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ModifiedFidelis CarePolicy N/A

Authorization and Utilization Review — Selected Services (Medicaid/CHP/HealthierLife, NY)

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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.

Policy Summary

PayerFidelis Care

PolicyAuthorization & Utilization Review — Selected Services (NY)

Policy CodePolicy N/A

Change TypeMaterial revisions and additions

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests and required notification forms (e.g., OMH Two-Day or OASAS Appendix A/LOCADTR) within two business days where specified.

SourceLink

POLICY UPDATE CHANGES

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.

14 daysOMH concurrent-review-free period (<18)

28 daysOASAS concurrent-review-free period

4/1/2020CFTSS UM discontinued

UnlimitedAcute inpatient benefit

24 hoursInpatient not approved as inpatient if ≤

4+OB ultrasounds allowed without auth

Coverage and Medical Necessity Criteria

Inpatient admissions

Covered when ALL of the following are met

Inpatient Admission Authorization: All inpatient admissions require authorization except emergency room services or emergent stabilization services; post-stabilization inpatient admissions require prior authorization.

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)

OMH Inpatient MH <18: 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; performs daily clinical review; participates in periodic consultation with Fidelis Care; Fidelis Care will not conduct concurrent utilization review during the first 14 days of the inpatient admission.14 days

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)

OASAS Inpatient SUD: Facility notifies Fidelis Care of the inpatient admission and initial treatment plan within two business days by faxing or emailing the OASAS Appendix A Notification Form and the LOCADTR Medical Necessity Tool; performs daily clinical review; no concurrent utilization review is conducted during the first 28 days of the admission; facilities must periodically consult with Fidelis Care starting on or just prior to day 14; services may be subject to utilization review after 28 days or retrospectively and a written discharge plan using LOCADTR must be provided prior to discharge.28 days

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

Outpatient Behavioral Health General: Authorization requirement has been removed for most in-network, in-state outpatient behavioral health services (including outpatient office visits, therapy, outpatient clinic visits, intensive outpatient programs within initial days, outpatient rehabilitation, and opioid treatment programs); out-of-state or out-of-network providers still require authorization.

Fidelis will manage outlier members via quality and case management initiatives.

Behavioral Health Services still requiring authorization: Psychological/neuropsychological testing, developmental pediatric testing, outpatient ECT, partial hospitalization beyond specified allowances, intensive outpatient beyond initial days, ASD DME and Applied Behavioral Analysis, and specified HCBS-related services continue to require authorization per the listed codes and submission forms.

Specific code lists and submission instructions are provided in the policy.

CFTSS coverage

Children and Family Treatment & Support Services (CFTSS)

CFTSS: Effective 4/1/2020, utilization management requirements and concurrent review for CFTSS are discontinued; CFTSS include OLP, CPST, PSR, FPSS/YPSS, and Crisis Intervention (codes listed).

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

Children's HCBS initial auth: Member is age 20 or younger AND determined to be HCBS-eligible by a Health Home or the Children and Youth Evaluation Service (C-YES) AND HCBS eligibility and a plan of care are documented for initial authorization of 96 units or 24 hours within 60 days of HCBS notification.96 units or 24 hours; 60 days

Concurrent review is required for continued stay.

Respite services

Respite services: Planned Respite does not require prior authorization; concurrent review is required after 7 consecutive days. Crisis Respite does not require prior authorization for access but Fidelis Care will conduct concurrent review for stays that exceed 72 hours.7 days for planned respite; 72 hours for crisis respite

CFTSS authorization stance

CFTSS utilization management: Effective 4/1/2020, utilization management requirements and concurrent review for Children and Family Treatment & Support Services (CFTSS) are discontinued.

Prior authorization was never required for these services.

Outpatient Therapy (PT/OT/ST)

Outpatient PT/OT/ST authorization: All services performed by a therapy provider after the initial evaluation require prior authorization through National Imaging Associates (NIA); PT/OT/ST initial evaluations do not require prior authorization. Non-therapy providers should request authorization for therapy services after the initial evaluation directly through Fidelis Care.

Medicaid/MLTC visit limits apply as specified elsewhere.

OB Ultrasounds

OB ultrasound authorization: The first four OB ultrasounds for a normal pregnancy do not require authorization; five or more ultrasounds for a normal pregnancy require authorization. OB ultrasounds for a high-risk pregnancy do not require authorization.4 ultrasounds without auth

Diagnosis code lists specify normal versus high-risk pregnancies.

DXA Scans

DXA authorization exceptions: Authorization is not required for DXA (77080/77081) for defined age/diagnosis groups (women >65 and men >70 one scan every two years with diagnosis Z13.820; selected men and women age groups with specified diagnoses every two years); requests for other age/diagnosis combinations require authorization.One per two years for specified groups

Requests outside these criteria require authorization.

Diabetes Self-Management Training (DSMT)

Covered when ALL of the following are met

DSMT basic criteria: Member receives DSMT services provided by certified providers and billed with G0108 or G0109; limited to 10 hours (20 units) in a continuous 6-month period.10 hours / 20 units per 6-month period

Authorization is not required.

Asthma Self-Management Training (ASMT)

Covered when ALL of the following are met

ASMT delivery and billing: ASMT may be provided individually or in groups (maximum 8 patients); billed with S9441, S9445, S9446, 98960-98962 and diagnosis code J45x.Group max 8 patients

Authorization is not required.

ASMT hour allowances: Members newly diagnosed or medically complex: up to 10 hours in a continuous 6-month period; medically stable members: up to 1 hour in a continuous 6-month period (includes pregnant women).10 hours or 1 hour per 6 months

Smoking Cessation Counseling (SCC)

Covered when ALL of the following are met

SCC billing and diagnosis: Smoking cessation counseling is reimbursed for up to 8 visits per calendar year using codes 99406 and 99407 and must be billed only with specified F17.xx diagnosis codes.Up to 8 visits/year

Authorization is not required.

Enteral Therapy

Covered when ANY one of the following beneficiary categories is met and clinical criteria documented

Enteral therapy eligibility categories: 1) Tube-fed individuals who can only obtain nutrition through a tube; 2) Individuals with inborn metabolic disorders requiring specific nutritional formulas not available through other means; 3) Children under age 21 who require medical formulas for growth and development; 4) Adults with HIV/AIDS or related illness who are oral-fed and require supplemental nutrition with documented compliance and BMI < 18.5, or BMI < 22 with ≥5% unintentional weight loss in prior 6 months, or total nutritional support with contraindication to feeding tube placement.See BMI/weight-loss limits for supplemental nutrition

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

Pharmacy PA submission: Many listed HCPCS/CPT/J/G-coded drugs and biologics require prior authorization; prior authorization requests must be submitted to the Pharmacy Team via e-fax to 1-877-533-2405.N/A

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

Concurrent-review-free initial period

OMH inpatient MH (members <18)Concurrent utilization review is suspended for the first 14 days when the OMH Two‑Day Notification and Initial Treatment Plan form is submitted within two business days; facility must perform daily clinical review and participate in periodic consultation.

OASAS inpatient SUD (in‑state, in‑network)Concurrent utilization review is suspended for the first 28 days when the OASAS Appendix A Notification Form and LOCADTR tool are submitted within two business days; facility must perform daily clinical review and consult with Fidelis beginning on or just before day 14.

Provider Requirements, Submission, and Authorization Actions

Denial Risk

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).

Prior Authorization

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.

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

LOCADTR

LOCADTR tool definitionLOCADTR Medical Necessity Tool is the clinical review instrument referenced for medical necessity determination and retrospective or continued‑stay review in OASAS‑licensed inpatient SUD facilities.

Use in notificationsFacilities must submit the LOCADTR tool with the OASAS Appendix A Notification Form within two business days of admission for in‑network, in‑state OASAS facilities.

Role in utilization reviewLOCADTR is used for periodic consultation, utilization review after day 28, discharge planning and retrospective medical necessity assessments.

OMH Two-Day Notification

OMH Two‑Day Notification formOMH's 'Two‑Day Notification and Initial Treatment Plan' form must be completed and submitted to Fidelis Care by fax (718‑896‑1784) or email to Mental_Health_Admission@fideliscare.org within two business days of admission for OMH‑licensed inpatient MH members under age 18.

Policy Summary

PayerFidelis Care

PolicyAuthorization & Utilization Review — Selected Services (NY)

Policy CodePolicy N/A

Change TypeMaterial revisions and additions

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization requests and required notification forms (e.g., OMH Two-Day or OASAS Appendix A/LOCADTR) within two business days where specified.

SourceLink

On This Page

Out‑of‑state / Out‑of‑network facilitiesRemain subject to prior authorization and concurrent review throughout the admission (no concurrent‑review‑free period).

Initial HCBS authorization units

Initial HCBS authorizationInitial authorization for Children's HCBS services 1–6 requires documentation of HCBS eligibility and plan of care and is limited to 96 units or 24 hours total within 60 days of HCBS notification.

Concurrent review for continued stayConcurrent review is required for continued stay beyond the initial authorized units/hours.

Services 9–11 (mods/equipment)Services 9–11 (environmental, vehicle, adaptive equipment) require prior authorization and have a $15,000 annual limit.

DSMT allowance

DSMT allowance (per 6‑month period)Members are allowed 10 hours (20 units) of Diabetes Self‑Management Training in a continuous 6‑month period; billed with G0108 or G0109 and provided by certified providers.

Billing codesDSMT services are billed with CPT codes G0108 (individual) and G0109 (group).

AuthorizationAuthorization is not required for DSMT services meeting these criteria.

Outpatient therapy visit limits (Medicaid/MLTC)

Medicaid/MLTC OT and ST limitOccupational and Speech Therapy are limited to 20 visits per member per calendar year (Medicaid/MLTC).

Medicaid/MLTC PT limitPhysical Therapy is limited to 40 visits per member per calendar year (effective 7/1/2018).

Initial evaluationPT/OT/ST initial evaluations do not require prior authorization, but all subsequent services require prior authorization through NIA.

DXA frequency limits

DXA frequency (specified groups)One DXA (CPT 77080 or 77081) is allowed every two years for specified age/diagnosis groups (e.g., women >65 and men >70 with diagnosis Z13.820; selected age ranges 51–64 women and 51–69 men with listed diagnoses).

Other requestsRequests for DXA (77080/77081) outside these age/diagnosis combinations require prior authorization.

Authorization pathwayDXA prior authorization handled per policy; radiology services otherwise require prior auth through eviCore as noted.

DSMT units

DSMT units (repeat)Allowed 10 hours (20 units) in a continuous 6‑month period; billed with G0108/G0109 by certified providers.

No authorization requiredDSMT as described does not require prior authorization.

Provider requirementDSMT must be provided by certified providers to be covered.

ASMT hours

ASMT hour allowancesMembers newly diagnosed or medically complex: up to 10 hours of ASMT in a continuous 6‑month period; medically stable members: up to 1 hour in a continuous 6‑month period.

Delivery formatASMT may be delivered individually or in groups (maximum 8 patients per group).

Billing codes and diagnosisBilled with S9441, S9445, S9446, 98960–98962 and must be billed with diagnosis codes J45x; authorization is not required.

SCC visits

SCC visit limitSmoking cessation counseling reimbursed for up to 8 visits per calendar year using codes 99406 and 99407 when billed with F17.xx diagnosis codes.

Billing diagnosis requirementSCC services must be billed only with specified nicotine dependence diagnosis codes (F17.200, F17.201, F17.210, F17.211, F17.220, F17.221, F17.290, F17.291).

AuthorizationNo prior authorization is required for SCC per policy.

Enteral therapy BMI criteria

Enteral therapy BMI/weight‑loss criteriaSupplemental enteral nutrition up to 1,000 kcal/day is allowed for adults who (a) have BMI < 18.5, or (b) have BMI < 22 with documented unintentional weight loss ≥5% within the prior 6 months; total nutrition allowed if feeding tube placement is medically contraindicated.

Eligible beneficiary categoriesBenefit applies to tube‑fed individuals dependent on tube nutrition; individuals with inborn metabolic disorders needing specialized formulas; children <21 needing medical formulas for growth/development; and certain adults with HIV/AIDS or related illness meeting supplemental/total nutrition criteria.

Authorization for HCPCSEnteral therapy formulas and disposables (HCPCS B4034–B4162) require prior authorization; pharmacy supplies generally do not require authorization (check CHP benefit).

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.

Prior Authorization

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.

Prior 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).

Prior Authorization

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.

Prior Authorization

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.

Prior Authorization

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.

Billing Rule

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.

Documentation Required

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.

Step Therapy

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.

Facility responsibilities

Facility must perform daily clinical review and participate in periodic consultation with Fidelis Care during the concurrent‑review‑free period.

Retrospective reviewAll services may be reviewed retrospectively using the plan's OMH‑approved clinical review criteria.

CFTSS

CFTSS componentsChildren and Family Treatment & Support Services include OLP, CPST, PSR, FPSS, YPSS and Crisis Intervention (codes listed in policy).

Utilization management changeEffective 4/1/2020, utilization management requirements and concurrent review for CFTSS were discontinued.

Prior authorization historyPrior authorization was never required for CFTSS services.

Asthma Self-Management Training (ASMT)

ASMT descriptionAsthma Self‑Management Training consists of patient education sessions delivered individually or in groups (maximum 8 patients) and billed using S9441, S9445, S9446, 98960‑98962 with diagnosis J45x.

Hour allowancesNewly diagnosed or medically complex members: up to 10 hours in a 6‑month period; medically stable members: up to 1 hour in a 6‑month period.

AuthorizationAuthorization is not required for ASMT when billed as specified.

Diabetes Self-Management Training (DSMT)

DSMT definition and codesDiabetes Self‑Management Training provides diabetes education billed with G0108 (individual) and G0109 (group); allowed 10 hours/20 units in a continuous 6‑month period.

Provider requirementServices must be provided by certified providers to be covered.

AuthorizationAuthorization is not required for DSMT when criteria are met.

Smoking Cessation Counseling (SCC)

SCC visit allowanceSmoking Cessation Counseling is reimbursed for up to 8 visits per calendar year using CPT codes 99406 and 99407.

Diagnosis requirementSCC must be billed only with specified nicotine dependence diagnosis codes (F17.xx list in policy).

AuthorizationNo prior authorization is required for SCC per policy.