Prior Authorization and Coverage Criteria — Fidelis Care Medicaid/CHP/HealthierLife
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Operational and authorization guidance for Fidelis Care Medicaid/CHP/HealthierLife providers covering inpatient, outpatient, behavioral health, transplant, surgical, and substance use disorder services in New York State. Affects network and non-network providers rendering services to Fidelis Care members.
Applied Behavior Analysis (ABA) services are included in the Medicaid managed care benefit for members under age 21 and require prior authorization and enrollment of providers in NYS Medicaid.
First seven days of Intensive Outpatient Treatment and Mental Health Continuing Day Treatment do not require prior authorization; additional days require authorization.
PROS no longer requires prior authorization effective February 1, 2022.
Transcranial Magnetic Stimulation (TMS) covered with authorization required for CPT codes 90867-90869 with clinical criteria including adult MDD and failure of medication and psychotherapy.
Developmental screening CPT 96110 reimbursed without authorization in the first three years of life with specific limits and required diagnosis codes for Medicaid.
Coverage Criteria and Medical Necessity
Inpatient admissions
Covered when authorization obtained and medically necessary:
All facility admissions are reviewed for medical necessity; prior authorization fax number referenced in policy.
Inpatient SUD (OASAS) exemption
Inpatient SUD in-network OASAS-licensed facility coverage rules:
Facility must perform daily clinical review; periodic consultation with Fidelis Care begins on or just prior to Day 14; services may be subject to utilization review after Day 28 or upon discharge.
OMH inpatient mental health
OMH-licensed inpatient mental health coverage rules:
Notification via OMH Two-Day Notification and Initial Treatment Plan form is required; facility must perform daily clinical review and participate in periodic consultation to ensure use of approved clinical review criteria.
Out-of-network inpatient mental health services remain subject to concurrent review throughout the admission.
Notification fax/email details available in policy.
Outpatient surgery
Outpatient surgical/procedural authorization rules:
Refer to code lists in policy for code-level requirements and delegated vendors.
Exact HCPCS and ICD-10 codes are enumerated in the policy text.
Behavioral health testing
Behavioral health testing coverage stance:
ASD screening reimbursable up to two times beginning at 18 months; global delay screening up to once per year.
Partial Hospitalization medical necessity
Partial Hospitalization (PH) mental health treatment for all ages is covered when ALL of the following NYS OMH criteria are met:
Utilization review (admission and concurrent/continued stay) is conducted only for members meeting these criteria; out-of-network facilities are subject to concurrent review throughout admission.
Intensive Outpatient medical necessity
Intensive Outpatient (IOP) mental health treatment is covered under the following logic:
Authorization required for additional days beyond seven; concurrent review considerations apply from Day 31 for LOS triggers.
ABA coverage criteria
Applied Behavior Analysis (ABA) coverage conditions:
Prior authorization is required; Fidelis ABA authorization form is provided via policy link.
TMS coverage criteria
Transcranial Magnetic Stimulation (TMS) coverage conditions:
Authorization required for CPT codes 90867, 90868, and 90869; requests may be submitted via specified fax/email/phone for Behavioral Health.
Developmental screening coverage
Developmental screening coverage in first three years of life:
Screening should follow AAP/Bright Futures periodicity schedule (9, 18, 30 months for global delay; 18 and 24 months for ASD).
DXA authorization exceptions
DXA coverage exceptions and authorization rules:
Requests outside these age/diagnosis combinations require prior authorization.
OB Ultrasound Criteria
OB ultrasound coverage rules
High-risk pregnancy ICD-10 diagnosis codes are enumerated in the policy.
DXA Coverage Criteria
DXA scan coverage without authorization
Requests outside these criteria require authorization.
Therapeutic Services - Not Covered / PA
Therapeutic services requiring authorization or not covered
These services are explicitly listed as non-covered in the policy.
Oncology Pharmacy PA Criteria
Oncology and pharmacy PA delegation
Certain request types are excluded from Evolent review as enumerated in policy (e.g., antibiotics, bone marrow/stem cell transplants, CAR-T, inpatient drug requests).
Diabetes Self-Management Training
Diabetes Self-Management Training
No prior authorization required for covered DSMT services.
Asthma Self-Management Training
Asthma Self-Management Training
Group sessions limited to a maximum of eight patients.
Out-of-state or out-of-network facilities that are not OASAS‑licensed or that are outside Fidelis Care’s provider network must request prior authorization and remain subject to concurrent review for outpatient substance use disorder (SUD) services. In-network, in‑state outpatient SUD services (including office visits, clinic visits, intensive outpatient programs, outpatient rehabilitation, and opioid treatment programs) are exempt from prior authorization and concurrent review only when provided by in‑network OASAS‑licensed facilities and when facility notification requirements are met. Providers with questions should contact Fidelis Care Behavioral Health at 1‑888‑FIDELIS, extension 16072.
CPT 20610 (arthrocentesis/therapeutic injection; major joint) is explicitly non‑covered when billed together with the listed hyaluronic acid HCPCS products (J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332) for members with a diagnosis of osteoarthritis of the knee (ICD‑10 codes M17 series). In all other situations CPT 20610 does not require prior authorization.
Core Limited Health Related Services (CLHRS) provided by eligible 29‑I Health Facilities are covered on a per‑diem basis and include nursing, skill building LBHP, treatment planning and discharge planning, clinical consultation/supervision, and VFCA liaison/administration. No utilization review will be conducted for these CLHRS services when delivered by an eligible 29‑I Health Facility in accordance with the 29‑I Billing Guidance.
For members with a diagnosis of Low Back Pain, the policy lists several therapeutic services as not covered: prolotherapy; therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT fluoroscopic guidance); therapeutic steroid injections into intervertebral discs; and continuous or intermittent traction. These therapies should not be provided or billed for Low Back Pain under the medical benefit.
Certain request types are excluded from Evolent (Oncology) review and should not be submitted to Evolent. Exclusions include: antibiotics; bone marrow/stem cell transplants and CAR‑T cell therapy; specified individual products (for example, Cablivi); controlled substances; equipment requests; genetic laboratory testing and lab services; hemophilia drugs and immune globulins; inpatient drug requests; iron preparations; pain medications; radiopharmaceuticals; surgeries/surgical procedures; and sickle cell diagnoses. These requests must be handled outside the Evolent oncology review workflow per the policy.
Authorization is generally required for the J‑/HCPCS codes in Appendix I; however, an explicit exception applies to ophthalmic uses of bevacizumab. The policy states that authorization is not required for ophthalmic indications of bevacizumab (J9035 family). Providers should follow Appendix I mapping instructions for other J‑/HCPCS codes and note member‑type specific authorization footnotes where present.
Many procedures completed within a 24‑hour period will not be approved as inpatient level of care. These same procedures, when billed as outpatient and performed within the Fidelis Care network, generally do not require authorization. Providers should not assume inpatient status for short‑duration (≤24 hours) procedures; confirm place‑of‑service billing and consult the authorization grid for exceptions to avoid inpatient denials.
Selected gastroenterology procedures require prior authorization when performed in place of service 19 or 22 (off‑campus outpatient facility / off‑campus outpatient hospital) if an office‑based setting or ambulatory surgery center (ASC) is available to provide the service. The specified CPTs include 43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, and 46270; these procedures do not require authorization when performed in POS 11 (office) or POS 24 (ASC). Authorization is required for 43290 in any place of service.
Therapeutic facet joint steroid injections in the lumbar and sacral regions are specifically listed as not covered for members with a diagnosis of Low Back Pain. This represents an explicit not‑medically‑necessary (NMN) condition for those CPT/HCPCS services when the clinical indication is Low Back Pain.
All solid organ and bone marrow / tissue transplant procedures require prior authorization at the time of the transplant evaluation. The policy lists the transplant‑related CPT codes covered by this requirement (examples include 32850–32856; 33930–33945; 38204–38215; 38230–38242; 44133–44136; 47133–47147; 48160; 48550–48556; 50300–50380; 50547; 65710–65757). Providers must obtain authorization before proceeding with transplant evaluations and services.
Relevant Codes and Code Groups
| 38243 | Bone marrow transplant, unrelated donor (add-on) |
| 10040 | Incision and drainage of pilonidal cyst; simple |
| 11100 | Biopsy of single lesion, skin |
| 15011 | Excision of benign lesion of trunk, arms or legs; excised diameter 0.5 cm or less |
| 15012 | ... diameter 0.6 to 1.0 cm |
| 11300 | Shaving of epidermal or dermal lesion |
| 11400 | Excision of benign lesion including margins |
| 11730 | Avulsion of nail plate, partial or complete, simple |
| 11200 | Removal of skin tags, up to 15 |
| A2030 | Medicated dressing, each |
| A2031 | Disposable electrode |
| 96116 | Neurobehavioral status exam |
| 96121 | Neurobehavioral status exam by physician |
| 96130 | Psychological testing evaluation services by psychologist |
| 96131 | Psychological testing evaluation by technician |
| 96132 | Neuropsychological testing evaluation services |
| 96133 | Neuropsych testing by technician |
| 96136 | Psychological testing admin and scoring |
| 96137 | Psych test admin by technician |
| 96138 | Psychological testing administration complex |
| 96139 | Psychological testing admin by tech complex |
| 96116 | Neurobehavioral status exam |
| 96130 | Psychological testing evaluation services |
| 96136 | Psychological or neuropsych testing admin/scoring |
| 96146 | Psych testing interpretation report |
| 96121 | Physician neurobehavioral status exam |
| 96131 | Psych testing by technician |
| 96132 | Neuropsych testing eval |
| 96133 | Neuropsych testing by tech |
| 96137 | Psych test admin by technician |
| 96138 | Psych testing complex |
| 43290 | Esophagogastroduodenoscopy with single/double balloon |
| 45384 | Colonoscopy, biopsy or polypectomy complex |
| 91110 | Wireless capsule endoscopy, esophagus |
| 91111 | Wireless capsule endoscopy, small intestine |
| 46270 | Local excision of lesion of rectum |
| 45380 | Colonoscopy, removal of tumor |
| 43235 | Esophagoscopy with dilation |
| 45378 | Colonoscopy with removal of foreign body |
| 42975 | Laryngoplasty |
| Z32.01 | Pregnancy test positive |
| Z34.00 | Encounter for supervision of normal first pregnancy |
| Z33.1 | Pregnancy with uterine scar from previous surgery |
| O09.00 | Supervision of high-risk pregnancy |
| O36.80X0 | Pregnancy complication, fetus not specified |
| Z34.9 | Encounter for supervision of normal pregnancy, unspecified |
| J0887 | Epoetin beta, ESRD (Mircera) mapping noted in appendix |
| J0888 | Epoetin beta, non-ESRD |
| J0889 | Daprodustat oral, ESRD mapping |
| J0897 | Denosumab (Prolia, Xgeva) mapping |
| J0901 | Vadadustat mapping (Vafseo) |
| J0911 | Taurolidine/heparin mapping |
| J1072 | Testosterone cypionate injection mapping |
| J1075 | Oritavancin mapping |
| J1096 | Dextenza insert mapping |
| J1201 | Cetirizine (Quzyttir) mapping |
| J2350 | Immune globulin mapping (example from appendix) |
| J2351 | Immune globulin mapping |
| J2353 | IVIG mapping |
| J2356 | Immune glob over 10cc mapping |
| J2323 | Immune glob mapping (C9145 group) |
| J2326 | Immune glob mapping (J0879 group) |
| J2327 | Immune glob mapping (J0887 group) |
| J2329 | Immune glob mapping (J0888 group) |
| J2358 | IVIG mapping |
| J2370 | IVIG mapping |
Provider Actions, Authorization & Documentation
Inpatient authorizations
All inpatient admissions require prior authorization. Emergency room services and emergency stabilization do not require authorization, but post-stabilization services and any inpatient admissions following ED care do require authorization. Facilities must notify Fidelis Care within required timelines and failure to obtain authorization may result in denial of coverage.
- New fax number for Inpatient ER: 833-663-1602 (formerly 347-868-6411)
Transplant authorization
Authorization is required at the time of transplant evaluation for all solid organ and bone marrow/tissue transplants. Lack of authorization at transplant evaluation may lead to claim denial.
Outpatient surgery preauthorization
Multiple outpatient surgery and procedure CPT/HCPCS codes require prior authorization; some authorization responsibilities are delegated to partner vendors (e.g., TurningPoint, Evolent) as noted. For CPT codes delegated to TurningPoint or Evolent, requests should be submitted to the delegated vendor per their instructions.
- Selected categories requiring authorization include bariatric surgery, blepharoplasty, breast reconstruction/mammoplasty, skin surgery (selected CPTs when performed as ambulatory surgery POS 24), eyelid & ocular surgery, abdominoplasty/lipectomy/panniculectomy, facial cosmetic/septoplasty/rhinoplasty, vascular procedures, spine surgery, CAR-T therapy, hernia repair, and others listed in Section III.
- For CPT codes delegated to TurningPoint, submit prior authorization to TurningPoint Healthcare Solutions, LLC.
- For CPT codes delegated to Evolent (NIA), submit per Evolent instructions.
Partial Hospitalization authorization
Partial Hospitalization (PH) services require utilization review for admission and concurrent/continued stay. PH provided by OMH-licensed programs in NY are reviewed only when clinical criteria per NYS OMH Best Practice Manual are met. The first 7 service days do not apply here (see Continuing Day Treatment note) — ongoing concurrent review applies as described and services not meeting OMH criteria may be denied.
- Rate codes: 4349–4363 and revenue codes 912, 913. HCPCS: H0035 and S9484.
- Clinical criteria triggers include AOT court orders, high utilization (3+ psych inpatient hospitalizations or 4+ psych ED visits in prior 12 months, or 3+ medical inpatient hospitalizations), readmission within 30 days, or length of stay >30 days (concurrent review from Day 31).
- Requests for members under 21: email chmmc@fideliscare.org or fax 833-663-1604; phone 1-888-FIDELIS and follow Children's Medicaid prompts.
Outpatient diagnostic prior authorization
Outpatient diagnostic testing and selected gastroenterology procedures require prior authorization. Some genetic tests and radiology services are excluded or have specific rules; wireless capsule endoscopy and wireless motility capsule require authorization. Gastroenterology procedures listed require authorization when performed in POS 19 or 22 if an office or ASC is available; certain codes (e.g., 43290) require authorization in any POS.
- Sleep studies (including home sleep studies) require authorization.
- Wireless Capsule Endoscopy: CPT 91110, 91111; Wireless Motility Capsule: 91112, 91113 require authorization.
- Gastroenterology: 43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270 require authorization in POS 19/22 when office/ASC available; 43290 requires authorization in any POS.
- Breast cancer/genetic testing: authorization not required for CPT 81244, 81329, 81331, 81336, 81420; CPT 81220 has lifetime limit of 1; CPT 81329 and 81336 combined limit of 1 per lifetime.
Therapy services authorization
Home and outpatient therapy services (PT, OT, ST) after the initial evaluation require prior authorization through Evolent (NIA). Inpatient therapy authorization requests must be faxed to the dedicated inpatient therapy fax. Non-therapy providers should request authorizations through Fidelis Care.
- Home & Outpatient PT/OT/ST (after initial evaluation) require PA through Evolent (NIA). Home therapy initial evaluation requires authorization.
- CPT 92610 and 92611 do not require prior authorization.
- For outpatient setting, authorization to Evolent (NIA) must be sent within 1 business day when billing codes other than initial evaluation codes.
- Inpatient therapy PA fax: 833-663-1611 (formerly 716-803-8307).
- Requests for inpatient therapy should be submitted to Fidelis; non-therapy providers (MD/DO/DPM) must request authorization directly through Fidelis Care.
DME and supply authorization
Durable medical equipment (DME) and specific medical supplies may require authorization — rules differ by product, member line of business, and place of service. Refer to the Medicaid DME Program Manual and the Fidelis lists for codes that require authorization. Certain supply codes for MLTC require authorization.
- DME coverage guidance: https://www.emedny.org/ProviderManuals/DME/index.aspx
- Effective 4/1/23, specific DME supplies billed by physicians (POS 12/14) for Medicaid/HARP were transitioned to NYS FFS (NYRx) — see Medical Supply Procedure Codes & Coverage Guidelines.
- MLTC-only supply codes requiring authorization: A4335, A4554, T4521–T4524, T4529, T4530, T4533, T4535, T4537, T4539, T4540, T4543.
- T2101 (Donor Breast Milk) requires authorization only in outpatient setting.
Therapeutic Services PA
Prior authorization is required for a number of therapeutic services and procedures, including phototherapy, hyperbaric oxygen, selected pain management/interventional pain procedures, topical oxygen, radiation therapy (delegated to Evolent), ambulatory continuous glucose monitoring, RFA of uterine fibroids, bronchial thermoplasty, and other listed therapies.
- Phototherapy CPTs: 96567, 96573, 96574, 96900, 96910, 96912, 96913, 96920–96922.
- Pain management and interventional pain CPTs include a wide range (e.g., 20526, 20550–20553, 27096, 62263–62290, 62320–62327, 64400–64530, 64553–64595, 64600–64640, 64618–64640); select interventional pain CPTs: 63650, 63655, 63661–63664, 63685, 63688 and specified HCPCS (C1778, C1787, C1883, C1897).
- Topical oxygen requires prior authorization.
- Ambulatory CGM: 95249 requires prior authorization.
- Radiofrequency ablation of uterine fibroids: 58674 requires prior authorization.
- Bronchial Thermoplasty: 31660, 31661 require prior authorization.
- Radiation Therapy prior authorization delegated to Evolent (NIA).
Partial Hospitalization denial triggers
Partial Hospitalization and Intensive Outpatient services have specific denial triggers when authorization or clinical criteria are not met. Partial hospitalization services not meeting NYS OMH criteria may be denied; intensive outpatient days beyond the first seven require authorization and extended stays or days without authorization may lead to denial.
- PH denial triggers: services not meeting NYS OMH Best Practice Manual criteria (see PH callout) may be denied.
- IOP: No prior authorization needed for first seven days; additional days require authorization — failure to obtain authorization for additional days may result in denial.
- All out-of-network PH and IOP services are subject to concurrent review throughout the admission.
TMS denial risk
TMS requests must document prior trials of medication and evidence-based psychotherapy during the current episode of illness and meet FDA-labeled indications (e.g., confirmed diagnosis of Major Depressive Disorder). Requests lacking documentation of medication and psychotherapy failure risk denial.
- Covered when using an FDA-cleared device and meeting clinical criteria including failure to respond to multiple medication trials and psychotherapy during the current episode.
- Authorization required for CPT codes 90867, 90868, 90869.
- Submit requests via email qhcmbh@fideliscare.org, fax 833-561-0098, or call 1-888-FIDELIS and follow Behavioral Health prompts (ext. 16072).
TMS step therapy requirement
TMS authorization requires documented trials of prior medications and psychotherapy (step therapy requirement) before authorization will be granted.
- Members over 18 eligible when TMS administered with FDA-cleared device and documented failure of multiple medication trials and evidence-based psychotherapy during the current episode of illness.
Prior authorization required for listed codes
Prior authorization is required for drugs and biologics listed in Appendix I and for J-/HCPCS codes enumerated in Appendix I prior to billing or administration. Oncology medications and supportive agents are reviewed by Evolent; pharmacy PA submissions to Fidelis Pharmacy Team must use the specified e-fax.
- Appendix I lists HCPCS/J-codes that require PA prior to service or administration; failure to obtain PA may result in claim denial.
- Oncology meds/supportive agents: submit to Evolent via their web portal or phone per Section IV(B).
- Submit PA requests to Fidelis Pharmacy Team via e-fax: 1-844-235-5090 for Appendix I items not under Evolent review.
- Authorization not required for ophthalmic bevacizumab (J9035 family) for ophthalmic indications (see Appendix notes).
Developmental screening documentation
Developmental screening (CPT 96110) is reimbursed under specific conditions and must include scoring and documentation using validated instruments. For Medicaid, 96110 must be billed with diagnosis Z13.41 or Z13.42 and follow the Bright Futures/AAP periodicity schedule; documentation must record objective scores and any delays.
- CPT 96110: No authorization required (excluding CHP). Reimbursed in the first three years of life and may be billed in addition to an E/M visit effective 4/1/2022.
- ASD screening may be reimbursed up to twice in the first three years (beginning at 18 months); global developmental delay screening reimbursed up to once per year in first three years.
- For Medicaid, bill CPT 96110 with Z13.41 (autism screen) or Z13.42 (screening for global developmental delays).
- Providers must score and document objective data from standardized, validated screening tools and record measurable parameters.
Respite services documentation
Short-term planned and crisis respite services have annual limits; respite beyond those limits requires medical necessity documentation including LPHA attestation and NYS DOH Children's HCBS Authorization and Care Manager Notification form. Submit required forms prior to rendering service to avoid claims disruption.
- Short-term Planned and Crisis Respite: annual limit of 14 days (1,344 15-minute units). Beyond this requires medical necessity.
- Required documentation: LPHA Attestation and NYS DOH Children's HCBS Authorization & Care Manager Notification Form.
- Submit by email to SM_Childrens_HCBS@fideliscare.org or fax 833-663-1604, or call 1-888-FIDELIS and follow Children's Medicaid prompts.
- Providers should not wait until initial authorization expires before requesting concurrent review; submit before end of existing authorization.
Inpatient therapy PA fax and routing
For inpatient therapy prior authorization requests, use the dedicated fax number and follow routing guidance to ensure timely processing. Non-therapy providers must request inpatient therapy authorizations through Fidelis Care.
- Inpatient therapy PA fax: 833-663-1611 (formerly 716-803-8307).
- For other inpatient prior authorization questions, contact Fidelis Care per standard UM channels.
Fidelis Care will utilize quality and case management oversight
Fidelis Care will utilize quality and case management oversight initiatives to manage outlier behavioral health member needs. Providers can reference Fidelis Care communications on the Behavioral Health Outliers Management Program for additional details.
- Effective 01/01/2020 Fidelis removed authorization for many outpatient SUD services in-network/in-state; for outlier management, Fidelis will use quality and case management oversight and may require authorization for out-of-state or out-of-network services.
Member-specific authorization notes
Some codes in Appendix I contain member-type or line-of-business specific authorization notes (for example, CHP exceptions or authorization requirements that differ by NYM/HARP/CHP). Review Appendix I entries and section notes carefully before submission.
- Examples: authorization may be required for CHP members but not for NYM or HARP for select drugs; ophthalmic bevacizumab (J9035 family) is noted as not requiring authorization for ophthalmic indications.
- Maximum unit edits apply to all HCPCS codes regardless of authorization status.
Background and Scope
This policy provides administrative and utilization management guidance across a broad range of services and settings, including inpatient admissions, inpatient behavioral health (OMH/OASAS), outpatient procedures, surgical services, diagnostic testing, therapeutic services, transplant evaluations, and pharmacy/oncology review. Key operational rules include: all non‑emergent inpatient admissions require prior authorization (emergency stabilization is exempt); in‑network OASAS inpatient SUD facilities are exempt from concurrent review for the first 28 days when notification and required forms are submitted; OMH‑licensed inpatient admissions for members under 18 are exempt from concurrent review for the first 14 days with timely notification; many outpatient procedures and specific J/HCPCS codes require prior authorization or delegated review by vendor partners (Evolent/TurningPoint); and delegated oncology/pharmacy review processes and Appendix I coding mappings govern prior authorization for many specialty drugs.
Definitions and Key Terms
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