Prior authorization and authorization requirements for inpatient, outpatient, surgical, transplant, behavioral health and related services
Defines which facility, surgical, transplant, behavioral health, and other services require prior authorization or notification for Fidelis Care members (NY-focused operational rules), and describes delegated reviewers and special rules for substance use and mental health inpatient services. Affects providers in-network and out-of-network, and facilities submitting authorization requests.
Effective 1/1/2023 New York State is carving additional Behavioral Health Services into the Medicaid Advantage Plus (MAP) Plan benefit package.
A detailed crosswalk lists OMH-regulated behavioral health services (inpatient, outpatient, ACT, CDT, CPEP, PH, PROS, crisis residence) and indicates MAP coverage beginning January 2023.
A comprehensive prior authorization list for outpatient and DME services and specific CPT/HCPCS codes that do or do not require authorization.
Outpatient home therapy (PT/OT/ST) services after initial evaluation require prior authorization through Evolent (NIA) for services on/after 10/1/2021.
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.