Fidelis Care Prior Auth & Coverage Rules

Coverage Criteria and Authorization Rules

Inpatient Admissions

Covered when authorization is obtained and medical necessity is established

Inpatient admissions requirement: All inpatient admissions require an authorization; emergency room services or emergent stabilization do not require prior authorization, but post-stabilization services and inpatient admissions after ER completion do require authorization.

All facility admissions are reviewed for medical necessity

Inpatient SUD (OASAS) Exception

Exception for in-state, in-network OASAS-licensed facilities when notification/timely documentation is provided

OASAS SUD in-state/in-network exemption: Inpatient SUD services provided by New York State OASAS‑licensed facilities participating in Fidelis Care's network are not subject to prior authorization or concurrent utilization review for the first 28 days of the admission provided the facility notifies Fidelis Care of the admission and initial treatment plan within two business days and performs daily clinical review; periodic consultation with Fidelis Care begins on or just prior to day 14.28 days

Services may be reviewed after 28 days or retrospectively; facilities must provide written discharge plan prior to discharge and indicate whether post‑discharge services are secured or reasonably available

Inpatient Mental Health (OMH) Exception

Exception for OMH-licensed hospitals treating members under 18 in-state and in-network

OMH pediatric inpatient exemption: Inpatient mental health treatment for members under age 18 provided by OMH‑licensed hospitals in New York State participating in Fidelis Care's network are not subject to prior authorization or concurrent utilization review for the first 14 days of the admission provided the facility 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, performs daily clinical review, and participates in periodic consultation to ensure use of approved clinical review criteria.14 days

Inpatient mental health services for members 18 and older continue to require prior authorization and concurrent review; out‑of‑state and out‑of‑network providers must request prior authorization for all ages

Behavioral Health - Outpatient

Most outpatient behavioral health services do not require authorization except specified services

Behavioral health services requiring authorization: Authorization is required for psychological/neuropsychological testing (e.g., 96116, 96121, 96130-96133, 96136-96139, 96146), developmental pediatric testing (96112, 96113), outpatient ECT (90870), partial hospitalization (revenue codes 912, 913, 944, 945; HCPCS H0035), and certain intensive outpatient treatments (bill type 131, revenue 905 or 912, CPT 90899, S9480, HCPCS H2013).

Authorization requirement has been removed for other outpatient behavioral health services

Imaging / OB Ultrasounds

OB ultrasound authorization rules

OB ultrasound authorization: For a normal pregnancy, the first four OB ultrasounds can be performed without authorization; five or more ultrasounds require authorization. OB ultrasounds for high‑risk pregnancies do not require authorization.4 ultrasounds

High‑risk pregnancy diagnosis codes (examples listed) are exceptions

Outpatient Therapy

Therapy authorization rules

Outpatient therapy authorization: Initial evaluation for physical, occupational, and speech therapy does not require prior authorization; all subsequent visits require authorization, including swallow function and therapy.

Members enrolled in Fidelis Dual Advantage Flex (Plan 017) have separate annual dollar limits

Outpatient Therapy

Covered outpatient therapy services with authorization requirements and member limits

Outpatient therapy authorization rules: Initial evaluation does not require prior authorization; all subsequent therapy visits require authorization. Swallow function and therapy visits also require authorization.

Members in Fidelis Dual Advantage Flex (Plan 017) have a $2,010 annual dollar limit for Physical & Speech combined and a $2,010 annual dollar limit for Occupational Therapy

Medical Nutrition Therapy (MNT)

MNT coverage for diabetes or renal disease

MNT coverage: Medical nutrition therapy by a licensed nutrition provider is covered when billed with specified diabetes or renal disease ICD‑10 diagnoses; eight visits per year are covered without authorization using codes 97802/97803 or G0270/G0271.8 visits/year

Applicable ICD‑10 diagnosis codes are listed in the policy

Diabetes Self-Management Training (DSMT)

DSMT coverage

DSMT coverage: Members are allowed 10 hours (20 units) of Diabetes Self‑Management Training in a continuous 12‑month period; services must be provided by certified providers and no longer require authorization. Services are covered when billed.10 hours/20 units per 12 months

Not covered — specific services

Explicit noncovered items for Low Back Pain

Not covered for Low Back Pain: The following are not covered for members with a diagnosis of Low Back Pain: prolotherapy; therapeutic injections of steroids into intervertebral discs. Topical oxygen is also not a covered service.

In-state, in-network facilities licensed by OASAS for substance use disorder (SUD) and OMH-licensed inpatient mental health hospitals treating members under age 18 are eligible for limited prior authorization and concurrent review exemptions when specific notification and documentation steps are followed. For OASAS-licensed inpatient SUD facilities, services are not subject to prior authorization or concurrent utilization review during the first 28 days of the admission provided the facility notifies Fidelis Care and submits the OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool within two (2) business days of admission, performs daily clinical review, and begins periodic consultation with Fidelis Care by about day 14; services may be reviewed after day 28 or retrospectively and a discharge plan must be provided prior to discharge (fax: 646-829-1421 or LOCADTR@fideliscare.org).

For OMH-licensed inpatient mental health treatment of members under age 18 at in-state, in-network hospitals, Fidelis Care will not conduct prior authorization or concurrent utilization review during the first 14 days of the admission if the facility: (1) notifies Fidelis Care and submits the OMH 'Two-Day Notification and Initial Treatment Plan' form within two business days (fax: 718-896-1784 or Mental_Health_Admission@fideliscare.org), (2) performs daily clinical review of the patient, and (3) participates in periodic consultation using evidence-based clinical review criteria approved by OMH. Inpatient services for members age 18 and older, out-of-state, and out-of-network providers remain subject to prior authorization and concurrent review.

Topical oxygen is explicitly listed as not a covered service and therefore is excluded from coverage and prior authorization consideration.

Certain Medicare-level HCPCS/Q/S codes and named products are noted in the Medicare section; when these codes are used for oncology indications and are identified with an asterisk in the listings, authorization is not required for those oncology indications.

Codes and Code-Based Rules

Transplant CPT codes requiring authorizationCPTCovered

32850-32856	Thoracic transplant procedures (examples)
33930-33945	Cardiac transplant procedures
38204-38215	Hematopoietic progenitor cell harvesting/packing
38230-38242	Stem cell transplant related procedures
44133-44136	Intestinal transplant procedures
47133-47147	Liver transplant procedures
48160	Pancreas transplant procedure example
48550-48556	Kidney/pancreas related transplant procedures
50300-50380	Genitourinary transplant procedures
50547	Transplant related procedure

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Outpatient surgery CPT codes requiring authorizationCPTCovered

43770-43888	Bariatric surgery
S2083	Bariatric device code
15820-15823	Blepharoplasty
11920-11971	Breast reconstruction (range)
19300	Breast surgery
19316-19342	Breast reconstruction techniques
19355	Breast nipple-areola reconstruction
19370-19396	Breast procedures range
10040	Outpatient skin surgery requiring auth in POS 24
11300-11313	Skin surgery codes requiring auth in POS 24

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Behavioral health CPT/HCPCS codes requiring authorizationmixedCovered

96116	Neurobehavioral status exam
96121	Neuropsych testing add-on
96130-96133	Psychological testing services
96136-96139	Psychological/Neuropsych testing
96146	Psych testing scoring/reporting
96112-96113	Developmental pediatric testing
90870	Outpatient electroconvulsive therapy (ECT)
Revenue 912,913,944,945	Partial hospitalization revenue codes
H0035	Partial hospitalization HCPCS
90899	Intensive outpatient CPT code example

Diagnostic and GI procedure codesCPTCovered

91110	Wireless capsule endoscopy
91111	Wireless capsule endoscopy — additional or variant
91112	Wireless motility capsule
43235	Esophagoscopy with intervention
43239	Esophagoscopy with dilation
43248	Esophagoscopy procedural
45378	Colonoscopy with biopsy
45380	Colonoscopy with removal
45384	Colonoscopy with mucosal resection
45385	Colonoscopy with other procedures

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DME codes not requiring authorization (examples)HCPCSNot Covered

A4604	Non-covered DME example
E0130	Crutch; underarm, other
E0135	Forearm crutch
E0168	Walker adjustable

Orthotic codes not requiring authorization (examples)HCPCSNot Covered

A4565	Orthotic example
A8000	Orthotic unspecified
L0220	Knee orthosis
L0861	Ankle-foot orthosis

OB ultrasound authorization examplesICD-10

Z32.01	Confirmed pregnancy, first trimester
Z33.1	Pregnant state

Therapeutic and pain management CPT codes requiring authorizationCPTCovered

96567	Phototherapy
96573-96574	Phototherapy ranges
96900	Phototherapy code
96910-96913	Phototherapy related
20526	Injection, tendon sheath, ligament — therapeutic
20550-20553	Injection procedures for tendon sheath/ligament
21073	Spinal stabilization procedure
27096	Injection/nerve block
62263-62264	Injection of diagnostic/therapeutic spinal procedures
62273	Other spinal injection procedures

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Telehealth HCPCS codes requiring authorizationHCPCSCovered

G2010	Remote evaluation of recorded video/ images
G2012	Virtual check-in

Medical Nutrition Therapy codes (covered without auth up to limits)CPTCovered

97802	Medical nutrition therapy; initial assessment
97803	Medical nutrition therapy; re-assessment
G0270	MNT group session
G0271	MNT individual session

Pharmacy injectable / J- and C-codes requiring prior authorization (examples)mixedCovered

C9047	caplacizumab-yhdp (Cablivi)
C9049	tagraxofusp (Elzonris)
C9050	emapalumab (Gamifant)
J0129	Injection product example
J0178	Injection product example
J0222	Injection product example
J1745	infliximab (Remicade) — example
J3591	Unclassified drug/biological — example

Medicare J-codes (examples)HCPCS

J0574

buprenorphine/naloxone oral

Medicare J-codes continued (examples)HCPCS

J1300	eculizumab (Soliris)
J1428	eteplirsen (Exondys)
J1745	infliximab (Remicade)
J3591	unclassified drug/biological
J7608	Respiratory drug example
J7296	Immunosuppressive drug example
J7311	Intravitreal implant example

Q- and S- codes and products (examples)HCPCS

Q5107	bevacizumab-awwb (Mvasi)
Q5115	rituximab-abbs (Truxima)
Q5118	bevacizumab-bvzr (Zirabev)
Q9991	buprenorphine ER (Sublocade) example
S4981	Levonorgestrel intrauterine system
S0191	misoprostol, oral (Cytotec)
S0126	follitropin alfa (Menopur)
G0516	Physician visit code example
G0517	Physician visit code example
G0518	Physician visit code example

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Provider Responsibilities, Submission & Authorization Processes

Prior Authorization

Therapeutic Services Prior Authorization

Specific therapeutic services require prior authorization. Submit requests before providing services to avoid denials or retrospective review.

Phototherapy (96567, 96573-96574, 96900, 96910, 96912, 96913, 96920)
Chiropractic services
Hyperbaric oxygen therapy
Pain management codes including injections and related procedures (examples: 20526, 20550-20553, 21073, 27096, 62263-62264, 62273, 62280-62282, 62290, 62310-62311, 62318-62319, 62320-62327, 63622, 63688, 64400-64530, 64553-64595, 64600-64640)
Note: 63622 and 63688 do not require authorization when requested by orthopedic specialties
Radiation therapy services require prior authorization through eviCore (see https://www.evicore.com/healthplan/fideliscare)
Ambulatory continuous glucose monitoring (95249) requires authorization
Bronchial thermoplasty (31660, 31661) and radiofrequency ablation of uterine fibroids (58674) require authorization

Background and Scope

This policy document summarizes Fidelis Care's prior authorization requirements and related temporary COVID-19 guidance for covered services, and highlights state-regulated exceptions for inpatient behavioral health and substance use disorder care. It distinguishes in-network/in-state exceptions (OASAS for inpatient SUD and OMH for pediatric inpatient mental health) from providers that remain subject to authorization (out-of-state or out-of-network), clarifies that all inpatient admissions otherwise require authorization and are reviewed for medical necessity, and references delegated or external authorization processes where applicable.

Definitions & Exceptions

OASAS / OMH exception summary

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 if the facility notifies Fidelis Care and provides the initial treatment plan within two business days and performs daily clinical review

OMH pediatric inpatient exceptionIn-state, in-network OMH‑licensed hospitals providing inpatient mental health treatment for members under 18 are not subject to prior authorization or concurrent review for the first 14 days if the facility submits the OMH Two‑Day Notification and Initial Treatment Plan within two business days, performs daily clinical review, and participates in periodic consultation

Exclusions to exceptionsFacilities outside New York State, out-of-network, or not OASAS/OMH‑licensed must request prior authorization and remain subject to concurrent review throughout admission

OpenPayer

Prior Authorization and Service Coverage Guidelines

Coverage Criteria and Authorization Rules

Codes and Code-Based Rules

Provider Responsibilities, Submission & Authorization Processes

Background and Scope

Definitions & Exceptions