CurrentFidelis CarePolicy N/A

COVID-19 UPDATE

Provider-facing update describing prior authorization, utilization review, and billing requirements for Medicaid, Child Health Plus (CHP), HealthierLife and related programs during COVID-19; lists services, settings, and CPT/HCPCS codes that require authorization or are exempted, plus delegated vendors and operational contact/fax information. This is Part 1 of 3.

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE

Policy CodePolicy N/A

Change TypeOperational guidance / PA rules

Effective Date

Next Review Date

Key ActionObtain authorization for services provided by nonparticipating providers and for all inpatient admissions, and submit delegated prior authorization requests to named vendors (Evolent, TurningPoint) where specified.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes identified in this brief (has_material_change = false).

multipleCPT/HCPCS codes listed

Evolent/TurningPointDelegated reviewers

OMH/OASASOMH/OASAS exceptions

1Document part

10DSMT hours per 6 months

8Smoking cessation visits/yr

Policy scope and summary

This Part 1 of 3 is a provider-facing summary of Fidelis Care COVID-19 operational guidance that modifies prior authorization, utilization review and billing requirements for Medicaid, Child Health Plus (CHP) and HealthierLife programs. It confirms that any Medicaid/CHP/HealthierLife service provided by a nonparticipating (out‑of‑network) provider/facility/physician requires prior authorization, and that all inpatient admissions require authorization (emergency room stabilization services are not subject to authorization but post‑stabilization inpatient admissions are).

The guidance aligns with New York State OMH and OASAS policies for behavioral health and substance use disorder care: OMH‑licensed inpatient mental health services in‑state are not subject to prior authorization with specified utilization‑review triggers and notification requirements, and in‑state, in‑network OASAS‑licensed inpatient SUD services are exempt from prior authorization and concurrent review for the first 28 days if facilities notify Fidelis and submit required LOCADTR/Appendix A forms.

The policy identifies delegated third‑party reviewers for specific specialties and programs: prior authorization reviews for specified outpatient orthopedic/spinal and musculoskeletal services, therapy, radiology and radiation therapy functions have been delegated to Evolent (NIA) effective per program dates, and ENT and cardiac surgical procedure prior authorization has been delegated to TurningPoint Healthcare Solutions, LLC (associated devices/HCPCS are reviewed by the same delegates).

The document lists numerous service categories, CPT/HCPCS and revenue codes that continue to require prior authorization (including transplants, many outpatient surgical groups, behavioral health testing, select DME/MLTC supplies, home health/personal care, therapeutic/interventional procedures and pharmacy/oncology medications) and provides operational contacts, fax/email instructions, and vendor submission routes (including Evolent web portal and Pharmacy e‑fax) to support authorization and utilization‑management workflows.

Authorization and utilization-review rules (grouped criteria)

Authorization required for out-of-network services

Any Medicaid, CHP and HealthierLife service provided by a nonparticipating provider/facility/physician requires prior authorization.

All out-of-network services require prior authorization before rendering.

Inpatient admissions and review

All inpatient admissions require prior authorization except emergency room services needed for stabilization. Post-stabilization services and inpatient admissions following ER care require authorization. All facility admissions are reviewed for medical necessity.

All acute inpatient facility services are covered and benefits are unlimited when medically necessary.

Inpatient Rehabilitation Services (acute, sub-acute and skilled nursing rehabilitation) require prior authorization. Medical rehabilitation may be completed at an acute or sub-acute level of care.

Fidelis Care does not require authorization of emergency department services or any emergent service required to provide stabilization of an emergent condition. Authorization is required for post-stabilization services and inpatient admissions after ER services are completed.

Code lists and categories requiring authorization

Transplant codes requiring authorizationCPT|HCPCSCovered

32850
32851
32852
32853
32854
32855
32856
33930
33931
33932

1–10 of 74

1/8

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

43770
43771
43772
43773
43774
43775
15820
15821
15822
15823

1–10 of 76

1/8

Behavioral health testing codes requiring authorizationCPT|HCPCSCovered

96116
96121
96130
96131
96132
96133
96136
96137
96138
96139

1–10 of 13

1/2

Partial hospitalization and intensive outpatient rate/revenue/HCPCS codesRevenue|HCPCS|CPTCovered

Rate codes 4349-4363	Partial hospitalization rate codes
Revenue code 912
Revenue code 913
H0035
S9484
Revenue 905	Intensive outpatient revenue code
Revenue 906	Intensive outpatient revenue code
CPT 90899
S9480
H2013

DXA and TBS codesCPT

77080	DXA (see age/diagnosis exceptions)
77081	DXA (see age/diagnosis exceptions)
77089	TBS
77090	TBS
77091	TBS
77092	TBS

Therapeutic and pain management codesCPT|HCPCSCovered

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

1–10 of 59

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DME MLTC-specific codes requiring authorizationHCPCSCovered

A4335
A4554
T4521
T4522
T4523
T4524
T4529
T4530
T4533
T4535

1–10 of 14

1/2

Home health / personal care codes and unitsHCPCS|RevenueCovered

T1001	Nursing Assessment - per visit
S5130U1	Level I - per 15 mins
T1019U1	Level II - per 15 mins
T1019U3	Level II Mutual Case - per 15 mins
T1019U2	Level II Shared Aide - per 15 mins
T1019U4	Level II Hard to Serve - per 15 mins
T1020	Live In Level II - per diem (1 unit/day)
T1020U2	Live In Level II Mutual Case - per diem (1 unit/day)
T1020U5	Live In Level II Two Client Hard to Serve - per diem (1 unit/day)
G0162	Nursing supervision - one per visit

1–10 of 16

1/2

Erectile dysfunction DME/services codesCPT|HCPCSNot Covered

37788
37790
54360
54400
54401
54405
54408
54410
54411
54416

1–10 of 13

1/2

Interventional Pain Management (examples listed)CPT|HCPCS

63650
63655
63661
63662
63663
63664
63685
63688
C1778
C1787

1–10 of 12

1/2

Services not covered for Low Back PainprocedureNot Covered

No codes listed

Ambulatory continuous glucose monitoringCPT

95249

Ambulatory continuous glucose monitoring

Radiofrequency Ablation of Uterine FibroidsCPT

58674

Radiofrequency ablation of uterine fibroids

Bronchial ThermoplastyCPT

31660
31661

Erectile Dysfunction DME / ProceduresCPT|HCPCS

37788
37790
54360
54400
54401
54405
54408
54410
54411
54416

1–10 of 13

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DSMT billing codesCPTCovered

G0108	Diabetes self-management training 30-minute individual session
G0109	Diabetes self-management training 30-minute group session

ASMT / Smoking Cessation codesCPT|HCPCSCovered

S9441	Asthma self-management training
S9445
S9446
98960
98961
98962
99406	Smoking cessation counseling, intermediate
99407	Smoking cessation counseling, intensive

Appendix I: Codes Requiring Prior Authorization (sample/highlighted)HCPCS|J-codes|C-codesCovered

C9047	multiple drug mappings (e.g., caplacizumab-yhdp (Cablivi) mapping entries)
C9145	multiple mappings (e.g., aprepitant aponvie inj / adalimumab (Humira) listed)
C9166	secukinumab, intravenous and related mappings
C9167	related mappings
J0178	aflibercept (Eylea) and related mappings
J0179	brolucizumab-dbll and related
J0200	alatrofloxacin and mappings
J0217	velmanase alfa-tycv and mappings
J0222	patisiran (Onpattro) mapping
J0240	placeholder (many J-codes listed throughout Appendix I)

1–10 of 13

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What providers must do (actions, notifications, vendor contacts)

Prior Authorization

Verify authorization for out-of-network services

Obtain authorization before providing any Medicaid, CHP, or HealthierLife service delivered by a nonparticipating (out-of-network) provider/facility/physician.

Prior Authorization

Authorize all inpatient admissions (except ED stabilization)

Obtain authorization for all inpatient admissions (ER stabilization services do not require authorization). For inpatient notifications related to ER admissions, use the new Inpatient ER fax: 833-663-1602.

Key terms and abbreviations

Definitions

POSPlace of Service

OMHNew York State Office of Mental Health

OASASNew York State Office of Addiction Services and Supports

HCBSHome and Community Based Services

CHPChild Health Plus

MLTCManaged Long Term Care

NYRxNew York State Medicaid Fee-for-Service Pharmacy Program (medication coverage transitioned effective 2023-04-01)

Quantitative limits and timing thresholds

Thresholds / Limits

Partial Hospitalization / Intensive Outpatient auth-free daysPartial Hospitalization: utilization review only when OMH clinical triggers are met; Intensive Outpatient: first 7 days do not require prior authorization; additional days require authorization

OB ultrasound count before authorizationFirst 4 OB ultrasounds can be performed without authorization; five or more ultrasounds for a normal pregnancy require authorization; high-risk pregnancy ultrasounds do not require authorization

DXA frequency exceptionsNo authorization required for: women >65 — one 77080/77081 every 2 years with Z13.820; men >70 — one 77080/77081 every 2 years with Z13.820; women 51-64 and men 51-69 — one 77080/77081 every 2 years with specified diagnosis codes; other ages/diagnoses require authorization

Children's short-term respite annual limitPlanned and Crisis Respite services may not exceed 14 days (1,344 15‑minute units) per calendar year without medical necessity; beyond this requires LPHA attestation and NYS DOH Children's HCBS Authorization form

DSMT limitMembers allowed 10 hours / 20 units in a continuous 6‑month period; services must be provided by certified providers; authorization not required

Delegated reviewers and operational contacts

Delegated vendors and summary of delegations

Operational contact points and fax/email numbers

Document changes and effective dates

policy_metadataLatest

Part 1 of 3 — Status: CURRENT; no effective or last_review dates available in source

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE

Policy CodePolicy N/A

Change TypeOperational guidance / PA rules

Effective Date

Next Review Date

SourceLink

On This Page

New fax number for Inpatient ER notifications: 833-663-1602 (formerly 347-868-6411).

Transplants

All solid organ and bone marrow/tissue transplants require authorization at the time of transplant evaluation.

Authorization required at transplant evaluation for all transplants (solid organ, bone marrow/tissue).

Examples of included CPT codes (not exhaustive): 32850-32856, 33930-33942, 33943-33945, 38204-38215, 38230-38242, 44133-44136, 47133-47147, 48160, 48550-48556, 50300-50380, 50547, 65710-65757.

Breast cancer surgery site requirement

Mastectomy and lumpectomy procedures associated with a breast cancer diagnosis must be performed at high-volume facilities per New York State policy.

Members must receive mastectomy and lumpectomy at facilities meeting NYS surgical volume requirements for breast cancer surgery. See NYS policy link for facility criteria.

OASAS Licensed Inpatient Substance Use Disorder Treatment (In-state, in-network)

In-state, in-network OASAS-licensed inpatient SUD services are not subject to prior authorization and are exempt from concurrent utilization review for the first 28 days if timely notification is provided.

Inpatient detoxification, inpatient rehabilitation, and inpatient residential treatment provided by OASAS-licensed facilities in New York State and participating in Fidelis Care's network do NOT require prior authorization.

The facility must notify Fidelis Care of the inpatient admission and the initial treatment plan within two (2) business days of admission by fax or email using the OASAS Appendix A Notification Form and the LOCADTR Medical Necessity Tool to fax 833-663-1608 or LOCADTR@fideliscare.org.

Facilities must perform daily clinical review of the patient (this does not require completing a LOCADTR concurrent review module every day).

Facilities must periodically consult with Fidelis Care starting on or just prior to Day 14 to ensure LOCADTR is being used appropriately.

Services may be subject to utilization review after Day 28 or upon discharge using LOCADTR. Prior to discharge, facilities must provide a written discharge plan to the member and Fidelis Care and indicate whether services in the discharge plan are secured or reasonably available.

All services may be subject to retrospective review to assess clinical necessity.

OASAS Licensed Inpatient SUD (Out-of-state or non-OASAS or out-of-network)

Facilities that are out-of-state, not OASAS-licensed, or out-of-network must obtain prior authorization and are subject to concurrent review throughout the admission.

Out-of-state facilities, facilities not licensed/certified/authorized by OASAS, and out-of-network facilities must request prior authorization for Inpatient SUD services.

Such admissions are subject to concurrent review during the entire admission.

Providers with questions may call 1-888-FIDELIS (1-888-343-3547), ext. 16072 for Behavioral Health.

Outpatient SUD services (in-network, in-state) effective 1/1/2020

Effective 01/01/2020, the following in-network, in-state outpatient SUD services do not require prior authorization. Out-of-state or out-of-network providers must still request authorization.

No prior authorization required for: outpatient office visits, therapy visits, or counseling visits for SUD; outpatient clinic visits for SUD treatment; intensive outpatient treatment programs; outpatient rehabilitation treatment; and Opioid Treatment Programs.

Fidelis Care will use quality and case management oversight to manage outlier member needs (see Behavioral Health Outliers Management Program).

Child Health Plus - Residential Rehabilitation Services for Youth (RRSY)

Child Health Plus covers Residential Rehabilitation Services for Youth (RRSY) when services are provided in a facility with a Part 817 operating certificate from OASAS.

RRSY is a covered benefit effective 04/01/2023 when provided in a Part 817-certified facility pursuant to Article 32 of the Mental Hygiene Law.

Covered services include all services described in OASAS Part 817: clinical services, recovery support, educational and vocational assessments and services, Medication for Addiction Treatment (MAT), and food/nutrition services.

Clinical services include individual, group, and family counseling, assessment and referral services for patients and significant others, medical and psychiatric consultation, and education/support/referral for communicable diseases (HIV/AIDS, hepatitis C, tuberculosis).

Elective surgical procedures and inpatient level of care rule

Many procedures completed within 24 hours will not be approved as inpatient. When performed outpatient within the Fidelis network, authorization is not required.

Elective same-day procedures are typically not approved at an inpatient level of care.

Typical examples include laparoscopic procedures and thyroid surgery completed within 24 hours of surgery.

Refer to the NYS List of Inpatient Only Procedures for additional guidance.

Orthopedic and spinal surgical procedures

Orthopedic and spinal surgical procedures require prior authorization. As of 01/01/2024, prior authorization for the Musculoskeletal Management Program is delegated to Evolent.

Prior authorization is required for orthopedic and spinal surgical procedures performed in inpatient and outpatient settings.

Effective 01/01/2024, the Musculoskeletal Management Program transitioned to Evolent (NIA); a list of codes requiring prior authorization is available from Evolent.

If a CPT code is delegated to Evolent, associated devices (HCPCS codes) will also be reviewed by Evolent for medical necessity.

OMH Licensed Inpatient Mental Health Treatment (in-state)

OMH-licensed inpatient mental health treatment in New York State is not subject to prior authorization; notification and selective utilization review triggers apply.

Inpatient mental health treatment provided by OMH licensed hospitals in NYS are not subject to prior authorization per OMH Best Practice Manual.

Facilities must notify the insurer within 2 business days of admission by calling 1-888-FIDELIS, ext. 16072 for Behavioral Health or fax 833-561-0094 (formerly 718-896-1784).

Utilization review will be conducted only for members meeting specific clinical criteria per NYS OMH Best Practice Manual, including AOT court orders, high utilization triggers (e.g., ≥3 psychiatric inpatient hospitalizations in prior 12 months or ≥4 psychiatric ED visits), readmission within 30 days, or length of stay exceeding 30 days.

For members under 18, in-network OMH licensed hospitals are not subject to prior authorization and are exempt from concurrent review for the first 14 days provided the facility notifies Fidelis Care within 2 business days (submit OMH Two-Day Notification and Initial Treatment Plan), performs daily clinical review, and participates in periodic consultation with Fidelis Care.

Delegation to TurningPoint and Evolent for prior authorization

Prior authorization for certain specialties has been delegated to TurningPoint and Evolent. When delegated, associated devices (HCPCS) are also reviewed by the delegate.

Delegated specialties include: ENT surgical procedures (TurningPoint); Cardiac surgical procedures (TurningPoint); Musculoskeletal/orthopedic and spinal procedures (Evolent).

If a CPT code is delegated to a vendor (TurningPoint or Evolent), associated devices (HCPCS codes) will be reviewed by that vendor for medical necessity.

Outpatient surgery services that require prior authorization

Selected outpatient surgery services require prior authorization — use payer links for full code lists and POS-specific rules.

Outpatient surgery services requiring prior authorization include various procedures across specialties; refer to Fidelis Care code lists and delegated vendor lists for details.

Point-of-service distinctions (hospital outpatient, ASC, physician office) may affect whether authorization is required; verify per-code POS rules.

Behavioral Health - Outpatient services authorization exceptions & requirements

Most outpatient behavioral health services do not require prior authorization except for select programs and testing.

No prior authorization required for most outpatient behavioral health visits.

Exceptions that do require authorization or special handling include: structured testing, multi-disciplinary evaluations, partial hospitalization programs (PHP), and intensive outpatient programs (IOP) which have their own authorization/notification requirements.

Applied Behavior Analysis (ABA) - NYS Managed Medicaid/CHP

Applied Behavior Analysis (ABA) for NYS Managed Medicaid and Child Health Plus requires eligibility verification, provider enrollment, referral, and prior authorization.

ABA is a covered service for eligible members when delivered by enrolled providers.

Providers must be enrolled and authorized to deliver ABA; referrals and prior authorization may be required per program rules.

Mental Health Continuing Day Treatment (H2012) and PROS/ACT/IPRT/HCBS/CORE

Mental health continuing day treatment and related programs require authorization per program rules; CORE services are defined.

Authorization rules apply for Mental Health Continuing Day Treatment (H2012), PROS, ACT, IPRT, HCBS, and CORE programs as specified by program guidance.

CORE services include a defined set of rehabilitative supports (refer to program materials for the full list).

Children and Family Treatment & Support Services (CFTSS) and Children's HCBS

CFTSS and Children's HCBS UM has been discontinued; covered services are listed and prior authorization is not required. HCBS notification rules and respite limits apply.

Children and Family Treatment & Support Services (CFTSS) and Children's HCBS are covered as listed; prior authorization is not required.

HCBS notification rules and limits for respite services apply per program guidance.

Core Limited Health Related Services (CLHRS) and OLHRS for 29-I Facilities

Core Limited Health Related Services (CLHRS) and OLHRS for 29-I facilities are covered with per diem payment; these services are not subject to utilization review.

CLHRS and OLHRS are covered services provided by certified 29-I facilities.

Services are paid via per diem and are not subject to utilization review.

Outpatient and DME Services requiring prior authorization (selected highlights)

Selected outpatient and DME services require prior authorization; delegates handle certain therapies and devices.

Diagnostic testing (selected), sleep studies, and many endoscopy procedures require authorization; POS rules apply for endoscopy.

DXA/TBS services have stated exceptions; refer to payer guidance.

Therapies and certain device-intensive services may be delegated to Evolent for authorization review.

Durable Medical Equipment (DME)

Refer to the DME manual for comprehensive DME coverage and prior authorization rules. NYRx transition and MLTC-specific code rules apply.

Durable Medical Equipment requires prior authorization per the Fidelis Care DME manual and associated policies.

Note transition of pharmacy benefits to NYRx (see pharmacy section) and that certain MLTC codes require authorization.

Home Health Care and Personal Care Services

Home health care and personal care services require prior authorization and follow specific billing/unit rules.

All home health care and personal care services require prior authorization.

This includes PERS, CDPAS, and related services; follow specified HCPCS codes and billing units per program manuals.

Hospice

Hospice requires submission of admission/discharge notifications and follows pre-existing FFS notes where applicable.

Hospice admissions and related submissions must follow Fidelis Care hospice submission rules.

For services prior to 2013, reference pre-2013 FFS notes as applicable.

Imaging studies requiring authorization

Certain imaging studies require authorization and some radiology reviews are delegated.

OB ultrasound limitations apply; DXA rules summarized in imaging guidance.

Radiology prior authorization and utilization management functions may be delegated to Evolent; verify per-code delegation lists.

Therapeutic services requiring authorization or non-coverage

Therapeutic services such as phototherapy, HBOT, and interventional pain management have authorization rules or are non-covered.

Phototherapy, Hyperbaric Oxygen Therapy (HBOT), and interventional pain management codes require prior authorization or are subject to coverage restrictions.

Services for low back pain have an explicit non-covered list; topical oxygen is not covered unless prior authorization criteria met. Radiation therapy review is delegated.

Adult Day Health Care (ADHC/AADHC)

ADHC/AADHC have authorization rules for new patients and initial assessments; see grandfathering notes.

Initial assessments and authorization rules apply for Adult Day Health Care (ADHC) and AADHC for new patients.

Grandfathering provisions may apply for existing members.

DME and services for Erectile Dysfunction

Erectile dysfunction devices and related DME have coverage rules and exclusions.

DME and services for erectile dysfunction follow DME prior authorization rules and DME manual guidance.

Devices or services for erectile dysfunction are not covered for registered sex offenders per policy.

Services Not Covered for Low Back Pain

The policy lists non-covered services for low back pain which must be followed to avoid denials.

Explicitly not covered for low back pain: certain injections, imaging, procedures and therapies as listed in the payer's low back pain non-coverage list.

Authorization Requirements (selected items)

Additional authorization requirements include topical oxygen, radiation therapy delegation, ambulatory CGM, bronchial thermoplasty, and vision therapy notes.

Topical oxygen requires prior authorization and is generally not covered unless criteria met.

Radiation therapy prior authorization and utilization management has been delegated.

Ambulatory continuous glucose monitoring (CGM) and bronchial thermoplasty require authorization per program rules.

Vision therapy requires prior authorization; see vision policy for details.

Long Term Home Health Care (LTHHCP) transition benefits

Long Term Home Health Care transition benefits (LTHHCP) are covered with authorization for specified codes.

S9127 and S5170 services under LTHHCP are covered when prior authorization is obtained.

Adult Day Health Care (ADHC/AADHC) - cross-reference

ADHC/AADHC duplication note: cross-reference to earlier ADHC block where applicable.

See the Adult Day Health Care (ADHC/AADHC) block for authorization and assessment rules.

DME and services for Erectile Dysfunction - cross-reference

DME/Erectile Dysfunction duplication note: cross-reference to earlier DME block.

See the DME and services for Erectile Dysfunction block for coverage rules and exclusions.

Pharmacy Program Transition and PA rules

Pharmacy program transition: pharmacy benefits moved to NYRx effective 2023-04-01; oncology medication prior authorizations handled by Evolent.

Pharmacy benefits transitioned to NYRx on 2023-04-01; prior authorization processes moved accordingly.

Oncology medication prior authorizations are managed by Evolent. Appendix I PA submissions may be sent via e-fax; maximum unit edits apply per drug policy.

Orthodontic and Vision Prior Authorization

Orthodontic and vision prior authorization: ensure coverage rules, device and appliance reviews, and provider enrollment are followed.

Orthodontic services require prior authorization and must meet clinical and age-related criteria in payer guidance.

Vision services that require prior authorization (including vision therapy and certain durable medical equipment like therapeutic lenses) must follow prior authorization processes; device/appliance reviews are conducted under the DME/orthotics policies.

Ensure providers are properly enrolled and that necessary clinical documentation is submitted to support medical necessity for orthodontic and vision PA requests.

Documentation Required

OASAS inpatient SUD notification and LOCADTR

For in‑state, in‑network OASAS‑licensed inpatient SUD facilities: notify Fidelis within 2 business days of admission and initial treatment plan and submit the OASAS Appendix A Notification Form and the LOCADTR tool via fax to 833-663-1608 or email LOCADTR@fideliscare.org. Facilities must perform daily clinical review and consult with Fidelis around day 14; notification within 2 business days prevents prior authorization/concurrent review for the first 28 days.

Prior Authorization

Transplant authorization at evaluation

Obtain prior authorization at the time of transplant evaluation for all solid organ and bone marrow/tissue transplants. A representative (non‑exhaustive) list of CPT/HCPCS codes requiring authorization is provided in the policy (e.g., 32850–32856; 33930–33945; 38204–38242; 44133–44136; 47133–47147; 48160; 48550–48556; 50300–50380; 50547; 65710–65757).

Prior Authorization

Use delegated reviewers for specified specialties

Submit prior authorization requests to delegated third‑party reviewers when applicable. TurningPoint Healthcare Solutions handles prior authorization for ENT and cardiac surgical procedures (associated HCPCS device codes are also reviewed by TurningPoint). Evolent (NIA) handles musculoskeletal/orthopedic and other delegated surgical and radiology reviews; when a CPT is delegated, associated HCPCS devices are reviewed by the same delegate.

TurningPoint reviews ENT and cardiac surgical procedures and associated devices.
Evolent (NIA) reviews musculoskeletal/orthopedic procedures and associated devices.

Prior Authorization

Submit behavioral health testing requests on forms

Submit Psychological/Neuropsychological and Developmental Pediatric testing requests on the required request forms. Testing CPTs requiring authorization include: 96116, 96121, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146, and developmental testing 96112, 96113 (authorization required).

Billing Rule

OB ultrasound billing limits

The first four obstetrical ultrasounds do not require authorization. Five or more ultrasounds for a normal pregnancy require prior authorization; ultrasounds for high‑risk pregnancy do not require authorization when appropriate high‑risk diagnosis codes are used.

Prior Authorization

Therapy prior authorization via Evolent

Therapy after the initial evaluation (home, outpatient, office) requires prior authorization through Evolent (NIA). Initial home therapy evaluations require authorization. For outpatient claims billed with non‑initial evaluation codes, an authorization request must be submitted to Evolent within 1 business day (outpatient) or within 2 business days (home). CPT codes 92610 and 92611 do NOT require prior authorization.

Prior Authorization

Home health and personal care authorization

Obtain authorization for home health, personal care, PERS and CDPAS services prior to billing. Relevant HCPCS and billing units include: T1001 (nursing assessment — per visit); S5130U1 (Level I housekeeping — per 15 minutes); T1019U1/T1019U2/T1019U3/T1019U4 (Level II variants — per 15 minutes); T1020/T1020U2/T1020U5 (Live‑in levels — per diem, 1 unit/day); G0162 (nursing supervision — one per visit); consumer‑direct codes T1019U6–T1019U9 and T1020U6–T1020U7 with specified units.

Documentation Required

Children HCBS notification and forms

For Children's HCBS services submit the NYS Children's HCBS Authorization and Care Manager Notification Form prior to service to avoid claim disruptions. For planned or crisis respite beyond the annual limit, submit a Licensed Practitioner of the Healing Arts (LPHA) attestation plus the NYS DOH Children's HCBS Authorization form by email to SM_Childrens_HCBS@fideliscare.org or fax to 833-663-1604.

Denial Risk

Non-covered low back pain services

The following services are not covered for members with a diagnosis of Low Back Pain and should not be billed: prolotherapy; therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT fluoroscopic guidance); therapeutic injections of steroids into intervertebral discs; and continuous or intermittent traction.

Prolotherapy
Lumbar/sacral therapeutic facet joint steroid injections
Intradiscal steroid injections
Continuous or intermittent traction

Billing Rule

MLTC DME supply authorization

For MLTC members obtain authorization for the listed supply codes before billing. MLTC‑specific supply HCPCS codes requiring authorization include: A4335; A4554; T4521, T4522, T4523, T4524, T4529; T4530, T4533, T4535, T4537, T4539; T4540, T4543.

Prior Authorization

Oncology medication PA via Evolent

Oncology medications and supportive agents (medical benefit) require prior authorization from Evolent (formerly New Century Health) before dispensing or administration for Medicaid Managed Care and HARP members; this excludes Child Health Plus. Requests may be submitted via Evolent's web portal or by calling 1-888-999-7713 (option 1).

Prior Authorization

Appendix I prior authorization

Submit prior authorization requests for codes listed in Appendix I to the Fidelis Pharmacy Team via e‑fax 1-844-235-5090. Oncology‑related requests follow the Evolent process described elsewhere and are excluded from Appendix I submission to pharmacy.

Billing Rule

Smoking cessation billing

Bill smoking cessation counseling using CPT codes 99406 and 99407. Reimbursement is allowed for up to 8 visits per calendar year (sum of 99406 and 99407) and claims must be billed only with specified tobacco dependence diagnosis codes (F17.200–F17.291).

Documentation Required

DSMT provider certification and documentation

Diabetes Self‑Management Training (DSMT) must be provided by certified providers and billed with G0108 (individual) or G0109 (group). Members are allowed 10 hours (20 units) in a continuous six‑month period. These services no longer require prior authorization but must meet certification/documentation requirements.

Prior Authorization

Topical oxygen prior authorization

Topical oxygen therapy requires prior authorization before delivery.

Billing Rule

Maximum unit edits

Maximum unit edits apply to all HCPCS codes regardless of authorization status; providers must follow Fidelis Care's Maximum Units of Service policy.

Prior Authorization

Orthodontic and vision vendor PA

Orthodontic prior authorizations for Medicaid members under age 21 are handled by DentaQuest (1-800-516-9615). Vision prior authorizations are handled by Davis Vision (1-800-601-3383).

Delegate/vendor (formerly New Century Health) handling prior authorization reviews for oncology medications/supportive agents and other delegated reviews

ASMT limits - newly diagnosed/complexUp to 10 hours of asthma self-management training during a continuous six‑month period for newly diagnosed or medically complex asthma

ASMT limits - medically stableUp to 1 hour of asthma self-management training during a continuous six‑month period for medically stable asthma

Smoking cessation visitsReimbursed for up to 8 visits per calendar year using the sum of codes 99406 and 99407; billed only with specified tobacco dependence diagnosis codes