CurrentFidelis CarePolicy N/A

Authorization and Coding Guidance — Prior Authorization, Utilization Review, and Coding Expectations

Governs prior authorization, utilization review, and coding expectations for a range of inpatient, outpatient, behavioral health, transplant, and DME services for Fidelis Care members (primarily New York State). Affects providers requesting authorization and billing for listed services.

Policy Summary

PayerFidelis Care

PolicyAuthorization and Coding Guidance — Prior Authorization, Utilization Review, and Coding Expectations

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2020

Next Review DateN/A

Key ActionObtain prior authorization for all inpatient admissions (post-stabilization) and for listed procedures/drugs; notify Fidelis within required timeframes for OMH/OASAS inpatient admissions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All inpatientrequire authorization

28 daysOASAS in‑network SUD no concurrent review

14 daysOMH <18 no concurrent review

40Home health max visits

60 visitsRehab/Habilitation limit

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Coverage and Medical Necessity Criteria

inv-01: OMH inpatient mental health utilization review triggers

Utilization review (admission and concurrent/continued stay) for OMH licensed inpatient mental health services will be conducted only for members who meet the following clinical criteria per NYS OMH Best Practice Manual:

OMH review triggers: Any of the following: (1) Individuals subject to a current Assisted Outpatient Treatment (AOT) court order; OR (2) Individuals who had an AOT court order that expired within the past five years; OR (3) Individuals with high utilization as evidenced by: three (3) or more psychiatric inpatient hospitalizations in the prior 12 months OR four (4) or more psychiatric ED visits in the prior 12 months OR three (3) or more medical inpatient hospitalizations in the prior 12 months; OR (4) Individuals readmitted to any mental health inpatient unit within thirty (30) days of discharge from a prior mental health inpatient admission; OR (5) Individuals not meeting any of the above triggers whose length of stay exceeds 30 days (concurrent review from Day 31 onwards).see text

Per NYS OMH Best Practice Manual

inv-02: OASAS inpatient SUD prior authorization and concurrent review suspension

Inpatient SUD (in-state, OASAS‑licensed, in‑network facilities): not subject to prior authorization and not subject to concurrent utilization review for the first 28 days provided ALL conditions are met:

OASAS in-state in-network SUD requirements: (1) Facility is OASAS licensed and participating in Fidelis Care's provider network; AND (2) Facility notifies Fidelis Care of the inpatient admission and the initial treatment plan within two (2) business days by fax or email using OASAS Appendix A and LOCADTR; AND (3) Facility performs daily clinical review of the patient (use of LOCADTR concurrent review module every day is not required); AND (4) Facility periodically consults with Fidelis Care starting on or just prior to day 14 to ensure LOCADTR use; AND (5) Prior to discharge, facility provides a written discharge plan and indicates whether services in the discharge plan are secured or reasonably available.28 days without concurrent review

Services may be subject to utilization review after day 28 or upon discharge; out-of-state or out-of-network facilities remain subject to prior authorization and concurrent review

inv-03: OMH under-18 inpatient review suspension criteria

Effective 01/01/2020: For OMH-licensed inpatient mental health treatment for members under 18 in-network, prior authorization is not required and concurrent review is suspended for the first 14 days if ALL apply:

OMH <18 admission requirements: (1) Facility notifies Fidelis Care of admission and the initial treatment plan within two (2) business days by completing and submitting the OMH 'Two-Day Notification and Initial Treatment Plan' form (fax: 833-561-0094 or email: Mental_Health_Admission@fideliscare.org); AND (2) Facility performs daily clinical review of the patient; AND (3) Facility participates in periodic consultation with Fidelis Care to ensure use of OMH‑approved evidence‑based clinical review criteria appropriate to patient age.14 days without concurrent review

Out-of-network inpatient mental health services remain subject to concurrent review throughout admission

inv-04: Home Health Care

Covered when medical necessity and program limits are met

Home Health Approval: Home care approvals are based on the medical need for skilled services.maximum 40 visits per plan year

inv-05: Hospice Care

Covered when program criteria are met

Hospice Care: Hospice care must be provided as part of a Hospice Care program certified pursuant to Article 40 of the N.Y. Public Health Law.coverage available up to 210 days when medically necessary

inv-06: Rehabilitation and Habilitation

Therapy services coverage limits

Rehabilitation: Benefit limited to 60 visits per condition per plan year; the visit limit applies to all therapies combined.60 visits per condition per plan year

Habilitation: Benefit limited to 60 visits per condition per plan year; the visit limit applies to all therapies combined.60 visits per condition per plan year

inv-07: OB Ultrasound Coverage

OB ultrasound authorization rules

Normal pregnancy ultrasounds: First four OB ultrasounds for a normal pregnancy do not require authorization; five or more ultrasounds for a normal pregnancy require authorization (uses listed diagnosis codes for normal pregnancy).>=5 ultrasounds

High-risk pregnancy ultrasounds: OB ultrasounds for a high‑risk pregnancy do not require authorization (uses listed high‑risk diagnosis codes).n/a

inv-08: Low Back Pain - Not Covered Services

Not covered services for low back pain diagnosis

Low back pain exclusions: Prolotherapy; therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT fluoroscopic image guidance); therapeutic injections of steroids into intervertebral discs; and continuous or intermittent traction are not covered for members with a diagnosis of Low Back Pain.n/a

There are no out-of-network benefits under this policy. However, when a medically necessary service is not available from in-network providers, authorization will be provided for that service. Providers should follow standard prior authorization submission processes when seeking authorization for out-of-network providers in these limited circumstances.

Orthotics are explicitly listed as not covered under Durable Medical Equipment/Supplies. Do not request prior authorization for orthotics because they are excluded from benefits.

For members with a diagnosis of Low Back Pain, the following services are not covered: 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. These exclusions apply regardless of place of service.

S codes are generally treated as benefit exclusions. Exceptions noted in the policy are S0013, S0190, S0191, and S9435, which are not excluded. For oral therapies normally billed with S codes, use the prescription benefit when appropriate. HCPCS codes for medications that are not FDA approved are also considered benefit exclusions.

Appendix I contains a detailed list of HCPCS/J/Q/C codes that require prior authorization. The appendix entries enumerate the codes and mapped drug/product entries but the excerpt does not include additional clinical criteria or explicit exclusions tied to each listed code within these chunks.

CPT 20610 (injection procedure) is explicitly identified as non-covered when billed with hyaluronic acid J-codes (for example J7318, J7320–J7332 as listed) for the indication of osteoarthritis of the knee (Diagnosis codes: M17, M17.0–M17.5, M17.9). In situations other than those combinations, 20610 does not require authorization.

Developmental testing code 96110 is specifically listed as a non-covered service. Developmental pediatric testing CPTs 96112 and 96113 require authorization; requests for psychological/neuropsychological testing (e.g., 96116, 96121, 96130–96139, 96146) must be submitted on the designated testing request form.

The policy explicitly identifies several procedures as not covered for members with Low Back Pain — see the Low Back Pain exclusions: prolotherapy; therapeutic facet joint steroid injections in the lumbar and sacral regions; therapeutic injections of steroids into intervertebral discs; and continuous or intermittent traction. These items are not reimbursable when the primary diagnosis is Low Back Pain.

Code Lists and Coding Rules

Transplant-related CPTsCPTCovered

32850
32851
32852
32853
32854
32855
32856
33930
33931
33932

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Outpatient surgery CPTs (selected)CPTCovered

43770	Bariatric surgery
43771
43772
43773
43774
43775
15820	Blepharoplasty
15821
15822
15823

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Additional outpatient surgery CPTsCPTCovered

65760-65775	Eyelid & ocular surgery range
66987
66988
66989
67900-67911
66991
68841
15830-15879	Abdominoplasty/lipectomy/panniculectomy range
15847
15876-15879

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Behavioral health codesmixedCovered

96116	Psychological/Neuropsychological testing
96121
96130-96139
96146
96112-96113	Developmental pediatric testing (authorization required); 96110 non-covered
90870	Outpatient ECT
H0035	Partial hospitalization HCPCS
H2013,90899,S9480	Intensive outpatient treatment related codes
Revenue 912,913,944,945,905	Partial/Intensive outpatient revenue codes
1001,1002	Residential treatment CPTs

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Diagnostic and gastroenterology CPTsCPTCovered

91110-91113	Wireless capsule and motility studies
43235,43239,43248,45378,45380,45384,45385,46255,46260,46270	GI procedures requiring authorization in POS19/22 if office/ASC available
43290	Authorization required in any POS
54405	Penile prosthesis
97037	Other listed service

DME codes: no-PA list and new no-PA additionsHCPCSCovered

A4287	DME not requiring authorization (selected list)
A4341
A4342
A4457
A4468
A4541
A4560
A4590
A6591
A7049

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Outpatient diagnostic and gastroenterology CPT codes requiring prior authorizationCPTCovered

43235	Esophagogastroduodenoscopy-related code listed as requiring authorization in POS 19 and 22 if office or ASC available
43239	Listed gastroenterology procedure requiring authorization in POS 19 and 22
43248	Listed gastroenterology procedure requiring authorization in POS 19 and 22
45378	Colon/colonoscopy-related code requiring authorization in POS 19 and 22
45380	Listed gastroenterology procedure requiring authorization in POS 19 and 22
45384	Listed gastroenterology procedure requiring authorization in POS 19 and 22
45385	Listed gastroenterology procedure requiring authorization in POS 19 and 22
46255	Listed gastroenterology procedure requiring authorization in POS 19 and 22
46260	Listed gastroenterology procedure requiring authorization in POS 19 and 22
46270	Listed gastroenterology procedure requiring authorization in POS 19 and 22

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DME codes not requiring prior authorization (partial list)HCPCS

A4287	DME code not requiring authorization (listed)
A4341	DME code not requiring authorization (listed)
A4342	DME code not requiring authorization (listed)

Glucose monitor/testing supply codesHCPCSCovered

A4253	Blood glucose monitor/testing supplies covered through prescription drug benefit
A9275	Blood glucose monitor/testing supplies covered through prescription drug benefit
E0607	Blood glucose monitor/testing supplies covered through prescription drug benefit
E2100	Blood glucose monitor/testing supplies covered through prescription drug benefit
E2101	Blood glucose monitor/testing supplies covered through prescription drug benefit

Therapeutic services and associated CPT/HCPCS codesmixedCovered

96567	Phototherapy
96573	Phototherapy
96574	Phototherapy
99183	Hyperbaric Oxygen Therapy
95249	Ambulatory continuous glucose monitoring

Chiropractic codes requiring prior authorizationCPTCovered

98940	Chiropractic service requiring prior authorization
98941	Chiropractic service requiring prior authorization
98942	Chiropractic service requiring prior authorization
98943	Chiropractic service requiring prior authorization

Pain management noteCPT

63622

Pain management code; does not require authorization for requests from orthopedic specialties

Interventional pain management codesCPTCovered

63650	Interventional pain management code requiring prior authorization
63655	Interventional pain management code requiring prior authorization

Appendix I: HCPCS/Codes requiring prior authorization (partial, many J- and C- codes listed)mixedCovered

C9047	Appendix I entry (codes requiring prior authorization)
C9096	filgrastim-ayow (Releuko) and related entries in Appendix I
J0207	amifostine (Ethyol) and related oncology/drug entries in Appendix I

Codes Requiring Prior AuthorizationHCPCSCovered

J0221	listed in Appendix I (multiple mappings shown in source)
J0222	listed in Appendix I
J0223	listed in Appendix I
J0224	listed in Appendix I
J0225	listed in Appendix I
J0256	listed in Appendix I
J0257	listed in Appendix I
J0270	listed in Appendix I
J0275	listed in Appendix I
J0490	listed in Appendix I

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Codes Requiring Prior Authorization (partial list)HCPCSCovered

J7518	listed mapping entries (see appendix)
J7520	listed mapping entries (see appendix)
J7527	listed mapping entries (see appendix)
J7599	listed mapping entries (see appendix)
J7607	listed mapping entries (see appendix)
J7609	listed mapping entries (see appendix)
J7610	listed mapping entries (see appendix)
J7622	listed mapping entries (see appendix)
J7624	listed mapping entries (see appendix)
J7626	listed mapping entries (see appendix)

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High utilization triggers

High-utilization psychiatric criteriaTriggers include: three (3) or more psychiatric inpatient hospitalizations in the prior 12 months; OR four (4) or more psychiatric ED visits in the prior 12 months; OR three (3) or more medical inpatient hospitalizations in the prior 12 months.

Readmission triggerReadmission to any mental health inpatient unit within 30 days of discharge triggers utilization review.

Length-of-stay triggerIndividuals not meeting other triggers whose length of stay exceeds 30 days will be subject to concurrent review beginning Day 31.

Provider Notifications, Prior Authorization & Submission Requirements

Denial Risk

Prior Authorization Required for Inpatient Admissions

All inpatient admissions require authorization. Emergency room services for stabilization do not require authorization, but post-stabilization services and inpatient admissions after ER care do. Notify Fidelis for inpatient admissions; new fax for Inpatient/ER notification: 833-663-1602. Inpatient rehabilitation services (acute, sub‑acute, skilled nursing rehabilitation) require prior authorization. Note: failure to obtain required inpatient authorization may result in claim denial.

All acute inpatient facility services require authorization
Inpatient Rehabilitation Services require prior authorization
New fax for Inpatient ER notifications: 833-663-1602

Denial Risk

Transplant Authorization Required

All solid organ and hematopoietic (bone marrow) transplants require authorization at the time of transplant evaluation. Providers must obtain authorization prior to transplant services to avoid claim denials.

Background and Scope

This policy provides operational authorization and utilization review guidance during the COVID-19 update period and incorporates state-specific rules for OMH and OASAS licensed facilities. Key purposes are to: (1) define prior authorization requirements for inpatient and selected outpatient services; (2) describe temporary concurrent review suspensions and notification procedures for certain in‑state OMH and OASAS inpatient admissions; and (3) list codes and drug/biologic mappings that require prior authorization (Appendix I). During the COVID-19 update, providers should follow the specified notification timeframes and use the forms/tools (e.g., LOCADTR, OMH Two‑Day Notification form) referenced in the policy when applicable.

Key Terms and Tools

LOCADTR definition and use

LOCADTR definitionLOCADTR is the OASAS medical necessity tool (LOCADTR Medical Necessity Tool) used for inpatient SUD clinical review and discharge planning; facilities must provide LOCADTR forms when notifying Fidelis.

Use during concurrent review suspensionLOCADTR is used to conduct utilization review after day 28 or upon discharge and to determine medical necessity and discharge planning.

Facility responsibilitiesFacilities must perform daily clinical review (not necessarily the LOCADTR concurrent review module every day) and consult with Fidelis starting on or just prior to day 14 to ensure LOCADTR use.

OMH Best Practice Manual triggers

OMH Best Practice Manual triggersUtilization review for OMH‑licensed inpatient, partial hospitalization, and intensive outpatient services is conducted only for members meeting NYS OMH Best Practice Manual triggers: AOT status (current or expired within 5 years), high utilization (see psychiatric/ED/medical thresholds), 30‑day readmission, or length of stay >30 days.

Policy Summary

PayerFidelis Care

PolicyAuthorization and Coding Guidance — Prior Authorization, Utilization Review, and Coding Expectations

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2020

Next Review DateN/A

Key ActionObtain prior authorization for all inpatient admissions (post-stabilization) and for listed procedures/drugs; notify Fidelis within required timeframes for OMH/OASAS inpatient admissions.

SourceLink

On This Page

Concurrent review suspension periods

OASAS inpatient SUD suspensionIn‑state, OASAS‑licensed, in‑network inpatient SUD services are not subject to concurrent utilization review for the first 28 days if the facility notifies Fidelis within two (2) business days and submits OASAS Appendix A and LOCADTR; facility must perform daily clinical review and consult with Fidelis starting on or just prior to day 14.

OMH <18 suspensionOMH‑licensed inpatient mental health for members <18: concurrent review is suspended for the first 14 days if the facility notifies Fidelis within two (2) business days using the OMH 'Two‑Day Notification and Initial Treatment Plan' form, performs daily clinical review, and participates in periodic consultation with Fidelis.

Notification requirementFacilities must submit required forms to the specified Fidelis fax/email numbers within the two‑business‑day window to qualify for the suspension periods.

OB ultrasound without authorization

Normal pregnancy allowanceThe first four (4) OB ultrasounds for a normal pregnancy can be performed without authorization.

High‑risk pregnancy exceptionOB ultrasounds for high‑risk pregnancies do not require authorization (high‑risk diagnosis codes listed in policy).

Diagnosis linkageNormal‑pregnancy ultrasounds subject to the four‑scan allowance use the listed Z32/Z33/Z34 diagnosis codes per the policy.

OB ultrasound requiring authorization

Authorization threshold for normal pregnancyFive (5) or more OB ultrasounds for a normal pregnancy require prior authorization.

Delegated radiology PAPrior authorization for many radiology services has been delegated to Evolent (NIA); cardiac ultrasounds are delegated to TurningPoint per the policy.

Authorization not required for high‑riskOB ultrasounds performed for high‑risk pregnancy diagnosis codes do not require authorization.

Therapy evaluation authorization

Initial therapy evaluationInitial therapy evaluations (designated initial evaluation CPT codes) do not require prior authorization.

Subsequent therapy servicesAll other therapy services performed after the initial evaluation require prior authorization prior to billing; if billing codes other than the initial evaluation codes are used, send authorization request to Evolent (NIA) within 1 business day for outpatient or 2 business days for home health, or to Fidelis within 1 business day for inpatient settings.

Speech therapy exceptionCPT codes 92610 and 92611 do not require prior authorization.

Includes (not limited to) listed transplant CPTs and related codes: e.g. 32850–32856, 33930–33941, 38204–38242, 44133–44136, 47133–47147, 48160, 48550–48556, 50300–50380, 50547, 65710–65757

Prior Authorization

Delegated Prior Authorization Programs

Fidelis delegates certain prior authorization programs to external vendor partners. When a CPT or service is delegated, authorization requests and associated device (HCPCS) reviews must be submitted to the delegated vendor per their process.

Musculoskeletal Management Program (effective 1/1/24) transitioned to Evolent (NIA) — orthopedic and spinal codes may be delegated to Evolent; associated devices (HCPCS) are reviewed by Evolent
ENT and some cardiac surgical procedure authorizations have been delegated to TurningPoint Healthcare Solutions (see outpatient surgery lists)
Radiology prior authorization has been delegated to Evolent (NIA)

Prior Authorization

Outpatient, Diagnostic & DME Authorization

Many outpatient, diagnostic, and DME services require prior authorization. Specific outpatient surgical categories (bariatric, blepharoplasty, breast reconstruction, dermatologic ambulatory surgery codes, certain ASC bill types, selected orthopedic/ENT/spinal procedures, etc.) and diagnostic testing (sleep studies, genetic testing, wireless capsule endoscopy, select GI procedures) require authorization. Durable Medical Equipment (DME) generally requires authorization except for explicitly listed codes.

Outpatient surgery categories requiring authorization include bariatric, blepharoplasty, breast reconstruction, specified dermatology/skin surgery CPTs when performed in ambulatory surgery settings, eyelid/ocular surgery, abdominoplasty/lipectomy, reduction mammoplasty, facial cosmetic procedures (some delegated to TurningPoint), vascular procedures, speech processor implants, spinal surgery, esophageal procedures, and other listed codes
Diagnostic testing requiring authorization: sleep studies (including home sleep), selected genetic testing (exceptions noted), wireless capsule endoscopy (91110–91113), select gastroenterology procedures when alternative office/ASC POS available; 43290 always requires authorization
DME/Supplies: orthotics not covered; many DME codes require authorization with a specific list of DME codes that do NOT require authorization (see next block)

Prior Authorization

New DME Codes Not Requiring Prior Authorization

The following Durable Medical Equipment (DME) and supply HCPCS codes do not require prior authorization. In addition, codes newly added as of 4/1/24 also do not require PA.

Current DME/Supply codes not requiring authorization include (partial list): A4287, A4341, A4342, A4457, A4468, A4541, A4560, A4590, A6591, A7049, E0130, E0135, E0168, E0182, E0184, E0235, E0274, E0305, E0310, E0424, E0431, E0434, E0439, E0492, E0570, E0575, E0580, E0602, E0603, E0621, E0655, E0660, E0677, E0711, E0776, E0890, E0900, E0942, E2001, E2361, E2363, K1035, K1036, L0130, L0140, L0150, L0160, L0170, L0172, L0174, L0180, L0190, L0200, L1652, L1681, L1902, L2132, L2134, L2136, L2210, L3100, L3221, L3702, L3762, L4350, L5991, L7360, L7362, L7364, L7366, L8678, S8421, S8424, V5010, V5020, V2625, V2626, V5266
New codes effective 4/1/24 not requiring PA: A4271, A4438, A4564, A4593, A4594, E0152, E0736

Documentation Required

Admission Notification and Required Forms

Providers must notify Fidelis and submit required forms for admissions and certain inpatient program notifications. Specific two‑day notification forms and OASAS/OMH notification processes apply for licensed SUD and pediatric mental health inpatient stays.

OASAS Inpatient SUD: facility must notify Fidelis within two business days using the OASAS Appendix A Notification Form and LOCADTR tool — fax/email to 833-663-1608 or LOCADTR@fideliscare.org. Facilities must provide written discharge plan prior to discharge and consult with Fidelis near day 14 of treatment
OMH pediatric inpatient mental health: facility must notify Fidelis within two business days via the OMH 'Two‑Day Notification and Initial Treatment Plan' form — fax: 833-561-0094 or email Mental_Health_Admission@fideliscare.org. Behavioral Health inquiries: 1‑888‑FIDELIS ext 16072
Admission notifications for inpatient/ER: fax 833-663-1602

Prior Authorization

Imaging & Therapy Authorization Timing

OB ultrasounds: first four ultrasounds for a normal pregnancy do not require authorization; five or more for a normal pregnancy require authorization. OB ultrasounds for high‑risk pregnancies do not require authorization. Outpatient therapy (PT/OT/ST): initial evaluations in office or facility do not require authorization, but all subsequent therapy services after the initial evaluation require prior authorization through Evolent (NIA). For therapy provided in the home, authorization must be requested within 2 business days; for outpatient settings, within 1 business day. For inpatient settings (POS 31 & 32), send therapy prior auth requests to fax 833-663-1611.

OB ultrasound rules: up to 4 for normal pregnancy without auth; 5+ require authorization; high‑risk pregnancy OB ultrasounds exempt from auth
Therapy authorization timing: Initial office/facility evaluations do not require auth. All services after the initial evaluation require authorization through Evolent (NIA). Authorization submission timing: outpatient setting — within 1 business day; home health — within 2 business days; inpatient settings — submit to Fidelis within 1 business day or fax to 833-663-1611 for POS 31/32
CPT codes 92610 and 92611 (speech codes) do not require prior authorization

Prior Authorization

Pharmacy & Oncology Prior Authorization Submission

Oncology medications and supportive agents require prior authorization from Evolent (formerly New Century Health) before dispensing or administration in outpatient/office/ambulatory settings. Some oncology review requests are excluded from Evolent review and should be submitted to Fidelis Pharmacy instead. Submit pharmacy prior authorization requests electronically or via e‑fax per directions.

Oncology PA requests: use Evolent/New Century Health portal (https://um.newcenturyhealth.com/) or call 1‑888‑999‑7713, option 1; check Fidelis website for the current oncology auth grid
Exclusions from Evolent review (do NOT send to Evolent): antibiotics, bone marrow/stem cell transplants, CAR‑T, certain specialty drugs (see policy exclusions list)
Pharmacy prior authorization submission: send prior authorization requests to Fidelis Pharmacy Team electronically or via e‑fax to 1‑844‑235‑5090

Denial Risk

Prior Authorization Required for Listed J/Q/HCPCS Codes

Many J‑codes, Q‑codes, and select HCPCS medication/device codes require prior authorization and are listed in Appendix I. Claims for these codes may be denied if prior authorization is not obtained. Providers must include supporting clinical documentation when submitting PA requests.

Appendix I contains extensive lists of J‑codes, Q‑codes and HCPCS requiring prior authorization (e.g., many oncology and injectable drugs such as J0221, J0256, J7518, J7520, J7622, J7624, J7634–J7643, J7680–J7686, etc.)
All 'Unlisted' or 'Temporary' codes (including C‑codes) require authorization
Failure to obtain prior authorization for listed codes risks claim denial
Provide clinical documentation as detailed in PA requirements (see documentation callout)

Documentation Required

Documentation Required for Prior Authorization

When submitting prior authorization requests, include comprehensive documentation to support medical necessity. Documentation should include relevant clinical notes, test results, treatment history, and any required forms (e.g., transplant evaluation documentation, LOCADTR for SUD, OMH two‑day form for pediatric mental health). Incomplete documentation may delay review or result in denial.

Include clinical rationale, prior treatments, diagnostic test results, and prognosis
For transplants: provide transplant evaluation documentation and program specifics
For OASAS/OMH programs: include completed notification forms and LOCADTR tool outputs where applicable

Note

UM Voicemail HIPAA Requirements

Voicemail left by Utilization Management staff may contain detailed UM information only if the provider's voicemail is HIPAA‑compliant. The mailbox greeting must identify the mailbox owner and organization, state confidentiality, and permit PHI. If not compliant, UM will leave a generic message requesting a callback and will make a second direct contact attempt as required by Department of Health Reasonable Effort Policy.

HIPAA‑compliant voicemail greeting must identify owner and organization and state mailbox is confidential and can accept PHI
If voicemail non‑compliant, UM will leave a generic message and request callback; a second attempt to reach provider directly will be made

Step Therapy

Oncology Step/Management Program

Oncology management and step therapy processes are in place: Evolent/New Century Health manages oncology medication reviews and has an auth grid of drugs requiring review. Providers should follow the oncology step/management program procedures and submit required clinical information to Evolent for medical review.

Evolent (NCH) handles oncology prior authorization and clinical management for outpatient-administered oncology drugs
Check Fidelis Care Pharmacy/Oncology resources for the current oncology authorization grid and program details

Applies across settingsThese triggers are referenced for inpatient, partial hospitalization, and intensive outpatient mental health services provided by OMH licensed programs.

Reference linkPolicy references the NYS OMH Best Practice Manual for full criteria and implementation guidance.

Rehabilitation vs Habilitation limits

Visit limitsRehabilitation and habilitation benefits are each limited to 60 visits per condition per plan year; the visit limit applies to all therapies combined.

Applies to PT/OT/STThe 60‑visit per condition per plan year limit applies across physical, occupational, and speech therapies as noted in the outpatient therapy section.

Authorization for services after evaluationServices performed after the initial therapy evaluation require prior authorization through Evolent (NIA), per the therapy authorization rules.

Home health benefit definition and use

Home health medical necessityHome care approvals are based on medical need for skilled services.

Benefit maximumHome health benefit has a maximum of 40 visits per plan year.

Authorization timing for home health therapyFor home health therapy services, authorization requests must be sent to Evolent (NIA) within 2 business days when billing codes beyond the initial evaluation are used.