CurrentFidelis CarePolicy N/A

Authorization Grid Detail, Effective June 1, 2026

Part 2 of Fidelis Care Authorization Grid Detail describes services that require prior authorization or are exempt (imaging, DXA/TBS, therapy authorizations, podiatry, therapeutic services, long-term home health, ADHC, certain DME/ED items, counseling limits, outside vendor prior auths) and provides Appendix I: extensive list of HCPCS/J-codes requiring prior authorization.

Policy Summary

PayerFidelis Care

PolicyAuthorization Grid Detail, Effective June 1, 2026

Policy CodePolicy N/A

Change TypeNo material change

Effective Date06/01/2026

Next Review Date

Key ActionSubmit prior authorization requests per delegated workflows: radiology and oncology to Evolent (NIA) per Evolent process; pharmacy Appendix I requests to Pharmacy Team via e-fax to 1-844-235-5090; therapy auths to Evolent within required timeframes or fax inpatient SNF/Sub-Acute to 833-663-1611.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

>200Appendix I codes listed (approximate)

4OB ultrasounds exempt before auth

10DSMT hours allowed (6-month)

8SCC visits per year

Member-type exception markers

Policy overview and scope

This Authorization Grid covers which imaging, therapy and therapeutic services, certain DME and a large set of pharmacy/HCPCS/J-codes require prior authorization. Imaging items include OB ultrasounds, DXA (77080/77081), TBS scans (77089-77092), other imaging (G0680, 75577) and related CPT/HCPCS codes. Therapy and therapeutic services covered include home & outpatient PT/OT/ST (post-evaluation), phototherapy, hyperbaric oxygen, interventional pain and other listed procedure codes. DME and procedure codes for erectile dysfunction and select supplies are included. Pharmacy/physician-administered drugs and many HCPCS/J/C/G codes are listed in Appendix I and require prior authorization.

Prior authorization for radiology reviews and oncology medication reviews has been delegated to Evolent (NIA). Therapy prior authorization for home and outpatient PT/OT/ST (after the initial evaluation) is also handled through Evolent (NIA); certain cardiac ultrasounds and other specific delegations are noted separately. Pharmacy and oncology-related PA routing and exclusions are addressed in the pharmacy section and Appendix I.

Appendix I provides an extensive, itemized list of HCPCS/J/C/G/Q/S and related codes mapped to specific high-cost drugs and biologics that require prior authorization (representative/sample entries are shown in the Appendix). Providers should consult the Appendix I list when determining PA requirements for medications and related HCPCS codes.

Policy metadata: Payer = Fidelis Care; this document is the Authorization Grid Detail policy describing imaging, therapies, DME and pharmacy/HCPCS/J-codes requiring prior authorization (Appendix I).

Authorization requirements and coverage criteria

OB Ultrasound Authorization Rules

Authorization requirements for obstetric ultrasounds

Codes requiring prior authorization (grouped lists)

Imaging / DXA / TBS / Ultrasound / Other Imaging CodesCPT|HCPCSCovered

77080	DXA bone density scan
77081	DXA bone density scan (other)
77089	TBS scan
77090	TBS scan
77091	TBS scan
77092	TBS scan
G0680	Other imaging
75577	Cardiac MRI? (listed under Other)

Therapeutic / Pain / Phototherapy / Other Procedure CodesCPT|HCPCS|C-codesCovered

96567	Phototherapy
96573	Phototherapy
96574	Phototherapy
96900	Phototherapy
96910	Phototherapy
96912	Phototherapy
96913	Phototherapy
96920	Phototherapy
96921	Phototherapy
96922	Phototherapy

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PodiatryCPT

11719

Toenail debridement — non-covered when rendered by physician for Medicaid; covered with prior auth when facility POS 11

Transportation CPT/HCPCS requiring authHCPCSCovered

A0430	Ambulance round trip? (transportation code requiring authorization)
A0431	Ambulance mileage? (requires authorization)
A0435	Fixed wing air ambulance? (requires authorization)
A0436	Helicopter ambulance? (requires authorization)

Erectile Dysfunction DME / Procedure CodesCPT|HCPCS|L-codesCovered

37788	Pudendal or penile arterial procedure
37790	Erectile dysfunction procedure
54400	Penile implant insertion
54401	Penile implant insertion revision
54405	Penile implant removal
54408	Penile implant other
54410	Other penile prosthesis procedure
54411	Other penile prosthesis procedure
54416	Other penile procedure
54417	Other penile procedure

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Appendix I: HCPCS/J-codes requiring prior authorization (representative sample)HCPCS|J-codes|C-codes|G-codesCovered

C9047	Caplacizumab-yhdp (Cablivi) mapping entries and related J-codes
C9166	Secukinumab IV mapping and related J-codes
C9309	Onasemnogene abeparvovec and related J-codes
C9399	Unclassified drugs/biologics mapping
C9818	Insertion of implant mapping
G0516	Insertion of implant / alpha-1 related mappings
G0517	Removal of implant mappings
J0013	Esketamine nasal spray and related mappings
J0139	Adalimumab (Humira) and related mappings
J0174	Donanemab (Kisunla) and related mappings

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Codes Requiring Prior Authorization (J-codes and Q/S/other codes) - excerpt (Part 3 of 3)mixedCovered

J9015	aldesleukin (Proleukin) / related string entries
J9203
J9204
J9205
J9216
J9217
J9223
J9225
J9226
J9227

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Special notes / member-type exceptionsmixed

ophthalmic indications	authorization is not required for ophthalmic indications (general note)
CHP marker ^	authorization is required for CHP members; it is not required for NYM or HARP members
NYM/HARP marker ~	authorization is required for NYM/HARP members; it is not required for CHP members

What providers must do (prior auth submissions, documentation, and billing rules)

Prior Authorization

Radiology prior authorization delegated to Evolent

Prior authorization for radiology services has been delegated to Evolent (NIA). Consult Evolent’s authorization grid and use Evolent submission channels (portal or phone) per their process. Note: cardiac ultrasound reviews are delegated to TurningPoint per policy.

Consult Evolent auth grid for codes delegated to Evolent (NIA).
Submit requests via Evolent’s portal or phone per Evolent process.
Cardiac ultrasounds are delegated to TurningPoint per policy.

Prior Authorization

Therapy prior authorization via Evolent

Home and outpatient PT/OT/ST provided after the initial evaluation require prior authorization through Evolent (NIA). For outpatient services, submit authorization within 1 business day; for home health, submit within 2 business days. Home therapy initial evaluations require authorization. For inpatient settings, follow Fidelis submission rules (see inpatient fax guidance).

Key terms and abbreviations

Special notes and member-type exceptions

Special notes: authorization is not required when services are billed for ophthalmic indications as noted in the Appendix.

Member-type markers: the caret marker ^ indicates authorization is required for CHP members and not required for NYM/HARP members; the tilde marker ~ indicates authorization is required for NYM/HARP members and not required for CHP members.

Other member-type exceptions and routing: oncology medication and supportive agent PAs are delegated to Evolent for Medicaid Managed Care and HARP (excludes Child Health Plus which continues to route to Fidelis); Appendix I also flags S-code exclusions and non‑covered HCPCS medication codes per the pharmacy section.

Document changes and history

2026-06-01Effective DateLatest

Authorization Grid Detail effective; major delegations to Evolent (NIA) and NYRx transition noted.

Policy Summary

PayerFidelis Care

PolicyAuthorization Grid Detail, Effective June 1, 2026

Policy CodePolicy N/A

Change TypeNo material change

Effective Date06/01/2026

Next Review Date

SourceLink

On This Page

Outpatient: authorization to Evolent within 1 business day.
Home health: authorization to Evolent within 2 business days; initial home evaluations require authorization.
Inpatient submissions follow Fidelis timelines and fax processes.

Documentation Required

DXA age/diagnosis documentation

When billing DXA (CPT 77080 or 77081) include the member’s age and the appropriate diagnosis to qualify for no-authorization benefit. Examples: women >65 or men >70 with diagnosis Z13.820 are eligible for one 77080 or 77081 every two years; women 51–64 and men 51–69 qualify every two years when accompanied by the listed diagnosis codes. Requests outside these age/diagnosis combinations require authorization.

DXA CPT codes: 77080, 77081 must include appropriate age and diagnosis (e.g., Z13.820).
No-authorization frequency: one 77080 or 77081 every two years for specified age/diagnosis groups.
Other age/diagnosis combinations require prior authorization.

Billing Rule

Appendix I PA submission

Appendix I lists HCPCS/J-codes that require prior authorization. Submit prior authorization requests for Appendix I codes to the Pharmacy Team electronically via e-fax to 1-844-235-5090. Note: outpatient oncology-related requests are handled by Evolent per the pharmacy section; refer to that section for oncology submission routing.

Submit Appendix I PA requests via e-fax: 1-844-235-5090.
Appendix I is separate from Evolent oncology program; oncology outpatient requests route to Evolent as described in the pharmacy section.

Billing Rule

Therapy fax for inpatient SNF/Sub-Acute

For therapy services provided in inpatient Skilled Nursing Facility/Sub-Acute settings (POS 31 & 32), prior authorization requests must be faxed to 833-663-1611.

Fax prior authorization requests for inpatient SNF/Sub-Acute (POS 31 & 32) to: 833-663-1611.

Prior Authorization

Oncology medication prior authorization

Oncology medications and supportive agents require prior authorization from Evolent before being dispensed at a pharmacy or administered in a physician’s office, outpatient hospital, or ambulatory setting for members of all ages. Child Health Plus oncology requests continue to require prior authorization to Fidelis. Follow Evolent submission channels for oncology requests.

Evolent PA required prior to dispensing/administration for oncology meds/supportive agents (all ages, excludes Child Health Plus).
Child Health Plus oncology requests continue to be submitted to Fidelis.
Submit oncology outpatient requests via Evolent’s portal or phone per instructions in the pharmacy section.

Billing Rule

Submit non-therapy provider auths to Fidelis

Non-therapy providers (MD, DO, DPM, etc.) should submit prior authorization requests for services rendered after the initial therapy evaluation directly to Fidelis Care (not to Evolent).

MD/DO/DPM and other non-therapy providers must request PAs through Fidelis Care for services after the initial therapy evaluation.

Prior Authorization

Prior authorization required for listed codes

Claims for the HCPCS/J/Q/S codes listed in the Appendix require prior authorization per Fidelis Care policy. Check the pharmacy and appendix notes for member-type exceptions (e.g., CHP, NYM/HARP markers) before submission.

Appendix I codes require PA prior to billing.
Review special member-type exception markers (CHP, NYM/HARP) for applicability.

Documentation Required

Voicemail HIPAA compliance for UM messages

UM voicemail messages may include detailed utilization management information only if the provider voicemail greeting is HIPAA-compliant. The greeting must identify the mailbox owner and organization and state that the mailbox is confidential and that PHI may be left. If not compliant, only a generic message will be left and a callback requested.

Voicemail greeting must identify owner and organization and state confidentiality/PHI may be left to be HIPAA-compliant.
If mailbox is not HIPAA-compliant, UM will leave a generic message and request a callback.

Documentation Required

Reasonable Effort Policy callback

When notifying a provider of a utilization management determination, Fidelis will make a second attempt to reach the provider directly as required by the Department of Health Reasonable Effort Policy.

A second direct contact attempt will be made when notifying providers of UM determinations per Dept. of Health Reasonable Effort Policy.