Fidelis Care prior auth & coverage update

Policy overview and scope

This Fidelis Care communication provides COVID-19–related updates and broad prior authorization and coding clarifications across the plan. It covers authorization expectations for inpatient admissions (medical, substance use disorder, behavioral health), outpatient surgery and selected cosmetic procedures, imaging and diagnostic testing, durable medical equipment (DME) and orthotics, outpatient therapy, pharmacy (Part D and specialty/infused drugs), and vendor-delegated authorizations.

High-level scope: All inpatient facility admissions require authorization (emergency stabilization services are excluded), with specific state-licensed exceptions for in‑state OASAS inpatient SUD facilities (no authorization or concurrent utilization review for the first 28 days if notification and LOCADTR submission conditions are met) and for OMH‑licensed in‑network hospitals treating members under 18 (no concurrent review for the first 14 days if OMH two‑day notification form and other conditions are met).

Vendor delegations and contacts: outpatient orthopedic/spinal prior authorization requirements (see TurningPoint delegation) and radiology prior authorizations are managed via eviCore; pharmacy prior authorizations are submitted to the Pharmacy Team by e‑fax. Specific lists of CPT/HCPCS/DME/orthotic codes that do or do not require authorization are provided in the policy.

Key thresholds and plan-specific limits

Inpatient SUD no-concurrent-review days28 days

OMH inpatient minor no-concurrent-review days14 days (members under 18)

OB ultrasounds without authFirst 4 ultrasounds

DSMT hours/units allowed10 hours / 20 units in a continuous 12-month period

Fidelis Dual Advantage Flex therapy limits - Physical + Speech$2,010 annual limit (combined)

Fidelis Dual Advantage Flex therapy limits - Occupational$2,010 annual limit

TurningPoint delegation effective date2019-12-23

Authorization requirements and applicability

Inpatient Admissions / General Authorization Requirements

All inpatient facility services require prior authorization. Emergency room services or other emergent services required to stabilize an emergent condition do not require authorization for the emergent stabilization itself; however, any post-stabilization services and subsequent inpatient admissions do require authorization and will be reviewed for medical necessity.

All inpatient facility services (medical, substance use disorder, and behavioral health) require authorization prior to admission unless otherwise noted below.

Emergency Department (ED) care: Fidelis Care does not require authorization for emergency room services provided to stabilize an emergent condition. Authorization is required for post-stabilization services and for any inpatient admission that follows ED services; such admissions will be reviewed for medical necessity.

Inpatient Rehabilitation Services

Inpatient rehabilitation services require prior authorization.

Acute rehabilitation admissions require authorization.

Outpatient surgery and procedure prior authorization

Selected outpatient surgical and certain cosmetic procedure CPT and HCPCS ranges require prior authorization as listed (examples include blepharoplasty, bariatric surgery, breast reconstruction, abdominoplasty, facial cosmetic/rhinoplasty ranges, vascular vein procedures, sinuplasty, esophageal sphincter augmentation, and selected spinal surgery codes).

Orthopedic and spinal surgical procedures required authorization for dates of service beginning 10/1/2019; authorization for delegated codes with dates of service on or after 12/23/2019 has been delegated to TurningPoint Healthcare Solutions, LLC (TurningPoint will also review associated HCPCS device codes when a CPT is delegated).

Outpatient surgery codes requiring prior authorization (selected)CPT|HCPCSCovered

15820-15823	Blepharoplasty
43770-43888	Bariatric surgery
S2083	Bariatric HCPCS
11920-11971	Breast reconstruction (range)
19300	Breast surgery
19316-19342	Breast reconstruction (range)
19355	Breast reconstruction
19370-19396	Breast reconstruction (range)
10040	Ambulatory surgery example (may require auth if POS 24)
11300-11313	Skin repair (range)

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Outpatient Surgery — Prior Authorization Required (selected lists)

Lists of outpatient procedures and CPT ranges that require prior authorization; orthopedic/spinal delegation note.

Key outpatient surgery CPT/HCPCS ranges requiring prior authorization: Selected outpatient surgery codes require prior authorization, including but not limited to: Blepharoplasty CPT 15820-15823; Bariatric surgery CPT 43770-43888 and HCPCS S2083; Breast reconstruction CPT ranges 11920-11971, 19300, 19316-19342, 19355, 19370-19396; select ambulatory surgery CPTs (10040, 11300-11313, 11400-11471, 11721); dermal injection codes Q2026, Q2027, G0429 for Facial Lipodystrophy (HIV + depression) with authorization; freestanding ASC bill type 0831 CPTs (10060, 11100, 11900, 17000, 20600, 20605, 20610); codes that continue to require authorization for any POS (11200-11201, 11719, 15769-15829, 17340-17999); ear repair/piercing 69300, 69090; abdominoplasty ranges 15830-15839,15847,15876-15879; eyelid/ocular and ocular ranges 65760-65775,66987-66988,67900-67911; reduction mammoplasty 19300,19318; facial cosmetic and rhinoplasty/septoplasty ranges 21120-21296,30400-30520; vascular vein procedures 36465-36466; sinuplasty 31295-31297; esophageal sphincter augmentation 43284; spinal surgery selected codes 20932-20934,22867-22870,62380.

Behavioral health — outpatient testing, ECT, and program rules

Most outpatient behavioral health authorization requirements have been removed, but authorization remains required for specific psychological and neuropsychological testing codes and certain treatments.

Testing codes that continue to require authorization include 96116, 96121, 96130–96133, 96136–96139, and 96146; requests for these tests should be submitted using the Psychological/Neuropsychological testing request form.

Outpatient ECT and related neurobehavioral status exams require authorization (for example, CPT 90870 and 96112/96113 require authorization; CPT 96110 is listed as non‑covered). Partial hospitalization and intensive outpatient billing types also have specified authorization requirements and revenue/HCPCS/CPT mappings.

Outpatient behavioral health tests that continue to require authorizationCPTCovered

96116	Neuropsych testing/interpretation
96121	Psych testing administration
96130-96133	Psych testing (range)
96136-96139	Psych testing (therapist-administered range)
96146	Neuropsych test scoring/report

ECT and related codesCPTCovered

90870	ECT
96112	Neurobehavioral status exam (authorization required)
96113	Neurobehavioral status exam (authorization required)
96110	96110 noted as non-covered service

Partial hospitalization / Intensive outpatient codesCPT|HCPCS|RevenueCovered

H0035	Partial hospitalization HCPCS (requires authorization)
90899	Intensive outpatient CPT (requires authorization)
S9480	Intensive outpatient HCPCS/S code (requires authorization)
Revenue 912,913,944,945	Partial hospitalization revenue codes (require authorization)
Revenue 905 or 912	Intensive Outpatient revenue codes (require authorization)

Outpatient Behavioral Health — Psychological/Neuropsychological Testing and ECT

Authorization removed from most outpatient behavioral health but retained for specified testing and services.

Authorization requirement removed from outpatient behavioral health services except specified testing and ECT; psychological/neuropsychological testing codes continuing to require authorization include 96116, 96121, 96130-96133, 96136-96139, 96146; requests for testing should be submitted on the Psychological/Neuropsychological testing request form.

ECT and related codes:

Imaging, genetic and diagnostic testing

Radiology and diagnostic imaging authorization rules: radiology services require prior authorization through eviCore Healthcare; a full CPT list is maintained on the eviCore site.

OB ultrasound rules: the first 4 OB ultrasounds can be performed without authorization; five or more ultrasounds for a normal pregnancy require authorization (normal pregnancy diagnosis examples include Z32.01 and specified ICD‑10 ranges). OB ultrasounds for listed high‑risk pregnancy ICD‑10 codes do not require authorization.

Additional diagnostic notes: sleep studies (including home sleep studies) require prior authorization; selected genetic testing guidance notes CPT 81329 and 81336 have a combined limit of 1 per lifetime and genetic/BRCA testing authorization status is addressed in the policy. Other diagnostic procedures (wireless capsule endoscopy, motility capsule, infectious agent detection) are listed with authorization requirements.

OB ultrasound and imaging rulesCPT|ICD-10Covered

OB Ultrasound - first 4	First 4 OB ultrasounds can be performed without authorization
Z32.01	Pregnancy encounter code used in normal pregnancy listing (five or more normal pregnancy ultrasounds require authorization)
List of high-risk pregnancy ICD-10 codes	OB ultrasounds for high-risk pregnancy ICD-10 codes do not require authorization

Outpatient and DME Services

Authorization requirements for diagnostic testing, genetic testing, DME/orthotics, imaging and select GI procedures when performed in POS 19/22.

Sleep and selected diagnostic testing: Sleep studies (including home sleep studies) require prior authorization; Wireless Capsule Endoscopy CPTs 91110, 91111 and Wireless Motility Capsule 91112 require authorization; infectious agent detection by DNA/RNA 87483 requires authorization; BRCA/genetic testing note: CPTs 81329 and 81336 have combined limit of 1 per lifetime (authorization stated as not required for some genetic testing in the document).

DME, orthotics, and outpatient therapy

DME and orthotic authorization: the policy provides a selected list of DME HCPCS codes and orthotic codes that do NOT require authorization (examples listed in the document). Other DME and orthotic codes do require authorization.

Outpatient therapy authorization timing and plan limits: initial evaluations for physical, occupational and speech therapy do not require authorization, but all subsequent visits require authorization (including swallow function). Members enrolled in Fidelis Dual Advantage Flex (Plan 017) have plan‑specific annual dollar limits: $2,010 combined for Physical and Speech therapy and $2,010 for Occupational Therapy.

DME codes not requiring authorization (selected list)HCPCS

A4604	DME code not requiring auth (listed)
E0130	DME code not requiring auth (listed)
E0135	DME code not requiring auth (listed)
E0168	DME code not requiring auth (listed)
E0182	DME code not requiring auth (listed)
E0184	DME code not requiring auth (listed)
E0235	DME code not requiring auth (listed)
E0274	DME code not requiring auth (listed)
E0305	DME code not requiring auth (listed)
E0310	DME code not requiring auth (listed)

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Orthotic codes not requiring authorization (selected list)HCPCS

L3650	Orthotic code not requiring auth
L3710	Orthotic code not requiring auth
L3913	Orthotic code not requiring auth
L3919	Orthotic code not requiring auth
L3921	Orthotic code not requiring auth
L3923	Orthotic code not requiring auth
L3925	Orthotic code not requiring auth
L3929	Orthotic code not requiring auth
L3931	Orthotic code not requiring auth
L3933	Orthotic code not requiring auth

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Outpatient Therapy and Limits

Authorization requirements and Plan 017 dollar limits for therapy.

Initial evaluation for physical, occupational, and speech therapy does not require authorization; all subsequent visits require authorization, including swallow function.

Plan 017 limits: Members enrolled in Fidelis Dual Advantage Flex (Plan 017) have a separate $2,010 annual limit for Physical and Speech combined and a $2,010 annual limit for Occupational Therapy.$2,010

Therapeutic services and special procedures

Various therapeutic and procedural services are explicitly listed as requiring authorization or are addressed in coverage statements: phototherapy and chiropractic services are included; hyperbaric oxygen therapy and specific pain management/interventional codes are listed.

Specific procedure notes include ambulatory continuous glucose monitoring (CPT 95249), bronchial thermoplasty (CPTs 31660, 31661), and radiofrequency ablation of uterine fibroids (CPT 58674). The policy also lists certain services that are not covered for members with a diagnosis of low back pain (for example, therapeutic injections of steroids into intervertebral discs, prolotherapy, and topical oxygen).

Radiation therapy services require prior authorization through eviCore per the radiology/vendor guidance.

Selected therapeutic and procedural codes listedCPT|HCPCSCovered

95249	Ambulatory continuous glucose monitoring
31660,31661	Bronchial thermoplasty
58674	Radiofrequency ablation of uterine fibroids
96567,96573-96574,96900,96910,96912,96913,96920	Phototherapy CPTs listed under therapeutic services
20526,20550-20553,21073,27096,62263-62264,62273,62280-62282,62290,62310,64640,C9752,C9753	Pain management injection and related codes listed

Therapeutic Services / Other Special Procedures

Authorization status and coverage statements for various therapeutic and special procedures.

Therapeutic and pain management services: Phototherapy CPTs (96567, 96573-96574, 96900, 96910, 96912, 96913, 96920), chiropractic services, hyperbaric oxygen therapy, selected pain management injection codes and therapeutic services (eg. 20526, 20550-20553, 21073, 27096, 62263-62264, 62273, 62280-62282, 62290, 62310, 64640, C9752, C9753) are listed and require prior authorization as indicated; some services are not covered for members with Low Back Pain (eg. steroid injections into intervertebral discs, prolotherapy, topical oxygen).

Telehealth, counseling, MNT and DSMT

Telehealth

Authorization for telehealth CPT/HCPCS codes.

Authorization is required for telehealth G2010 and G2012.

Counseling / Nutrition / DSMT

Authorization and coverage rules for counseling, medical nutrition therapy (MNT) and Diabetes Self-Management Training (DSMT).

MNT: Medical Nutrition Therapy (CPT 97802, 97803 or G0270 and G0271) is covered without authorization when provided by a licensed nutrition provider and when billed with a diabetes diagnosis.

DSMT: Diabetes Self-Management Training (DSMT) is allowed 10 hours/20 units in a continuous 12-month period, must be provided by certified providers, and no longer requires authorization.10 hours / 20 units

Pharmacy prior authorization and injectables

Pharmacy program guidance: all covered Medicare Part D drugs must be prescribed for medically accepted indications (FDA or Medicare‑approved compendia references). Self‑administered medications are covered under the pharmacy benefit.

There are numerous injectable/infused/specialty drugs and HCPCS/J/C codes listed that require authorization; oncology indications have a noted exception where authorization is not required for oncology indications.

Prior authorization requests to the Pharmacy Team should be submitted electronically via e‑fax to 1‑877‑882‑5892.

Pharmacy — Prior Authorization and Billing Codes

Pharmacy prior authorization submission instructions and enteral therapy Part B note.

Submit PAs to Pharmacy Team: Prior authorization requests to the Pharmacy Team should be submitted electronically via e-fax to 1-877-882-5892.

Enteral therapy (Part B): Enteral therapy HCPCS codes B4034-B4162 (enteral formulas/disposable items) require authorization under the Part B benefit.

Coding, billing rules and vendor delegations

Include a confirmed diabetes diagnosis on claims to avoid podiatry authorization requirement for diabetic members.

Obstetric ultrasound claims must indicate whether pregnancy is normal or high-risk; use the appropriate ICD-10 code set for normal vs high-risk antenatal conditions when filing.

TurningPoint Healthcare Solutions, LLC is delegated for certain orthopedic/spinal surgical procedure authorizations and associated devices; check TurningPoint for the current delegated CPT/HCPCS lists and delegation effective date.

eviCore is the delegated vendor for radiology prior authorizations — refer to evicore.com for the up-to-date CPT list.

Telehealth codes requiring authorizationCPT

(see payer list)

Codes for telehealth services that require prior authorization per Fidelis Care — refer to internal telehealth authorization list.

Behavioral health MNT/DSMT codesCPT

96156	Health behavior intervention, individual, per 15 minutes (example)
G0108	Diabetes outpatient self-management training services — group (example)

Enteral therapy (Part B) HCPCS B4034-B4162HCPCSCovered

B4034	Enteral formula, nutritionally complete, caloric density 1.0 kcal per mL
B4162	Enteral supply set with 2 ports, per set

Billing Rule

Podiatry diabetes diagnosis on claim

Include a confirmed diabetes diagnosis on the claim to avoid an additional podiatry authorization requirement for members with diabetes.

Affected area: Podiatry services — diabetic members.
Action: Ensure ICD-10 diabetes diagnosis is present on the claim line or claim to prevent unnecessary prior authorization.

Action checklist for providers

Documentation Required

OASAS Inpatient SUD notification and LOCADTR submission

For in-network New York State OASAS‑licensed inpatient SUD facilities, notify Fidelis Care within two business days of admission and submit the OASAS Appendix A Notification Form and the OASAS LOCADTR Medical Necessity Tool by fax or email. Facilities must perform daily clinical review and periodically consult with Fidelis Care beginning on or just prior to day 14 of treatment.

Fax/email submission: 646-829-1421 or LOCADTR@fideliscare.org
Required forms: OASAS Appendix A Notification Form and OASAS LOCADTR Medical Necessity Tool
Notify within two (2) business days of admission
Perform daily clinical review and periodic consultation with Fidelis Care starting near day 14

Prior Authorization

OMH Two-Day Notification

For OMH‑licensed in‑network hospitals treating members under age 18, submit the OMH 'Two-Day Notification and Initial Treatment Plan' form to Fidelis Care within two business days of admission to avoid concurrent utilization review for the first 14 days. The form may be sent by fax or email.

Vendor services and contact points

Vendor responsibilities and contacts: authorization for selected orthopedic and spinal procedures (effective for dates of service on/after 12/23/2019) has been delegated to TurningPoint Healthcare Solutions, LLC — providers should review TurningPoint checklists and code lists for delegated CPTs and associated HCPCS device reviews.

Radiology prior authorizations are managed through eviCore Healthcare; the policy directs providers to eviCore's Fidelis Care page for the full list of CPT codes requiring radiology review.

Vision prior authorizations are handled by Davis Vision (prior authorizations: 1‑800‑601‑3383), and transportation authorization guidance is referenced in the Transportation Provider Manual.

State licensing exception processes and submission contacts: for OASAS‑licensed in‑state inpatient SUD facilities follow the LOCADTR/Appendix A notification process (fax or email as provided) and for OMH‑licensed in‑state hospitals treating minors submit the OMH 'Two‑Day Notification and Initial Treatment Plan' form by fax (718‑896‑1784) or email to MentalHealthAdmission@fideliscare.org as described in the policy.

Definitions

OASASNew York State Office of Addiction Services and Supports (licensing/certification authority for SUD facilities).

OMHNew York State Office of Mental Health (licensing/certification authority for psychiatric hospitals).

OpenPayer

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