Authorization and Utilization Review — Selected Services (Medicaid/CHP/HealthierLife, NY)
Governs prior authorization and utilization review requirements for Fidelis Care Medicaid, CHP and HealthierLife services (New York State), including inpatient, outpatient, behavioral health, substance use disorder, and selected procedure categories. Affects providers delivering these services to Fidelis Care members.
OMH-licensed inpatient mental health treatment for members under 18 in-network in NYS is not subject to prior authorization and not subject to concurrent review for the first 14 days if notification and initial treatment plan are provided within two business days.
OASAS-licensed inpatient SUD services provided in-network and in-state are not subject to prior authorization or concurrent utilization review for the first 28 days when notification and LOCADTR submission occur within two business days.
Certain outpatient behavioral health and CFTSS utilization management requirements are removed: outpatient BH visits generally no longer require authorization, and CFTSS utilization management and concurrent review are discontinued effective 4/1/2020.
List of outpatient surgical and dermatology procedure codes that continue to require prior authorization, and clarification of place-of-service rules for skin surgery.
Coverage and Medical Necessity Criteria
Inpatient admissions
Covered when ALL of the following are met
All facility admissions are reviewed for medical necessity.
OMH inpatient mental health (ages <18)
Authorization and concurrent review suspension conditions (OMH-licensed, in-network, NYS, members <18)
All services may be reviewed retrospectively using the plan clinical review criteria approved by OMH.
OASAS inpatient SUD
Authorization and concurrent review suspension conditions (OASAS-licensed, in-network, NYS)
Out-of-state or out-of-network facilities remain subject to prior authorization and concurrent review throughout the admission.
Behavioral health outpatient coverage
Coverage stance for outpatient behavioral health services
Fidelis will manage outlier members via quality and case management initiatives.
Specific code lists and submission instructions are provided in the policy.
CFTSS coverage
Children and Family Treatment & Support Services (CFTSS)
Prior authorization was never required for these services.
Children's Home and Community Based Services - Initial Authorization
Covered when ALL of the following are met
Concurrent review is required for continued stay.
Respite services
CFTSS authorization stance
Prior authorization was never required for these services.
Outpatient Therapy (PT/OT/ST)
Medicaid/MLTC visit limits apply as specified elsewhere.
OB Ultrasounds
Diagnosis code lists specify normal versus high-risk pregnancies.
DXA Scans
Requests outside these criteria require authorization.
Diabetes Self-Management Training (DSMT)
Covered when ALL of the following are met
Asthma Self-Management Training (ASMT)
Covered when ALL of the following are met
Authorization is not required.
Smoking Cessation Counseling (SCC)
Covered when ALL of the following are met
Enteral Therapy
Covered when ANY one of the following beneficiary categories is met and clinical criteria documented
Enteral formulas and disposables (HCPCS B4034-B4162) require authorization; pharmacy supplies do not require authorization except where noted in the benefit plan.
Pharmacy drugs and biologics requiring prior authorization
Covered when prior authorization is obtained for listed codes
Exception: B4088 does not require authorization where noted.
CPT code 20610 (arthrocentesis; aspiration and/or injection, major joint or bursa) is explicitly identified as non‑covered when billed in combination with certain knee osteoarthritis diagnoses. Providers should note that claims reporting 20610 with diagnosis codes M17.0, M17.10–M17.12, M17.2, M17.20–M17.32, M17.4, M17.5 (and related M17.x codes listed in policy) will be denied as non‑covered.
In addition, specific J‑codes for intra‑articular hyaluronan and related products (for example J7318, J7320–J7329, J7331–J7333) are also non‑covered when billed with CPT codes 20610 or 20611 or with the knee osteoarthritis diagnosis codes listed above. Verify code pairings and diagnosis coding before submission to avoid denial.
The policy lists several therapeutic services that are not covered for members with a diagnosis of Low Back Pain. Specifically, the following are non‑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. Providers should not bill these services for members whose primary diagnosis is low back pain, as they will be denied.
Separately, the policy also identifies that topical oxygen requires prior authorization (see therapeutic services section); however, topical oxygen is not listed as a covered intervention for low back pain and therefore is restricted per policy.
DME and pharmaceutical treatments for erectile dysfunction (codes such as 54360, 54400–54402, 54405, L7900) are explicitly not covered for registered sex offenders. Do not submit authorization requests or claims for these items for members identified as registered sex offenders.
Separately, enteral therapy rules note that pharmacy supplies generally do not require authorization but that supplies not covered for CHP should be referenced to the member’s benefit plan; providers should confirm CHP benefit exclusions when ordering enteral pharmacy supplies.
For members in the Children’s Health Plus (CHP) program, the policy indicates that certain pharmacy supplies are not covered by the benefit; providers must refer to the individual member’s benefit plan for specific CHP exclusions. Note that, in general, enteral therapy formulas and disposables (HCPCS B4034–B4162) require prior authorization, while pharmacy supplies normally do not—except where the CHP benefit excludes the item. Confirm CHP coverage before dispensing or billing.
The policy identifies a group of J‑codes that are non‑covered when billed with certain CPT procedures (notably joint injection codes) or diagnosis codes. In particular, hyaluronan and related intra‑articular product codes (J7318, J7320–J7329, J7331–J7333) are non‑covered when billed with 20610 or 20611 or with the specified knee osteoarthritis diagnoses (e.g., M17.0, M17.10–M17.12, M17.2, M17.20–M17.32, M17.4, M17.5).
Additionally, the policy contains broader guidance that many listed J‑codes require prior authorization through the Pharmacy Team; verify whether a J‑code is subject to non‑coverage pairing rules or requires prior authorization before billing.
All services reported with Unlisted or Temporary procedure codes require prior authorization. Submit authorization requests in advance for any claim that uses an unlisted or temporary code to avoid denials or retrospective review—these code types are not eligible for automatic payment without prior review and approval.
The policy restricts coverage for several interventions related to low back pain and also specifies that topical oxygen requires prior authorization. Topical oxygen is listed under therapeutic services and must be authorized before provision. Other listed low back pain interventions (for example, prolotherapy and certain lumbar facet or disc steroid injections) are identified as not covered for members with a primary diagnosis of low back pain; providers should not submit claims for those interventions when the member’s diagnosis is low back pain.
Codes and Frequency / Unit Limits
Provider Requirements, Submission, and Authorization Actions
Out of Network Authorization Required
Any Medicaid, CHP and HealthierLife service provided by a non‑participating (out‑of‑network) provider, facility, or physician requires prior authorization. Failure to obtain required authorization may result in claim denial or payment reduction.
- Applies to all lines of business noted (Medicaid, CHP, HealthierLife).
- Emergency stabilization services provided in an ER do not require authorization, but post‑stabilization inpatient admissions do (see inpatient rules).
Behavioral Health Prior Authorization
Behavioral health services listed below require prior authorization or have specific authorization timing/notification requirements. Submit requests via the channels noted for children’s services when applicable.
- Psychological/Neuropsychological testing: CPT 96116, 96121, 96130–96133, 96136–96139, 96146 require authorization; use the Psychological/Neuropsychological testing request form.
- Developmental pediatric testing: CPT 96112, 96113 require authorization (96110 is non‑covered).
- Outpatient ECT: CPT 90870 requires authorization.
- Partial Hospitalization (MH/SUD): specified rate and revenue codes and HCPCS H0035 and S9484 require authorization (special submission routes for members under 21).
- Intensive Outpatient Treatment: first 7 days do not require authorization; additional days require authorization (CPT 90899, H2013, S9480; revenue 905/906/912).
- Autism Spectrum Disorder: Authorization required for DME speech generation equipment and for Applied Behavioral Analysis; diagnosis attestation by a licensed physician or psychologist required at time of request.
- Mental Health Continuing Day Treatment (H2012) and PROS (H2018/H2019): first 7 days do not require authorization; additional days require authorization. Requests for members ages 18–20 have dedicated submission routes.
- Assertive Community Treatment (ACT) H0040 and other children's BH carve‑in services: ACT requires prior authorization and concurrent review for applicable ages; requests for members 18–20 may be submitted via children’s Medicaid contacts (email/fax/phone).
- Children and Family Treatment & Support Services (CFTSS): prior authorization and concurrent review requirements have been discontinued effective 4/1/2020 for listed CFTSS services; prior authorization was never required for these services and concurrent review is no longer required.
Diagnostic Testing Prior Authorization
Diagnostic testing procedures and certain circumstances require prior authorization. Authorization requirements may depend on place of service and diagnosis.
- Sleep studies (including home sleep studies) require authorization.
- Genetic testing/BRCA: authorization required except CPT 81220, 81329, 81336 (these three do not require authorization; CPT 81220 limited to 1 lifetime; CPT 81329 and 81336 have a combined lifetime limit of 1).
- Wireless capsule endoscopy/motility capsule: CPT 91110, 91111, 91112 require authorization.
- Select gastroenterology procedures (43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270) require authorization when performed in POS 19 or 22 if an office or ambulatory surgery center (POS 11 or 24) is available; no authorization required when performed in POS 11 or 24.
- Imaging: Five or more OB ultrasounds for a normal pregnancy require authorization; radiology services require prior authorization via eviCore (full CPT list available on evicore.com for Fidelis Care).
- DXA scans: authorization not required for specified age/diagnosis combinations (e.g., women >65, men >70, specified ages 51–69 with accompanying diagnosis codes); all other DXA requests require authorization.
DME Supply Prior Authorization
Certain DME supplies (particularly for MLTC members) require prior authorization per the Medicaid DME Program Manual. Refer to the DME manual for coverage rules and limits.
- Disposable supplies and items: coverage varies by line of business (Medicaid covers some supplies; CHP may not).
- For MLTC members, the following supply HCPCS codes require authorization (effective 4/1/16): A4335, A4554, T4521–T4524, T4529, T4530, T4533, T4535, T4537, T4539, T4540, T4543.
- All DME items requiring authorization are subject to benefit limits defined in the Medicaid DME Program Manual (emedny.org).
Pharmacy Prior Authorization for Specified Drug Codes
Many J‑codes, C‑codes and miscellaneous drug/biologic HCPCS codes require prior authorization through the Pharmacy Team. Submit PA requests electronically via e‑fax to 1‑877‑533‑2405.
- Extensive list of HCPCS/CPT/J/C codes require authorization (examples in the provider guidance include J714x/J71xx series, J9145, J9173–J9176, J9198, many C‑codes and unclassified drug codes).
- Exception: B4088 is noted as an exception in the listed pharmacy code blocks.
- Clinical criteria and step guidance for specific medications (for example: J7318–J7333 group non‑coverage rules in certain billing/diagnosis scenarios; J9306 Perjeta available on the medical benefit without PA; J9035 Avastin and J9355 Herceptin available on the medical benefit with PA; J2350 Xolair available on the medical benefit with PA).
- For complete, current drug/biologic code lists and clinical criteria, providers should consult the Fidelis Care provider portal and submit PA requests to the Pharmacy Team via e‑fax 1‑877‑533‑2405.
Therapy Prior Authorization Triggers
Outpatient therapy (PT/OT/ST) after the initial evaluation requires prior authorization through National Imaging Associates (NIA). Initial evaluations do not require authorization, but all other billed therapy procedure codes—even if on the same date—require authorization before billing.
- Effective 10/1/2019, PT/OT/ST services by therapy providers require prior authorization after the initial evaluation (excludes inpatient, ER, SNF, observation stays).
- Medicaid and MLTC benefit visit limits: OT and ST limited to 20 visits per calendar year; PT limited to 40 visits per calendar year (effective 7/1/2018). No visit limit for CHP.
- Non‑therapy providers (MD/DO/DPM etc.) must request authorization for therapy services after the initial evaluation directly through Fidelis Care.
Vendor Prior Authorization Requirement
Certain services provided by outside vendors require vendor‑specific prior authorization; providers must contact the vendor directly to obtain authorization.
- Orthodontic services for Medicaid members under age 21 require prior authorization by DentaQuest: 1‑800‑516‑9615.
- Vision prior authorizations are handled by Davis Vision: 1‑800‑601‑3383.
Non‑covered Code/Diagnosis Combinations
Some drug/code/diagnosis combinations are non‑covered when billed together. Claims with these non‑covered combinations will be denied if billed as specified.
- CPT code 20610 is non‑covered when billed with the following diagnosis codes: M17.0, M17.10–M17.12, M17.2, M17.20–M17.32, M17.4, M17.5, M17.9.
- HCPCS J‑code group (J7318, J7320–J7333, etc.) are non‑covered when billed with CPT 20610 or 20611 or with the M17.x diagnoses listed above.
- Refer to the provider portal or the pharmacy/drug code lists for additional specific non‑covered J‑code/CPT combinations.
Claim Diagnosis Documentation for Podiatry
When billing podiatry services for patients with Diabetes Mellitus, the diabetes diagnosis must be included on the claim to avoid a prior authorization requirement. Podiatric services for members without a diabetes diagnosis require authorization. For DME and orthotic codes that require authorization, podiatrists must obtain authorization even when items are supplied in the office.
- Include a confirmed Diabetes Mellitus diagnosis on the claim for podiatry services to waive authorization requirements.
- Podiatrists must obtain authorization for DME/orthotic items in which authorization is required regardless of supply location.
Clinical Criteria and Step Guidance
Clinical criteria and step therapy guidance for selected medications and biologics are available on the Fidelis Care provider portal. Some medications are available on the medical benefit with or without PA as noted; others require PA and must meet clinical criteria.
- Perjeta (J9306) is available through the medical benefit without prior authorization.
- Avastin (J9035) and Herceptin (J9355) are available on the medical benefit with prior authorization.
- Xolair (J2350) is available through the medical benefit with prior authorization.
- Clinical criteria, step therapy, and coverage requirements for many medications are published on the provider portal — consult the portal for the most current criteria before submitting a PA request.
Background and Scope
This policy document sets out operational prior authorization and utilization review rules that apply broadly to Fidelis Care Medicaid, CHP and HealthierLife members and includes COVID‑19‑era operational clarifications. Key operational points include: all inpatient admissions require prior authorization (emergency department stabilization services are excluded from the authorization requirement, but post‑stabilization inpatient admissions do require authorization), and state‑licensed behavioral health and substance use disorder facilities have defined notification and concurrent‑review suspension periods when certain submission requirements are met. For OMH‑licensed inpatient mental health for members under age 18, facilities must submit the OMH Two‑Day Notification and Initial Treatment Plan within two business days and are not subject to concurrent review for the first 14 days. For in‑state OASAS‑licensed inpatient SUD facilities, submission of OASAS Appendix A and the LOCADTR tool within two business days suspends concurrent utilization review for the first 28 days. The document also directs providers to required forms, fax numbers, and the Pharmacy Team e‑fax (for listed drug/biologic prior authorizations) for submission of prior authorization requests.
Definitions and Tools
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