CurrentFidelis CarePolicy N/A

COVID-19 UPDATE

Provider authorization, prior authorization, and billing-related rules for a wide range of services during the COVID-19 period (part 1). Covers inpatient admissions, behavioral health, outpatient surgeries, diagnostic testing, DME, imaging, therapy, pharmacy (enteral and certain drugs), vendor authorizations, transportation, and specific code-level authorization requirements and exceptions.

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE

Policy CodePolicy N/A

Change TypeOperational update (no material coverage change)

Effective DateOct 1, 2019

Next Review DateN/A

Key ActionObtain prior authorization for inpatient admissions and specified services as detailed in the policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes in this brief.

60Rehabilitation visit limit per condition per plan year

60Habilitation visit limit per condition per plan year

28 daysInpatient SUD no concurrent review period (in-network NYS OASAS)

14 daysOMH inpatient mental health no concurrent review period (members <18)

10 hrs

DSMT allowance in 12 months

~60Listed code mappings in this part

Policy Overview

This policy provides operational authorization and prior-authorization routing decisions for a broad set of services, delegating specialty reviews to TurningPoint, eviCore, NIA, and New Century Health, and specifying code-level authorization requirements to guide providers during the COVID-19 period and beyond. It covers inpatient admissions (all require authorization except emergency stabilization), many outpatient surgeries, diagnostics, imaging, therapy (PT/OT/ST after initial evaluation), DME, behavioral health programs, enteral and specialty pharmacy agents, and vendor-specific routing. NYS OMH-licensed inpatient mental health and NYS OASAS-licensed inpatient SUD facilities are exempt from prior authorization and certain concurrent review requirements when they meet notification and procedural requirements (OMH two-day notification and OASAS Appendix A/LOCADTR submissions). General routing: radiology and radiation therapy reviews go to eviCore; therapy prior-authorization after initial evaluation goes to NIA; certain orthopedic/spinal outpatient procedures delegated to TurningPoint (effective 12/23/2019 for DOS on/after 10/1/2019); oncology/supportive specialty drug PA for adults routed to New Century Health with specified exceptions; other vendor authorizations (e.g., DentaQuest, Davis Vision) as noted. Effective date: 2019-10-01; Last review: 2021-08-01.

Key thresholds & quick reference

Inpatient SUD exemption periodNo concurrent utilization review for first 28 days if facility notifies Fidelis Care & submits OASAS Appendix A and LOCADTR within 2 business days

OMH <18 exemption periodNo concurrent review for first 14 days for members under 18 if facility submits OMH Two‑Day Notification & Initial Treatment Plan within 2 business days and meets daily review/consultation requirements

Rehabilitation visit limitRehabilitation benefit limited to 60 visits per condition per plan year (applies to all therapies combined)

Habilitation visit limitHabilitation benefit limited to 60 visits per condition per plan year

DSMT limitDiabetes Self‑Management Training: 10 hours / 20 units in a continuous 12‑month period (no prior authorization; billed with G0108/G0109)

OB ultrasound ruleFirst 4 ultrasounds for a normal pregnancy do not require authorization; five or more require authorization (specified dx codes listed)

Authorization & Coverage Criteria

Out of Network / Authorization general rule

Authorization and access rules for out-of-network and emergent services:

OON benefits and exceptions: There are no Out Of Network (OON) benefits. However for any medically necessary service not available in network, authorization will be provided
Emergency services: Emergency room services or any emergent service required to stabilize an emergent condition do not require authorization
Post-stabilization and inpatient: Post-stabilization services and inpatient admissions after emergency room services are completed require authorization

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Outpatient Surgery — Prior Authorization Requirements

Bariatric surgery (requires prior authorization): CPT 43770-43775, HCPCS S2083.

Skin surgery and dermatologic procedures: No authorization required when performed in office or outpatient facility (POS 11 or 22) for many repairs. However, the following codes require authorization if performed as ambulatory surgery (POS 24): 10040, 11300-11313, 11400-11471, 11721. Additionally, the following codes always require authorization regardless of place of service: 11200-11201, 11719, 15769-15829, 17340-17999.

Ambulatory Surgery Center (ASC) billing type 0831 exceptions and billing rule: Services billed by freestanding ASCs with bill type 0831 require authorization for the following CPT codes: 10060, 11100, 11900, 17000, 20600, 20605, 20610. Note: CPT 20610 is non-covered when billed with any of these knee diagnosis codes: M17.0, M17.10-M17.12, M17.2, M17.20-M17.32, M17.4, M17.5, M17.9.

Ear repair and ear piercing: CPT 69300 and 69090 require prior authorization.

Behavioral Health — Inpatient and Outpatient Rules

Behavioral Health - Outpatient Services

Authorization requirements and utilization review triggers for outpatient behavioral health services:

Testing: Psychological/Neuropsychological Testing requires authorization: CPT 96116, 96121, 96130-96133, 96136-96139, 96146; requests must be submitted on the Psychological/Neuropsychological testing request form
Developmental testing: Developmental Pediatric Testing requires authorization: CPT 96112, 96113 (CPT 96110 is non-covered)
ECT: Outpatient ECT requires authorization: CPT 90870
Partial Hospitalization (Revenue 912, 913, 944, 945; HCPCS H0035) requires utilization review for admission and concurrent/continued stay only for members who meet OMH Best Practice Manual clinical criteria; out-of-network partial hospitalization is subject to concurrent review throughout the admission

Diagnostic Testing, DME, Imaging & Therapy

DME codes not requiring prior authorizationHCPCS

A9270	Noncovered - miscellaneous supplies
A9276	Noncovered
A9277	Noncovered
A9278	Noncovered
A9279	Noncovered
E0100	Cane, other than single point
E0105	Crutches, underarm
E0110	Crutches, forearm
E0111	Crutches, platform
E0130	Walker, folding

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Orthotics not coveredHCPCSNot Covered

L0626	Noncovered
L0640	Noncovered
L0641	Noncovered
L0642	Noncovered
L0648	Noncovered
L0650	Noncovered
L1906	Noncovered
L1907	Noncovered
L1908	Noncovered
L1910	Noncovered

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Prior Authorization

Therapy prior authorization via NIA

Prior authorization required for therapy services after initial evaluation. Initial evaluation visits for physical therapy, occupational therapy and speech therapy do not require prior authorization. All subsequent therapy services require prior authorization to be obtained via NIA. This requirement is effective 10/01/2019. When submitting authorizations, route therapy prior authorization requests through NIA per delegated management instructions.

Initial evaluation visits for PT/OT/ST do not require prior authorization.
All services following the initial evaluation require prior authorization via NIA.
Effective date: 10/01/2019.
Route all therapy prior authorization requests to NIA (per delegated arrangement).

Prior Authorization

Pharmacy — Enteral Therapy & Specialty Drug Authorization Routing

Pharmacy — Enteral Therapy and Specialty Drug PA routing

Authorization routing for enteral therapy and oncology/supportive specialty medications:

Enteral therapy HCPCS: Enteral Therapy HCPCS codes B4034-B4162 require authorization
Enteral therapy order requirements: Non-prescription enteral formulas for home use require a written order stating medical necessity and disease-specific treatment rationale (examples include inherited metabolic diseases, Crohn's disease, GERD with failure to thrive, chronic intestinal pseudo-obstruction, multiple severe food allergies)
New Century Health routing for oncology/supportive agents: Oncology medications and supportive agents require prior authorization from New Century Health (NCH) before being dispensed or administered for members 18 and over; PA can be requested at my.newcenturyhealth.com or by calling 1-888-999-7713, option 1; list of drugs requiring NCH review available on Fidelis pharmacy services web page

Code Lists by Category

Inpatient transplant and related CPT codes (authorization required)CPTCovered

32850-32856	transplant-related
33930-33945	transplant-related
38204-38215	bone marrow harvest/transplant
38230-38242	transplant-related
44133-44136	transplant-related
47133-47147	transplant-related
48160	transplant-related
48550-48556	transplant-related
50300-50380	transplant-related
50547	transplant-related

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Outpatient surgery codes requiring authorizationCPT|HCPCSCovered

43770-43775	bariatric surgery
S2083	bariatric
15820-15823	blepharoplasty
11920-11971	breast reconstruction
19300, 19316-19342, 19355, 19370-19396	breast reconstruction related
10040	skin surgery (auth if POS24)
11300-11313	skin surgery (auth if POS24)
11400-11471	skin surgery (auth if POS24)
11721	skin surgery (auth if POS24)
11200-11201	skin surgery (auth any POS)

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Ambulatory continuous glucose monitoring and therapeutic codes (authorization required)CPTCovered

95249	ambulatory continuous glucose monitoring
58674	radiofrequency ablation of uterine fibroids
31660-31661	bronchial thermoplasty

Behavioral health testing and program codes (authorization required)CPT|HCPCS|RevenueCovered

96116, 96121, 96130-96133, 96136-96139, 96146	psychological/neuropsychological testing
96112, 96113	developmental pediatric testing (96110 non-covered)
90870	outpatient ECT
Revenue 912, 913, 944, 945; HCPCS H0035	partial hospitalization mental health
Revenue 905 or 912; CPT 90899; S9480; HCPCS H2013	intensive outpatient treatment
CPT 1001-1002; HCPCS H0017-H0019, H2036	residential treatment

DME codes not requiring prior authorizationHCPCS

E0130
E0135
E0168
E0182
E0184
E0235
E0274
E0305
E0310
E0424

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Therapy prior-authorization (delegated vendor)mixedCovered

PT/OT/ST all codes after initial evaluation

authorization via National Imaging Associates (NIA) for services after initial eval effective 10/1/2019

Radiology and Radiation Therapy prior authorizationCPTCovered

Radiology CPTs list at evicore	prior authorization through eviCore; full list on evicore site
Radiation therapy CPTs list at evicore	prior authorization through eviCore

Obstetric ultrasound rulesCPT|ICD-10Covered

OB ultrasound up to 4 for normal pregnancy	no auth required
Five or more OB ultrasounds for normal pregnancy	require authorization; dx codes Z32.01, Z33.1, Z34.00-Z34.03, Z34.80-Z34.83, Z34.9-Z34.93
OB ultrasound for high risk pregnancy (O09., O36.80X)	no auth required

Chiropractic services requiring authorizationCPT|RevenueCovered

98940-98943	chiropractic codes
rev code 0940	chiropractic revenue code

Cardiac and Pulmonary Rehab codes (authorization required outpatient)CPT|HCPCS|RevenueCovered

S9472, 93797, 93798, G0422, G0423, rev code 0943	cardiac rehab
G0237-G0239, G0424, S9473, rev code 0943	pulmonary rehab

Ophthalmic authorization notemixedCovered

NOTE	authorization is not required for ophthalmic indications

Actionable Provider Requirements

Prior Authorization

Obtain prior authorization for inpatient admissions and specified services

Obtain prior authorization for all inpatient admissions (except emergency stabilization) and for many outpatient services. Examples of services that require prior authorization or delegated vendor review include outpatient surgeries, diagnostic testing, DME and supplies, imaging (eviCore), therapy after initial evaluation (NIA), certain behavioral health programs, and specified pharmacy/oncology agents (NCH or direct Fidelis review). Facility admissions are reviewed for medical necessity.

All inpatient admissions require authorization (emergency stabilization excluded)
Outpatient surgeries, diagnostic tests, DME, imaging, therapy, behavioral health programs, and specified pharmacy agents require PA or delegated vendor review

Prior Authorization

Therapy prior authorization via NIA

Transportation

Non-emergency and emergency transport coverage and review rules:

Non-emergency ambulance coverage conditions: Non-emergency ambulance transportation by a licensed provider may be covered between facilities when transport is from a non-participating hospital to a participating hospital; when transport is to a hospital that provides a higher level of care not available at the original hospital; when transport is to a more cost-effective acute care facility; or when transport is from an acute facility to a sub-acute setting
Emergency transport review: Emergency transportation by air/water ambulance are reviewed for medical necessity

Patient Education & Diabetes Self-Management Training (DSMT)

Education and Diabetes (duplicate)

Patient education services and DSMT limits (duplicate block for Education and Diabetes routing requested):

Education and Diabetes (routing): Diabetes Self-Management Training (DSMT) — members allowed 10 hours/20 units in a continuous 12-month period; provided by certified providers and no longer require authorization; covered when billed with G0108 and G0109. Education and Training for patient self-management: CPT 9896010 hours / 20 units per 12 months

Key Definitions

Definitions (brief)

POSPlace of Service

OASASNew York State Office of Addiction Services and Supports

OMHNew York State Office of Mental Health

LOCADTRLevel of Care and Determination Tool for addiction services (clinical review tool)

Benefit applies toPhrase indicating the payer has mapped a code/entry to benefit applicability in the member's plan (specific coverage criteria in plan not shown here)

Revision History

2019-10-01effective

Effective date for site-of-care requirement and prior-authorization rules for certain orthopedic and spinal procedures and start date for therapy services prior-authorization (PT/OT/ST) after initial evaluation.

2019-12-23delegation

Delegation of prior authorization for certain orthopedic and spinal procedures to TurningPoint Healthcare Solutions effective for dates of service on or after 12/23/2019.

2021-08-01last_reviewLatest

Policy last reviewed on 2021-08-01 (FIDELIS CARE AUTHORIZATION REQUIREMENTS benefit/service detail).

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE

Policy CodePolicy N/A

Change TypeOperational update (no material coverage change)

Effective DateOct 1, 2019

Next Review DateN/A

Key ActionObtain prior authorization for inpatient admissions and specified services as detailed in the policy.

SourceLink

On This Page

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Inpatient Admissions

All inpatient admissions require authorization except emergency stabilization (see above):

Authorization requirement: All inpatient admissions require an authorization
Medical necessity review: All facility admissions are reviewed for medical necessity
Inpatient rehabilitation: Inpatient Rehabilitation Services (acute, sub-acute and skilled nursing rehabilitation) require prior authorization

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Transplants

Authorization required at time of transplant evaluation for solid organ and bone marrow/tissue transplants:

Includes but not limited to
- CPT codes: CPT 32850-32856
- CPT codes: CPT 33930-33945
- CPT codes: CPT 38204-38215
- CPT codes: CPT 38230-38242
- CPT codes: CPT 44133-44136
- CPT codes: CPT 47133-47147
- CPT codes: CPT 48160
- CPT codes: CPT 48550-48556
- CPT codes: CPT 50300-50380
- CPT codes: CPT 50547
- CPT codes: CPT 65710-65757

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Breast Cancer Surgery Centers

Site-of-care requirement for mastectomy/lumpectomy associated with breast cancer:

Site-of-care requirement: Members must receive mastectomy and lumpectomy procedures associated with a breast cancer diagnosis at high volume facilities
NY State policy reference: Refer to NY State policy link provided for details

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OASAS Licensed Inpatient Substance Use Disorder Treatment

Prior authorization and utilization review rules dependent on facility licensing, location, and network participation:

In-network NYS OASAS-licensed facilities: Inpatient SUD services provided by facilities in New York State that are OASAS licensed and participating in Fidelis Care's network are not subject to prior authorization review and are not subject to concurrent utilization review during the first 28 days if the facility notifies Fidelis Care of the inpatient admission and the initial treatment plan within 2 business days28 days
Notification via OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool to 646-829-1421 or LOCADTR@fideliscare.org; facility must perform daily clinical review and periodically consult with Fidelis starting on/just prior to day 14
Out-of-state/non-licensed/out-of-network facilities: Facilities outside NYS, not OASAS-licensed, or out-of-network must request prior authorization and are subject to concurrent review throughout the admission
Operational and discharge requirements: Prior to discharge, facility must provide the member and Fidelis Care with a written discharge plan and indicate whether services in the discharge plan are secured or reasonably available; services may be reviewed retrospectively

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Ophthalmic indication exception: Certain ophthalmic procedures performed for medically necessary ocular diagnoses (for example vision-threatening conditions) may be considered under medical necessity even if similar codes are listed as cosmetic in other contexts. Providers should document the ophthalmic indication clearly in the clinical record and on the authorization request to support coverage of eyelid/ocular procedures when medically necessary.

Eyelid and ocular surgery: CPT 65760-65771, 65772-65775, 66987-66988, 67900-67911 require prior authorization.

Abdominoplasty, lipectomy, panniculectomy: CPT 15830-15839, 15847, 15876-15879 require prior authorization.

Reduction mammoplasty: CPT 19300, 19318 require prior authorization.

Facial cosmetic, septoplasty, rhinoplasty and related facial procedures: CPT 21120-21296, 30400-30450, 30460, 30462, 30465-30520, 30620-30802, 30999, 31298, and HCPCS C9749, Q2028 require prior authorization.

Vascular procedures (vein stripping, ligation, ablation, sclerotherapy): CPT 36465-36466, 36468-36479, 36482-36483, 37718-37785, and 37241-37244 require prior authorization.

Gender reassignment surgery: CPT 55970, 55980 require prior authorization.

Sinuplasty: CPT 31295, 31296, 31297 require prior authorization.

Spinal surgery: CPT 20932-20934, 22867-22870, 62380 require prior authorization.

Esophageal sphincter augmentation: CPT 43284 requires prior authorization.

Delegation to TurningPoint for certain orthopedics/spinal procedures: Certain outpatient orthopedic and spinal surgical procedures required prior authorization for dates of service beginning 10/1/2019. Effective 12/23/2019, prior authorization for delegated orthopedic/spinal codes has been delegated to TurningPoint Healthcare Solutions, LLC. If a CPT code is delegated to TurningPoint, associated devices (HCPCS codes) will also be reviewed by TurningPoint for medical necessity. Providers should refer to Section II.G for delegation details and the TurningPoint code list.

Billing Rule

ASC bill type 0831 authorization

ASC bill type 0831 authorization: Freestanding ambulatory surgery centers billing with bill type 0831 must obtain authorization for the listed CPTs. Note that CPT 20610 is non-covered with specified knee diagnosis codes.

Affected CPT codes: 10060, 11100, 11900, 17000, 20600, 20605, 20610
CPT 20610 is non-covered when billed with diagnosis codes: M17.0, M17.10-M17.12, M17.2, M17.20-M17.32, M17.4, M17.5, M17.9

Intensive Outpatient Treatment (Revenue 905 or 912; CPT 90899; S9480; HCPCS H2013) requires utilization review for admission and concurrent/continued stay only for members meeting OMH triggers; out-of-network services subject to concurrent review

Routing for members under 21: Requests for members under 21 can be sent to chmmc@fideliscare.org, fax (347) 690-7362, or by calling 1-888-FIDELIS and following prompts for Children's Medicaid

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

Residential treatment codes: Residential Treatment CPT codes: 1001 and 1002; HCPCS H0017-H0019, H2036

Prior Authorization

Submit OASAS notification for Inpatient SUD

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 LOCADTR Medical Necessity Tool to Fidelis Care. Use fax 646-829-1421 or email LOCADTR@fideliscare.org. This notification preserves the no-prior-authorization and no-concurrent-review protection for the first 28 days; follow LOCADTR submission and consultation requirements per the policy.

Notification fax/email: 646-829-1421 or LOCADTR@fideliscare.org
Submit OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool
Facility must notify within 2 business days to avoid concurrent review for first 28 days

Documentation Required

OMH Two-Day Notification for inpatient mental health (under 18)

For OMH-licensed inpatient mental health admissions of members under 18, the facility must notify Fidelis Care of the admission and the initial treatment plan within two business days using the OMH Two‑Day Notification and Initial Treatment Plan form. Submit by fax to 718-896-1784 or by email to Mental_Health_Admission@fideliscare.org. If these requirements (notification, daily clinical review, periodic consultation) are met, Fidelis Care will not conduct concurrent utilization review during the first 14 days.

Fax: 718-896-1784
Email: Mental_Health_Admission@fideliscare.org
Two-day notification and initial treatment plan required to avoid concurrent review for first 14 days

Documentation Required

ASD attestation

Authorization requests for Applied Behavior Analysis (ABA) and DME speech generation equipment must include an attestation of an Autism Spectrum Disorder (ASD) diagnosis. The attestation must be provided at the time of request and completed by a licensed physician or licensed psychologist.

Attach attestation of ASD diagnosis by a licensed physician or psychologist at time of request
Required for ABA and for DME speech generation equipment

Radiology and radiation therapy authorization via eviCore

Use eviCore Health for authorization of advanced imaging and radiation therapy. Many radiology and radiation oncology CPT codes require authorization and clinical review by eviCore. Providers must use the eviCore portal/site for full code lists and submission instructions.

Submit requests for advanced imaging (MRI, MRA, CTA, PET, nuclear medicine) and radiation therapy via eviCore.
Refer to the eviCore website for the complete list of CPT codes managed and clinical submission requirements.

Billing Rule

Blood glucose monitors billed via pharmacy benefit

Blood glucose monitors and certain diabetes supplies are billed through the pharmacy benefit — do not bill as DME.

Affected codes: A4253, A9275, E0607, E2100, E2101.
These items should be billed through the pharmacy benefit and not as durable medical equipment (DME).

Items reviewed directly by Fidelis Care: The following requests should not be sent to NCH and will be directly reviewed by Fidelis Care: CAR T-cell therapy; Cablivi; Immune Globulins; Sickle Cell Disease therapy; Pain Medications; Controlled Substances; Retrospective reviews; Radiopharmaceuticals; Anti-infectives; Iron preparations

How to request PA for listed J/HCPCS codes: Selected C9054-C9399, G0516-G0517, J0129-J3245 etc. coded mappings provided in document; providers must submit PA to Pharmacy Team via e-fax 1-877-533-2405 for listed codes

Self-administered medications are covered under the pharmacy benefit (defined as medications typically administered by patient/caregiver without medical supervision)

Prior Authorization

Oncology medication PA via New Century Health

Oncology and supportive specialty medications for members 18 and over require prior authorization via New Century Health (NCH) before dispensing or administration in pharmacy, physician office, outpatient hospital, or ambulatory settings. Submit PA requests through NCH's portal or phone. Certain specified agents (e.g., CAR T-cell therapy, Cablivi, immune globulins, sickle cell therapies, pain medications, controlled substances, radiopharmaceuticals, etc.) are reviewed directly by Fidelis Care and should NOT be sent to NCH.

Request PA via my.newcenturyhealth.com or call 1-888-999-7713, option 1
Do not send the listed directly-reviewed agents (CAR T-cell therapy, Cablivi, immune globulins, Sickle Cell therapies, pain medications, controlled substances, radiopharmaceuticals, etc.) to NCH

Prior Authorization

Enteral therapy authorization

Enteral therapy items (HCPCS B4034–B4162) require prior authorization. Requests must include a written order from a physician or licensed provider stating medical necessity and a disease‑specific treatment rationale (examples include inherited metabolic disorders, Crohn's disease with failure to thrive, chronic intestinal pseudo‑obstruction, multiple severe food allergies).

HCPCS range B4034–B4162 require authorization
Must include written order stating medical necessity and disease-specific rationale

Mapped J/HCPCS codes and associated benefit entries (as listed)HCPCS|mixed

Q5123	associated entry (from top line)
J7642	rituximab-arrx (Riabni)*
J7643	glycopyrrolate inh; inotuzumab ozo (Besponsa); S0012; butorphanol nasal
J7659	isoproterenol inh; melphalan hydrochloride; esketamine nasal spray
J7677	revefenacin inh; melphalan (Evomela); bupivacaine inj
J7681	terbutaline inh; nelarabine (Arranon); cefoperazone inj
J7683	triamcinolone inh; tagraxofusp (Elzonris); ofloxacin inj
J7684	triamcinolone inh; pembrolizumab (Keytruda); ticarcillin inj
J7685	tobramycin inh; mitomycin; cefotetan inj
J7686	treprostinil (Tyvaso); olaratumab (Lartruvo); nivolumab (Opdivo); pentamidine inj

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The Essential Plan / numeric mapping notemixed

NOTE	Essential Plan entries and numeric '12' mapping appear in document contextually

Additional J/HCPCS benefit mappings (documented list)HCPCS|mixed

J7642..J7686 etc.

Large matrix of J- and HCPCS-code to benefit/product mappings as listed in source

Billing Rule

Use listed J/HCPCS mappings

Bill using the payer's mapped J/HCPCS code mappings as listed in the policy. When a PA is required for one of the listed J/HCPCS codes, submit the prior authorization to the Fidelis Pharmacy Team via e-fax 1-877-533-2405 per the document's instructions.

Use the listed payer J/HCPCS mappings when billing
Submit PA for listed codes to Pharmacy Team via e-fax: 1-877-533-2405

Therapy prior authorization requirement via NIA (effective 10/1/2019): initial PT/OT/ST evaluations do not require prior authorization, but all subsequent services performed by the therapy provider require PA through National Imaging Associates. Billing teams should route authorizations to NIA per vendor instructions.

Initial evaluations do not require PA
All services after the initial evaluation require PA via NIA
Effective date: 10/1/2019

Denial Risk

Chiropractic and low back pain exclusions

Certain interventions for low back pain are not covered (prolotherapy; therapeutic facet joint steroid injections in the lumbar/sacral regions; therapeutic injections of steroids into intervertebral discs; continuous or intermittent traction). Billing these non-covered interventions for low back pain may result in denials.

Non-covered for low back pain: prolotherapy
Non-covered: therapeutic lumbar/sacral facet joint steroid injections
Non-covered: therapeutic intradiscal steroid injections
Non-covered: continuous or intermittent traction

Documentation Required

No prior authorization required for ophthalmic indications

Authorization is not required for ophthalmic indications per the policy. Cite this exception when applicable to avoid unnecessary prior authorization submissions.

Billing Rule

Bill using listed J/HCPCS mappings

Bill using the payer's specified J/HCPCS mappings provided in the policy. When the listed J/HCPCS codes require prior authorization, submit PA requests to the Pharmacy Team via e-fax 1-877-533-2405 as instructed.

Use payer J/HCPCS mappings from the document
Submit PA to Pharmacy Team via e-fax: 1-877-533-2405

Billing Rule

Blood glucose monitors billed via pharmacy benefit

Codes for blood glucose monitors and testing supplies (A4253, A9275, E0607, E2100, E2101) are covered through the pharmacy benefit and should not be billed as DME. Billing teams should route claims accordingly to the prescription drug benefit.

A4253
A9275
E0607
E2100
E2101
Do not bill as DME; bill via pharmacy benefit