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CurrentFidelis CarePolicy N/A

Authorization and Prior Authorization Coverage Criteria (Appendix I excerpt)

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This document describes Fidelis Care authorization, prior authorization delegation, inpatient/outpatient service requirements, behavioral health and substance use disorder authorization changes, and selected coding lists that affect providers serving Fidelis members in New York State.

Policy Summary

PayerFidelis Care

PolicyAuthorization and Prior Authorization Coverage Criteria (Appendix I excerpt)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2020

Last ReviewJul 1, 2023

Next Review DateN/A

Key ActionObtain prior authorization for all inpatient admissions and for listed procedures and codes before billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All admissionsInpatient authorization requirement

28 daysOASAS inpatient SUD waiver

14 daysOMH pediatric inpatient waiver

First 4OB ultrasounds without authorization

60Rehab/habilitation visit limit

40Home health max visits

Coverage and Medical Necessity Criteria

Inpatient admissions

Covered when ALL of the following are met

Inpatient Admission Authorization: All inpatient admissions require an authorization.

Fidelis Care does not require authorization for emergency room services or emergent stabilization, but requires authorization for post-stabilization services and inpatient admissions after ER services are completed. All facility admissions are reviewed for medical necessity; inpatient rehabilitation (acute, sub-acute, skilled nursing rehabilitation) requires prior authorization.

OASAS Inpatient SUD treatment

Behavioral health - Inpatient SUD (OASAS licensed, in-state, in-network)

OASAS Inpatient SUD prior auth exception: Inpatient SUD provided by in-state, in-network OASAS licensed facilities are not subject to prior authorization and are not subject to concurrent utilization review during the first 28 days of the inpatient admission provided the facility notifies Fidelis Care of the admission and initial treatment plan within two business days and performs daily clinical review.28 days

Facility must periodically consult with Fidelis Care starting on or just prior to day 14 using the LOCADTR tool; services may be subject to utilization review after day 28 or upon discharge and facilities must provide a written discharge plan prior to discharge. Out-of-state, non-OASAS-licensed, or out-of-network facilities remain subject to prior authorization and concurrent review throughout the admission.

OMH inpatient mental health

Behavioral health - OMH licensed inpatient mental health (in-state, in-network)

OMH inpatient <18 prior auth exception: For members under 18, inpatient mental health treatment provided by OMH licensed hospitals in New York State participating in Fidelis Care's network are not subject to prior authorization and Fidelis Care will not conduct concurrent utilization review during the first 14 days provided the facility notifies Fidelis Care of the admission and initial treatment plan within two business days, performs daily clinical review, and participates in periodic consultation.14 days

All inpatient mental health services provided by out-of-network facilities are subject to concurrent review throughout the admission. For all ages, utilization review may be conducted for individuals meeting listed triggers (AOT status, recent AOT within 5 years, high utilization, recent readmission, or length of stay >30 days).

Partial hospitalization and Intensive Outpatient

Partial hospitalization and intensive outpatient behavioral health

Partial Hospitalization authorization criteria: Utilization review for partial hospitalization (OMH licensed) will be conducted only for members who meet the clinical criteria per the NYS OMH Best Practice Manual: current AOT; AOT expired within 5 years; high utilization (>=3 psychiatric inpatient hospitalizations in prior 12 months OR >=4 psychiatric ED visits in prior 12 months OR >=3 medical inpatient hospitalizations in prior 12 months); readmission within 30 days; or length of stay exceeding 30 days (concurrent review from Day 31 onwards).see criteria list

All partial hospitalization services provided by out-of-network facilities are subject to concurrent review throughout the admission.

Intensive Outpatient authorization criteria: Utilization review for intensive outpatient treatment (OMH licensed) will be conducted only for members who meet the NYS OMH Best Practice Manual clinical criteria (same triggers as partial hospitalization: AOT status/current or recent, high utilization thresholds, recent readmission, or length of stay >30 days).see criteria list

All intensive outpatient services provided by out-of-network facilities are subject to concurrent review throughout the admission.

Prior Authorization coverage criteria

Services require prior authorization under the following grouped conditions:

Outpatient & DME: Diagnostic testing (including sleep studies and selected genetic testing), wireless capsule endoscopy/motility (91110-91113), select gastroenterology procedures (codes listed) and certain procedures (e.g., penile prosthesis 54405) require prior authorization; some GI procedures (43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270) require authorization only when performed in POS 19 or 22 if office/ASC is available; 43290 requires authorization in any place of service.

See outpatient diagnostic and gastroenterology code list for POS exceptions and exact CPTs.

DME & Supplies: Orthotics are not covered. A large list of DME/HCPCS codes do not require authorization (see list). Other DME codes and specified supplies (compression garments, electric heat pads, surgical stockings, protective helmets, wigs, insulin pumps, infusion pumps) require prior authorization.

See DME lists for non-PA and PA-required codes; new non-PA codes effective 4/1/23 are identified.

Imaging: The first four OB ultrasounds for a normal pregnancy do not require authorization; five or more ultrasounds for normal pregnancy (specified diagnosis codes) require authorization. OB ultrasounds for high-risk pregnancy do not require authorization. Prior authorization for radiology services has been delegated to National Imaging Associates (NIA); TBS scans (77089-77092) require authorization.

Orthotics are not covered.

The following services are not covered for members with a diagnosis of Low Back Pain: 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.

Certain drug categories and service types are handled outside New Century Health review and/or are excluded from NCH review and must be submitted to Fidelis Pharmacy or managed separately. Examples include: antibiotics; bone marrow, stem cell transplants, and CAR-T cell therapy; controlled substances; equipment requests; genetic lab testing; hemophilia drugs; immune globulins; inpatient drug requests; radiopharmaceuticals; and certain surgical procedures and S-codes (S codes are benefit exclusions except listed exceptions).

Authorization is not required for ophthalmic indications.

CPT code 20610 (joint injection) is specifically addressed: when billed with certain osteoarthritis diagnosis codes or when performed in freestanding ambulatory surgery centers billed with bill type 0831, it requires authorization in that ASC scenario and may be non-covered in specified combinations as noted in the outpatient surgery section.

The policy lists several specific therapeutic services requiring authorization or considered not covered for Low Back Pain, including prolotherapy, specified facet joint steroid injections in lumbar/sacral regions, steroid injections into intervertebral discs, and use of continuous or intermittent traction. It also identifies other therapeutic categories requiring authorization such as phototherapy, hyperbaric oxygen therapy, specified pain management codes, and cardiac and pulmonary rehabilitation.

Code Lists and Coding Rules

Transplant CPT codes requiring authorizationCPTCovered

32850	listed transplant-related CPT
32851	listed transplant-related CPT
32852	listed transplant-related CPT
32853	listed transplant-related CPT
32854	listed transplant-related CPT
32855	listed transplant-related CPT
32856	listed transplant-related CPT
33930	listed transplant-related CPT
38204	listed transplant-related CPT
44133	listed transplant-related CPT

Outpatient surgery CPT codes requiring authorizationCPTCovered

43770-43775	Bariatric surgery CPTs (43770-43775)
15820-15823	Blepharoplasty CPTs
11920-11971	Breast reconstruction CPT range
10040,11100,11900,17000,20600,20605,20610	Codes that should not be performed in freestanding ASC without auth; 20610 hyaluronic acid joint injection non-covered with certain conditions
65760-65775,66987-66991,67900-67911,68841	Eyelid & ocular surgery and related CPTs
15830-15839,15847,15876-15879	Abdominoplasty, lipectomy, panniculectomy CPTs
19300,19318	Reduction mammoplasty CPTs
21120-21296,30400-30520,30620-30802,30999,31298,C9749,Q2028	Facial cosmetic, septoplasty, rhinoplasty codes
36465-36479,36482-36483,37718-37785,37241-37244	Vascular procedures (vein) CPTs
69716,69719,69726,69727	Speech Processor Implant Procedures

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Behavioral health outpatient codes requiring authorizationmixedCovered

96112,96113,96116,96121,96130-96139,96146	Psychological/Neuropsychological and Developmental testing CPTs
90870	Outpatient ECT
H0035	Partial hospitalization HCPCS
90899,S9480,H2013	Intensive Outpatient Treatment codes

Diagnostic, DME and other outpatient codesmixedCovered

91110-91113	Wireless Capsule Endoscopy and Wireless Motility capsule
43235,43239,43248,45378,45380,45384,45385,46255,46260,46270	GI procedures that require authorization in POS 19/22 when office/ASC available
43290	Authorization required when performed in any place of service
54405	Penile prosthesis
E0130,E0135,E0168,E0182,E0184,E0235,E0274,E0305,E0310,E0424,E0431,E0434,E0439,E0570,E0575,E0580,E0602,E0603,E0621,E0655,E0660,E0776,E0890,E0900,E0942,E2361,E2363,L0130,L0140,L0150,L0160,L0170,L0172,L0174,L0180,L0190,L0200,L1652,L1902,L2132,L2134,L2136,L3100,L3221,L3762,L4350,L7360,L7362,L7364,L7366,S8421,S8424,V5266	DME codes that do not require authorization
A4341,A4342,A4560,A6590,A6591,A7049,E0677,E0711,K1035,L8678	New DME codes effective 4/1/23 that do not require prior authorization

Outpatient diagnostic and gastroenterology codesCPTCovered

43235	esophagogastroduodenoscopy w/ procedures (listed)
43239	esophagoscopy procedures (listed)
43248	esophagogastroduodenoscopy with dilation (listed)
45378	colonoscopy therapeutic (listed)
45380	colonoscopy with ablation (listed)
45384	colonoscopy with polypectomy (listed)
45385	colonoscopy with removal of lesion (listed)
46255	sigmoidoscopy with biopsy (listed)
46260	sigmoidoscopy procedures (listed)
46270	sigmoidoscopy other (listed)

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DME codes not requiring authorization / new non-PA DME codesHCPCS

E0130	Crutches, underarm, other
E0135	Crutches, underarm, pair
E0168	Walker
E0182	Standard wheelchair
E0184	Heavy-duty wheelchair
E0235	Hospital bed
E0274	Patient lift
E0305	Oxygen concentrator
E0310	Nebulizer
E0424	Home ventilator

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TBS scan codesCPTCovered

77089	Bone density TBS scan
77090	Bone density TBS scan
77091	Bone density TBS scan
77092	Bone density TBS scan

Therapy and monitoring codesCPT|HCPCS|G-codesCovered

92610	Evaluation of speech/language
92611	Evaluation of speech/language (related)
95249	Ambulatory continuous glucose monitoring
S9472	Cardiac rehab related
93797	Cardiac rehab code
93798	Cardiac rehab code
G0422	Cardiac rehab
G0423	Cardiac rehab
G0237	Pulmonary rehab
G0238	Pulmonary rehab

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Counseling/education codesCPT|GCovered

G0108	Diabetes self-management training individual session
G0109	Diabetes self-management training group session
98960	Education and training for patient self-management

Pharmacy and Appendix I codes requiring PAHCPCS|C-codes|J-codes|rangeCovered

B4034-B4162	Enteral therapy HCPCS range requiring authorization
C9054	lefamulin (Xenleta) / mapped entries in Appendix I
C9055	brexanolone (Zulresso) / mapped entries in Appendix I
C9074	lumasiran (Oxlumo) entries
C9094	sutimlimab-jome entries
C9147	tremelimumab-actl inj (Imjudo)
G0516	insertion of implant / J0221 mapping
J0129	abatacept (Orencia) mapping
J0172	brexanolone mapping
J0180	sutimlimab mapping

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Chiropractic codes requiring PACPT|RevenueCovered

98940	Chiropractic manipulative treatment, 1-2 regions
98941	Chiropractic manipulative treatment, 3-4 regions
98942	Chiropractic manipulative treatment, 5 regions
98943	Chiropractic adjunct procedures
0940	Revenue code listed

Codes appearing in appendix partHCPCS

J0596	listed (multiple mapped entries)
J0598	listed (multiple mapped entries)
J0593	listed (multiple mapped entries)
J0599	listed (multiple mapped entries)
J0638	listed
J0641	listed
J0642	listed

Additional J-codes in this appendix segmentHCPCS

J0691	listed
J0699	listed
J0706	listed
J0717	listed
J0725	listed
J0739	listed
J0741	listed
J0879	listed
J0887	listed
J0896	listed

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Codes Requiring Prior Authorization (excerpt)HCPCSCovered

J9119

Imlygic (listed)

Appendix I code list (grouped)HCPCSCovered

J9120	adalimumab-aacf (Idacio) and related mappings
J9145	daratumumab (Darzalex) and related mappings
J9173	durvalumab (Imfinzi) and related mappings
J9176	elotuzumab (Empliciti) and related mappings
J9177	enfortumab (Padcev) and related mappings
J9196	gemcitabine (Gemzar-Accord) and related mappings
J9198	gemcitabine (Infugem) and related mappings
J9203	gemtuzumab (Mylotarg) and related mappings
J9204	mogamulizumab-kpkc (Poteligeo) and related mappings
J9205	irinotecan liposome (Onivyde) and related mappings

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OASAS Inpatient SUD concurrent review waiver — 28 days

OASAS inpatient SUD concurrent review waiverIn-state, in-network OASAS‑licensed inpatient SUD services are not subject to prior authorization or concurrent utilization review during the first 28 days of admission provided the facility notifies Fidelis Care within 2 business days, performs daily clinical review, and begins periodic consultation around day 14

Notification requirementFacility must notify Fidelis Care of the inpatient admission and initial treatment plan within two (2) business days (OASAS Appendix A Notification Form and LOCADTR may be faxed or emailed)

Post‑28 day reviewInpatient SUD services may be subject to utilization review after day 28 or upon discharge using the LOCADTR clinical review tool

What Providers Must Do / Billing and Authorization Steps

Prior Authorization

Obtain prior authorization for all inpatient admissions

All inpatient admissions require prior authorization. Fidelis Care does not require authorization for emergency stabilization services but does require authorization for post-stabilization services and inpatient admissions after ER services are completed. Inpatient rehabilitation (acute, sub-acute and skilled nursing rehabilitation) also requires prior authorization.

Authorization required for all acute inpatient facility services
Inpatient rehabilitation services require prior authorization

Documentation Required

Follow OASAS notification to qualify for 28-day PA/concurrent review waiver

In-state OASAS-licensed inpatient SUD facilities participating in Fidelis Care's network are not subject to prior authorization or 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 and performs daily clinical review and periodic consultation beginning around day 14.

Policy Scope and Background

This policy covers utilization management and authorization processes across inpatient, outpatient, surgical, behavioral health and DME services for Fidelis Care members, including delegation of prior authorization for select categories and state-specific notification/waiver procedures for OMH- and OASAS-licensed facilities in New York State.

Definitions and Limits

OASAS / OMH licensed facilities — definition for exceptions

Definition — OASAS/OMH licensed in‑state network facilitiesFacilities licensed/certified by NYS OASAS (substance use disorder) or OMH (mental health) that are participating in Fidelis Care's provider network and located in New York State; such facilities qualify for the specified prior authorization/notification exceptions when conditions are met

Scope of exceptionExceptions apply only to in‑state, in‑network OASAS or OMH licensed facilities; out‑of‑state or out‑of‑network facilities remain subject to standard prior authorization and concurrent review

Operational conditionsFacilities must notify Fidelis Care within two business days and perform daily clinical review and periodic consultation as required by the respective OASAS or OMH rules

Normal pregnancy OB ultrasound — diagnostic codes and PA rule

Normal pregnancy OB ultrasound diagnosis codesNormal pregnancy diagnosis codes: Z32.01, Z33.1, Z34.00‑Z34.03, Z34.80‑Z34.83, Z34.9‑Z34.93 (first 4 ultrasounds do not require authorization)

Policy Summary

PayerFidelis Care

PolicyAuthorization and Prior Authorization Coverage Criteria (Appendix I excerpt)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2020

Last ReviewJul 1, 2023

Next Review DateN/A

Key ActionObtain prior authorization for all inpatient admissions and for listed procedures and codes before billing.

SourceLink

On This Page

OB ultrasounds >=5 require PA

Submission/delegation instructions and full CPT lists are maintained by NIA.

Outpatient Therapy: Effective 10/1/2021, outpatient PT/OT/ST services after the initial evaluation require prior authorization through NIA. Initial office/facility evaluations do not require prior authorization, but all other billed procedure codes, even if on same date as the initial evaluation, require authorization prior to billing. Rehabilitation and habilitation benefits are limited to 60 visits per condition per plan year (combined therapies).60 visits per condition per plan year

Authorization request timing: send to NIA within 1 business day for outpatient or 2 business days for home health; Fidelis within 1 business day for inpatient settings.

Therapeutic Services: Certain therapeutic services require authorization: phototherapy, hyperbaric oxygen therapy, specified pain management codes (list provided), cardiac and pulmonary rehabilitation (codes listed), radiation therapy (delegated), ambulatory continuous glucose monitoring (95249), radiofrequency ablation of uterine fibroids (58674), bronchial thermoplasty (31660,31661) and other specified procedures.

Some pain procedure codes (63622, 63688) do not require authorization when requested by orthopedic specialties. Specific non-covered therapies for low back pain (prolotherapy, certain facet/disc injections, traction) are listed as not covered.

Pharmacy & Enteral: Enteral therapy HCPCS range B4034-B4162 requires authorization. Oncology medications and supportive agents require prior authorization via New Century Health (NCH) before dispensing/administration; certain drug requests are excluded from NCH review and should be submitted directly to Fidelis Pharmacy. Appendix I enumerates numerous HCPCS/C/J drug and biologic codes that require prior authorization.

Providers should consult NCH portal for oncology auths and the Appendix I code lists for drug/biologic PA requirements.

OMH inpatient concurrent review initial period (under 18) — 14 days

OMH inpatient concurrent review initial period (under 18)In‑state, in‑network OMH‑licensed inpatient mental health for members under age 18 are not subject to prior authorization or concurrent utilization review during the first 14 days when the facility notifies Fidelis Care within two business days, performs daily clinical review, and participates in periodic consultation

Two‑day notification formFacility must complete the OMH 'Two‑Day Notification and Initial Treatment Plan' form and submit it to Fidelis Care by fax or email within two business days of admission

Out‑of‑network ruleAll inpatient mental health services provided by out‑of‑network facilities remain subject to concurrent review throughout the admission

OB ultrasound count before PA

OB ultrasound authorization threshold for normal pregnancyFirst 4 OB ultrasounds for a normal pregnancy (dx codes Z32.01, Z33.1, Z34.00‑Z34.03, Z34.80‑Z34.83, Z34.9‑Z34.93) do not require authorization; five or more require prior authorization

High‑risk pregnancy exceptionOB ultrasounds for high‑risk pregnancy (listed O09.* and selected O36.* codes) do not require authorization

Delegation for radiology PAPrior authorization for radiology services has been delegated to National Imaging Associates (NIA); a full CPT list is maintained by NIA

Rehabilitation/habilitation visit limit

Rehabilitation/habilitation visit limitBenefit is limited to 60 visits per condition per plan year; the visit limit applies to all therapies combined

Applies to PT/OT/STRehabilitation and habilitation visit limits apply across physical, occupational and speech therapies following the stated limit

Authorization pathwayEffective 10/1/2021, outpatient therapy services after the initial evaluation require prior authorization through NIA; initial office/facility evaluations do not require PA but subsequent billed codes do

Home health benefit maximum

Home health benefit maximumHome health care benefit maximum is 40 visits per plan year (approvals based on medical need for skilled services)

Visit determinationHome care approvals are based on medical need for skilled services

Related DME itemsHome health guidance appears alongside DME and supply rules in the DME/Supplies section

Hospice coverage maximum

Hospice coverage maximumWhen medically necessary, hospice coverage is available for up to 210 days

Program certification requirementHospice care must be provided as part of a Hospice Care program certified pursuant to Article 40 of the N.Y. Public Health Law

Medical necessity standardCoverage is subject to medical necessity determinations

Fax or email OASAS Appendix A Notification Form and LOCADTR to 646-829-1421 or LOCADTR@fideliscare.org within 2 business days
Perform daily clinical review and consult with Fidelis Care starting on/just before day 14

Prior Authorization

Obtain PA for listed diagnostic and select GI procedures

For the listed outpatient diagnostic and gastroenterology procedures (including wireless capsule endoscopy 91110-91113, select GI CPTs such as 43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270) and penile prosthesis (54405), obtain prior authorization where required; several procedures require authorization only when performed in POS 19 or 22 and 43290 requires authorization in any place of service.

Wireless capsule/motility: 91110-91113 require PA
GI procedures listed require PA when performed in POS 19/22 (authorization not required in POS 11 or 24)
43290 requires authorization in any place of service
Penile prosthesis (54405) requires authorization

Prior Authorization

Check DME code list and obtain PA for DME/supplies that require authorization

Many specific DME/HCPCS codes are listed as not requiring authorization; however other DME items and supplies (including compression garments, electric heat pads, surgical stockings, protective helmets, wigs, insulin pumps, and infusion pumps) require prior authorization—confirm authorization requirements using the code lists before ordering or billing.

Do not request PA for listed non-PA DME codes (e.g., E0130, E0135, E0168, …, V5266 and new non-PA codes effective 4/1/23 such as A4341, A4342)
Request PA for other DME codes and supplies including compression garments, electric heat pads, surgical stockings, protective helmets, wigs, insulin pumps, and infusion pumps

Prior Authorization

Follow OB ultrasound limits and submit radiology PA to NIA

The first four OB ultrasounds for a normal pregnancy do not require authorization; five or more ultrasounds for a normal pregnancy require prior authorization. Prior authorization for radiology services has been delegated to National Imaging Associates (NIA).

OB ultrasounds for normal pregnancy: first 4 without authorization; >=5 require PA (diagnosis codes listed in policy)
Radiology prior authorization is delegated to NIA (see NIA for CPT lists)

Prior Authorization

Obtain authorization for CGM and outpatient cardiac/pulmonary rehab

Authorization is required for ambulatory continuous glucose monitoring (CPT 95249) and for outpatient cardiac and pulmonary rehabilitation services (codes S9472, 93797, 93798, G0422, G0423, G0237-G0239, G0424, S9473).

Obtain PA for ambulatory CGM: 95249
Obtain PA for outpatient cardiac and pulmonary rehab codes as listed

Prior Authorization

Submit PA for enteral formulas and oncology meds (NCH)

Enteral therapy HCPCS codes B4034-B4162 require prior authorization. Oncology medications and supportive agents require prior authorization via New Century Health (NCH) before dispensing or administration; follow NCH submission instructions for oncology PA requests.

Submit PA for enteral therapy codes B4034-B4162
Submit oncology medication/supportive agent PA requests to New Century Health per NCH portal or phone

Prior Authorization

Submit PA for Appendix I drugs and biologics before billing

Appendix I enumerates numerous HCPCS/C and J-codes that require prior authorization; providers must submit prior authorization requests for these specific drug and biologic codes before billing or administration.

Refer to Appendix I code list (C- and J-codes) for codes requiring PA
Submit PA for listed drugs/biologics prior to claim submission or administration

Prior Authorization

Obtain PA for listed J-codes and mapped entries

Prior authorization is required for the J-codes and their mapped entries listed in this appendix section; identify the applicable J-code or mapped entry and obtain authorization prior to billing.

Identify listed J-codes (e.g., J0596, J0598, J0638, J0641, etc.) and mapped entries
Obtain PA for those J-codes before providing or billing for the service

Prior Authorization

Do not bill listed J- and S-codes without prior authorization

Prior authorization is required for the J-codes and S-codes enumerated in Appendix I (see chunks 54–62 for the list); do not bill these items without prior authorization.

Examples include J9119, J9120, J9145, J9173, J9176, J9177, J9196, J9198, J9203, J9204, J9205, J9216, J9210, J9217, J9225, J9227, J9228, J9229, J9245, J9246, J9247, J9259, J9261, J9269, J9272, J9273, J9281, J9285, J9294, J9296 and S-codes S0172–S0179
Claims for these codes may be denied if PA is not obtained

Note

Confirm submission instructions and delegated workflows before requesting PA

Refer to the policy text and code tables for additional provider responsibilities regarding PA submission, delegation, and where to send notifications; follow the exact submission instructions in the source for each service type.

Review the policy code lists before ordering services
Follow submission/contact instructions specific to the service (e.g., NCH, NIA, fax/email addresses)

Step Therapy

Refer to NCH program and formulary updates for oncology step-therapy

For oncology step-therapy and formulary requirements, refer to the New Century Health (NCH) Oncology Program and the Fidelis Care Pharmacy Services web pages for the most recent formulary and step-therapy grids; NCH handles PA for most oncology medications.

Check https://www.fideliscare.org/Provider/Provider-Resources/Pharmacy-Services for monthly formulary and NCH program updates
Submit oncology medication PA requests via NCH Web portal or phone per policy

Note

Use Appendix I and code lists to determine PA requirements

Follow the policy code lists and delegated arrangements when determining whether a prior authorization is required; consult the Appendix I and other sections for exact codes and mapped entries that trigger PA.

Use Appendix I to identify drug/biologic codes requiring PA
Obtain PA for codes and mapped entries before providing service

Documentation Required

Follow specific notification and submission timelines in policy

Follow notification requirements and timelines specified in the policy (see OMH/OASAS sections and delegated vendor instructions) and use the provided contact points for submission of forms and tools.

Use the OMH Two-Day Notification form and provided fax/email for OMH admissions
Use OASAS Appendix A and LOCADTR submission contacts for OASAS admissions
Follow NIA delegation instructions for radiology and outpatient therapy authorizations

Documentation Required

Submit OMH two-day notification for pediatric inpatient mental health

For OMH-licensed inpatient admissions of members under age 18 at in-state, in-network facilities, 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 via fax (718-896-1784) or email (Mental_Health_Admission@fideliscare.org).

Complete and submit the OMH 'Two-Day Notification and Initial Treatment Plan' form within 2 business days
Perform daily clinical review and participate in periodic consultation with Fidelis Care

Documentation Required

Notify Fidelis and submit LOCADTR for OASAS inpatient SUD admissions

For in-state, in-network OASAS-licensed inpatient SUD admissions, the facility must notify Fidelis Care and may fax or email the OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool to 646-829-1421 or LOCADTR@fideliscare.org within two business days of admission; facilities must perform daily clinical review and begin periodic consultation around day 14.

Notify Fidelis Care within 2 business days and submit OASAS Appendix A and LOCADTR as instructed
Provide written discharge plan prior to discharge and indicate whether post-discharge services are secured

Prior Authorization

Submit PA to delegated vendor (NIA) where applicable

When prior authorization is delegated to a vendor (for example, National Imaging Associates for radiology and NIA for outpatient therapy), submit authorization requests to that delegated vendor per the timeline and process specified in the policy.

Submit radiology PAs to NIA (delegated)
Submit outpatient therapy PAs to NIA per timing rules (NIA within 1 business day outpatient or 2 business days home health)

Documentation Required

Identify Appendix I J-codes and obtain PA before billing

Providers must identify J-codes and associated items listed in Appendix I and request prior authorization for those codes before billing or administering these drugs/biologics.

Review Appendix I for applicable J-codes and mapped entries
Obtain PA for identified codes prior to providing service

Note

Ophthalmic indications: PA not required

Authorization is not required for ophthalmic indications as explicitly stated in the Appendix I section.

Ophthalmic indications are an explicit exception to PA requirements in Appendix I

Denial Risk

Denial risk for inpatient admissions without PA

Failure to obtain prior authorization for inpatient admissions or for post-stabilization inpatient services may result in the care being non-authorized and subject to denial or non-payment.

Obtain authorization prior to inpatient admission when not an emergency stabilization
Post-stabilization inpatient services require authorization

Denial Risk

Outpatient and DME services may be denied without PA

Services listed under Outpatient and DME Services (diagnostic testing, select gastroenterology procedures, DME/supplies) require prior authorization or may be denied if not authorized; verify PA requirements before providing the service.

Diagnostic testing and listed GI procedures require PA in specified POS
DME and supplies may be denied if authorization is not obtained when required

Denial Risk

Therapeutic services require PA or risk denial

Certain therapeutic services (phototherapy, hyperbaric oxygen, specified pain management codes, radiation, cardiac and pulmonary rehab, ambulatory CGM) require authorization; lack of authorization may result in claim denial.

Obtain PA for phototherapy, hyperbaric oxygen, specified pain management and rehab codes
95249 (ambulatory CGM) requires authorization

Denial Risk

Claims for listed J-/related codes require PA

Claims submitted for the listed J-codes and related codes in Appendix I require prior authorization; submitting claims without authorization may trigger claim denials.

Do not submit claims for Appendix I J-codes without first obtaining PA
Mapped entries and related HCPCS/C codes in Appendix I are also subject to PA

Denial Risk

Appendix I items: risk of denial without PA

Claims for the J-codes and associated products listed in Appendix I (chunks 54–62) may be denied without prior authorization; ensure PA is obtained and documented before billing these items.

Appendix I includes numerous J- and S-codes whose claims may be denied without PA
Review the Appendix I listings (chunks 54–62) and obtain PA accordingly

Authorization triggerFive or more ultrasounds for a normal pregnancy with the listed diagnosis codes require prior authorization

High‑risk pregnancy codesHigh‑risk pregnancy diagnosis codes (O09.* and selected O36.* codes) are exempt and do not require authorization for OB ultrasounds

Rehabilitation benefit — scope and limits

Rehabilitation benefit definitionRehabilitation benefit limited to 60 visits per condition per plan year; the visit limit applies to all therapies combined

Includes habilitationHabilitation benefit is similarly limited to 60 visits per condition per plan year and counts toward the combined therapy limit

Authorization and timingOutpatient therapy after the initial evaluation requires prior authorization through NIA; initial evaluations in office/facility do not require PA but other same‑date codes do