This operational document sets forth Fidelis Care's prior authorization requirements and related processes for a broad range of services affecting providers requesting coverage for members in New York State. It is an operational guide describing which inpatient admissions and many outpatient, surgical, imaging, therapy, durable medical equipment, behavioral health and pharmacy services require prior authorization, and it identifies situations that are exempt from authorization or subject to modified review.
The policy enumerates vendor delegations and instructs providers to submit authorization requests to the delegated utilization management vendors where applicable: eviCore for radiology and radiation therapy services, National Imaging Associates (NIA) for outpatient therapy (PT/OT/ST) authorizations effective 10/1/2019, TurningPoint Healthcare Solutions for certain orthopedic and spinal procedure authorizations (delegation effective 12/23/2019), and New Century Health for oncology medications and supportive agents for adults. Providers must follow the submission routes and vendor portals or fax numbers specified by Fidelis Care and the delegated vendors.
The document also lists New York State–specific exceptions for licensed behavioral health facilities: In-network, NY State OASAS-licensed inpatient substance use disorder (SUD) facilities are not subject to prior authorization review and are exempt from concurrent utilization review during the first 28 days of admission when the facility notifies Fidelis Care of the admission and initial treatment plan within two business days (submission via Appendix A and LOCADTR forms). Similarly, inpatient mental health treatment for members under age 18 at participating NY State OMH-licensed hospitals are not subject to authorization review and are exempt from concurrent utilization review during the first 14 days when the facility completes the OMH two-day notification and initial treatment plan form and meets the notification and clinical-review requirements.
As an operational resource, the policy provides lists and examples of CPT/HCPCS/J/C codes and code ranges that require authorization, as well as a selected list of DME/HCPCS codes that do not require authorization. It also documents provider responsibilities such as obtaining authorization for all inpatient admissions (except emergency stabilization), following vendor-specific submission instructions, and meeting special documentation or attestation requirements (for example, ASD diagnostic attestation for residential treatment).