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ModifiedFidelis CarePolicy N/A

Authorization and Utilization Review Requirements (Coverage Criteria)

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Defines Fidelis Care authorization requirements, utilization review rules, and delegated prior authorization arrangements for inpatient, outpatient, behavioral health, SUD, and certain surgical services in New York State; applies to providers delivering services to Fidelis Care members.

Policy Summary

PayerFidelis Care

PolicyAuthorization and Utilization Review Requirements (Coverage Criteria)

Policy CodePolicy N/A

Change TypeMaterial operational updates

Effective DateApr 1, 2022

Next Review Date

Key ActionNotify Fidelis Care within two business days of inpatient SUD or OMH admissions and submit required LOCADTR/initial treatment plan documentation.

SourceLink

POLICY UPDATE CHANGES

Effective 04/01/2022 SUD inpatient rules: first 28 days of in-network OASAS-licensed inpatient SUD are not subject to concurrent utilization review if the facility notifies Fidelis Care within two business days and uses LOCADTR.

Effective 01/01/2020 certain in-state OMH licensed inpatient mental health treatment for all ages is not subject to prior authorization; facilities must notify Fidelis Care within two business days.

Delegation of prior authorization to TurningPoint Healthcare Solutions for specified ENT, cardiac, and certain orthopedic/spinal procedures effective for specified dates.

28 daysSUD concurrent review exemption period

2 business daysNotify Fidelis Care within

Day 31OMH concurrent review begins

TurningPointDelegated vendor

40Home health max/yr

60Rehab visit limit/yr

Coverage and Utilization Rules

Inpatient Admissions

All inpatient admissions require prior authorization except emergent services for stabilization:

Inpatient Authorization: Authorization required for all inpatient admissions; emergency services do not require pre-authorization for stabilization but post-stabilization inpatient admissions do.

All facility admissions are reviewed for medical necessity. Includes acute inpatient and inpatient rehabilitation (acute, sub-acute, skilled).

Inpatient SUD (OASAS-licensed)

In-network OASAS-licensed inpatient SUD authorization rules:

SUD Inpatient Authorization Exemption: In-network OASAS-licensed inpatient detoxification, rehabilitation and residential treatment are not subject to prior authorization or concurrent review during the first 28 days if the facility notifies Fidelis Care of the admission and the initial treatment plan within two business days and provides the OASAS LOCADTR medical necessity data.28 days

Policy Summary

PayerFidelis Care

PolicyAuthorization and Utilization Review Requirements (Coverage Criteria)

Policy CodePolicy N/A

Change TypeMaterial operational updates

Effective DateApr 1, 2022

Next Review Date

Key ActionNotify Fidelis Care within two business days of inpatient SUD or OMH admissions and submit required LOCADTR/initial treatment plan documentation.

SourceLink

On This Page

Facility must perform daily clinical review and begin periodic consultation with Fidelis Care on or just before day 14; services may be subject to utilization review after day 28 or upon discharge; facilities outside NYS, not OASAS-licensed, or out-of-network remain subject to authorization and concurrent review throughout admission.

OMH Licensed Inpatient Mental Health Treatment

OMH-licensed inpatient mental health treatment rules and when utilization review applies:

OMH Inpatient Utilization Review Triggers: Utilization review (prior authorization and concurrent review) is conducted only for members who meet NYS OMH Best Practice Manual clinical triggers: current or recent AOT court order; high utilization defined as 3+ psychiatric inpatient hospitalizations in prior 12 months OR 4+ psychiatric ED visits in prior 12 months OR 3+ medical inpatient hospitalizations in prior 12 months; readmission within 30 days; or length of stay exceeding 30 days (concurrent review from Day 31 onwards).Day 31 for extended stays

Providers must notify Fidelis Care within 2 business days. For members under 18 in-network OMH hospitals are not subject to prior authorization and no concurrent review during the first 14 days if the OMH two-day notification and initial treatment plan form is submitted and other conditions are met.

Delegated Surgical Prior Authorization

Certain surgical and device services require prior authorization or have delegated review:

Delegated Prior Auth to TurningPoint: For specified ENT, cardiac, and certain orthopedic/spinal CPT codes prior authorization has been delegated to TurningPoint Healthcare Solutions; when a CPT is delegated, associated HCPCS device codes will also be reviewed by TurningPoint.

Providers must submit requests for delegated CPTs to TurningPoint per the delegated arrangement; effective dates and code lists are provided in the document.

Behavioral Health Testing Authorization

Behavioral health outpatient services authorization requirements:

Psych/Neuropsych and Developmental Testing: Authorization is required for psychological/neuropsychological testing (96116, 96121, 96130-96133, 96136-96139, 96146) and for developmental pediatric testing (96112, 96113). Note: CPT 96110 is non-covered.

All testing requests should be submitted on the specified testing request form. Partial hospitalization, IOP, and intensive outpatient utilization review follow OMH Best Practice triggers.

Autism Spectrum Disorder (ASD) Services

ASD services:

ASD Authorizations: Authorization is required for DME speech generation equipment and for Applied Behavior Analysis (ABA) which requires Behavioral Health authorization.

Attestation of ASD diagnosis must be provided at the time of request by a licensed physician or psychologist.

Autism Spectrum Disorder (ASD) Services

Covered when documentation and authorization requirements are met:

ASD services: Authorization required for DME speech generation equipment; ABA requires Behavioral Health authorization; attestation of ASD diagnosis by a licensed physician or psychologist must accompany the request.

Outpatient Therapy (PT/OT/ST)

Outpatient therapy coverage rules:

Outpatient PT/OT/ST after initial evaluation: All services provided by a therapy provider after the initial evaluation require prior authorization through National Imaging Associates (NIA). Initial evaluations in office/facility do not require authorization; all home therapy treatments (including evaluations) require authorization.

If billing non-initial evaluation CPTs, authorization requests must be submitted to NIA within 1 business day for outpatient or 2 business days for home health. Non-therapy providers must request authorizations through Fidelis Care.

Rehabilitation / Habilitation Limits

Visit limits that apply when services are covered:

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

OB Ultrasound Coverage

OB ultrasound authorization rules:

OB ultrasound authorization: First 4 OB ultrasounds for a normal pregnancy can be performed without authorization; five or more for a normal pregnancy require authorization. OB ultrasounds for high-risk pregnancy do not require authorization.4

Diagnosis code lists for normal and high-risk pregnancy are provided in the document.

Durable Medical Equipment (DME) Coverage

DME and supplies:

DME authorization: A set of listed DME HCPCS codes do not require authorization (codes listed in the policy); other DME codes require authorization. Specific supplies such as compression garments, electric breast pumps, electric heat pads, surgical stockings, protective helmets, wigs, insulin pumps and infusion pumps require authorization.

Blood glucose monitors and testing supplies are covered through the pharmacy benefit per the code listing.

Pharmacy and Specialty Drug Coverage Rules

Pharmacy prior authorization delegation and exclusions:

Oncology medications and supportive agents for members 18 and over require prior authorization and review by New Century Health (NCH); PA can be requested via NCH web portal or phone. Several drug categories (e.g., CAR T-cell therapy, immune globulins, radiopharmaceuticals, inpatient drug requests, medications not used for oncology indications) are reviewed directly by Fidelis Care and should not be sent to NCH.

Refer to the pharmacy services web resources for full drug lists and routing instructions.

Therapeutic Services Coverage and Exclusions

Therapeutic services requiring authorization or not covered:

Therapeutic services: Specific therapeutic services (phototherapy, hyperbaric oxygen therapy, listed pain management and other procedure codes) require authorization. Certain services are not covered for members with a diagnosis of Low Back Pain (prolotherapy, therapeutic facet joint steroid injections in lumbar/sacral regions, steroid injections into intervertebral discs, continuous or intermittent traction).

63622 and 63688 do not require authorization when requested by orthopedic specialties; cardiac and pulmonary rehabilitation in outpatient settings require authorization.

Outpatient oncology prior authorization (adult members)

Covered when prior authorization and review are obtained

Outpatient oncology prior auth requirement: Outpatient oncology-related requests require prior authorization and review by New Century Health for members 18 and over in Medicaid Managed Care, Essential Plan, and Qualified Health Plan (excluding Child Health Plus).

Authorization is not required for oncology indications for members under 18 and is not required for ophthalmic indications. Refer to the pharmacy services web resources and J-code listings for specific drug/code mappings and submission requirements.

All facility inpatient admissions require prior authorization. Emergency department services provided for stabilization do not require pre-authorization, but post-stabilization inpatient admissions do require authorization. Failure to obtain authorization for an inpatient admission may result in claim denial; all facility admissions are reviewed for medical necessity.

Certain therapeutic injection services are either excluded or require prior authorization depending on diagnosis and site of service. For members with a diagnosis of Low Back Pain, the following are not covered: prolotherapy; therapeutic facet joint steroid injections in the lumbar and sacral regions; therapeutic injections of steroids into intervertebral discs; and continuous or intermittent traction. Additionally, several pain management and injection codes are listed under therapeutic services and require authorization when applicable; some codes (for example, 63622 and 63688) are exempt from authorization when requested by orthopedic specialties.

There are specified authorization exceptions. Authorization is not required for oncology indications for members under 18, and authorization is not required for ophthalmic indications as noted in the oncology section. For in-network OASAS‑licensed inpatient substance use disorder facilities and OMH‑licensed inpatient mental health facilities, providers must follow the notification and documentation processes (including use of LOCADTR or the OMH two‑day notification procedures) to qualify for the limited concurrent review exemptions described elsewhere in this policy.

CPT code 20610 is specifically non‑covered when billed with specified knee osteoarthritis diagnosis codes (the policy lists M17.0, M17.10‑M17.12, M17.2, M17.20‑M17.32, M17.4, M17.5, M17.9 and related M17.x codes). Billing CPT 20610 with these diagnoses may result in denial.

Codes and Limits

Transplant CPT codes listedCPTCovered

32850-32856
33930-33945
38204-38215
38230-38242
44133-44136
47133-47147
48160
48550-48556
50300-50380
50547

1–10 of 11

1/2

Outpatient surgery CPT codes requiring auth (selected groups)CPTCovered

43770-43775	Bariatric surgery
S2083	Bariatric
15820-15823	Blepharoplasty
11920-11971	Breast reconstruction range
19300	Breast-related
19316-19342
19355
19370-19396
10040
11300-11313

1–10 of 23

1/3

ENT/ophthalmic codes requiring authCPTCovered

69300	Ear repair and ear piercing
69090	Ear piercing
65760-65771	Eyelid & ocular surgery
65772-65775
66987-66988
67900-67911
66989
66991
68841

Cosmetic/reconstructive facial and body codesCPT|HCPCSCovered

15830-15839	Abdominoplasty/lipectomy/panniculectomy
15847
15876-15879
19318	Reduction mammoplasty
21120-21296	Facial cosmetic
30400-30520	Rhinoplasty/septoplasty
30620-30802
30999
31298
C9749

1–10 of 11

1/2

Vascular procedures codesCPTCovered

36465-36466	Vascular/vein procedures
36468-36479
36482-36483
37718-37785
37241-37244

Gender reassignment surgeryCPTCovered

55970	Gender reassignment surgery
55980

Speech processor implant CPTsCPTCovered

69716	Speech processor implant procedures
69719
69726
69727

Esophageal procedure CPTsCPTCovered

43284	Esophageal procedures
43497

Spinal surgery CPTsCPTCovered

20932-20934	Spinal surgery codes
22867-22870
62380

Behavioral health testing and partial/intensive outpatient codesCPT|HCPCS|RevenueCovered

96116	Psychological/Neuropsychological Testing
96121
96130-96133
96136-96139
96146
96112-96113	Developmental Pediatric Testing (auth required)
96110	Non-covered
90870	Outpatient ECT
H0035	Partial hospitalization HCPCS
H2013	Intensive outpatient HCPCS

1–10 of 13

1/2

ASD and residential treatment codesmixedCovered

DME (speech generation equipment)	DME requiring authorization for ASD
H0017-H0019	Residential treatment HCPCS
H2036
1001	Residential treatment CPT?
1002

Residential Treatmentmixed

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

Wireless capsule/motility capsuleCPTCovered

91110	Wireless Capsule Endoscopy
91111	Wireless Capsule Endoscopy
91112	Wireless Motility Capsule
91113	Wireless Motility Capsule

Gastroenterology procedures (site-specific auth)CPTCovered

43235
43239
43248
45378
45380
45384
45385
46255
46260
46270

DME codes that do not require authorizationHCPCSCovered

E0130
E0135
E0168
E0182
E0184
E0235
E0274
E0305
E0310
E0424

1–10 of 50

1/5

TBS ScansCPTCovered

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

Cardiac and Pulmonary Rehab CodesCPTCovered

S9472	Cardiac Rehab
93797	Cardiac Rehab
93798	Cardiac Rehab
G0422	Cardiac Rehab
G0423	Cardiac Rehab
G0237	Pulmonary Rehab
G0238	Pulmonary Rehab
G0239	Pulmonary Rehab
G0424	Pulmonary Rehab
S9473	Pulmonary Rehab

ChiropracticCPTCovered

98940-98943	Chiropractic codes
rev code 0940	Chiropractic revenue code

Diabetes Self-Management Training (DSMT)CPTCovered

G0108	DSMT group
G0109	DSMT individual

HCPCS J-code listing (partial)HCPCS

J0275	belimumab (Benlysta) and related entries
J0517	benralizumab (Fasenra) and related entries
J0565	bezlotoxumab (Zinplava) and related entries
J0567	cerliponase alfa (Brineura) and related entries
J0584	burosumab-twza (Crysvita) and related entries
J0585	onabotulinum toxin A (Botox) and related entries
J0586	abobotulin toxin A (Dysport) and related entries
J0591	deoxycholic acid (Kybella) and immune/gamma globulin entries
J0638	canakinumab (Ilaris) and related entries
J0641	levoleucovorin and related entries

1–10 of 120

1/12

J-code mappings (excerpt)HCPCS

J9216	interferon beta-1a, SC (Rebif)
S0182	associated mapping for J9216 (position 4)
J9217	procarbazine oral / leuprolide depot 7.5mg / Q4074 / iloprost (Ventavis) / S0183 (multiple mappings)

J-code mappings (additional)HCPCS

J9223	lurbinectedin; infliximab-dyyb (Inflectra); tamoxifen citrate oral; testosterone pellet (Testopel); Q5103; S0187; S0189 (multiple mappings repeated)
J9225	Q5109; infliximab-qbtx (Ixifi); S0194; vitamin suppl, 100 capsules

Oncology and supportive drug J-codesHCPCS

J9227	isatuximab; filgrastim-aafi (Nivestym); Q5110; S0197; prenatal vitamins - 30 days
J9229	inotuzumab ozo (Besponsa); trastuzumab-dttb (Ontruzant); trastuzumab-pkrb (Herzuma); Q5113; S4990; S4991; nicotine patches (legend and non-legend)
J9247	melphalan flufenamide inj; Q5121; infliximab-axxq (Avsola); S9430; pharmacy compounding

J9269 mappingHCPCS

J9269

tagraxofusp (Elzonris); S0012

Unlisted/Temporary codesHCPCS

C-codes

Unlisted or Temporary Codes (example category that requires authorization)

SUD concurrent review exemption — first 28 days from admission

Exemption periodFirst 28 days of an in-network OASAS-licensed inpatient SUD admission are not subject to concurrent utilization review if the facility notifies Fidelis Care and submits LOCADTR within 2 business days.

Notification requirementFacility must notify Fidelis Care of the inpatient admission and initial treatment plan within two (2) business days (fax/email accepted).

LOCADTR useFacility must provide OASAS LOCADTR Medical Necessity Tool data; periodic consultation with Fidelis Care begins on or just before day 14 to ensure LOCADTR use.

Post-exemption reviewServices may be subject to utilization review after day 28 or upon discharge; all services remain subject to retrospective review for medical necessity.

OMH/Partial/IOP concurrent review trigger — concurrent review for stays exceeding 30 days or for members meeting high-utilization triggers

Concurrent review triggerUtilization review (admission and concurrent) is conducted for OMH-licensed inpatient, partial hospitalization, and intensive outpatient programs when members meet OMH Best Practice Manual clinical triggers (e.g., AOT court order, high utilization, readmission within 30 days) or when length of stay exceeds 30 days (concurrent review from Day 31).

High-utilization definitionHigh utilization examples: 3+ psychiatric inpatient hospitalizations in prior 12 months; OR 4+ psychiatric ED visits in prior 12 months; OR 3+ medical inpatient hospitalizations in prior 12 months.

Notification timingFacilities must notify Fidelis Care within two (2) business days of admission using the OMH Two-Day Notification and Initial Treatment Plan form (fax/email options provided).

Pediatric/under‑21 noteFor members under 18 (per effective dates), in-network OMH hospitals are not subject to prior authorization and limited concurrent review applies if notification/processes are followed (see policy).

OB ultrasound count — First 4 ultrasounds for normal pregnancy without authorization; 5+ require authorization

Authorization thresholdFirst 4 OB ultrasounds for a normal pregnancy can be performed without authorization; five or more ultrasounds for a normal pregnancy require authorization.

High-risk pregnancyOB ultrasounds for a high-risk pregnancy (specified O09./O36.80Xx diagnosis codes) do not require authorization.

Diagnosis codesNormal and high-risk pregnancy diagnosis code lists are provided in the policy to determine authorization requirement.

DSMT limit — 10 hours / 20 units in a continuous 12 month period

Allowed amountMembers are allowed 10 hours (20 units) of DSMT in a continuous 12-month period.

Billing codesServices are covered when billed with codes G0108 (group) and G0109 (individual).

Provider requirementServices must be provided by certified providers; authorization is no longer required for DSMT per policy text.

Rehabilitation/habilitation visit limit — 60 visits per condition per plan year

Visit limitRehabilitation and habilitation benefits are limited to 60 visits per condition per plan year; the limit applies to all therapies combined.

Therapy types includedLimit applies across Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST).

Authorization routingEffective 10/1/2021, outpatient therapy after the initial evaluation requires prior authorization through NIA; initial evaluations in office/facility do not require authorization.

Home health visits — Maximum 40 visits per plan year

Home health maximumHome care approvals are based on medical need for skilled services; benefit maximum is 40 visits per plan year.

Authorization basisApprovals are contingent on medical necessity for skilled services; providers must follow authorization requirements for other home services as applicable.

Relation to therapyHome therapy treatments (including evaluations) require authorization; submission timeframes differ for home health setting (see policy).

Hospice coverage duration — Up to 210 days when medically necessary

Coverage durationHospice care coverage is available up to 210 days when medically necessary and provided as part of a certified Hospice Care program under NY Public Health Law Article 40.

Certification requirementHospice care must be provided as part of a program certified pursuant to Article 40 of the N.Y. Public Health Law.

Medical necessityCoverage is available when hospice care is determined to be medically necessary per program criteria.

Document version marker — V22.0-03/01/2022

Version markerDocument version marker: V22.0-03/01/2022.

Location in documentVersion marker appears in J-code listing section and indicates policy revision/version date.

Effective date contextPolicy contains effective-date changes (e.g., SUD effective 04/01/2022) referenced elsewhere in the document.

What Providers Must Do

Prior Authorization

Prior authorization required for many specified services

Prior authorization is required for the listed inpatient transplants, all inpatient admissions (except emergency stabilization), many outpatient surgical procedures, behavioral health testing and developmental testing, selected ASD-related DME/ABA services, diagnostic testing, DME not on the exemption list, outpatient therapy after the initial evaluation, cardiac/pulmonary rehab, and outpatient oncology drugs for members 18 and over per the delegated routing rules. Failure to obtain required authorization may result in claim denial; all facility admissions are reviewed for medical necessity.

All inpatient admissions require authorization; emergency stabilization services do not require pre-authorization but post-stabilization inpatient admissions do. (chunk 1)
All solid organ and bone marrow/tissue transplants require authorization at time of transplant evaluation (examples listed). (chunk 2)
Numerous outpatient surgical CPT groups require authorization (see outpatient surgery lists). (chunks 12–14)
Behavioral health testing and developmental pediatric testing require authorization (96116 series, 96112/96113). (chunk 15)
Authorization required for diagnostic testing (sleep studies, wireless capsule/motility capsules) and for many gastroenterology procedures performed in certain POS. (chunk 20)
Outpatient therapy after initial evaluation requires authorization through NIA. (chunk 23)
Oncology medications/supportive agents for members 18+ require PA via New Century Health unless explicitly routed elsewhere. (chunks 30–31, 56)

Prior Authorization

TurningPoint delegated prior authorization — submit delegated CPTs to TurningPoint

For CPT codes delegated to TurningPoint Healthcare Solutions, providers must submit prior authorization requests directly to TurningPoint; when a CPT is delegated, associated device HCPCS codes will also be reviewed by TurningPoint.

Delegation to TurningPoint applies to specified ENT, cardiac, and certain orthopedic/spinal procedures — request prior authorization through TurningPoint. (chunk 11)
The policy notes CPT-level delegation; associated HCPCS device codes tied to a delegated CPT are reviewed by TurningPoint. (chunk 11)
TurningPoint-delegated CPTs are referenced in outpatient surgery sections and spinal/orthopedic delegation notes. (chunks 13–14)

Prior Authorization

Authorization and diagnosis attestation required for ASD services

Authorization is required for DME speech generation equipment and for Applied Behavior Analysis (ABA); an attestation of ASD diagnosis by a licensed physician or psychologist must be provided at the time of request.

DME speech generation equipment requires authorization. (chunk 18)
ABA requires Behavioral Health authorization. (chunk 18)
Attestation of ASD diagnosis must be provided by a licensed physician or psychologist at time of request. (chunk 18)

Prior Authorization

Authorization required for select diagnostic tests and specified GI procedures

Prior authorization is required for specified diagnostic tests (sleep studies, wireless capsule endoscopy and motility capsules) and for listed gastroenterology procedures when performed in POS 19 or 22 if an office-based or ambulatory surgery center is available; these GI codes are not authorized when performed in POS 11 or 24.

Wireless capsule endoscopy: 91110–91111 and wireless motility capsule: 91112–91113 require authorization. (chunk 20)
Certain GI procedures (e.g., 43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270) require authorization if performed in POS 19 or 22 when an office/ASC is available; authorization is not required when performed in POS 11 or 24. (chunk 20)

Prior Authorization

DME authorization list: exemptions and supplies that require authorization

A defined list of DME HCPCS codes do not require authorization; all other DME codes require authorization. Certain supplies (compression garments, electric breast pumps, insulin pumps, wigs, protective helmets, surgical stockings, electric heat pads) specifically require authorization.

The policy lists numerous HCPCS (E0130, E0135, L0130, L0140, etc.) that do not require authorization. (chunk 21)
Other DME codes not on the list require authorization. (chunk 21)
Supplies requiring authorization include compression garments/stockings, electric breast pumps, electric heat pads, surgical stockings, protective helmets, wigs, insulin pumps and insulin infusion pumps. (chunk 21)

Prior Authorization

OB ultrasounds: first 4 normal-pregnancy scans exempt; 5+ require authorization

The first four OB ultrasounds for a normal pregnancy do not require authorization; five or more ultrasounds for a normal pregnancy require prior authorization. OB ultrasounds for high-risk pregnancies do not require authorization.

First 4 OB ultrasounds for normal pregnancy performed without authorization; 5+ require authorization. (chunk 22)
High-risk pregnancy OB ultrasounds (listed diagnosis codes) do not require authorization. (chunk 22)

Prior Authorization

Outpatient therapy after initial evaluation requires PA via NIA (effective 10/1/2021)

Effective 10/1/2021, outpatient therapy (PT/OT/ST) services after the initial evaluation require prior authorization through National Imaging Associates (NIA); initial in-office/facility evaluations do not require authorization, but all subsequent billed therapy procedure codes do.

All services by a therapy provider after the initial evaluation require prior authorization through NIA. (chunk 23)
Initial office or facility-based evaluations do not require authorization, but other billed codes on the same date do. Authorization requests for non-initial codes must be sent to NIA within 1 business day for outpatient or 2 business days for home health. (chunk 23)
TBS scans (77089–77092) require authorization. (chunk 23)

Prior Authorization

Authorization required for outpatient cardiac and pulmonary rehabilitation

Authorization is required for cardiac and pulmonary rehabilitation services delivered in the outpatient setting; the policy lists cardiac and pulmonary rehab CPT/revenue codes that require authorization.

Cardiac rehab codes include S9472, 93797, 93798, G0422, G0423 and rev code 0943. (chunk 25)
Pulmonary rehab codes include G0237–G0239, G0424, S9473 and rev code 0943. (chunk 25)

Prior Authorization

Outpatient oncology drugs (age 18+) require PA via New Century Health; some categories route to Fidelis Care

Oncology medications and supportive agents for members age 18 and over require prior authorization and review by New Century Health (NCH); PA requests should be submitted via NCH's web portal or phone. Certain oncology-related drug categories are reviewed directly by Fidelis Care and should not be sent to NCH.

PA for oncology medications/supportive agents for members 18+ must go to New Century Health (my.newcenturyhealth.com or 1-888-999-7713, option 1). (chunk 30)
Do not send requests for CAR T-cell therapy, immune globulins, radiopharmaceuticals, inpatient drug requests, medications for clinical trials, and other listed categories to NCH — these are reviewed by Fidelis Care directly. (chunk 31)
Section reiterates outpatient oncology PA requirement for members 18+ and mapping of various J-codes. (chunk 56)

Prior Authorization

Orthodontic/major dental services require PA by DentaQuest

Orthodontic and major dental services require prior authorization through DentaQuest; providers should route PA requests to DentaQuest as specified.

Orthodontic and major dental services require prior authorization by DentaQuest (1-800-516-9615). (chunk 28)

Prior Authorization

Chiropractic services (98940–98943; rev code 0940) require prior authorization

Chiropractic services billed with CPT codes 98940–98943 and revenue code 0940 require prior authorization before provision.

Codes 98940–98943 and rev code 0940 require prior authorization. (chunk 26)

Billing Rule

HCPCS J-code listing (partial) — reference for PA and billing

A partial list of HCPCS J-codes is provided for billing and prior authorization mapping; when submitting oncology or specialty drug requests, reference the J-code list and include required supporting documentation.

The policy includes an extensive HCPCS J-code listing (partial) used for PA matching (e.g., J0275, J0517, J0565, J9216, J9223, J9227, J9247). (chunks 36, 54, 55)
Providers should consult the J-code mappings in the policy when preparing PA submissions for specialty drugs. (chunks 36, 54, 55)

Prior Authorization

Outpatient oncology requests (adults) require PA and NCH review

Outpatient oncology-related requests for members 18 and over require prior authorization and review by New Century Health in Medicaid Managed Care, Essential Plan, and Qualified Health Plan lines of business (Child Health Plus excluded).

PA for outpatient oncology for members 18+ must be requested via NCH's web portal or phone. (chunk 30)
The policy explicitly states the requirement applies to Medicaid Managed Care, Essential Plan, and Qualified Health Plan (excluding Child Health Plus). (chunk 56)

Note

Outlier management for outpatient SUD services

Fidelis Care will use quality and case management oversight initiatives to manage outlier member needs for outpatient substance use disorder services; providers may be contacted as part of outlier management.

Fidelis Care utilizes quality and case management oversight initiatives to manage outlier outpatient SUD needs. (chunk 6)

Note

Pharmacy routing and step therapy — NCH routing and Fidelis Care exceptions

Certain pharmacy products are routed to New Century Health (NCH) for review; other categories (e.g., CAR T-cell therapy, immune globulins, radiopharmaceuticals, inpatient drugs, medications for clinical trials) are reviewed directly by Fidelis Care and should not be sent to NCH.

Oncology medications/supportive agents for members 18+ are routed to NCH. (chunk 30)
Do not send CAR T-cell therapy, immune globulins, radiopharmaceuticals, inpatient drug requests, medications for clinical trials, and other listed categories to NCH — these are reviewed by Fidelis Care. (chunk 31)

Note

Documentation Required

Admission notification and submission of LOCADTR/OMH two-day form within 2 business days

Facilities must notify Fidelis Care of inpatient SUD or OMH admissions and submit the initial treatment plan/LOCADTR (for SUD) or OMH Two-Day Notification and Initial Treatment Plan form within two business days of admission; LOCADTR submissions may be faxed or emailed to the specified contacts.

For inpatient SUD, the facility must notify Fidelis Care and fax/email OASAS Appendix A Notification Form and LOCADTR to 646-829-1421 or LOCADTR@fideliscare.org within two business days and provide the initial treatment plan. (chunk 5)
For OMH inpatient admissions, facilities must submit the OMH 'Two-Day Notification and Initial Treatment Plan' form to Fidelis Care by fax (718-896-1784) or email (Mental_Health_Admission@fideliscare.org) within two business days. (chunk 10)

Documentation Required

SUD admission notification, LOCADTR submission, and discharge documentation requirements

For inpatient SUD admissions, providers must fax or email the OASAS Appendix A Notification Form and the LOCADTR Medical Necessity Tool to the designated fax/email addresses and provide a written discharge plan prior to discharge; facilities must perform daily clinical review and consult with Fidelis Care starting on or just before day 14.

Fax/email LOCADTR and OASAS Appendix A to 646-829-1421 or LOCADTR@fideliscare.org. (chunk 5)
Facilities must provide a written discharge plan to the member and Fidelis Care prior to discharge and indicate whether discharge plan services are secured/available. (chunk 5)
Facilities must perform daily clinical review and periodically consult with Fidelis Care beginning on/near day 14; services may be subject to utilization review after day 28 or on discharge. (chunk 5)

Documentation Required

Provide licensed physician/psychologist attestation of ASD diagnosis with requests

At the time of request for ASD-related services, providers must include an attestation of the ASD diagnosis signed by a licensed physician or psychologist.

Attestation of ASD diagnosis must be provided at time of request by a licensed physician or psychologist. (chunk 18)

Documentation Required

Enteral therapy requires physician/licensed provider written order stating medical necessity

Enteral formula requests require a written order from a physician or other licensed provider stating that the enteral formula is medically necessary and effective as disease-specific treatment for the member's condition.

Written order must state enteral formula is medically necessary and effective as disease‑specific treatment and reference applicable conditions (e.g., inherited metabolic disorders, Crohn's disease, GERD with failure to thrive). (chunk 30)
HCPCS codes B4034–B4162 describe enteral formulas/disposable items that require authorization. (chunk 30)

Note

Billing Rule

Provide supporting documentation when billing referenced J-codes

When submitting claims or prior authorization requests for the listed J-codes (for example J9216, J9223, J9227, J9229, J9247, J9269 and others shown), include the appropriate supporting documentation and drug-to-code mapping information as required by the payer/authorization program.

The policy contains J-code mappings and examples; providers should include supporting documentation for J-code submissions. (chunks 54–56)
Specific J-codes referenced include J9216, J9223, J9227, J9229, J9247, J9269, among many others in the listing. (chunks 54–56)

Denial Risk

Failure to obtain inpatient authorization risks denial

Failure to obtain prior authorization for any inpatient admission may result in denial; all facility admissions are reviewed for medical necessity.

All inpatient admissions require authorization; emergency stabilization is exempt but post-stabilization inpatient admissions require authorization. (chunk 1)
All facility admissions are reviewed for medical necessity. (chunk 1)

Denial Risk

Risk of denial: CPT 20610 billed with specified knee osteoarthritis diagnoses

CPT code 20610 is non‑covered when billed with specified knee osteoarthritis diagnosis codes (listed M17.x ranges); billing 20610 with those diagnosis codes risks denial.

Policy states CPT 20610 is non-covered when billed with the listed M17.x diagnosis codes. (chunk 12)

Denial Risk

Site-based authorization required for select GI procedures (POS 19/22)

Certain gastroenterology procedures performed in POS 19 or 22 may require site-specific authorization when an office-based or ambulatory surgery center is available; performing these procedures in POS 19 or 22 without authorization may trigger denial.

GI procedure codes 43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270 require authorization if performed in POS 19 or 22 when an office or ASC is available. (chunk 20)
Authorization is not required when these services are performed in POS 11 or 24. (chunk 20)

Denial Risk

Therapy after initial evaluation requires NIA authorization — lack of PA may lead to denial

Outpatient therapy services (PT/OT/ST) after the initial evaluation require prior authorization through NIA; failure to obtain authorization prior to billing may result in denial.

All therapy services after the initial evaluation require PA through NIA; initial evaluations do not require PA. (chunk 23)
If claims are submitted using non-initial evaluation CPTs, authorization requests must be sent to NIA within 1 business day for outpatient or 2 business days for home health. (chunk 23)

Note

J-code listing (informational)

This section lists J-codes and drug names for mapping/reference; it does not include explicit authorization or denial rules beyond the mapped codes.

Large J-code mapping window provided for provider reference; authorization rules are specified elsewhere. (chunks 36, 54, 55)

Prior Authorization

Authorization required for all unlisted or temporary codes (e.g., C-codes)

All services billed with 'Unlisted' or 'Temporary' Codes (for example C-codes) require prior authorization and must be submitted for review.

Policy states all services for 'Unlisted' or 'Temporary' Codes require authorization (such as C-codes). (chunk 56)

Policy Background

This document establishes the operational rules for prior authorization and utilization review that apply across inpatient and outpatient settings, including behavioral health and substance use disorder (SUD) programs. It incorporates New York State licensing distinctions—such as OMH and OASAS facility rules—and references tools and forms used for clinical review (for example, LOCADTR for SUD determinations and OMH Best Practice Manual criteria for mental health triggers). Providers must follow the specified notification and documentation timeframes to ensure appropriate handling of admission and concurrent review processes.

Key Terms and Tools

LOCADTR — LOCADTR Medical Necessity Tool (definition / reference)

DefinitionLOCADTR — OASAS LOCADTR Medical Necessity Tool used to assess clinical necessity for inpatient SUD treatment and to guide utilization review.

Use in processFacilities must submit LOCADTR data for inpatient SUD admissions and consult with Fidelis Care beginning on or just before day 14.

Submission optionsLOCADTR and OASAS Appendix A Notification Form may be faxed to 646-829-1421 or emailed to LOCADTR@fideliscare.org.

OMH Best Practice Manual — OMH Best Practice Manual clinical criteria used to determine when utilization review will be conducted for OMH licensed inpatient mental health.

DefinitionOMH Best Practice Manual — evidence-based clinical criteria (per NYS OMH) used to determine when utilization review will be conducted for OMH-licensed inpatient mental health treatment, partial hospitalization, and intensive outpatient programs.

Role in triggersClinical triggers specified by the OMH Best Practice Manual (AOT orders, high utilization, readmission, extended length of stay) determine when review is required.

Reference linkPolicy references the OMH Best Practice Manual URL for details on criteria used to trigger utilization review.

Applied Behavior Analysis (ABA) — Definition and note that ABA requires Behavioral Health authorization.

DefinitionApplied Behavior Analysis (ABA) — a form of enhanced behavioral modification for Autism Spectrum Disorder that requires authorization from Behavioral Health.

Authorization noteAuthorization is required for ABA services; attestation of ASD diagnosis must be provided by a licensed physician or psychologist at the time of request.

Related DMEAuthorization is also required for DME speech generation equipment used in ASD care.

Enteral Therapy — Use of enteral formulas and disposable items (HCPCS B4034-B4162) requiring authorization for disease-specific therapeutic nutritional treatment.

DefinitionEnteral Therapy — use of enteral formulas and disposable items (HCPCS B4034-B4162) that require authorization for disease-specific therapeutic nutritional treatment.

IndicationsIncludes therapeutic formulas for conditions such as inherited metabolic disorders, Crohn's disease, GERD with failure to thrive, chronic intestinal pseudo-obstruction, and severe food allergies where medically necessary.

Order requirementNon-prescription enteral formulas for home use require a written order from a physician or licensed provider stating medical necessity and effectiveness for the disease-specific treatment regimen.

HCPCS J-code — Definition: HCPCS Level II codes used to bill for drugs administered other than oral medications.

DefinitionHCPCS J-code — a HCPCS Level II code used to bill for drugs administered other than oral medications (injectable/infusible), referenced throughout the policy for prior authorization and mapping.

Usage in policyThe policy lists numerous J-codes (partial list) to match drug-to-code for authorization programs (New Century Health and Fidelis Care reviews).

Reference sectionSee the HCPCS J-code listing (partial) in the policy for specific code mappings and review routing information.

Outpatient oncology-related requests — definition reference for oncology prior authorization and review by New Century Health for members 18 and over.

DefinitionOutpatient oncology-related requests — oncology medications and supportive agents for members 18+ require prior authorization and review by New Century Health (NCH) for specified lines of business.

Routing and exceptionsPA requests for applicable drugs should be submitted via NCH portal or phone; certain oncology-related categories/drugs are reviewed directly by Fidelis Care and should not be sent to NCH (policy lists exceptions).

Age/lines of business noteRequirement applies to members 18 and over in Medicaid Managed Care, Essential Plan, and Qualified Health Plan (excluding Child Health Plus); authorization not required for oncology indications for members <18.

Unlisted/Temporary Codes — Codes such as C-codes which are not specifically listed and therefore require authorization.

DefinitionUnlisted/Temporary Codes — 'Unlisted' or 'Temporary' codes (e.g., C-codes) are not specifically listed and therefore all services billed with these codes require authorization.

Policy requirementAll services for Unlisted or Temporary Codes must be authorized prior to billing; lack of authorization may result in denial.

ExamplesPolicy specifically cites C-codes as examples of temporary/unlisted codes that require authorization.