Prior authorization and utilization review requirements for inpatient and outpatient services
Defines which inpatient admissions, inpatient rehabilitation, transplants, elective surgeries, behavioral health, and specified outpatient procedures require prior authorization or are exempt; applies to Fidelis Care providers and facilities in New York State (with distinctions for in-network vs out-of-network and in-state vs out-of-state).
Behavioral Health Services are being carved into the MAP Plan benefit package effective 1/1/2023.
A long list of outpatient, DME, imaging, therapeutic, counseling and pharmacy services now require prior authorization or have delegated prior authorization to Evolent (NIA).
Specific DME and orthotic HCPCS codes are listed as not requiring prior authorization (effective 4/1/24 for some additions).
Outpatient PT/OT/ST after the initial evaluation require prior authorization through Evolent for dates of service on/after 10/1/2021; initial evaluations do not require authorization.
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.