ModifiedFidelis CarePolicy N/A

Prior Authorization Requirements for Inpatient, Outpatient, and Ancillary Services

This document describes Fidelis Care authorization requirements for inpatient admissions, specific outpatient surgeries and procedures, behavioral health services, durable medical equipment, imaging, therapy, and selected therapeutic services for members (New York-focused). It affects providers submitting claims and requests for authorization.

Policy Summary

PayerFidelis Care

PolicyPrior Authorization Requirements for Inpatient, Outpatient, and Ancillary Services

Policy CodePolicy N/A

Change TypeMaterial coverage and operational waivers added

Effective DateN/A

Next Review DateN/A

Key ActionProviders must notify Fidelis Care and submit the OMH Two-Day Notification or OASAS Appendix A and LOCADTR within two business days to qualify for early concurrent-review waivers.

SourceLink

POLICY UPDATE CHANGES

Effective 01/01/2020, in-state OMH-licensed inpatient mental health treatment for members under age 18 is not subject to authorization review for the first 14 days if notification and initial treatment plan are submitted within two business days.

Effective 01/01/2020, in-state OASAS-licensed inpatient substance use disorder (SUD) services are not subject to authorization or concurrent utilization review for the first 28 days if facilities notify Fidelis Care and submit LOCADTR tools.

Authorization for certain orthopedic and spinal surgical procedures delegated to TurningPoint Healthcare Solutions effective 12/23/2019 for dates of service on/after that date (authorization required starting 10/1/2019).

14 daysOMH waiver period (<18)

28 days

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Coverage Criteria and Medical Necessity

Behavioral Health / SUD Inpatient Waivers

Covered without prior authorization when ALL listed conditions are met for specified in-state licensed facilities

OMH inpatient mental health waiver (<18): Inpatient mental health treatment for members under age 18 provided by OMH‑licensed hospitals in New York State that participate in Fidelis Care's provider network are not subject to authorization review and concurrent utilization review for the first 14 days if: (1) the facility notifies Fidelis Care of the admission and initial treatment plan within two business days by completing and submitting the OMH 'Two‑Day Notification and Initial Treatment Plan' form via fax (718‑896‑1784) or email to the Fidelis Care mental health admission address, (2) the facility performs daily clinical review of the patient, and (3) the facility participates in periodic consultation with Fidelis Care using OMH‑approved, evidence‑based clinical review criteria appropriate to the patient's age to ensure ongoing medical necessity.14 days

Services may be reviewed retrospectively; out‑of‑state and out‑of‑network providers are not eligible for this waiver.

OASAS inpatient SUD waiver: Inpatient detoxification, inpatient rehabilitation and inpatient residential SUD services provided by OASAS‑licensed New York State facilities that participate in Fidelis Care's network are not subject to authorization review or concurrent utilization review during the first twenty‑eight (28) days of the inpatient admission if: (1) the facility notifies Fidelis Care of the inpatient admission and the initial treatment plan within two business days of admission by faxing or emailing the OASAS Appendix A Notification Form and the OASAS LOCADTR medical necessity tool to the designated Fidelis contacts, and (2) the facility performs daily clinical review and uses the LOCADTR tool; utilization review may occur after the 28th day and all services may be reviewed retrospectively.28 days

Facilities outside New York State, not OASAS‑licensed, or out‑of‑network must request authorization and remain subject to concurrent review.

Inpatient Admissions

Covered when ALL of the following are met

Inpatient admission authorization: All inpatient admissions (medical, substance abuse, behavioral health) require prior authorization; emergency room services required for stabilization do not require authorization, but post‑stabilization inpatient admissions do and all facility admissions are reviewed for medical necessity.

Acute, sub‑acute and skilled nursing rehabilitation services also require authorization where applicable.

Outpatient Therapy

Authorization requirements for outpatient therapy

Therapy visits: Initial evaluations for physical, occupational, and speech therapy do not require authorization; all subsequent therapy visits require prior authorization, including swallow function therapy.

Some plans (e.g., Fidelis Dual Advantage Flex) have separate annual dollar limits for therapy services.

General coverage notes

Coverage notes and conditions from document excerpt

Therapeutic services coverage notes: Phototherapy, chiropractic services, hyperbaric oxygen, pain management procedures (including listed injection and spinal codes), ambulatory continuous glucose monitoring (95249), bronchial thermoplasty (31660, 31661), and radiofrequency ablation of uterine fibroids (58674) are referenced with varying authorization or coverage rules. Radiation therapy requires authorization through eviCore. Topical oxygen is explicitly not a covered service.

Some spinal/neurosurgical codes (63622, 63688) do not require authorization when requested by orthopedic specialties; see individual code groups and vendor authorization requirements for specifics.

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 prior authorization. DSMT services are billed with codes G0108 and G0109.10 hours/20 units

Medical Nutrition Therapy (MNT)

MNT coverage

MNT Coverage: Medical Nutrition Therapy visits per year are covered without prior authorization when billed with codes 97802 or 97803, or G0270 and G0271. MNT provided by a licensed nutrition provider is covered for members with a diagnosis of diabetes.

Topical oxygen is explicitly listed as a non-covered therapeutic service. Providers should not bill topical oxygen applications as covered services for Fidelis Care members.

Topical oxygen is not a covered service under the therapeutic services section; this treatment is excluded from coverage and should not be authorized or billed to Fidelis Care.

For members with a diagnosis of Low Back Pain, the policy identifies specific non-covered procedures: therapeutic injections of steroids into intervertebral discs are not covered. Additional pain management and injection codes are listed separately with varying authorization requirements; confirm coverage before provision.

Certain listed drugs and biologics include an authorization exception for oncology indications. Items marked with an asterisk in the Medicare drug/J-code lists do not require prior authorization when used for oncology indications.

Authorization is not required for items used for ophthalmic indications where noted. Entries marked with a double asterisk in the listed Q- and S-code sections are exempt from prior authorization for ophthalmic use.

Code 96110 is specifically identified in the document as a non-covered service and should not be submitted for reimbursement under Fidelis Care benefits.

The policy denotes several specific items as not covered, including topical oxygen. It also calls out particular injections for Low Back Pain (for example, steroid injections into intervertebral discs) as not covered; providers must refer to the therapeutic services list for full details before providing or billing these treatments.

Codes and Code Tables

Provider Actions, Authorization Processes, and Denial Risks

Prior Authorization

Inpatient admissions — Authorization required

All inpatient admissions (medical, substance use disorder, behavioral health) require prior authorization. Emergency department stabilization services do not require authorization, but post-stabilization inpatient admissions do and will be reviewed for medical necessity. Inpatient rehabilitation (acute, sub‑acute, skilled) and inpatient mental health for members age 18+ require authorization; OMH‑licensed inpatient mental health for members under 18 and OASAS‑licensed in‑state inpatient SUD have specific notification/authorization exceptions (see items below).

Documentation Required

OASAS notification requirement

Effective 01/01/2020, OASAS‑licensed, in‑state, in‑network inpatient SUD facilities are not subject to Fidelis Care authorization or concurrent utilization review for the first 28 days of admission provided the facility notifies Fidelis Care and submits the initial treatment plan within two business days. Facilities must fax or email the OASAS Appendix A Notification Form and the LOCADTR Medical Necessity Tool to Fidelis Care, perform daily clinical review, and periodically consult with Fidelis Care beginning by day 14. Out‑of‑state, non‑OASAS‑licensed, or out‑of‑network facilities must request authorization and are subject to concurrent review.

Background and Policy Scope

This policy establishes Fidelis Care authorization workflows and special-case waivers for behavioral health and substance use disorder inpatient services in New York State. For OMH-licensed inpatient mental health treatment of members under age 18 and in-state OASAS-licensed inpatient SUD services, the document provides time-limited waivers of concurrent authorization provided specified notification and documentation requirements are met. Facilities must notify Fidelis Care and submit the required OMH Two-Day Notification form or OASAS Appendix A Notification/LOCADTR tool within two business days, perform daily clinical review, and participate in periodic consultation with Fidelis Care; these operational details are prerequisites to the waiver periods.

Definitions and Tools

LOCADTR (SUD clinical review tool)

LOCADTR definitionA clinical medical necessity review tool (LOCADTR) required for inpatient SUD treatment determinations and referenced for notification and clinical review processes.

Use in OASAS waiverOASAS‑licensed inpatient SUD facilities must submit the LOCADTR tool with the Appendix A Notification Form to qualify for the 28‑day waiver.

Clinical review roleLOCADTR is used by facilities to perform daily clinical review and may be used retrospectively by Fidelis Care for utilization review after 28 days.

Two‑Day Notification and Initial Treatment Plan (OMH)

Two‑Day Notification formAn OMH‑developed 'Two‑Day Notification and Initial Treatment Plan' form must be completed and submitted within two business days of admission for OMH‑licensed inpatient mental health treatment of members under 18.

Submission methods

Policy Summary

PayerFidelis Care

PolicyPrior Authorization Requirements for Inpatient, Outpatient, and Ancillary Services

Policy CodePolicy N/A

Change TypeMaterial coverage and operational waivers added

Effective DateN/A

Next Review DateN/A

Key ActionProviders must notify Fidelis Care and submit the OMH Two-Day Notification or OASAS Appendix A and LOCADTR within two business days to qualify for early concurrent-review waivers.

SourceLink

On This Page

Prior Authorization

DME authorization scope

Durable medical equipment (DME) and orthotic authorization scope: the listed codes do NOT require authorization; all other DME and orthotic codes require prior authorization.

DME codes not requiring authorization include: A4604, E0130, E0135, E0168, E0182, E0184, E0235, E0274, E0305, E0310, E0424, E0431, E0434, E0439, E0570, E0575, E0580, E0621, E0655, E0660, L0160, L0170, L0174, L0180, L0190, L0200, L1652, L214, L216, L2126, L2128, L2132, L2134, L2136, L3100, L3221, L3762, L7360, L7362, L7364, L7366, L8695, S8421, S8424, V5266.
Orthotic codes not requiring authorization include: L3650, L3710, L3913, L3919, L3921, L3923, L3925, L3929, L3931, L3933, L3935, L3995, L8010, L8035, L8300, L8310, L8320, L8330, L8400, L8410, L8415, L8417.

Prior Authorization

OB ultrasound prior authorization

OB ultrasound prior authorization: In a normal pregnancy, the first four OB ultrasounds may be performed without prior authorization; five or more OB ultrasounds for a normal pregnancy require prior authorization and may be denied if not authorized. OB ultrasounds for high‑risk pregnancies do not require authorization.

Normal pregnancy dx codes referenced in source (examples): Z32.01 and related codes — five or more require authorization.
High‑risk pregnancy diagnosis codes (refer to source) are exempt from authorization.

Prior Authorization

Outpatient therapy — Authorization for visits

Outpatient therapy (physical, occupational, speech): the initial evaluation does not require authorization but all subsequent therapy visits require prior authorization. This includes swallow function therapy. Certain plans (e.g., Fidelis Dual Advantage Flex Plan 017) have annual dollar limits for therapy services.

Initial evaluations: no authorization required.
All follow‑up therapy visits: authorization required, including swallow therapy.
Fidelis Dual Advantage Flex (Plan 017): $2,010 annual combined limit for Physical and Speech Therapy; $2,010 annual limit for Occupational Therapy.

Prior Authorization

Selected procedures and HCPCS — Prior authorization required

Prior authorization is required for selected procedure and HCPCS codes across multiple service areas including pain management/spinal injections, ambulatory continuous glucose monitoring, bronchial thermoplasty, uterine fibroid ablation, radiofrequency ablation, and certain dermatologic/ambulatory procedures. Radiation therapy and many radiology services require authorization via external vendors (eviCore).

Pain management and spinal/injection codes (examples in source): 20526, 20550‑20553, 21073, 27096, 62263‑62264, 62273, 62280‑62282, 62290. (Some codes such as 63622 and 63688 may be exempt for orthopedic specialty requests per source.)
Ambulatory continuous glucose monitoring: 95249 requires authorization.
Bronchial Thermoplasty: 31660, 31661 require authorization.
Uterine fibroid radiofrequency ablation: 58674 requires authorization.
Radiation therapy: authorization required through eviCore Healthcare (refer to eviCore site).
Radiology: many CPT codes require authorization via eviCore (see eviCore Fidelis page).

Prior Authorization

Prior authorization — Drugs and injectables

Prior authorization note for listed drugs and injectables: a list of HCPCS (J‑, Q‑, S‑) codes require authorization; some oncology and ophthalmic indications are exempt from authorization per the source. Self‑administered medications are covered under the pharmacy benefit and certain injectable prior authorizations must be submitted to the Fidelis Pharmacy Team electronically.

Many J‑ and Q‑codes (see source lists) require prior authorization — examples include J7303 series, J9269, J9281, J9311‑J9316, and multiple biologic biosimilars listed in the Medicare section.
Authorization is NOT required for some oncology indications and certain ophthalmic indications as noted in the source (see asterisked entries).
Submit prior authorization requests for pharmacy/injectable drugs via e‑fax to 1‑877‑882‑5892 or other electronic channels as directed on the Fidelis website.

Step Therapy

Formulary and step therapy direction

Formulary and step therapy direction: the formulary, prior authorization criteria, and step therapy criteria are maintained on the Fidelis website and updated monthly. Covered Medicare Part D drugs must be prescribed for medically accepted indications supported by FDA or Medicare‑approved compendia.

Formulary and step therapy details: visit Fidelis website Prescription Drug / Medicare Information pages for monthly updates.
Medicare Part D coverage: drugs must be for FDA approved indications or supported by Medicare‑approved compendia (DRUGDEX, AHFS, Clinical Pharmacology, NCCN, PubMed).

Denial Risk

Authorization / Noncoverage risks

Authorization and noncoverage risks — some services are specifically not covered or require authorization through designated vendors; failure to obtain required authorization may result in denial of payment or noncoverage. Examples: topical oxygen therapy is not covered; certain radiology and radiation therapy services require authorization via eviCore; more than four OB ultrasounds in a normal pregnancy without authorization may be denied.

Topical oxygen therapy: not a covered service.
Radiation therapy and many radiology services: require authorization through eviCore.
Exceeding OB ultrasound limits for normal pregnancy: five or more without authorization may be denied.
Failure to obtain inpatient authorization (when required) may result in denial of admission or payment.