Authorization and coding guidance — inpatient, outpatient, behavioral health, therapy, imaging, DME, and select procedures
Describes Fidelis Care's authorization, delegation, and coding guidance for inpatient, outpatient, behavioral health, DME, therapy, imaging, and select procedures, including temporary COVID-19 updates and delegated vendors; applies to in‑network providers (NY-focused).
Authorization delegations to TurningPoint Healthcare Solutions, LLC and National Imaging Associates, Inc for specific service categories and code lists.
In-network, in-state OMH and OASAS licensed inpatient behavioral health and SUD services have revised notification and concurrent review expectations (reduced concurrent review windows).
Outpatient therapy initial evaluations do not require prior authorization, but all subsequent therapy services require prior authorization through NIA for dates on/after 10/1/2021.
Effective 9/20/2021 for dates of service on or after 10/1/2021, outpatient PT/OT/ST services performed after the initial evaluation require prior authorization through NIA.
Authorization has been delegated to NIA for radiation therapy services effective 9/20/2021 for dates of service on or after 10/1/2021.
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