Provider-facing authorization and utilization management rules for Fidelis Care Medicaid/CHP/HealthierLife covering inpatient admissions, behavioral health, outpatient surgery, DME, imaging, therapy, pharmacy-administered drugs, home health, HCBS and other services; includes code lists and program-specific authorization exceptions and vendor delegations. This is part 1 of 2.
Key ActionObtain authorization for all inpatient admissions; emergency stabilization services do not require authorization but post-stabilization and subsequent inpatient admission do.
No material clinical or coverage changes were identified in this brief.
numerousCPT/HCPCS/J-code groups referenced
3Vendor delegations named (eviCore, NIA, TurningPoint)
~50HCPCS codes mentioned in excerpt
3Agents available via medical benefit without PA (named)
13
J-codes non-covered with CPT 20610/20611
Coverage Summary & Scope
Overview: This document is a provider-facing authorization and utilization management policy for Fidelis Care covering Medicaid, CHP and HealthierLife lines of business. It outlines requirements for prior authorization across settings including all inpatient admissions, inpatient rehabilitation, transplant evaluations, outpatient procedures, behavioral health, DME, imaging/radiology, therapy, pharmacy-administered (J/C) drugs and telehealth. Key thresholds include: Inpatient SUD concurrent review exemption — first 28 days if facility notifies Fidelis Care within 2 business days and submits required OASAS forms; OMH-licensed inpatient MH concurrent review exemption for in-network NY facilities under age 18 — first 14 days if facility notifies Fidelis Care within 2 business days and completes OMH two-day notification and initial treatment plan; and PT/OT/ST visit limits for Medicaid/MLTC — OT & ST: 20 visits/year; PT: 40 visits/year. Telehealth G2010/G2012 require authorization. This is part 1 of 2.
General Authorization Requirements
General Authorization Requirements
Authorization requirements and exceptions described across settings and services:
General inpatient and transplant rules: All inpatient admissions require an authorization. Emergency room services or emergent stabilization do not require authorization; post-stabilization services and inpatient admissions after ER services do require authorization. All acute inpatient facility services are unlimited when medically necessary. Inpatient rehabilitation services (acute, sub-acute and skilled nursing rehabilitation) require prior authorization.
Transplant authorization: All solid organ and bone marrow tissue transplants require authorization at the time of the transplant evaluation.
Example transplant CPT ranges listed as examples: 32850-32856; 33930-33945; 38204-38215; 38230-38242; 44133-44136; 47133-47147; 48160; 48550-48556; 50300-50380; 50547; 65710-65757.
Inpatient SUD (OASAS) exception: In-state OASAS-licensed, participating inpatient SUD facilities are not subject to authorization review and are not subject to concurrent utilization review for the first 28 days provided the facility notifies Fidelis Care of the admission and initial treatment plan within two business days (fax/email of OASAS Appendix A Notification Form and LOCADTR), performs daily clinical review and periodically consults with Fidelis Care. Out-of-state, unlicensed, or out-of-network facilities must request authorization and are subject to concurrent review throughout admission.first 28 days if facility notifies within 2 business days
OMH inpatient mental health rules: OMH-licensed inpatient mental health services for members age 18 and older require authorization and are subject to concurrent review throughout admission. OMH-licensed hospitals in New York providing inpatient mental health treatment for members under 18 (in-network/participating) are not subject to authorization and not subject to concurrent utilization review for the first 14 days if the facility notifies Fidelis Care within two business days, completes the OMH Two-Day Notification and Initial Treatment Plan form, performs daily clinical review and participates in periodic consultation.first 14 days if facility notifies within 2 business days
Outpatient Surgery Authorization Criteria
Outpatient Surgery Authorization
Specific outpatient surgical procedures that require authorization:
Outpatient surgery code list: The following outpatient surgery codes require authorization: Blepharoplasty 15820-15823; Breast reconstruction 11920-11971, 19300, 19316-19342, 19355, 19370-19396; Bariatric surgery 43770-43775, S2083; plus the skin, ear, abdominoplasty, eyelid/ocular, reduction mammoplasty, vascular, facial cosmetic, sinuplasty, esophageal sphincter augmentation and spinal surgery codes listed in policy.
Skin surgery and POS distinctions: Certain skin surgery/dermatology codes continue to require authorization for any place of service (11200-11201, 11719, 15769-15829, 17340-17999). Authorization requirement removed for many skin surgery treatments when performed in office or outpatient facility (POS 11 and 22); the following codes require authorization if completed as ambulatory surgery (POS 24): 10040, 11300-11313, 11400-11471, 11721. Services performed in freestanding ambulatory surgery centers with bill type 0831 require authorization for: 10060, 11100, 11900, 17000, 20600, 20605, 20610. Note: CPT 20610 is non-covered when billed with specified diagnosis combinations per document.
Other outpatient surgery specifics and delegation:
Behavioral Health Authorization Criteria
Behavioral Health Outpatient Authorization
Behavioral health outpatient services authorization rules and code-specific requirements:
Psychological/neuropsych testing: Authorization is required for Psychological/Neuropsychological testing codes: 96116, 96121, 96130-96133, 96136-96139, 96146. All requests should be submitted on the Psychological/Neuropsychological testing request form.
Developmental pediatric testing: Developmental Pediatric Testing codes 96112 and 96113 require authorization. Note: 96110 is non-covered.
Outpatient ECT and partial hospitalization: Outpatient ECT requires authorization (90870). Partial Hospitalization (Mental Health and/or Substance Abuse) and associated rate codes (4349-4363, revenue 912/913) and HCPCS H0035 and S9484 require authorization.
Authorization rules for diagnostic testing, DME, enteral therapy and related services:
Sleep studies and wireless capsule endoscopy: Sleep studies, including home sleep studies, require prior authorization. Wireless capsule endoscopy (91110, 91111) requires authorization except when performed in POS 11 or 24.
Genetic testing exceptions: Breast cancer testing (BRCA) and other genetic testing require authorization except CPT 81220, 81329 and 81336 which do not require authorization. CPT 81220 has a lifetime limit of 1; CPT 81329 and 81336 have a combined lifetime limit of 1.lifetime limits as specified
Gastroenterology POS rules: Selected gastroenterology procedures (43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270) require authorization if performed in POS 19 or 22 when an office-based or ambulatory surgery center is available. Authorization is not required when performed in POS 11 or 24.
Home Health, Hospice & Long-Term Services Criteria
Home Health, Hospice and Long Term Services
Authorization and coverage rules for home health, hospice and LTHHCP transition items:
Home health and personal care services: Home care approvals are based on medical need for skilled services. Personal Care Services for Medicaid and MLTC require authorization and use specified codes. Consumer Directed Personal Assistance Services (CDPAS) require authorization for Medicaid and Medicare.
Personal Emergency Response System (PERS) is a Medicaid and MLTC benefit and requires authorization.
Hospice submission: Hospice requests for Medicaid members should be submitted to Fidelis Care (effective 10/1/2013). CHP hospice requests should continue to be submitted to Fidelis Care. Members already enrolled in hospice prior to that date remain covered by Medicaid FFS until no longer enrolled.
Authorization requirements, vendor delegations, and age/diagnosis exceptions for imaging and therapy:
Radiology / eviCore delegation: Radiology services require authorization through eviCore healthcare; a full CPT list is available on the eviCore Fidelis Care page. Radiation therapy services also require authorization through eviCore.
OB ultrasound limits: The first 4 OB ultrasounds can be performed without authorization. Five or more ultrasounds for a normal pregnancy (specified diagnosis codes) do not require authorization; high-risk pregnancy ultrasounds (specified diagnosis codes) do not require authorization. Other requests require authorization per age/diagnosis rules.first 4 OB ultrasounds no auth
DXA frequency rules: DXA scans (77080, 77081): Women >65: one every two years with dx Z13.820; Men >70: one every two years with dx Z13.820; Women 51-64 and Men 51-69: one every two years when accompanied by qualifying diagnosis codes per policy. Requests for other age groups or diagnoses require authorization.
Authorization rules and coverage exceptions for podiatry, phototherapy, hyperbaric oxygen, and certain pain management services:
Podiatry diabetes exception: Authorization is not required for podiatric services rendered to members with a confirmed diagnosis of Diabetes Mellitus; the diabetes diagnosis must be included on the claim. Podiatric services for members without diabetes require authorization. For DME and orthotic codes requiring authorization, podiatrists require authorization even when supplied in office.
Authorization for telehealth and counseling rules:
Telehealth G2010/G2012: Authorization is required for telehealth services billed with G2010 and G2012 prior to billing.
Counseling G0108/G0109: Counseling services billed with G0108 and G0109 are covered without authorization, limited to 10 hours (20 units) in a continuous 6-month period and must be provided by certified providers.10 hours/20 units per continuous 6-month period
Pharmacy-Administered & Specialty Drug Authorization
Pharmacy-Administered/Medical-Specialty Drug Authorization
Many J-codes/C-codes require prior authorization via Pharmacy team; submit requests by e-fax and note exceptions:
Pharmacy/administered drug PA submission: Submit prior authorization requests to the Pharmacy Team electronically via e-fax to 1-877-533-2405 for the listed specialty HCPCS/C/J-codes and drug groups. The document contains an extensive list of specific codes and groupings requiring authorization.
B4O8S exception and oncology note: Exception: B4O8S (B4085/B4O8S reference in document) is noted as not requiring authorization. Authorization is not required for some items when billed for oncology indications per the document note (ensure oncology indication documented).
B4O8S contact and delegation details: Pharmacy prior authorization contact method: e-fax 1-877-533-2405 as the channel for PA submission for listed drugs and HCPCS groups.
Codes Requiring Authorization or Special Handling
Inpatient/transplant example codesCPTCovered
32850-32856
thoracic procedures (listed as examples of transplants)
33930-33945
cardiac procedures (listed)
38204-38215
bone marrow transplant codes
38230-38242
hematopoietic progenitor cell transplant codes
44133-44136
intestinal procedures (listed)
47133-47147
liver procedures (listed)
48160
pancreas procedure (listed)
48550-48556
pancreas related
50300-50380
kidney procedures
50547
renal transplant related
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Outpatient surgery codes requiring authorizationCPTCovered
15820-15823
Blepharoplasty
11920-11971
Breast reconstruction—includes range
19300
Breast surgery/reduction/reconstruction
19316-19342
Breast reconstruction/revision ranges
19355
Breast reconstruction
19370-19396
Breast surgery series
43770-43775
Bariatric surgery codes
S2083
Bariatric supply/ancillary code
11020-11021
Skin debridement codes requiring auth (document lists 11200-11201 but policy shows these ranges)
11719
Nail procedure
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Behavioral health codes requiring authorizationCPT|HCPCS|RevenueCovered
96116
Neuropsych testing
96121
Neuropsych testing
96130-96133
Psych testing administration/scoring and report
96136-96139
Psych testing interpretation and report
96146
Psych testing adapter
96112-96113
Developmental testing (auth required)
90870
Outpatient ECT (authorization required)
H0035
Partial hospitalization/habilitation HCPCS listed
S9484
Partial hospitalization/SUD related
Revenue 4349-4363
Rate codes for partial hospitalization/behavioral programs
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DME / Supply codes requiring authorization for MLTCHCPCSCovered
A4335
DME supply (requires authorization for MLTC)
A4554
DME supply (MLTC auth)
T4521-T4524
DME supply codes (MLTC auth)
T4529
DME supply (MLTC auth)
T4530
DME supply (MLTC auth)
T4533
DME supply (MLTC auth)
T4535
DME supply (MLTC auth)
T4537
DME supply (MLTC auth)
T4539
DME supply (MLTC auth)
T4540
DME supply (MLTC auth)
1–10 of 11
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Enteral therapy HCPCSHCPCSCovered
B4034-B4162
Enteral formulas and disposable items requiring authorization
Pharmacy/Drug J-codes and C-codes requiring authorization (selection)HCPCS|CPTCovered
C9053
crizanlizumab-tmca group (listed)
C9054
lefamulin group (Xenleta) and associated J0885 etc.
C9047
IV drug/biologic group
C9055
brexanolone and related J0887 etc.
C9399
unclassified drugs/biologics (listed)
G0516-G0518
implant insertion/removal/reinsertion and associated J-codes
Counseling codes (no authorization required)HCPCSCovered
G0108
Counseling service (no authorization required) up to limits
G0109
Counseling service (no authorization required) up to limits
DXA and OB ultrasound codes with age/diagnosis exceptionsCPT|ICD-10
77080
DXA scan (frequency and DX exceptions described)
77081
DXA scan (frequency and DX exceptions described)
91110
Wireless capsule endoscopy (auth required except POS 11 or 24)
91111
Wireless capsule endoscopy (auth required except POS 11 or 24)
Podiatry exceptionCPTCovered
various podiatry codes
Authorization not required when member has confirmed Diabetes Mellitus (diabetes dx must be on claim)
Codes listed in document requiring authorization (Part 2 excerpt)HCPCS
J7190
listed
J7191
listed
J7193
listed
J7194
listed
J7195
listed
J7196
listed
J7199
listed
J7201
listed
J7202
listed
J7203
listed
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1/7
Medical benefit without PAHCPCSCovered
J9035
Bevacizumab (Avastin) - available through medical benefit without prior authorization
J9355
Trastuzumab (Herceptin) - available through medical benefit without prior authorization
J9306
Perjeta - available through medical benefit without prior authorization
Exception to authorization requirementHCPCS
B4O8S
Exception: authorization not required per document note
Non-covered when billed with CPT 20610/20611 or diagnosis MI7.0HCPCS|CPT|ICD-10Not Covered
J7318
listed — non-covered in combination with CPT 20610/20611 or diagnosis MI7.0
J7320
listed — non-covered in combination with CPT 20610/20611 or diagnosis MI7.0
J7321
listed — non-covered in combination with CPT 20610/20611 or diagnosis MI7.0
J7322
listed — non-covered in combination with CPT 20610/20611 or diagnosis MI7.0
J7323
listed — non-covered in combination with CPT 20610/20611 or diagnosis MI7.0
J7324
listed — non-covered in combination with CPT 20610/20611 or diagnosis MI7.0
J7325
listed — non-covered in combination with CPT 20610/20611 or diagnosis MI7.0
J7326
listed — non-covered in combination with CPT 20610/20611 or diagnosis MI7.0
J7327
listed — non-covered in combination with CPT 20610/20611 or diagnosis MI7.0
J7328
listed — non-covered in combination with CPT 20610/20611 or diagnosis MI7.0
1–10 of 16
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What Providers Must Do / Documentation & Submission
Prior Authorization
Inpatient admissions
Obtain prior authorization for all inpatient admissions. Emergency room services and emergency stabilization do not require authorization; however, any post-stabilization services and inpatient admissions following ER care do require authorization. All facility admissions are reviewed for medical necessity.
Authorization required for all inpatient admissions (acute, sub-acute, skilled nursing, inpatient rehabilitation)
Emergency stabilization exception: no prior auth required for emergency services needed to stabilize; prior auth required for admission after stabilization
Prior Authorization
Transplants
Obtain prior authorization at the time of transplant evaluation for all solid organ and bone marrow transplants.
Background & Definitions
Background: This policy excerpt applies to Fidelis Care populations (Medicaid, CHP and HealthierLife) and includes COVID-19 guidance references for pandemic-related authorization and coding updates. It describes payer-specific populations and special program rules (for example, CHP benefit differences for supplies) and notes delegated authorization vendors for certain services (eviCore for radiology/radiation therapy, National Imaging Associates for outpatient therapy, and TurningPoint for certain orthopedic/spinal procedures).
Behavioral health carve-ins and exceptions: In-state, participating OASAS-licensed inpatient SUD facilities are exempt from prior authorization and concurrent utilization review for the first 28 days when notification and LOCADTR submission occur within two business days; out-of-state, unlicensed or out-of-network SUD facilities remain subject to authorization and concurrent review. OMH-licensed inpatient mental health care for members <18 in-network in NY are exempt from authorization and concurrent review for the first 14 days if the facility notifies Fidelis Care within two business days and follows the OMH two-day notification/initial treatment plan process.
Delegated vendors and submission channels: The policy names delegations and external vendors (eviCore for radiology/radiation therapy authorizations; NIA for outpatient PT/OT/ST after initial evaluation; TurningPoint for orthopedic/spinal prior authorizations effective for specified DOS). Pharmacy/medical specialty drug prior authorizations for numerous J-/C-/G-codes must be submitted to the Pharmacy Team via e-fax (1-877-533-2405) with the document listing many specific HCPCS/J-code groups; an exception code (B4O8S/B4085 in the document) is explicitly noted as not requiring authorization.
Purpose of excerpt: The section provides code-level prior authorization requirements, program-specific exceptions and operational instructions (notification forms, LOCADTR and OMH forms, vendor referral links/contacts) to guide providers on when to obtain prior authorization, which services are carved in or exempt, and where to send requests or notifications.
Term
Definition
OASAS
New York Office of Addiction Services and Supports (licensing for SUD facilities referenced for authorization exceptions)
OMH
New York Office of Mental Health (licensing for inpatient mental health facilities referenced)
LOCADTR
Level of Care Determination and Treatment Referral tool (OASAS LOCADTR Medical Necessity Tool referenced for SUD reviews)
PA
Prior Authorization
e-fax
Electronic fax number provided for PA submission: 1-877-533-2405
Key ActionObtain authorization for all inpatient admissions; emergency stabilization services do not require authorization but post-stabilization and subsequent inpatient admission do.
Additional listed specialty codes requiring authorization include ear repair/piercing 69300 and 69090; abdominoplasty/lipectomy/panniculectomy 15830-15839,15847,15876-15879; eyelid & ocular surgery 65760-65771,65772-65775,66987-66988,67900-67911; reduction mammoplasty 19300,19318; vascular procedures 36465-36466; facial cosmetic/septoplasty/rhinoplasty ranges; sinuplasty 31295-31297; esophageal sphincter augmentation 43284; spinal surgery 20932-20934,22867-22870,62380. Certain outpatient orthopedic and spinal procedures require authorization for DOS beginning 10/1/2019; prior authorization was delegated to TurningPoint Healthcare Solutions, LLC (delegation effective 12/23/2019).
DOS on or after 10/1/2019; TurningPoint delegation effective 12/23/2019
Elective surgery level-of-care note: Elective surgical procedures completed within 24 hours will not be approved at inpatient level; same procedures billed as outpatient within Fidelis network do not require authorization if performed within network.within 24 hours
Intensive Outpatient Program (IOP):
Intensive Outpatient Treatment (H2013, CPT 90899, revenue 905/906/912, S9480): no prior authorization is needed for the first seven days of service for members under 21; additional days require authorization. Requests for members under 21 can be submitted via designated children's channels.
first 7 days no auth for members under 21
Autism / ABA / DME speech devices: Autism Spectrum Disorder: authorization is required for DME speech generation equipment. Authorization is required from Behavioral Health for Applied Behavioral Analysis (ABA); attestation of ASD diagnosis by a licensed physician or psychologist must be provided at time of request.
Mental health continuing treatment and PROS/CFTSS carve-in: Mental Health Continuing Treatment (H2012): first 7 service days do not require authorization; additional days require authorization. PROS (H2018,H2019), ACT (H0040), IPRT (H2012K) and other HCBS-like behavioral services have prior authorization/concurrent review requirements for certain age groups (notably ages 18-20) as detailed in the policy. Children and Family Treatment & Support Services (CFTSS): effective 4/1/2020 utilization management requirements were discontinued; prior authorization was never required and concurrent review is no longer required. Children's BH carve-in (effective 7/1/19) lists age-based auth requirements for many services; requests for services for members under 21 have specified submission channels.age-based exceptions (see policy)
DME and MLTC-specific auth: For Medicaid, supplies and disposable DME items are covered by Fidelis Care; supplies are not covered for CHP. For MLTC members only, specified supply codes require authorization (effective 4/1/16): A4335, A4554, T4521-T4524, T4529, T4530, T4533, T4535, T4537, T4539, T4540, T4543. DME items referenced to the Medicaid DME Program Manual require authorization per the manual; benefit limits in the manual apply.effective 4/1/16 for MLTC codes
Enteral therapy HCPCS B4034-B4162 (formulas and disposable items) require authorization. Eligibility criteria and BMI/weight-loss thresholds apply as described in the policy (e.g., BMI <18.5 or BMI <22 with unintentional weight loss >=5% within previous 6 months allow up to 1,000 cal/day in specified categories).BMI and weight-loss thresholds per policy
LTHHCP transition items:
For members transitioned from Medicaid FFS Long Term Home Health Care Program (LTHHCP) who were receiving services at transition, Medical Social Services (S9127) and Home Delivered Meals (S5170) are covered with authorization for Medicaid Managed Care enrollees.
one every two years for qualifying age/diagnosis groups
Outpatient therapy delegation and visit limits (NIA): Effective 10/1/2019, outpatient therapy (PT/OT/ST) services performed after the initial evaluation require authorization through National Imaging Associates (NIA). Initial evaluations do not require authorization, but all other billed procedure codes—even if on same date as initial evaluation—require authorization. Medicaid/MLTC visit limits: OT and ST limited to 20 visits per calendar year; PT limited to 40 visits per calendar year (effective 7/1/18). CHP has no visit limit; services received at home are excluded from the restriction.effective 10/1/2019 for NIA; PT/OT/ST visit limits as stated
Non-covered pain management services: Certain pain management and spine-related services are not covered for members with a diagnosis of Low Back Pain; listed CPT/HCPCS/C-codes include injections, prolotherapy, therapeutic injections into intervertebral discs, therapeutic facet joint steroid injections in lumbar/sacral regions (with or without CT guidance), continuous or intermittent traction, and specific codes listed in policy (e.g., 20526, 20550-20553, 21073, 27096, 62263-62264, 62273, 62280-62282, 62290, 62310 and designated C-codes for non-orthopedists).applies when diagnosis = Low Back Pain
Non-coverage when billed with specific CPT codes or diagnosis
Specific J-codes are non-covered when billed with certain CPT codes or diagnosis:
Non-covered combinations: The following J-codes are non-covered when billed with CPT code 20610 or 20611 or diagnosis MI7.0: J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332.
Medical benefit without prior authorization
Select agents available through the medical benefit without prior authorization:
Medical benefit without PA: J9035 (Bevacizumab / Avastin), J9355 (Trastuzumab / Herceptin), and J9306 (Perjeta) are available through the medical benefit without prior authorization. Note: Xolair is available through the medical benefit but requires prior authorization (clinical criteria on provider portal).
Authorization must be obtained at transplant evaluation (pre-procedure)
Documentation Required
OASAS Inpatient SUD notification & reporting
For OASAS-licensed inpatient Substance Use Disorder (SUD) treatment in New York State that are in-network and OASAS-authorized, notify Fidelis Care within two (2) business days of admission and submit required forms; these in-network in-state admissions are not subject to authorization and are exempt from concurrent review for the first 28 days when notification requirements are met.
Notify Fidelis Care within 2 business days of admission and initial treatment plan
Submit OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool
Fax or email: fax 646-829-1421 (or submit LOCADTR via Fidelis portal as applicable)
Inpatient SUD services are exempt from concurrent utilization review for first 28 days if timely notification provided; after day 28 services may be subject to utilization review
Out-of-state or out-of-network facilities and facilities not OASAS-authorized must request prior authorization and remain subject to concurrent review
Request prior authorization for outpatient orthopedic and spinal procedures via TurningPoint per the delegated authorization arrangement (delegation effective for dates noted by policy).
Authorization delegation to TurningPoint Healthcare Solutions, LLC effective for specified dates of service (see policy effective dates)
Providers must submit authorization requests to TurningPoint for the list of orthopedic/spinal procedure codes requiring auth
Prior Authorization
Radiology authorization via eviCore
Obtain prior authorization for specified radiology services via eviCore's authorization portal as directed by Fidelis Care.
Follow eviCore portal guidance for imaging prior authorization and submit requests through the eviCore portal (refer to Fidelis Care brief for portal URL and navigation)
Prior Authorization
Outpatient therapy authorizations (NIA)
Obtain prior authorization for outpatient therapy visits after the initial evaluation. The initial evaluation visit(s) are exempt from prior authorization but subsequent therapy visits require authorization and are subject to visit limits.
Initial evaluation does NOT require prior authorization
Authorization required for subsequent therapy treatment visits
Obtain prior authorization for pharmacy-administered drugs as required. Submit prior authorization documentation via e-fax to 1-877-533-2405. Note exception code B4O8S where applicable per policy.
E-fax for pharmacy-administered drug prior auth: 1-877-533-2405
B4O8S exception — follow policy guidance when this exception applies
Documentation Required
Podiatry — include diabetes diagnosis on claim
Include a diabetes diagnosis on the claim when performing podiatry services related to diabetes to avoid prior authorization requirements associated with non-diabetes podiatry procedures.
Ensure diabetes dx code is present on claim to reflect diabetes-related podiatric care and avoid unnecessary authorization
Billing Rule
Counseling service limits & billing (G0108/G0109)
Adhere to counseling service limits and bill using the correct G-codes when applicable. Certified providers must deliver services that count toward the limit.
Limit: up to 10 hours (20 units) of counseling in a continuous 6-month period
Bill using G0108/G0109 where applicable
Services must be delivered by certified provider types as required
Prior Authorization
Telehealth authorization (G2010/G2012)
Obtain prior authorization for telehealth billing of G2010 and G2012 prior to billing.
Authorization must be secured before billing telehealth services coded G2010/G2012
Documentation Required
OB ultrasound & DXA coding and documentation
Document member age and the appropriate diagnosis on claims to qualify for exceptions and frequency allowances for OB ultrasound and DXA services. Use the specified codes and include supporting diagnosis/age to meet coverage rules.
Relevant DXA/OB codes: 77080, 77081, 91110, 91111
Include appropriate diagnostic code and member age on the claim to meet exception criteria and frequency rules
Prior Authorization
Children's HCBS initial authorization limits
Obtain prior authorization for Children's Home and Community-Based Services (HCBS) initial authorizations. Initial authorization may allow up to 96 units/24 hours within a 60-day evaluation period; concurrent review is required for ongoing services.
Initial authorization: up to 96 units (covering 24-hour needs) within a 60-day period for initial assessment/authorization
Concurrent review required for continuation of services beyond initial authorization period
Billing Rule
Non-coverage — disallowed billing combinations
Do not cover and deny claims when the following code combinations are billed together. Ensure claims with these combinations are reviewed for non-coverage.
Non-covered when billed together: J7318 - J7332 (sclerosing agents), 20610, 20611, and MI7.0 (as listed in policy). Claims with these code combinations should be denied.
Documentation Required
Oncology indication exception — documentation
For certain implants and drugs used for oncology indications, prior authorization is not required when the claim documents the oncology indication. Clearly document the oncologic indication on the request/claim to qualify for the exception.
Document the oncology indication on the request/claim to avoid prior authorization for specified implants/drugs
Prior Authorization
ADHC / ADHC initial authorization
For Adult Day Health Care (ADHC) / ADHC initial authorization: obtain prior authorization for initial ADHC services as required. Initial authorizations may permit coverage consistent with program rules; follow Fidelis Care submission requirements and concurrent review processes for ongoing services.
ADHC/ADHC initial authorization is required—submit documentation to obtain initial approval prior to providing services
Follow Fidelis Care guidelines for initial authorization scope and subsequent concurrent review requirements for continuation of services