Fidelis Care Prior Auth & Coverage Update | OpenPayer
ModifiedFidelis CarePolicy N/A
Prior Authorization and Utilization Review — Coverage and Operational Guidance
Defines prior authorization, utilization review, and coverage-related operational changes for Fidelis Care providers (primarily New York State), including behavioral health, inpatient admissions, outpatient surgeries, transplants, and substance use disorder services.
Policy Summary
PayerFidelis Care
PolicyPrior Authorization and Utilization Review — Coverage and Operational Guidance
Policy CodePolicy N/A
Change TypeMaterial updates to DME PA listclarified TMS authorization criteria
Effective DateJan 1, 2020
Next Review DateN/A
Key ActionObtain prior authorization for inpatient admissions, transplants, TMS (90867-90869), and listed outpatient procedures as specified.
Effective 4/1/24, the following DME codes are new and do not require prior authorization: A4271, A4438, A4564, A4593, A4594, E0152, E0736.
Transcranial Magnetic Stimulation (TMS) is covered with authorization required for CPT 90867, 90868, 90869 for members over 18 meeting FDA labeled indications and additional failure-to-treat criteria; authorization requests may be submitted via email, fax, or phone following behavioral health prompts.
All inpatientFacility admissions requiring prior auth
28 daysOASAS inpatient SUD exemption
14 daysOMH pediatric inpatient MH exemption
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90867-90869
TMS authorization required
40Home health visit maximum
60Rehab visit limit
Coverage Criteria and Medical Necessity Rules
OMH pediatric inpatient MH criteria
OMH licensed inpatient mental health treatment exemptions and utilization review triggers
OMH pediatric in-network exemption: Inpatient mental health treatment for members under age 18 provided by OMH licensed hospitals in New York State that are participating in Fidelis Care's network are not subject to prior authorization and not subject to concurrent utilization review during the first 14 days provided the facility: (i) notifies Fidelis Care of the admission and initial treatment plan within two business days using the OMH 'Two-Day Notification and Initial Treatment Plan' form; (ii) performs daily clinical review of the patient; and (iii) participates in periodic consultation with Fidelis Care to ensure the facility is using OMH‑approved evidence‑based clinical review criteria appropriate to the patient's age to ensure medical necessity.age <18; days <=14
Notification via fax 833-561-0094 or Mental_Health_Admission@fideliscare.org
OMH inpatient MH utilization review triggers
Utilization review triggers for inpatient mental health (all ages) in OMH licensed hospitals
Triggers for utilization review: Utilization review (prior authorization and concurrent review) will be conducted for members who meet ANY of the following: 1) currently subject to an Assisted Outpatient Treatment (AOT) court order; 2) had an AOT court order that expired within the past five years; 3) high utilization as evidenced by (a) three or more psychiatric inpatient hospitalizations in the prior 12 months OR (b) four or more psychiatric ED visits in the prior 12 months OR (c) three or more medical inpatient hospitalizations in the prior 12 months; 4) readmitted to any mental health inpatient unit within 30 days of discharge; 5) length of stay exceeds 30 days (concurrent review from Day 31 onwards).three+ inpatient psych admissions OR four+ psych ED visits OR three+ medical inpatient admissions in prior 12 months; readmit within 30 days; LOS >30 days
OASAS inpatient SUD criteria
OASAS inpatient SUD in-network in NYS — limited review conditions
OASAS in-network inpatient SUD exemption: Inpatient SUD services provided by New York State OASAS licensed, in‑network 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: (i) notifies Fidelis Care of the inpatient admission and the initial treatment plan within two business days (by fax or email of the OASAS Appendix A Notification Form and LOCADTR tool); (ii) performs daily clinical review (does not require daily LOCADTR concurrent review module); and (iii) periodically consults with Fidelis Care starting on or just prior to day 14 to ensure LOCADTR use and medical necessity. Inpatient SUD services may be subject to utilization review after day 28 or upon discharge using the LOCADTR tool.days <=28
Fax LOCADTR/OASAS Appendix A to 833-663-1608 or LOCADTR@fideliscare.org
Transcranial Magnetic Stimulation (TMS)
TMS coverage criteria
TMS coverage requirements: TMS is covered for members over 18 when administered using an FDA‑cleared device consistent with FDA labeled indications, with a confirmed diagnosis of major depressive disorder (MDD), and after failure to respond to multiple trials of medication and evidence‑based psychotherapy during the current episode of illness.
Authorization required for CPT codes 90867, 90868, 90869
Transcranial Magnetic Stimulation (TMS)
Covered when ALL of the following are met
TMS general criteria: All of the following must be met: member is >18 years old; TMS is administered using an FDA‑cleared device in accordance with FDA labeled indications; there is a confirmed diagnosis of major depressive disorder (MDD); and there is documented failure to respond to multiple adequate trials of antidepressant medication and evidence‑based psychotherapy during the current episode of illness.age >18
Authorization required for CPT 90867, 90868, 90869; request submission via qhcmbh@fideliscare.org, fax 833-561-0098, or 1-888-FIDELIS ext.16072
OB Ultrasound Authorization
Coverage and authorization for OB ultrasounds
OB ultrasound normal pregnancy: For a normal pregnancy (specified diagnosis codes), the first four OB ultrasounds may be performed without prior authorization; five or more ultrasounds require prior authorization. OB ultrasounds for a high‑risk pregnancy (specified diagnosis codes) do not require authorization.<=4 without PA
See specified diagnosis code lists for normal vs high‑risk pregnancy
Per the outpatient surgery rules, CPT 20610 (arthrocentesis/aspiration and/or injection; major joint or bursa) is non‑covered when billed together with specified hyaluronic acid product HCPCS/J‑codes for members with a diagnosis of osteoarthritis of the knee (examples listed include J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332 and related M17 diagnosis codes).
For members with a primary diagnosis of Low Back Pain, the policy explicitly lists several interventional services as not covered. These include prolotherapy, therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT guidance), therapeutic steroid injections into intervertebral discs, and continuous or intermittent traction.
Appendix annotations include certain non‑standard or controversial items called out in the code appendix. For example, an entry in Appendix I references laetrile / amygdalin (Vitamin B17) among other listed items as an annotation in the product/code mappings; these appendix annotations are informational and flag products/items that are identified as non‑covered or controversial within the appendix mappings.
Specifically for knee osteoarthritis, the policy states that CPT 20610 is non‑covered when billed with the listed hyaluronic acid HCPCS/J‑codes and an osteoarthritis of the knee diagnosis (M17 series). In all other clinical situations, no authorization is required for 20610.
The policy lists a range of interventional and injection therapies for spine/low back conditions that are excluded from coverage for members diagnosed with Low Back Pain. These exclusions include prolotherapy; therapeutic lumbar/sacral facet steroid injections; therapeutic intradiscal steroid injections; and continuous or intermittent traction. Providers should not expect coverage for these services when billed for Low Back Pain as defined in the policy.
Coding Lists and Key Authorization Counts
Provider Requirements, Submission Paths, and Denial Risks
Prior Authorization
Outpatient surgery prior authorization
Multiple outpatient surgery and procedure CPT/HCPCS codes require prior authorization. Providers must obtain authorization for the listed outpatient surgical services before scheduling or performing procedures when indicated below; failure to obtain prior authorization may result in claim denial.
Bariatric surgery: 43770-43775 (S2083 no longer requires authorization as of 8/1/22)
Blepharoplasty: 15820-15823
Breast reconstruction: 11920-11971, 19300, 19316-19342, 19355, 19370-19396
Skin surgery: 15011-15012. Ambulatory surgery POS 24 requires auth for many skin codes (10040, 11300-11313, 11400-11471, 11721). Codes 11200,11201,11719,15769-15829,17340-17999 require authorization at any POS
Freestanding ambulatory surgery centers (bill type 0831) require preauthorization for: 10060, 11100, 11900, 17000, 20600, 20605
20610 is non-covered when billed with listed hyaluronic acid J-codes and knee osteoarthritis diagnosis (M17 series); otherwise no auth required
This document provides operational guidance for prior authorization and utilization review during the COVID‑19 update and routine operations. Note that all inpatient admissions require authorization, and the policy also documents state‑specific operational exceptions and notification requirements (for example, OMH and OASAS exemptions). Providers should follow the listed submission and notification paths and expect utilization review and authorization workflows to remain in effect per the policy.
Key Definitions and Notes
OASAS and OMH exemptions
OASAS inpatient SUD exemption (summary)In-network NYS OASAS licensed inpatient SUD services are not subject to prior authorization or concurrent utilization review during the first 28 days if the facility notifies Fidelis Care within 2 business days and follows daily clinical review and periodic consultation.
OMH pediatric inpatient MH exemption (summary)In-network NYS OMH licensed inpatient mental health treatment for members under 18 is not subject to prior authorization and not subject to concurrent utilization review during the first 14 days if the facility notifies Fidelis Care within two business days and meets daily review and consultation requirements.
Notification forms and contactsOASAS facilities submit Appendix A and LOCADTR to LOCADTR@fideliscare.org or fax 833-663-1608; OMH facilities submit the Two-Day Notification form by fax 833-561-0094 or email Mental_Health_Admission@fideliscare.org.
Transcranial Magnetic Stimulation (TMS)
TMS coverage and authorizationTranscranial Magnetic Stimulation (TMS) is covered but requires prior authorization for CPT codes 90867, 90868, and 90869.
Policy Summary
PayerFidelis Care
PolicyPrior Authorization and Utilization Review — Coverage and Operational Guidance
Policy CodePolicy N/A
Change TypeMaterial updates to DME PA listclarified TMS authorization criteria
Effective DateJan 1, 2020
Next Review DateN/A
Key ActionObtain prior authorization for inpatient admissions, transplants, TMS (90867-90869), and listed outpatient procedures as specified.
Other specified codes: C1600-C1604, C1737, C7556-C7557, C7560, C9807, 23140, 60660-60661
Certain outpatient orthopedic and spinal procedures delegated to Evolent (NIA) — refer to Section II G and Evolent list
ENT and Cardiac surgical procedures: prior authorization delegated to TurningPoint Healthcare Solutions, LLC
Note
DME authorization change
Effective 4/1/24, several new DME codes no longer require prior authorization. Providers should check the DME list before submitting authorization requests.
New codes effective 4/1/24 that do not require PA: A4271, A4438, A4564, A4593, A4594, E0152, E0736
Prior Authorization
Therapy services prior authorization and risks
Outpatient physical, occupational, and speech therapy services (PT/OT/ST) performed after the initial evaluation require prior authorization. Initial evaluations in office or facility do not require prior authorization, but any other billed therapy codes (including those on same date) do require authorization prior to billing.
Effective 10/1/2021, all PT/OT/ST services after the initial evaluation require prior authorization through Evolent (NIA). Initial therapy evaluation in the home requires authorization.
CPT codes 92610 and 92611 do not require prior authorization
If billing codes other than designated initial evaluation CPT codes, submit an authorization request to Evolent (NIA) within 1 business day for outpatient or 2 business days for home health; for inpatient settings submit to Fidelis within 1 business day
For therapy services in inpatient POS 31 & 32, send prior authorization requests to fax 833-663-1611 (formerly 716-803-8307)
Prior Authorization
Prior authorization required for listed codes
Prior authorization is required for the HCPCS/J/C/Q/S codes and associated products enumerated in Appendix I. Each listed code requires supporting documentation when submitting a prior authorization request.
Appendix I lists numerous J-, Q-, and other HCPCS codes that require prior authorization (see Appendix I for full list)
Submit pharmacy prior authorization requests electronically via e-fax to 1-844-235-5090 for non-oncology pharmacy requests
Oncology-related outpatient drug requests require prior authorization and review by Evolent before dispensing or administration (see Pharmacy/Section IX and Section B for oncology)
Denial Risk
Potential denial if prior authorization not obtained
Use of services or codes that require prior authorization but are billed without an approved prior authorization may be denied. Providers should obtain and document authorization before rendering services to reduce denial risk.
Claims for listed HCPCS/J/C/Q/S codes submitted without prior authorization may be denied or subject to retrospective review
Failure to obtain required authorization for outpatient surgeries, therapies, DME, or drugs may result in claim denials or payment delays
Documentation Required
OMH pediatric notification requirement
OMH-licensed inpatient pediatric mental health facilities must notify Fidelis Care within two business days of admission and submit the OMH Two-Day Notification and Initial Treatment Plan form; if requirements are met, concurrent review is not conducted for the first 14 days.
Notify Fidelis Care of admission and initial treatment plan within two business days by fax to 833-561-0094 (formerly 718-896-1784) or email Mental_Health_Admission@fideliscare.org
Facility must perform daily clinical review and participate in periodic consultation with Fidelis Care
Documentation Required
OASAS inpatient SUD documentation & notification
OASAS-licensed inpatient Substance Use Disorder (SUD) facilities must notify Fidelis Care within two business days of admission and submit the OASAS Appendix A Notification Form and LOCADTR tool; Inpatient SUD services are not subject to prior authorization or concurrent review for the first 28 days if notification requirements are met.
Fax or email OASAS Appendix A Notification Form and LOCADTR to fax 833-663-1608 or LOCADTR@fideliscare.org (formerly 646-829-1421)
Facilities must perform daily clinical review and consult with Fidelis Care starting on or just before Day 14 of treatment; services may be subject to utilization review after Day 28 or upon discharge
Provide written discharge plan to member and Fidelis Care prior to discharge
Prior Authorization
TMS prior authorization and submission instructions
Transcranial Magnetic Stimulation (TMS) is covered but requires prior authorization. Providers may submit TMS authorization requests via email, fax, or phone as listed below.
Authorization required for CPT codes 90867, 90868, 90869
Submission options: email qhcmbh@fideliscare.org, fax 833-561-0098, or call 1-888-FIDELIS (1-888-343-3547) and follow prompts for Behavioral Health or dial extension 16072
Members must be >18, have diagnosis of major depressive disorder (MDD), TMS must be delivered using an FDA-cleared device per labeled indications, and there must be documented failure of multiple medication trials and evidence-based psychotherapy during the current episode
Note
Pharmacy and enteral authorization contacts
Pharmacy and enteral therapy prior authorizations require submission to the Pharmacy Team or the enteral authorization process as specified; contact and e-fax information is provided for provider use.
Enteral therapy HCPCS B4034-B4162 require authorization (see Section IX)
Pharmacy e-fax for non-oncology prior authorizations: 1-844-235-5090
Oncology-related outpatient drug requests require review by Evolent (see Pharmacy Section and Section IX guidance)
Note
Voicemail HIPAA-compliance for detailed UM messages
Utilization Management (UM) voicemail messages containing detailed UM activity will only be left if the provider's voicemail is HIPAA-compliant. If voicemail is not HIPAA-compliant, a generic message will be left and a callback requested; UM will make a second attempt as required by Department of Health Reasonable Effort Policy.
Voicemail greetings must identify the mailbox owner, the owner's organization, and state that the mailbox is confidential and PHI can be left
If compliant, a detailed message will be left; if not, UM will leave a generic message and request a call back
Step Therapy
Oncology review/step program
Oncology medications and supportive agents administered outpatient require prior authorization and review by Evolent before dispensing or administration. Submit oncology-related requests per the Pharmacy/Oncology guidance.
Outpatient oncology-related drug requests are subject to Evolent review and prior authorization prior to dispensing/administration
Appendix I lists HCPCS codes that may require prior authorization; check Pharmacy Section IX and Evolent program instructions for submission pathways
Clinical eligibilityMembers over 18 may be eligible when TMS is administered using an FDA-cleared device per labeled indications with a confirmed diagnosis of major depressive disorder and failure to respond to multiple medication trials and evidence-based psychotherapy during the current episode.
How to submit requestsAuthorization requests for TMS can be submitted via email to qhcmbh@fideliscare.org, fax to 833-561-0098, or by phone at 1-888-FIDELIS following Behavioral Health prompts or extension 16072.
OB ultrasound (normal pregnancy)
Normal pregnancy OB ultrasound ruleFirst 4 OB ultrasounds for a normal pregnancy can be performed without authorization; five or more require authorization.
Relevant diagnosis codesThe policy lists the specific diagnosis codes (Z32.01, Z33.1, Z34.00-Z34.03, Z34.80-Z34.83, Z34.9-Z34.93) that define a normal pregnancy for this rule.
High-risk pregnancy exceptionOB ultrasounds for high-risk pregnancy diagnosis codes do not require authorization.
Appendix I (PA codes)
Appendix I purposeAppendix I lists codes requiring prior authorization and maps HCPCS/CPT/J/Q codes to specific drugs, biologics, implants, or services.
Code types includedAppendix I includes alphanumeric C-/J-/Q-/S- HCPCS codes and related mappings for drugs and biologics that require prior authorization.
Reference for providersProviders should reference Appendix I to determine which J- and Q- codes require prior authorization and submit supporting documentation per payer process.