Fidelis Care Prior Auths: Inpatient Outpatient Policy

Coverage & Medical Necessity Criteria

Inpatient Admissions

Covered when ALL of the following are met

Inpatient Admission Authorization: All inpatient admissions require an authorization (emergency room services required for stabilization do not require authorization, but post-stabilization inpatient admissions do).

All facility admissions are reviewed for medical necessity; inpatient rehabilitation (acute, sub-acute, skilled nursing rehabilitation) requires prior authorization.

Inpatient Substance Use Disorder (SUD)

Special SUD inpatient rules

OASAS Inpatient SUD Notification and Review: Inpatient SUD services provided by OASAS‑licensed, in‑network NY facilities are exempt from concurrent utilization review for the first 28 days if the facility notifies Fidelis Care of the admission and initial treatment plan within two business days and submits the OASAS Appendix A Notification Form and LOCADTR tool; facilities must perform daily clinical review and periodically consult with Fidelis Care beginning on or just prior to day 14.28 days

Out‑of‑state, unlicensed, or out‑of‑network facilities must request prior authorization and remain subject to concurrent review throughout the admission; services may be reviewed retrospectively.

Inpatient Mental Health (OMH-licensed)

OMH-licensed inpatient mental health rules

OMH Inpatient Mental Health Admissions (<18 and general): OMH‑licensed inpatient mental health treatment in NY provided by in‑network facilities is not subject to prior authorization and is exempt from concurrent utilization review for the first 14 days when the facility 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; facilities must perform daily clinical review and participate in periodic consultation with Fidelis Care. Utilization review thereafter follows OMH Best Practice Manual triggers (e.g., AOT, high utilization, readmission within 30 days, length of stay >30 days).14 days

Out‑of‑network facilities are subject to concurrent review throughout the admission.

Outpatient Surgery Authorization

Outpatient surgery and procedure authorization

Outpatient Surgery Authorization: Specific surgical and procedural CPT/HCPCS codes listed in the policy require prior authorization when performed as specified (examples include bariatric surgery 43770-43775, S2083; blepharoplasty 15820-15823; breast reconstruction codes; certain skin surgery codes when performed in ASC; specified codes always require authorization regardless of place of service).

Some codes require authorization only when billed from certain POS or bill types (e.g., specified codes require authorization when performed in free‑standing ASC billing bill type 0831); CPT 20610 is non‑covered when billed with certain M17.* diagnosis codes.

Behavioral Health Authorization and Criteria

Covered when ALL of the following are met

Behavioral Health Testing and Programs: Psychological/neuropsychological testing (96116, 96121, 96130-96139, 96146), developmental pediatric testing (96112, 96113), outpatient ECT (90870), partial hospitalization (Revenue 912,913,944,945; H0035), intensive outpatient (905/912, 90899, S9480, H2013), residential treatment and ASD‑related services require authorization as specified; CPT 96110 is non‑covered.

Requests for members under 21 have specified contact channels; authorization requirements and utilization review triggers for partial hospitalization/intensive outpatient follow OMH Best Practice Manual.

Home health and hospice

Home health approval: Home care approvals are based on medical need for skilled services.40 visits per plan year

Benefit maximum 40 visits per plan year.

Hospice care must be provided as part of a Hospice Care program certified pursuant to NY Public Health Law Article 40.210 days

Coverage available up to 210 days when medically necessary.

Therapy services

Outpatient therapy prior authorization and visit limits

Therapy prior auth: All outpatient PT/OT/ST services after the initial evaluation require prior authorization through National Imaging Associates (NIA). Initial evaluations do not require prior authorization. Non‑therapy providers should request PA for therapy services after the initial evaluation directly through Fidelis Care.Initial evaluation exempt

Excludes PT/OT/ST in inpatient, ER, SNF, or observation stays.

Therapy visit limits: Rehabilitation and habilitation benefits are each limited to 60 visits per condition per plan year; the visit limit applies to all therapies combined.60 visits

Applies to services rendered on or after 10/1/2019.

Therapeutic services: covered and excluded

Therapeutic services requiring authorization or excluded

Therapeutic services requiring PA: Services such as phototherapy (96567, 96573-96574, 96900, 96910, 96912-96913, 96920), hyperbaric oxygen therapy (99183, C1300), specified pain management injection codes, cardiac and pulmonary rehabilitation (codes listed), radiation therapy (prior auth via eviCore), ambulatory CGM (95249), radiofrequency ablation of uterine fibroids (58674), and bronchial thermoplasty (31660, 31661) require authorization as listed.

Some pain management codes (63622, 63688) do not require authorization when requested by orthopedic specialties.

Low back pain exclusions: For members with a diagnosis of Low Back Pain, prolotherapy; therapeutic facet joint steroid injections in the lumbar and sacral regions; therapeutic injections of steroids into intervertebral discs; and continuous or intermittent traction are not covered.

Explicit exclusion tied to low back pain diagnosis codes.

DME and pharmacy

Durable medical equipment, devices, and pharmacy review routing

DME authorization rules: Some DME codes listed do not require authorization (e.g., E0130, E0135, etc.); other DME codes require authorization. Supplies requiring authorization include compression garments, electric breast pumps, electric heat pads, surgical stockings, protective helmets, wigs, insulin pumps, and insulin infusion pumps. Blood glucose monitors and testing supplies (A4253, A9275, E0607, E2100, E2101) are covered through the prescription drug benefit.

Refer to policy code list for specific HCPCS/HCPCS ranges.

Pharmacy prior auth routing: Outpatient oncology medications and supportive agents for members 18+ require prior authorization and review by New Century Health (NCH) in specified lines of business; a list of drugs requiring NCH review is maintained on the Fidelis Care Pharmacy Services website. Certain medication requests (e.g., CAR T‑cell therapy, Cablivi, immune globulins, sickle cell therapies, inpatient drug requests) are reviewed directly by Fidelis Care and should not be sent to NCH. Prior authorization requests to the Pharmacy Team should be submitted via e‑fax when applicable.

Providers must consult the Fidelis Care Pharmacy Services webpage for the authoritative, current NCH review list.

Imaging studies

Imaging authorization rules

OB ultrasound rule: The first four OB ultrasounds for a normal pregnancy may be performed without authorization; five or more ultrasounds for a normal pregnancy (specified diagnosis codes) require authorization. OB ultrasounds for high‑risk pregnancies do not require authorization (diagnosis codes listed).>4 ultrasounds

Specific ICD‑10 diagnosis codes delineate normal vs. high‑risk pregnancy exceptions.

Radiology prior auth: Radiology services require prior authorization through eviCore healthcare; a full list of CPT codes is available on the eviCore website for Fidelis Care.

External vendor (eviCore) manages radiology prior authorizations; lack of authorization may result in non‑payment.

Orthotics are not covered under Fidelis Care durable medical equipment and supplies benefits. This exclusion applies to orthotic devices described in the DME section and means claims for orthotics should not be submitted for coverage authorization.

CPT code 20610 is specifically identified as a non-covered service when billed with the listed knee osteoarthritis diagnosis codes (ICD-10: M17.0, M17.10-M17.12, M17.2, M17.20-M17.32, M17.4, M17.5, M17.9). When 20610 is submitted with one of these M17.* diagnosis codes it will be denied as non-covered and should not be authorized.

Certain therapeutic injections and related procedures are excluded for members with a diagnosis of Low Back Pain. The policy explicitly lists the following services as not covered for Low Back Pain diagnoses: 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. Providers should not request authorization for these services when the primary diagnosis is Low Back Pain.

This document segment provides extensive HCPCS/J/S code-to-drug and composite-code mappings intended to identify medications that may require New Century Health (NCH) review or prior authorization. The listing itself does not present clinical coverage criteria or medical necessity rules in this section; providers must consult the Fidelis Care Pharmacy Services web page for the authoritative and current list of drugs requiring NCH review and the applicable prior authorization requirements.

CPT code 96110 (often used for cognitive screening or related services) is explicitly listed in the behavioral health section as a non-covered service and should not be submitted for authorization or payment under the covered outpatient behavioral health testing services.

Code Lists & Limits

DME codes not requiring authorization (partial list)HCPCSCovered

E0130	Cane, includes canes with wheels, each
E0135	Crutches, underarm, wood, adjustable or fixed, each
E0168	Platform attachment for crutches, each
E0182	Walker, folding, with seat and wheels, adjustable
E0184	Walker, folding, wheeled, adjustable, with seat
E0235	Pneumatic leg pump, intermittent
E0274	CPAP mask interface, replacement
E0305	Surgical trays and kits, reusable
E0310	Surgical appliance or device
E0424	Stationary compressed gaseous oxygen system, rental

1–10 of 50

1/5

Outpatient surgery and ASC codes requiring prior authorization (examples)CPTCovered

43770	Laparoscopic gastric bypass
43775	Revision of gastric bypass
S2083	Bariatric surgery services, ancillary
15820	Blepharoplasty lower eyelid
15823	Blepharoplasty, complicated
11920	Immediate reconstruction of breast, simple
11971	Revision of breast reconstruction
10040	In-office incision and drainage, skin
17000	Destruction of benign lesions (first)

Behavioral health outpatient codes (authorization required)CPTCovered

96116	Neurobehavioral status exam
96121	Psychological testing scoring and report
96130	Psychological testing by technician
96136	Psychotherapy, 45 minutes
96138	Psychological testing administered
96146	Neuropsych testing interpretation and report

Diagnostic procedures and DME (neutral listing)mixed

91110	Wireless capsule endoscopy, esophagus
91111	Wireless capsule endoscopy, small intestine
91112	Wireless motility capsule

Diagnostic/GI procedures requiring authorization in certain POSCPT

43235	Esophagogastroduodenoscopy with dilation
43239	Esophagogastroduodenoscopy, other
43248	EGD with biopsy
45378	Colonoscopy, therapeutic
45380	Colonoscopy, biopsy
45384	Colonoscopy with removal of tumor

DME codes explicitly listed as not requiring authorizationHCPCSCovered

E0130	Cane, includes canes with wheels, each
E0135	Crutches, underarm, wood, adjustable or fixed, each

Therapeutic services requiring authorizationCPT

96567	Phototherapy, UVB
99183	Hyperbaric oxygen therapy initial
95249	Ambulatory continuous glucose monitoring
58674	Radiofrequency ablation of uterine fibroids

Chiropractic services requiring prior authorizationCPT

98940	Chiropractic manipulative treatment, 1-2 regions
98943	Chiropractic manipulative treatment, 5 regions

Telehealth codes requiring authorizationCPT

G2010	Remote evaluation of recorded video
G2012	Brief check-in via telephone

Counseling / DSMT codesCPTCovered

G0108	Diabetes outpatient self-management training, individual, 30 minutes
G0109	Diabetes outpatient self-management training, group, per 30 minutes
98960	Education and training for patient self-management

Cardiac and Pulmonary Rehabilitation (auth required)mixed

S9472	Cardiac rehab, per session
93797	Physician services for cardiac rehab
G0422	Cardiac rehab, phase II, 36 sessions
G0237	Pulmonary rehab, per session
G0424	Pulmonary rehab, intensive
S9473	Pulmonary rehab, other
0943	Revenue code for rehab
93798	Cardiac rehab management

Genetic testing exceptions (no auth required)CPT

81220	BRCA1/BRCA2 (single site) - lifetime limit 1
81329	Other hereditary cancer panel - limit 1 combined
81336	Genetic testing, specified - limit 1 combined

Enteral therapy (requires authorization)HCPCS

B4034

Enteral formula, specific, requires auth

Pharmacy / provider-administered drugs requiring NCH review (partial list)HCPCS

C9054	Lefamulin (Xenleta) - provider admin
C9055	Brexanolone - provider admin
J0129	Abatacept (Orencia)
J0135	Injection, unspecified
J0178	Aflibercept (Eylea)
J0222	Patisiran (Onpattro)
J0270	Alprostadil
J1442	Filgrastim (Neupogen)
J1447	Tbo-filgrastim (Granix)

Listed HCPCS / J‑codes (partial excerpt)HCPCS

J7191	Treated drug - example
J7193	Treated drug - example 2
J7194	Treated drug - example 3

Additional HCPCS / S‑code excerptsHCPCS

S0012	Implant insertion
S0139	Piperacillin inj
S0177	Minoxidil oral

Miscellaneous listed HCPCS/J and S codes (document excerpts)mixed

J7686	Intravitreal implant
J9352	Bevacizumab
J9205	Budesonide comp

Partial J‑code mappings from documentHCPCS

J9185	Example mapping
J9203	Example mapping 2
J9216	Example mapping 3
J9226	Example mapping 4
J9271	Example mapping 5

Partial S‑code mappings (segment)HCPCS

S0081	Piperacillin inj
S0090	Sildenafil oral
S0117	Tretinoin topical
S0126	Follitropin alfa

Partial S‑code mappings (continuation)HCPCS

S0137	Didanosine oral
S0156	Mercaptopurine oral
S0178	Saquinavir oral
S0197	Dextroamphetamine oral

Listed HCPCS/J and S codes (document excerpts continued)HCPCS

J7324	Hyaluronan (Orthovisc)
J7336	Capsaicin 8% patch
J7351	Bimatoprost implant

Home Health Visit Limitmixed

Benefit maximum 40 visits per plan year

Authorization, Submission & Notification Requirements

Denial Risk

Prior Authorization Required for Inpatient Admissions

Prior authorization is required for the inpatient admissions and certain post-stabilization inpatient services. Failure to obtain authorization for inpatient admissions or for post-stabilization inpatient services may result in claim denial.

All acute inpatient facility services require authorization.
Inpatient rehabilitation services (acute, sub-acute and skilled nursing rehabilitation) require prior authorization.

Prior Authorization

Inpatient SUD and OMH‑Licensed Inpatient Notifications

Inpatient substance use disorder (SUD) and OMH‑licensed inpatient mental health admissions have special notification and review rules. Facilities must notify Fidelis Care within two business days of SUD admission and submit required forms; SUD admissions are not subject to concurrent utilization review for the first 28 days if notification and initial treatment plan are provided. OMH‑licensed inpatient mental health treatment for members under 18 is not subject to concurrent review for the first 14 days if the facility notifies Fidelis Care within two business days and meets other requirements.

Background & Scope

This policy documents the authorization and utilization review requirements for a broad set of services, and includes special notification and concurrent review provisions for New York State behavioral health and substance use disorder facilities. Key operational requirements include: all inpatient admissions require authorization (post-stabilization inpatient admissions are subject to authorization and review); OASAS-licensed in-network inpatient SUD facilities are exempt from concurrent utilization review for the first 28 days provided they notify Fidelis Care within two business days and submit the OASAS Appendix A/LOCADTR materials; OMH-licensed in-network inpatient mental health facilities must notify Fidelis Care within two business days and, for members <18 years, are exempt from concurrent review for the first 14 days when the Two-Day Notification form is submitted. Facilities must perform daily clinical review and engage with Fidelis Care per the timelines described to avoid potential denials.

Key Definitions

LOCADTR

LOCADTR definitionA clinical review tool used for assessing medical necessity in inpatient SUD treatment (OASAS LOCADTR Medical Necessity Tool)

Use caseUsed for concurrent and retrospective review and to inform discharge planning for inpatient SUD services

SubmissionFacilities may fax or email the LOCADTR tool to notify Fidelis Care as part of the two-business-day notification requirement

Two-Day Notification and Initial Treatment Plan

Two-Day Notification and Initial Treatment PlanOMH-developed form that must be submitted within two business days for OMH-licensed inpatient mental health admissions

Submission channelsSubmit by fax to 718-896-1784 or by email to Mental_Health_Admission@fideliscare.org

OpenPayer

Authorization and Utilization Review Requirements (Inpatient, Outpatient, Behavioral Health, Pharmacy, DME)

Coverage & Medical Necessity Criteria

Code Lists & Limits

Authorization, Submission & Notification Requirements

Background & Scope

Key Definitions