	(Zilretta) referenced
J7198	referenced
J3315	referenced
J3316	referenced

Benefit applies - ophthalmology/visco/hyaluronan and various J-codesHCPCSCovered

J7312	dexamethasone intravitreal / implant (Ozurdex) mappings
J7313	fluocinolone acetonide / related mappings
J7314	fluocinolone acetonide / related mappings
J7318	hyaluronan (Durolane)
J7320	hyaluronan (Genvisc)
J7321	hyaluronan (Hyalgan, Supartz, Visco-3) and other mappings
J7322	hyaluronan (Hymovis)
J7324	hyaluronan (Orthovisc)
J7325	hyaluronan (Synvisc) and related
J7327	hyaluronan (Gel-One) and related

1–10 of 19

1/2

Benefit applies - immunosuppressive and related J-codesHCPCSCovered

J7504	anti-thymocyte glob equine and related mappings
J7515	cyclosporine oral 25mg mapping and related
J7516	cyclosporine 250mg inj and related
J7517	mycophenolate mofetil related mappings
J7518	mycophenolic acid 180 mg mappings
J7520	sirolimus (Rapamune) and related
J7527	everolimus 0.25mg
J7599	Immunosuppress Drug Noc

Benefit applies - Q-codes for cellular therapies, biosimilars, and other specialty productsHCPCSCovered

Q2043	sipuleucel-T (Provenge) and related S-codes
Q2053	Brexucabtagene autoleucel (Tecartus) and related
Q2054	lisocabtagene maraleucel and related
Q2055	idecabtagene vicleucel and related
Q2056	ciltacabtagene autoleucel (Carvykti) and related
Q3028	interferon beta-1a SC (Rebif) mapping
Q5103	iloprost (Ventavis) and infliximab-dyyb (Inflectra) mappings
Q5107	bevacizumab-awwb (Mvasi)
Q5104	infliximab-abda (Renflexis)
Q5109	infliximab-qbtx (Ixifi)

1–10 of 20

1/2

High utilization triggers for review — OMH/behavioral health

Psychiatric inpatient admissions

Prior Authorization, Notifications, and Submission Requirements

Prior Authorization

Inpatient admissions and transplants

All inpatient admissions require prior authorization. Emergency department services and emergent stabilization do not require prior authorization; however post-stabilization inpatient services and any inpatient admission following an ER visit do require authorization. Unauthorized inpatient admissions may be denied. Transplant procedures (solid organ and bone marrow/tissue) require authorization at the time of transplant evaluation.

All acute inpatient facility services require authorization
Inpatient rehabilitation services (acute, sub-acute and skilled nursing rehabilitation) require prior authorization
Transplants require authorization at transplant evaluation (examples include CPT ranges listed in source)

Prior Authorization

Outpatient SUD prior authorization exemption (in-state/in-network)

For in-network, in-state outpatient substance use disorder (SUD) services, Fidelis does not require prior authorization, notification, or concurrent authorization review for the listed outpatient SUD services. Out-of-state or out-of-network providers must request prior authorization. Inpatient SUD has special notification and documentation requirements (see below).

Policy Background and Scope

This policy governs prior authorization, utilization review, and notification requirements across a broad set of services. Key program rules include: all inpatient admissions require prior authorization (emergency services are excluded for stabilization but subsequent inpatient care requires authorization); all solid organ and bone marrow/tissue transplants require authorization at the time of transplant evaluation; certain outpatient and elective surgical procedures require prior authorization; specific behavioral health services (including testing, partial hospitalization, and intensive outpatient programs) require authorization; outpatient therapy services after the initial evaluation require prior authorization through the delegated vendor (NIA) effective 10/01/2021; and many DME and therapeutic services have defined authorization stances or listed exceptions. The policy also specifies notification and documentation processes for OASAS inpatient SUD and OMH pediatric inpatient admissions (including timeframes and forms) and sets visit or coverage thresholds such as 40 home health visits per plan year, 60 therapy visits per condition per plan year, and 210 days maximum hospice coverage when medically necessary.

Definitions and Tools

LOCADTR medical necessity tool used for SUD inpatient clinical review and notification

LOCADTR toolOASAS LOCADTR Medical Necessity Tool is used for inpatient SUD clinical review and discharge planning

Submission optionsFacility may fax/email the OASAS Appendix A Notification Form and LOCADTR tool to provided Fidelis contacts

Role in utilization reviewLOCADTR may be used for retrospective or concurrent review after exemption period or upon discharge

OMH Best Practice Manual criteria used to trigger utilization review

OMH Best Practice Manual criteriaUtilization review is triggered per NYS OMH Best Practice Manual for AOT status, recent AOT within 5 years, high utilization thresholds, 30‑day readmission, or length of stay >30 days

AOT status

Document Revisions and Effective Dates

2023-01-01policy_effective_date

Updated Fidelis Care authorization requirements effective 01/01/2023, clarifying inpatient SUD concurrent review exemption (first 28 days) and other benefit changes

2021-10-01delegation_update

Delegated prior authorization for many radiology and radiation therapy services to National Imaging Associates (NIA) effective for dates of service on/after 10/01/2021

2021-10-04delegation_update

Policy Summary

PayerFidelis Care

PolicyAuthorization and Utilization Review Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionObtain prior authorization for all inpatient admissions and for procedures and services specified in the policy before scheduling or providing non-emergent care.

SourceLink

On This Page

3 or more psychiatric inpatient hospitalizations in the prior 12 months

Psychiatric ED visits4 or more psychiatric emergency department visits in the prior 12 months

Medical inpatient admissions3 or more medical inpatient hospitalizations in the prior 12 months

Recent readmissionReadmission to any mental health inpatient unit within 30 days of discharge

Extended stay triggerLength of stay exceeds 30 days (concurrent review from Day 31 onwards)

Inpatient SUD concurrent review exemption — initial 28 days

Initial concurrent review exemptionInpatient SUD services are exempt from concurrent utilization review for the first 28 days of admission

Notification requirementFacility must notify Fidelis Care of admission and initial treatment plan within 2 business days

LOCADTR use and consultationFacility must perform daily clinical review and periodically consult with Fidelis Care starting on or just prior to day 14 to ensure use of the LOCADTR tool

Post-28-day reviewServices may be subject to utilization review after day 28 or upon discharge using the LOCADTR clinical review tool

Discharge planningFacility must provide written discharge plan to member and Fidelis Care prior to discharge and indicate whether discharge services are secured or reasonably available

OMH pediatric concurrent review exemption — first 14 days

Pediatric OMH exemption periodOMH-licensed inpatient mental health admissions for members under age 18 are exempt from concurrent review for the first 14 days

Two-day notificationFacility must notify Fidelis Care of admission and initial treatment plan within 2 business days using OMH 'Two-Day Notification and Initial Treatment Plan' form

Daily clinical reviewFacility must perform daily clinical review of the patient during the exemption period

Periodic consultationFacility must participate in periodic consultation with Fidelis Care to ensure use of OMH‑approved clinical review criteria appropriate to the patient's age

OB ultrasounds without authorization

Authorization-free OB ultrasoundsThe first 4 OB ultrasounds for a normal pregnancy may be performed without authorization

Five or more ultrasoundsFive or more ultrasounds for a normal pregnancy require prior authorization

High-risk pregnancy ultrasoundOB ultrasounds for a high-risk pregnancy do not require authorization

Therapy visit limits

Rehabilitation visit limit60 visits per condition per plan year (rehabilitation services)

Habilitation visit limit60 visits per condition per plan year (habilitation services)

Combined visit cap noteVisit limit applies to all therapies combined (rehabilitation + habilitation)

Initial evaluationOffice/facility initial therapy evaluations do not require prior authorization; home initial evaluations require authorization

Post-evaluation authorizationAll therapy services performed after the initial evaluation require prior authorization through NIA (effective 10/1/2021)

Home health maximum

Home health maximumBenefit maximum is 40 visits per plan year

Medical necessity basisHome care approvals are based on the medical need for skilled services

Benefit contextApplies to skilled home health services per plan rules

Outpatient office visits, therapy, or counseling visits for SUD (in-state/in-network) do not require prior authorization
Outpatient clinic visits for SUD treatment do not require prior authorization
Intensive outpatient treatment programs and outpatient rehabilitation treatment do not require prior authorization
Opioid Treatment Programs (in-state/in-network) do not require prior authorization
Out-of-state or out-of-network providers must request authorization

Documentation Required

OASAS notification and inpatient SUD documentation

Inpatient SUD facilities: the facility must notify Fidelis Care of the inpatient admission and initial treatment plan within two business days using the OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool (fax 646-829-1421 or LOCADTR@fideliscare.org). Inpatient SUD services are not subject to concurrent utilization review for the first 28 days if notification and initial plan are provided; facilities must perform daily clinical review and begin periodic consultation with Fidelis on or just prior to Day 14. Inpatient SUD provided by out-of-state, non‑OASAS‑authorized, or out-of-network facilities require prior authorization and are subject to concurrent review throughout the admission.

Notify Fidelis within 2 business days of admission and initial treatment plan for in‑state OASAS facilities
Fax/email OASAS Appendix A and LOCADTR tool to 646-829-1421 or LOCADTR@fideliscare.org
Facilities must perform daily clinical review; periodic consultation with Fidelis starting on/just prior to Day 14
Inpatient SUD may be subject to utilization review after Day 28 or upon discharge
Out-of-state/non‑OASAS/in-network-excluded facilities must request prior authorization and will be concurrently reviewed

Prior Authorization

Behavioral health prior authorization and notification requirements

Behavioral health outpatient services (testing, ECT, PHP, IOP, and specified residential/partial programs) often require authorization and have specific clinical criteria and notification rules. Partial Hospitalization (revenue codes 912, 913, 944, 945; HCPCS H0035), Intensive Outpatient (revenue codes 905/912, CPT 90899, S9480, H2013), outpatient psychological/neuropsych testing, developmental pediatric testing, and outpatient ECT require authorization as specified. OMH‑licensed pediatric inpatient mental health (members under 18) are exempt from prior authorization for the first 14 days if the facility submits the OMH two-day notification and initial treatment plan to Fidelis (fax 718‑896‑1784 or Mental_Health_Admission@fideliscare.org).

Psychological/Neuropsychological testing (CPTs 96116, 96121, 96130-96139, 96146) — authorization required using the testing request form
Developmental pediatric testing (96112, 96113) — authorization required; 96110 non-covered
Outpatient ECT: 90870 — authorization required
Partial Hospitalization (rev codes 912, 913, 944, 945; H0035) — utilization review per NYS OMH criteria; concurrent review applies after Day 30 or per triggers listed
Intensive Outpatient Treatment (rev 905/912, 90899, S9480, H2013) — authorization per OMH criteria
OMH‑licensed inpatient mental health for members <18: notify Fidelis and submit two‑day notification form within 2 business days to avoid concurrent review for first 14 days

Prior Authorization

ASD-related authorizations and attestation

Autism Spectrum Disorder (ASD) related services: authorization is required for DME speech generation equipment and for Applied Behavior Analysis (authorization to be obtained from Behavioral Health). An attestation of the ASD diagnosis by a licensed physician or psychologist must be provided at the time of request.

Authorization required for DME speech generation equipment
Authorization required for ABA from Behavioral Health
Provide licensed physician or psychologist attestation of ASD diagnosis at time of request

Prior Authorization

Outpatient and elective surgery prior authorization lists and delegation

Certain outpatient and elective surgeries require prior authorization. Many orthopedic and spinal surgical procedures require prior authorization; TurningPoint Healthcare Solutions, LLC has delegated authorization for numerous CPTs (including some ENT and cardiac, and certain orthopedic/spinal lists). Some procedures require authorization only in specific places of service (see POS rules). If a CPT is delegated to TurningPoint, associated HCPCS device codes will also be reviewed by TurningPoint.

Bariatric surgery (43770-43775) — prior authorization (note S2083 no longer requires auth as of 8/1/22)
Blepharoplasty (15820-15823) — auth required
Breast reconstruction (11920-11971, 19300, 19316-19342, 19355, 19370-19396) — auth required
Specified skin surgery codes require auth when performed as ambulatory surgery (POS 24) and specific codes require auth in any place of service (see list)
Certain codes (10060, 11100, 11900, 17000, 20600, 20605, 20610) require authorization if performed in freestanding ambulatory surgery centers billing with bill type 0831
CPT 20610 (hyaluronic acid joint injection) is non-covered when billed with specified osteoarthritis diagnosis codes (M17.x ranges)
Facial cosmetic/septoplasty/rhinoplasty codes and other lists — prior authorization required (TurningPoint delegated codes should be sent to TurningPoint)
Spinal surgery, ENT, cardiac, and certain outpatient orthopedic procedures have authorization requirements; Delegation to TurningPoint effective for listed dates

Prior Authorization

GI procedure place-of-service authorization rules and penile prosthesis

Gastroenterology procedures: selected CPTs require authorization when performed in POS 19 or 22 if an office or ASC is available; authorization is not required when performed in POS 11 or 24. CPT 43290 requires authorization regardless of place of service. Penile prosthesis (54405) requires prior authorization.

GI CPTs requiring auth if performed in POS 19/22 when office/ASC available: 43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270
Authorization not required for these GI services when performed in POS 11 or 24
Authorization required for CPT 43290 regardless of POS
Penile prosthesis (54405) requires prior authorization

Prior Authorization

DME codes, non-covered orthotics, and supplies requiring authorization

Durable Medical Equipment (DME) and supplies have specific authorization rules. A defined list of DME HCPCS codes do not require authorization; all other DME requires prior authorization. Orthotics are not covered and claims may be denied. Certain supplies always require authorization.

Orthotics are not covered
DME codes that do NOT require authorization (examples): E0130, E0135, E0168, E0182, E0184, E0235, E0274, E0305, E0310, E0424, E0431, E0434, E0439, E0570, E0575, E0580, E0602, E0603, E0621, E0655, E0660, E0776, E0890, E0900, E0942, E2361, E2363, L0130, L0140, L0150, L0160, L0170, L0172, L0174, L0180, L0190, L0200, L1652, L1902, L2132, L2134, L2136, L3100, L3221, L3762, L7360, L7362, L7364, L7366, S8421, S8424, V5266
All other DME codes require authorization
Supplies requiring authorization: compression garments/compression gradient stockings; electric heat pads and 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 under the prescription drug benefit

Prior Authorization

TBS scan authorization

TBS (bone density) scans require prior authorization for CPTs 77089, 77090, 77091, and 77092.

TBS Scans (CPTs 77089-77092) require authorization

Prior Authorization

Imaging/radiation therapy and outpatient therapy delegation; speech therapy exception; SNF/Sub‑Acute therapy PA process

Imaging and radiation therapy prior authorization: many radiology and radiation therapy authorizations were delegated to National Imaging Associates, Inc. (NIA) effective 10/1/2021. Outpatient therapy (PT/OT/ST) after the initial evaluation also requires prior authorization through NIA; CPTs 92610 and 92611 for speech do not require prior authorization. Initial therapy evaluations performed in office/facility do not require prior authorization, but subsequent therapy visits do. For therapy in SNF/Sub‑Acute (POS 31/32), prior authorization requests should be sent to 716-803-8307.

Radiology and radiation therapy prior authorization delegated to NIA effective 10/1/2021
Outpatient PT/OT/ST after initial evaluation requires prior authorization via NIA; initial office/facility evaluations do not
Speech therapy CPTs 92610 and 92611 do not require prior authorization
Therapy benefit limits: Rehabilitation 60 visits per condition per plan year; Habilitation 60 visits per condition per plan year
SNF/Sub-Acute (POS 31/32) therapy prior authorization requests: send to 716-803-8307

Prior Authorization

Hyperbaric oxygen, continuous glucose monitoring, and cardiac/pulmonary rehab authorization

Hyperbaric oxygen therapy (CPT 99183 and HCPCS C1300) requires prior authorization. Ambulatory continuous glucose monitoring (95249) and listed cardiac/pulmonary rehabilitation codes also require authorization.

Hyperbaric oxygen therapy: CPT 99183 and HCPCS C1300 — authorization required
Ambulatory continuous glucose monitoring: 95249 — authorization required
Cardiac rehab (S9472, 93797, 93798, G0422, G0423, rev code 0943) — authorization required
Pulmonary rehab (G0237-G0239, G0424, S9473, rev code 0943) — authorization required

Prior Authorization

Chiropractic prior authorization

Chiropractic services billed with CPTs 98940-98943 (and revenue code 0940) require prior authorization.

Chiropractic CPTs 98940-98943 require prior authorization
Revenue code 0940 applies

Note

DSMT authorization stance (no authorization required)

Diabetes Self-Management Training (DSMT) codes G0108 and G0109 are covered and do not require prior authorization. Members are allowed 10 hours/20 units in a continuous 12-month period and services must be provided by certified providers.

DSMT covered: G0108 and G0109 — no prior authorization required
Benefit: 10 hours/20 units per 12-month period; provider must be certified

Prior Authorization

Dental and vision vendor authorization

Dental and vision prior authorizations are managed by vendor partners. Orthodontic and major dental services require prior authorization by DentaQuest (1-800-516-9615). Vision prior authorizations are handled by Davis Vision (1-800-601-3383).

Orthodontic and major dental prior authorization: DentaQuest 1-800-516-9615
Vision prior authorization: Davis Vision 1-800-601-3383

Prior Authorization

Oncology outpatient prior authorization and oncology UM via New Century Health

Oncology outpatient medications and supportive agents require prior authorization from New Century Health (NCH) before dispensing or administration in pharmacy, physician office, outpatient hospital, or ambulatory settings for all lines of business except exclusions noted. Submit requests via NCH web portal or 1-888-999-7713, option 1. Certain oncology-related services and J-/C-/Q‑codes additionally require prior authorization via the Pharmacy Team or Fidelis as specified.

Outpatient oncology meds/supportive agents — prior authorization via New Century Health (NCH)
Exclusions from NCH review include antibiotics, bone marrow/stem cell transplants, CAR-T, certain named products and inpatient drugs (see source)
Pharmacy-team authorization required for certain C- and J- codes — submit to Pharmacy Team e-fax 1-877-533-2405
Oncology outpatient prior authorization and utilization management handled by NCH; refer outpatient oncology requests to NCH

Prior Authorization

Pharmacy-coded drug authorization and listed J-/Q-codes

Pharmacy-coded drug authorization: specific HCPCS C-, J-, and Q-codes listed in the policy require prior authorization. Submit PA requests to the Pharmacy Team via e-fax 1-877-533-2405 unless they are managed through New Century Health per the oncology program.

Selected HCPCS C-, J-, and Q-codes enumerated in the policy require authorization (use the HCPCS lists in Sections B, 36, 37, 54, 71 when preparing requests)
Submit PA requests to Pharmacy Team e-fax 1-877-533-2405 unless directed to NCH

Prior Authorization

Unlisted and Temporary codes require authorization

All services billed with 'Unlisted' or 'Temporary' codes (including C‑codes) require prior authorization.

All Unlisted or Temporary codes (e.g., C-codes) require authorization

Documentation Required

Documentation and written order requirements (enteral formulas, HCPCS lists, ASD attestation)

Additional documentation and ordering requirements: Non‑prescription enteral formulas for home use require a written order from a physician or licensed provider stating medical necessity. Some lists of J‑ and Q‑codes with product mappings are provided in the policy and should be referenced when preparing authorization requests. If documentation requirements are not met, services may be denied or delayed.

Written order stating medical necessity required for non‑prescription enteral formulas for home use
Reference policy J‑ and Q‑code lists when preparing PA requests (product mappings provided)
Lack of required documentation or attestation (e.g., ASD diagnosis attestation) may result in denial or delay

Individuals subject to a current Assisted Outpatient Treatment (AOT) court order or whose AOT expired within past five years

High utilization definition3+ psych inpatient hospitalizations OR 4+ psych ED visits OR 3+ medical inpatient hospitalizations in prior 12 months

Applied Behavior Analysis (ABA) definition

ABA definitionApplied Behavior Analysis (ABA) is a form of enhanced behavioral modification for members with Autism Spectrum Disorder

Authorization requirementAuthorization is required from Behavioral Health for ABA services

Diagnosis attestationAttestation of ASD diagnosis by a licensed physician or psychologist must be provided at time of request

Initial therapy evaluation

Initial therapy evaluation definitionThe first evaluation visit for PT/OT/ST (office/facility initial evaluations do not require authorization)

Home initial evaluationInitial therapy evaluation conducted in the home requires authorization

Subsequent visitsSubsequent therapy services after the initial evaluation require prior authorization through NIA

'Benefit applies to' — coverage applicability phrase

Meaning of phrase'Benefit applies to' indicates the payer's applicability/coverage status for the listed HCPCS/J-code and corresponding product(s)

Catalog usePhrase is used repeatedly across J-code lists to denote items included in the benefit list

No condition impliedEntries under 'Benefit applies to' are presented as a catalog-style applicability list without additional clinical criteria in those chunks

Effective for dates of service on/after 10/04/2021, prior authorization for certain ENT and cardiac surgical procedures was delegated to TurningPoint Healthcare Solutions

2021-06-01clinical_exemption

OMH-licensed inpatient mental health treatment not subject to prior authorization per OMH Best Practice Manual, effective 06/01/2021; facilities must notify insurer within 2 business days

2020-01-01policy_changeLatest

Implemented exemptions effective 01/01/2020 removing prior authorization and concurrent review for certain in-state, in-network outpatient SUD services and providing a 14-day pediatric OMH concurrent review exemption for under-18 inpatient mental health admissions when notification conditions are met