OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentFidelis CarePolicy N/A

Authorization and Coverage Criteria — Administrative Prior Authorization and Coding Guidance

Customize your policy alerts

Sign up for all Fidelis Care policy alerts

Know when Fidelis Care releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Governs prior authorization, concurrent review, and coding guidance for inpatient admissions, outpatient procedures, behavioral health, diagnostic testing, DME, imaging, and therapy services for Fidelis Care members; affects in-network and out-of-network providers in the policy's jurisdiction.

Policy Summary

PayerFidelis Care

PolicyAuthorization and Coverage Criteria — Administrative Prior Authorization and Coding Guidance

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for all inpatient admissions and submit required notifications for OMH/OASAS exceptions within two business days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All inpatientinpatient authorization requirement

28 daysOASAS SUD exception

14 daysOMH pediatric MH exception

eviCoreRadiology vendor

4OB ultrasounds without auth

8MNT visits no auth

Service Coverage & Authorization Criteria

Service-specific coverage and authorization criteria

Covered or authorized when the following service-specific conditions are met:

OB Ultrasounds: First 4 OB ultrasounds for a normal pregnancy (encounter/supervision diagnosis codes listed) are covered without prior authorization; five or more ultrasounds for a normal pregnancy require prior authorization. OB ultrasounds for listed high-risk pregnancy diagnosis codes do not require authorization.4 without auth; >=5 requires auth

Normal and high-risk pregnancy diagnosis code lists are enumerated in policy.

Outpatient Therapy: Initial evaluation for physical, occupational, and speech therapy does not require prior authorization. All subsequent/outpatient therapy visits (including swallow function and therapy) require prior authorization.initial eval exempt; all other visits require auth

Members in Fidelis Dual Advantage Flex (Plan 017) have separate annual dollar limits for therapy services as specified in the policy.

Policy Summary

PayerFidelis Care

PolicyAuthorization and Coverage Criteria — Administrative Prior Authorization and Coding Guidance

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for all inpatient admissions and submit required notifications for OMH/OASAS exceptions within two business days.

SourceLink

On This Page

Therapeutic Services: Specific therapeutic services and codes (phototherapy, chiropractic, hyperbaric oxygen, specified pain management injection and procedure codes, ambulatory continuous glucose monitoring, radiofrequency ablation of uterine fibroids, bronchial thermoplasty) are addressed in the policy; many require prior authorization and select items are not covered for low back pain.service- and code-specific

Radiation therapy prior authorization is managed through eviCore; codes 63622 and 63688 are exempt from authorization when requested by orthopedic specialties. Prolotherapy and steroid injections into intervertebral discs are not covered for low back pain; topical oxygen is not covered.

The policy identifies specific therapeutic services that are either not covered or require authorization. Topical oxygen is explicitly noted as not a covered service. For members with a diagnosis of low back pain, prolotherapy and therapeutic steroid injections into intervertebral discs are not covered. Radiation therapy requires prior authorization through eviCore. Additional therapeutic services listed (phototherapy, chiropractic, hyperbaric oxygen, ambulatory CGM, radiofrequency ablation of fibroids, bronchial thermoplasty, and multiple pain management injection codes) are addressed elsewhere in the policy with service-specific authorization requirements.

CPT / HCPCS / ICD-10 Code Lists & Key Limits

Transplant codesCPTCovered

32850-32856	Transplant-related CPT range
33930-33945	Transplant-related CPT range
38204-38215	Bone marrow/transplant CPT range
38230-38242	Bone marrow/transplant CPT range
44133-44136	Transplant-related CPT range
47133-47147	Transplant-related CPT range
48160	Transplant-related CPT
48550-48556	Transplant-related CPT range
50300-50380	Transplant-related CPT range
50547	Transplant-related CPT

1–10 of 11

1/2

Outpatient surgery / skin / cosmetic codesCPT | HCPCSCovered

43770-43888	Bariatric surgery CPT range
S2083	Bariatric surgery HCPCS
15820-15823	Blepharoplasty CPT range
11920-11971	Breast reconstruction CPT range
19300	Breast reconstruction CPT
19316-19342	Breast reconstruction CPT range
19355	Breast reconstruction CPT
19370-19396	Breast reconstruction CPT range
10040	Skin surgery / ambulatory code
11300-11313	Skin surgery / ambulatory code range

1–10 of 23

1/3

Cosmetic / facial / ENT codesCPT | HCPCSCovered

69300	Ear repair
69090	Ear piercing
65760-65771	Eyelid & ocular surgery CPT range
65772-65775	Eyelid & ocular surgery CPT range
66987-66988	Ocular surgery CPT range
67900-67911	Ocular surgery CPT range
15830-15839	Abdominoplasty/lipectomy CPT range
15847	Abdominoplasty CPT
15876-15879	Abdominoplasty CPT range
19300	Reduction mammoplasty / breast CPT

1–10 of 21

1/3

Vascular proceduresCPTCovered

36465-36466	Vein procedures CPT range
36468-36479	Vein procedures CPT range
36482-36483	Vein procedures CPT range
37241-37244	Endovascular CPT range
37718-37785	Vascular surgery CPT range

Sinuplasty codesCPTCovered

31295	Sinuplasty CPT
31296	Sinuplasty CPT
31297	Sinuplasty CPT

Spinal surgery codesCPTCovered

20932	Spinal surgery related code
20933	Spinal surgery related code
20934	Spinal surgery related code
22867-22870	Spinal instrumentation CPT range
62380	Spinal injection / procedure CPT

Behavioral health outpatient codes requiring authorizationCPT | HCPCS | RevenueCovered

96116	Neuropsych testing
96121	Neuropsych testing
96130	Psych testing
96131	Psych testing
96132	Neuropsych testing
96133	Neuropsych testing
96136	Neuropsych testing
96137	Neuropsych testing
96138	Neuropsych testing
96139	Neuropsych testing

1–10 of 18

1/2

Diagnostic and GI procedure codesCPTCovered

91110	Wireless capsule endoscopy
91111	Wireless capsule endoscopy
91112	Wireless motility capsule
43235	GI endoscopic procedure
43239	GI endoscopic procedure
43248	GI endoscopic procedure
45378	Colonoscopy with biopsy
45380	Colonoscopy CPT
45384	Colonoscopy CPT
45385	Colonoscopy CPT

1–10 of 17

1/2

Orthotic codes not requiring authorization (partial list)HCPCS | CPTCovered

A4565	Orthotic code example
A8000	Orthotic code example
A8001	Orthotic code example
L0220	Orthotic code example
L0861	Orthotic code example
L0970	Orthotic code example
V2624	Orthotic code example

OB pregnancy diagnosis codes referenced for ultrasound rulesICD-10

Z32.01	Encounter for pregnancy ultrasound
Z33.1	Pregnant state
Z34.00-Z34.03	Supervision of normal first pregnancy
Z34.80-Z34.83	Supervision of other normal pregnancy
Z34.9-Z34.93	Supervision of pregnancy

OB pregnancy diagnosis codes referenced for ultrasound authorizationICD-10

Z32.01	Encounter for pregnancy test result
Z33.1	Pregnant state
Z34.00-Z34.03, Z34.80-Z34.83, Z34.9-Z34.93	Encounter for supervision of normal pregnancy
O09.00-O09.93	Supervision of high-risk pregnancy (range of O09 codes listed)
O36.80X0-O36.80X5, O36.80X9	Maternal care for fetal issues (examples listed)

Therapeutic / procedural CPT codes called outCPT

20526	Injection(s); trigger point(s)
95249	Ambulatory continuous glucose monitoring
58674	Radiofrequency ablation of uterine fibroids
31660	Bronchial thermoplasty
31661	Bronchial thermoplasty, additional

Telehealth codes requiring authorizationHCPCSCovered

G2010	Remote evaluation of recorded video and/or images
G2012	Brief communication technology-based service

MNT billing codes (8 visits/year without authorization)CPT|HCPCSCovered

97802	Medical nutrition therapy; initial assessment and intervention
97803	Medical nutrition therapy; re-assessment and intervention
G0270	MDT or group MNT components
G0271	Medical nutrition therapy, reassessment

Pharmacy/HCPCS/Codes list (injectables, biologics, implants)HCPCS|CPT|J-Codes|C-Codes

B4034-B4162	Enteral therapy HCPCS codes requiring authorization
C9048	Drug/biologic miscellaneous C-code examples (document lists associated J-codes/agents)
C9051-C9052	Additional C-codes with associated J-codes and agents
C9063-C9065	C-codes with specified biologic agents and J-codes
C9074	C-code entries with listed agents
C9257, C9399	More C-codes with associated J-codes/agents
G0516-G0518	Implant insertion/removal/reinsert codes with associated J-codes
J0129-J0179, J0222-J0223, J0270-J0275, J0476, J0517, J0570-J0575, J0584-J0588, J0593-J0598, J7200-J7212, J7296, J7188, J7202-J7209, J7210-J7212	Extensive list of J-codes mapped to specific drugs/agents in the pharmacy section

Pharmacy HCPCS/Q/S codes (selected entries)mixed

J7205	factor VIII Fc fusion protein recombinant (Eloctate)
J7207	factor VIII recomb pegylated (Adynovate)
J7208	factor VIII recomb pegyl (Jivi)
J7209	factor VIII recomb (Nuwiq)
J7210	factor VIII recomb (Afstyla)
J7211	factor VIIA (antihemophilic)
J7296	Sevenfact / mycophen mofet / CellCept and others (multiple entries)
J7300	intrauterine copper contraceptive and associated entries
J7304	contraceptive hormone patch
J7306	levonorgestrel implant

1–10 of 45

1/5

OB ultrasound count — first 4 without authorization

RuleFirst 4 OB ultrasounds can be performed without authorization; five or more ultrasounds for a normal pregnancy require prior authorization.

ScopeApplies to ultrasounds billed for normal pregnancy diagnosis codes (Z32.01, Z33.1, Z34.00–Z34.03, Z34.80–Z34.83, Z34.9–Z34.93).

ExemptionOB ultrasounds for listed high‑risk pregnancy diagnosis codes (O09.x series and O36.80x ranges) do not require authorization.

BRCA/genetic lifetime limits (CPT 81220, 81329, 81336 combined rules)

CPT 81220Authorization is not required; lifetime limit of 1.

CPT 81329Authorization is not required; combined lifetime limit of 1 with CPT 81336.

CPT 81336Authorization is not required; combined lifetime limit of 1 with CPT 81329.

OB ultrasound count — first 4 without authorization; 5+ require auth

Rule (duplicate)First 4 OB ultrasounds can be performed without authorization; five or more ultrasounds for a normal pregnancy require prior authorization.

Normal pregnancy DXsNormal pregnancy diagnosis codes include Z32.01, Z33.1, Z34.00–Z34.03, Z34.80–Z34.83, Z34.9–Z34.93.

High‑risk exceptionUltrasounds for high‑risk pregnancy diagnosis codes (O09.00–O09.93; O36.80X0–O36.80X5; O36.80X9) are exempt from authorization requirement.

MNT visits — 8 visits per year without authorization

Annual visit limitEight (8) Medical Nutrition Therapy (MNT) visits per year are covered without authorization when billed with 97802, 97803, G0270 or G0271.

Covered diagnosesMNT applies for diabetes (selected E10.x, E11.x, E13.x series) and specified pregnancy/renal diagnosis codes per policy.

Billing requirementClaims should use 97802/97803 or G0270/G0271 to reflect MNT visits for the annual limit to apply.

DSMT units — 10 hours / 20 units in 12-month period (no auth)

Allowed units/hoursDiabetes Self‑Management Training (DSMT) is allowed 10 hours (20 units) in a continuous 12‑month period and does not require authorization.

Provider requirementServices must be provided by certified DSMT providers as required by the policy.

Billing noteDSMT services are covered when billed to the plan and should reflect units/hours consistent with the 12‑month allowance.

Authorization Steps, Notifications & Denial Risks

Denial Risk

Inpatient Admissions Require Authorization

All inpatient admissions require prior authorization. Emergency department services and emergency stabilization do not require authorization; however any post-stabilization inpatient admission does. All facility admissions (medical, substance use, and behavioral health) are reviewed for medical necessity. Failure to obtain required inpatient authorization may result in claim denial or financial liability for the provider or member.

All inpatient facility services (medical, substance abuse, behavioral health) require authorization
Inpatient rehabilitation (acute, sub-acute, skilled nursing) requires authorization; acute/sub-acute permitted when skilled services provided
Emergency services/ED stabilization do not require authorization but post-stabilization inpatient admissions do

Prior Authorization

Transplants Require Authorization

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

Includes (but not limited to) CPT ranges listed in source (e.g., 32850-32856, 33930-33945, 38204-38215, 38230-38242, 44133-44136, etc.)

Prior Authorization

Orthopedic & Spinal Surgery Authorization (delegated)

Prior authorization is required for many outpatient orthopedic and spinal surgeries. As of 12/23/2019 prior authorization responsibility for many orthopedic/spinal codes has been delegated to TurningPoint Healthcare Solutions, LLC; TurningPoint will also review associated device HCPCS codes when applicable.

Certain outpatient and inpatient orthopedic and spinal surgery codes require prior authorization (see delegated list)
If a CPT code is delegated to TurningPoint, associated devices (HCPCS) are also reviewed by TurningPoint

Prior Authorization

Outpatient Surgery Prior Authorization Lists

A broad set of specified outpatient and cosmetic procedure codes require prior authorization when performed in outpatient or ambulatory surgical settings. Providers should check the listed CPT ranges and specific codes for procedures such as bariatric surgery, blepharoplasty, breast reconstruction, dermatologic ambulatory surgery codes, ear/ocular repairs, abdominoplasty, reduction mammoplasty, facial cosmetic procedures, vascular procedures, sinuplasty, and certain spinal surgery codes.

Ambulatory surgery center bill type 0831 procedures (e.g., 10060, 11100, 11900, 17000, 20600, 20605, 20610) require authorization
Many cosmetic/reconstructive codes and listed CPT ranges continue to require authorization regardless of place of service

Prior Authorization

Behavioral Health Outpatient Prior Authorization

Selected outpatient behavioral health services require authorization. This includes psychological and neuropsychological testing, developmental pediatric testing, outpatient ECT, partial hospitalization and intensive outpatient programs as indicated by the listed CPT/HCPCS/revenue codes.

Psychological/Neuropsychological Testing (e.g., 96116, 96121, 96130-96139, 96146) – authorization required and requests should use the testing request form
Developmental Pediatric Testing (96112, 96113) – authorization required; 96110 is non-covered
Outpatient ECT (90870) – authorization required
Partial Hospitalization and Intensive Outpatient Treatment – see revenue/CPT/HCPCS codes listed

Prior Authorization

Diagnostic & Radiology Prior Authorization

Many diagnostic tests and imaging studies require prior authorization depending on place of service. Radiology services require authorization via eviCore; OB ultrasound rules below outline authorization thresholds.

Radiology prior authorization is managed through eviCore (full CPT list at evicore.com/healthplan/fideliscare)
Certain GI endoscopy/GI procedures require authorization in POS 19 and 22 when an office or ASC is available; some genetic testing exceptions noted

Prior Authorization

OMH Two-Day Notification Requirement

Certain OMH-licensed inpatient mental health admissions for members under age 18 are not subject to prior authorization if the facility notifies Fidelis within two (2) business days using the OMH two-day notification and initial treatment plan form. Facilities must perform daily clinical review and participate in periodic consultation with Fidelis Care. Inpatient mental health services for members 18 and older continue to require authorization and concurrent review.

Submit OMH Two-Day Notification and Initial Treatment Plan form by fax to 718-896-1784 or email Mental_Health_Admission@fideliscare.org within two business days of admission
Facilities must perform daily clinical review and participate in periodic consultation; services remain subject to retrospective review

Prior Authorization

OASAS Notification & Discharge Planning

OASAS-licensed inpatient Substance Use Disorder (SUD) treatment in-network/in-state is not subject to prior authorization or to concurrent utilization review for the first 28 days if the facility notifies Fidelis within two (2) business days using the OASAS Appendix A Notification Form and LOCADTR tool. Facilities must provide a written discharge plan prior to discharge and may be subject to utilization review after day 28 or upon discharge.

Fax or email OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool to 646-829-1421 or LOCADTR@fideliscare.org within two business days
Out-of-state or out-of-network SUD providers must request prior authorization and are subject to concurrent review throughout admission

Prior Authorization

DME Authorization Exceptions

Durable Medical Equipment: a defined list of orthotic and DME HCPCS codes do not require authorization; all other DME/orthotic codes do require prior authorization.

DME/orthotic codes that do NOT require authorization include: A4565, A8000, A8001, L0220, L0861, L0970, L0972, L0974, L0976, L0978, L0980, L0982, L0984, L1010, L1020, L1030, L1040, L1050, L1060, L1070, L1080, L1085, L1090, L1100, L1120, L1240, L1250, L1260, L1270, L1280, L1290, L1600, L1610, L1620, L1630, L1650, L1660, L1810, L1820, L1902, L2180, L2182, L2184, L2190, L3650, L3710, L3913, L3919, L3921, L3923, L3925, L3929, L3931, L3933, L3935, L3995, L8010, L8035, L8300, L8310, L8320, L8330, L8400, L8410, L8415, L8417, L8420, L8430, L8435, L8440, L8460, L8465, L8470, L8480, L8485, L8505, V2624
Other DME and orthotic codes require authorization

Prior Authorization

Outpatient Therapy Prior Authorization

Outpatient therapy (physical, occupational, speech) initial evaluations do not require authorization, but all subsequent visits require prior authorization. Swallow function and related therapy visits are included. Specific plan members (Fidelis Dual Advantage Flex Plan 017) have separate annual dollar limits for therapy.

Initial evaluation: no prior authorization required
All follow-up therapy visits (PT/OT/ST), including swallow therapy, require authorization
Fidelis Dual Advantage Flex (Plan 017) annual limits: $2,010 combined PT+ST; $2,010 OT

Prior Authorization

Therapeutic Services Prior Authorization

Certain therapeutic services require prior authorization. Radiation therapy and many pain management and interventional procedures require authorization (radiation authorization managed via eviCore). Some procedures are excluded/not covered for low back pain (e.g., prolotherapy, steroid injections into intervertebral discs). Note: some spinal codes (63622, 63688) do not require authorization when requested by orthopedic specialties.

Therapeutic procedure codes listed (phototherapy, hyperbaric oxygen, pain management injections, TENS, epidural/spinal codes, radiofrequency ablation, bronchial thermoplasty, ambulatory continuous glucose monitoring 95249, etc.) require authorization as indicated
Radiation therapy prior authorization is via eviCore (full CPT list at evicore.com/healthplan/fideliscare)
63622 and 63688: authorization not required when request originates from orthopedic specialties
Prolotherapy and therapeutic intradiscal steroid injections are not covered for Low Back Pain
Topical oxygen is not covered

Prior Authorization

Telehealth Authorization

Telehealth brief communication codes G2010 and G2012 require authorization.

Claims billed with G2010 or G2012 require prior authorization

Prior Authorization

OB Ultrasound Authorization Rules

OB Ultrasound authorization rules: up to four OB ultrasounds for a normal pregnancy are allowed without authorization. Five or more ultrasounds for a normal pregnancy require authorization and should be supported by the pregnancy diagnosis codes listed. OB ultrasounds for high-risk pregnancies defined by the listed O09/O36 series and related codes do not require authorization.

First 4 OB ultrasounds for normal pregnancy do not require authorization
Five or more ultrasounds for a normal pregnancy require authorization
Normal pregnancy diagnosis codes include: Z32.01, Z33.1, Z34.00–Z34.03, Z34.80–Z34.83, Z34.9–Z34.93
High-risk pregnancy diagnosis codes (examples) include: O09.00–O09.03, O09.1–O09.13, O09.211–O09.213, O36.80X0–O36.80X5, etc.; ultrasounds with these dx codes do not require authorization

Prior Authorization

Unlisted / Temporary Codes Require Authorization

All services billed with Unlisted or Temporary codes (including C-codes and other temporary/unlisted codes) require prior authorization. Providers should submit documentation to justify medical necessity to avoid denials.

Unlisted/Temporary codes: authorization required (e.g., C-codes)
Failure to obtain authorization for unlisted/temporary codes may result in denial

Documentation Required

MNT and DSMT Provider Actions

Medical Nutrition Therapy (MNT) and Diabetes Self-Management Training (DSMT): MNT requires specific ICD-10 diagnosis codes to be eligible without authorization (list of diabetes and renal codes). Eight MNT visits per year are covered without authorization when billed with 97802/97803 or G0270/G0271. DSMT services (10 hours/20 units per 12-month period) are covered when provided by certified providers and no longer require authorization.

MNT: applicable ICD-10 codes include multiple diabetes codes (e.g., E10.*, E11.*, E13.* series) and renal disease codes (I12.0, I12.9, N18.1–N18.6, N18.9, etc.)
MNT coverage: up to 8 visits per year without authorization using codes 97802/97803 or G0270/G0271
DSMT: 10 hours/20 units in a continuous 12-month period; must be provided by certified providers and do not require authorization

Step Therapy

Pharmacy Prior Authorization & Enteral Therapy

Pharmacy prior authorization: Enteral therapy HCPCS codes B4034–B4162 require authorization and apply to Part B. Many injectable J/C/G/Q/S codes require prior authorization; some oncology and ophthalmic indications are exempt from authorization. Providers must submit prior authorization requests to the Pharmacy Team (e-fax 1-877-882-5892) and refer to the Fidelis formulary/step therapy criteria on the website.

Enteral therapy HCPCS B4034–B4162 require authorization (Part B benefit)
Numerous injectable codes (J/C/G/Q/S ranges and specific listed codes) require authorization; some oncology or ophthalmic indications are exempt
Authorization not required for certain oncology indications (*) and for ophthalmic indications where noted
Submit prior authorization requests to Pharmacy Team via e-fax: 1-877-882-5892
Refer to Fidelis formulary, prior authorization criteria and step therapy criteria on the Fidelis website

Policy Background

This document summarizes administrative prior authorization requirements and key exceptions across levels of care. All inpatient facility admissions require authorization; emergency department services for stabilization are not subject to prior authorization but subsequent inpatient admissions do require authorization. Certain state-regulated exceptions exist: OASAS-licensed in-state, in‑network inpatient substance use disorder facilities have an initial notification/clinical review process (first 28 days not subject to prior auth when requirements met), and OMH-licensed inpatient mental health treatment for members under 18 has a similar notification process (initial 14 days).

Outpatient categories frequently requiring prior authorization include specified outpatient surgeries and cosmetic procedures, radiology services (prior authorization via eviCore), many therapeutic and pain-management procedures, behavioral health outpatient services, and numerous pharmacy/enteral/ injectable items listed in the pharmacy section. Note that initial outpatient therapy evaluations (physical, occupational, speech) do not require prior authorization but all subsequent visits do.

Administrative expectations for providers: obtain required prior authorizations before non-emergent inpatient admissions or services requiring authorization; submit pharmacy prior authorization requests to the Pharmacy Team per the payer process (e-fax); and ensure required notification forms and documentation (for OMH/OASAS exceptions, OB ultrasound justification, MNT/DSMT credentialing and diagnosis codes, and enteral therapy/Part B HCPCS) are completed and submitted as specified. Failure to obtain prior authorization where required may result in review and potential denial of services.

Key Definitions & Regulatory Exceptions

OASAS / OMH exceptions — regulatory exceptions for in-state, in-network OASAS and OMH facilities

OASAS inpatient SUD exceptionIn‑state, in‑network OASAS‑licensed inpatient SUD facilities are not subject to prior authorization or concurrent review for the first 28 days of admission provided the facility notifies Fidelis Care within two business days and submits required forms (OASAS Appendix A, LOCADTR).

OMH pediatric MH exceptionIn‑state, in‑network OMH‑licensed inpatient mental health hospitals treating members under age 18 are not subject to prior authorization or concurrent review for the first 14 days if the facility notifies Fidelis Care within two business days using the OMH Two‑Day Notification form and meets documentation/consultation requirements.

Out‑of‑network/Out‑of‑stateFacilities outside New York State, not licensed by OASAS/OMH, or out‑of‑network remain subject to prior authorization and concurrent review throughout admission.

High‑risk pregnancy diagnosis codes (O09.x, O36.80x, etc.)

High‑risk pregnancy codes (examples)O09.00–O09.03, O09.1–O09.13, O09.211–O09.213, O09.219, O09.291–O09.293, O09.299, O09.33, O09.40–O09.43, O09.511–O09.513, O09.519, O09.521–O09.523, O09.529, O09.611–O09.613, O09.619, O09.621–O09.623, O09.629, O09.70–O09.73, O09.811–O09.813, O09.819, O09.821–O09.823, O09.829, O09.891–O09.893, O09.899–O09.93, O36.80X0–O36.80X5, O36.80X9.

UseThese diagnosis codes identify high‑risk pregnancies for which OB ultrasounds do not require prior authorization per the policy.

ContextHigh‑risk code list is used to determine authorization exemptions for imaging studies (OB ultrasounds).

MNT for diabetes or renal disease with specified ICD-10 codes

MNT target diagnosesMNT covered for diabetes (numerous E10.x, E11.x, E13.x codes), pregnancy diabetes codes (O24.x), and renal disease codes (I12.0, I12.9, N18.1–N18.6, N18.9, N28.9, N29, Z48.22, Z94.0).

MNT visit allowanceEight (8) visits per year without prior authorization when billed with 97802/97803 or G0270/G0271.

DSMT relationDSMT separate allowance: 10 hours/20 units in a continuous 12‑month period; DSMT must be provided by certified providers.