CurrentFidelis CarePolicy N/A

Prior Authorization and Utilization Management — Selected Services (New York State)

Describes Fidelis Care prior authorization, utilization review, and special authorization rules affecting inpatient, outpatient, behavioral health, transplant, and other procedures for members in New York State network and out-of-network settings.

Policy Summary

PayerFidelis Care

PolicyPrior Authorization and Utilization Management — Selected Services (NY)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for all inpatient admissions and for listed outpatient procedures and drug administrations per Appendix I.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All inpatientinpatient authorization requirement

Transplants at evaluationtransplant authorization

OMH in-state/network exemptOMH inpatient auth exception

OASAS first 28 daysOASAS SUD auth exception

Many J/HCPCS codesAppendix I codes

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60 visits/yrtherapy visit limits

Coverage Criteria and Medical Necessity Rules

OMH Inpatient Utilization Review Triggers

Utilization Review for OMH-licensed inpatient mental health treatment will be conducted only when ANY of the following triggers are present:

OMH triggers: 1) Current Assisted Outpatient Treatment (AOT) court order; 2) AOT court order expired within past 5 years; 3) High utilization in past year as evidenced by (a) three or more psychiatric inpatient hospitalizations in the prior 12 months OR (b) four or more psychiatric ED visits in the prior 12 months OR (c) three or more medical inpatient hospitalizations in the prior 12 months; 4) Readmission to any mental health inpatient unit within 30 days of discharge; 5) Length of stay exceeds 30 days (concurrent review from Day 31 onwards)see node text

Per NYS OMH Best Practice Manual

Partial Hospitalization / Intensive Outpatient Criteria

Utilization Review for partial hospitalization and intensive outpatient mental health treatment will be conducted only when ANY of the following OMH criteria are met:

Behavioral Health triggers: Same AOT/high utilization/readmission/length-of-stay triggers as OMH inpatient criteria (see OMH triggers)see node text

Applies to partial hospitalization and intensive outpatient programs provided by OMH licensed programs in NYS

Intensive Outpatient Treatment Criteria

Covered when ANY of the following are met (utilization review required):

IOP eligibility triggers: 1) Individuals subject to a current Assisted Outpatient Treatment (AOT) court order; 2) Individuals who had an AOT court order that expired within the past five years; 3) Individuals with high utilization as evidenced by (a) three or more psychiatric inpatient hospitalizations in the prior 12 months OR (b) four or more psychiatric ED visits in the prior 12 months OR (c) three or more medical inpatient hospitalizations in the prior 12 months; 4) Individuals readmitted to any mental health inpatient unit within thirty days of discharge; 5) Individuals not meeting above triggers whose length of stay exceeds 30 days (concurrent review from Day 31 onwards).see text

Utilization review applies for OMH licensed programs in NYS

TMS Medical Necessity Criteria

Covered with prior authorization when ALL of the following are met:

TMS eligibility: Member is >18 years old; TMS is administered using an FDA-cleared device per labeled indications; confirmed diagnosis of major depressive disorder (MDD); failure to respond to multiple trials of medication and evidence-based psychotherapy during the current episode.age>18

Authorization required for CPT 90867-90869

Outpatient Therapy Criteria

Outpatient PT/OT/ST coverage rules and limits

Therapy auth and limits: All therapy services after the initial evaluation require prior authorization through Evolent (NIA) for outpatient settings; initial office/facility evaluations do not require prior auth but subsequent billed procedure codes do; rehabilitation and habilitation are limited to 60 visits per condition per plan year; benefit exclusions for certain settings apply.60 visits per condition per plan year

Initial therapy evaluation in the home requires authorization

In-state, in-network inpatient behavioral health and substance use disorder admissions have specific notification and utilization review exceptions. For OASAS-licensed inpatient SUD facilities in New York State, services are not subject to prior authorization and are exempt from concurrent utilization review for the first 28 days provided the facility notifies Fidelis Care of the admission and initial treatment plan within two (2) business days and submits the OASAS Appendix A Notification Form and LOCADTR tool as directed (fax/email). After 28 days, services may be subject to utilization review and all inpatient SUD care remains subject to facility daily clinical review and discharge planning using LOCADTR (see OASAS notification requirements).

For OMH-licensed inpatient mental health treatment, Fidelis Care does not require prior authorization for inpatient admissions of members under age 18 during the initial 14-day period when the OMH two-day notification and initial treatment plan form is submitted to Fidelis Care within two business days, the facility performs daily clinical review, and participates in periodic consultation with Fidelis Care using OMH-approved clinical review criteria. Out-of-network inpatient mental health services remain subject to concurrent review throughout the admission.

Certain HCPCS/S-codes and non-FDA medication codes are handled as exclusions or are subject to different benefit rules. The policy states that S codes are benefit exclusions except for S0013, S0189, S0190, S0191, and S9435; self-administered S-code medications should be processed under the pharmacy benefit where applicable. In addition, HCPCS codes for medications that are not FDA approved (for example, J1726 as noted) are considered a benefit exclusion and are not covered under the listed HCPCS/Appendix I rules.

Appendix I lists many J- and HCPCS codes that require prior authorization; however, where an HCPCS medication is explicitly identified as non-FDA-approved it is treated as a benefit exclusion rather than a PA-eligible item.

Some Appendix I entries are annotated with disease- or condition-level designations that limit the applicability of prior authorization to specific diagnoses. For example, the Appendix includes entries tied to “Sickle Cell Diagnoses”, indicating that authorization requirements for the listed code(s) apply only when the member’s clinical record includes the specified diagnosis group.

Utilization Management (UM) voicemail practices require a HIPAA-compliant provider voicemail to convey detailed determination information. The mailbox greeting must identify the mailbox owner and organization and state that the mailbox is confidential and that Personal Health Information (PHI) may be left. If the voicemail meets these requirements, a detailed UM message will be left; if not, the UM team will leave a generic message requesting a callback. A second attempt to reach the provider directly will be made when notifying of a UM determination, per Department of Health reasonable effort rules.

CPT code 20610 (large joint injection) is specifically non-covered when billed with one or more hyaluronic acid J-codes (for example, J7318, J7320–J7332 listed in the policy) and when the member’s diagnosis is osteoarthritis of the knee (ICD-10 codes in the M17.* series). In all other circumstances, 20610 requires no authorization and is not excluded.

For members with a diagnosis of low back pain, several therapeutic services are not covered. The policy explicitly lists the following non-covered services: 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 exclusions apply to patients whose presenting diagnosis is low back pain as specified in the Therapeutic Services section.

Code Lists and Coding Rules

Covered CPT/HCPCS codes requiring prior authorization (selected groups)mixedCovered

51721	Insertion of temporary transurethral catheter or urethral stent (urodynamic/urogenital procedures)
53865	Fulguration of bladder tumor, operative (includes TURBT variants)
53866	Transurethral resection of bladder tumor, single or multiple
55866	Prostatectomy, radical, retropubic, with or without nerve sparing
55881	Laparoscopic radical prostatectomy
55882	Robotic-assisted radical prostatectomy
43281	Esophagogastroduodenoscopy, flexible, with directed submucosal injection(s) for esophageal varices or tumor
43282	Esophagogastroduodenoscopy, flexible, with other therapeutic intervention
C1600	Prosthetic implantable device, unspecified (HCPCS - oncology/implantable)
C1601	Prosthetic implantable device, specified (HCPCS)

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Provider Requirements, Prior Authorization and Submission Guidance

Prior Authorization

Inpatient Admissions — Prior Authorization Required

All inpatient admissions require prior authorization. Emergency room services or emergent stabilization do not require prior authorization, but post-stabilization services and any inpatient admissions following emergency care do require authorization and will be reviewed for medical necessity. Failure to obtain authorization for inpatient admissions may result in retrospective review and potential denial.

New fax for Inpatient ER: 833-663-1602 (formerly 347-868-6411)

Prior Authorization

Transplants — Authorization at Evaluation

All solid organ and bone marrow/tissue transplants require authorization at the time of transplant evaluation. Lack of authorization may lead to denial or retrospective review.

Includes (but not limited to) listed codes such as 32850-32856, 33930-33945, 38204-38215, 38230-38242, 44133-44136, 47133-47147, 48550-48556, 50300-50380, 50547, 65710-65757, and related procedure codes.

Background and Scope

This policy document defines utilization management and prior authorization rules across multiple service lines and identifies state-licensed exceptions and operational requirements. It describes that all inpatient admissions generally require prior authorization (with emergency stabilization and other limited exceptions), while OMH- and OASAS-licensed in-state, in-network inpatient programs have time-limited prior authorization and concurrent review waivers when the specified notification and documentation steps are completed. The document also sets out program-specific requirements — for example, OMH two-day notification and LOCADTR use for SUD inpatient care — and details Appendix I code-based prior authorization rules, voicemail HIPAA requirements for UM communications, and select non-coverage rules for procedures and therapeutic services.

Definitions and Abbreviations

LOCADTR (definition & use)

LOCADTR toolA clinical review tool used for SUD inpatient medical‑necessity assessment and discharge planning (facilities submit LOCADTR and notification forms)

Use timingLOCADTR used to assess necessity during admission and may be used for utilization review after 28 days or on discharge

Notification requirementFacilities must notify Fidelis Care and may fax/email OASAS Appendix A and LOCADTR within two business days of admission

OMH Best Practice Manual — triggers

OMH Best Practice Manual triggersClinical criteria include AOT status, high utilization (multiple hospitalizations or ED visits), readmission within 30 days, or length of stay >30 days

Applies toOMH‑licensed inpatient, partial hospitalization, and intensive outpatient programs in NYS

Policy Summary

PayerFidelis Care

PolicyPrior Authorization and Utilization Management — Selected Services (NY)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for all inpatient admissions and for listed outpatient procedures and drug administrations per Appendix I.

SourceLink

On This Page

Prior Authorization

Orthopedic/Spinal Prior Auth

Orthopedic and spinal surgical procedures require prior authorization. The Musculoskeletal Management Program has been delegated to Evolent (NIA) effective 1/1/24; if a CPT code is delegated to Evolent, associated devices (HCPCS) will also be reviewed by Evolent for medical necessity.

Orthopedic and spinal procedures performed inpatient or outpatient require PA.
Musculoskeletal Management Program transitioned to Evolent (NIA) effective 1/1/24.

Prior Authorization

Outpatient surgery prior authorization

A broad list of outpatient surgical procedures require prior authorization when performed in specified settings; some codes may be delegated to specialty vendors and should be routed accordingly.

Examples include bariatric surgery (43770, 43772-43774), blepharoplasty (15820-15823), breast reconstruction/mammoplasty (11920-11971, 19300, 19316-19342, etc.), many dermatologic and ambulatory surgery center codes, eyelid/ocular surgery codes (65760-65775, 66987-66991, 67900-67911, etc.), abdominoplasty and related codes (15830, 15832-15839, 15847, etc.), spinal surgery codes (20932-20934, 22867-22870, 62330-62331, 62380, 63032), CAR-T therapy (Q2058, 38225-38228), and many others listed in the outpatient surgery section.
title
Outpatient surgery prior authorization — Specified codes/settings

Prior Authorization

Behavioral Health Prior Auth

Behavioral health outpatient services and higher-intensity programs require prior authorization or utilization review as specified. Submit requests on the appropriate forms or via the listed channels.

Psychological/Neuropsychological Testing (96116, 96121, 96130-96139, 96146) — authorization required; use testing request form.
Developmental Pediatric Testing (96112, 96113) — authorization required; 96110 is non-covered.
Outpatient ECT (90870) — authorization required.
Partial Hospitalization (revenue 912,913,944,945; HCPCS H0035) — utilization review only for members meeting NYS OMH Best Practice Manual criteria (listed triggers); out-of-network programs subject to concurrent review.
Intensive Outpatient (rev 905 or 912, CPT 90899, S9480, H2013) — utilization review only for members meeting NYS OMH Best Practice Manual criteria (listed triggers); out-of-network programs subject to concurrent review.

Prior Authorization

TMS Authorization

TMS (Transcranial Magnetic Stimulation) is covered with authorization for CPT codes 90867, 90868, and 90869. Requests can be submitted by email, fax, or phone through the Behavioral Health channels. Members must be over 18 and meet clinical and FDA-labeled indication criteria, including a confirmed diagnosis of major depressive disorder and documented failure of multiple medication trials and evidence-based psychotherapy during the current episode.

Submission channels: email qhcmbh@fideliscare.org, fax 833-561-0098, or call 1-888-FIDELIS and follow Behavioral Health prompts (ext. 16072).
Member age: over 18 when administered with an FDA-cleared device and meeting additional criteria.

Prior Authorization

Diagnostic Testing Authorization

Diagnostic tests and procedures may require authorization depending on the test and place of service. Certain genetic tests (BRCA and others) have specific exceptions listed, and wireless capsule endoscopy and specified gastroenterology procedures require prior authorization in some POS.

Sleep studies (including home sleep studies) — authorization rules apply.
BRCA/genetic testing: authorization not required for CPT 81220, 81244, 81329, 81336, 81420; note lifetime limits for some codes.
Wireless capsule endoscopy (91110-91111) and Wireless Motility capsule (91112-91113) require auth.
Certain GI procedures (e.g., 43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270) require authorization if performed in POS 19 or 22 when office/ASC available; authorization not required in POS 11 or 24.
Authorization required for 43290 and 43889 in any POS.

Prior Authorization

DME Authorization Requirements

Certain Durable Medical Equipment (DME) codes do not require authorization; other DME codes and listed supplies do require authorization. Specific items and exclusions are called out.

DME codes that do NOT require authorization include (selected examples): A4239, A4271, A4287, A4288, A4341, A4342, A4438, A4457, A4468, A4541, A4554, A4560, A4564, A4590, A4593, A4594, A4670, A4927, A6530, A6533, A6540, A6591, A7021, A7046, A7049, E0130, E0135, E0152, E0168, E0182, E0184, E0235, E0274, E0305, E0310, E0424, E0431, E0434, E0439, E0492, E0562, E0570, E0575, E0580, E0601, E0602, E0603, E0621, E0655, E0660, E0677, E0711, E0736, E0776, E0890, E0900, E0942, E1390, E2001, E2361, E2363, K0001, K0739, K1035, K1036, L0130, L0140, L0150, L0160, L0170, L0172, L0174, L0180, L0190, L0200, L0621, L0642, L1652, L1681, L1902, L2132, L2134, L2136, L2210, L2630, L3100, L3221, L3702, L3762, L3809, L3915, L4350, L5991, L7360, L7362, L7364, L7366, L8000, L8035, L8678, S8421, S8424, V5010, V5020, V2625, V2626, V5266.
Supplies requiring authorization include compression garments/compression gradient stockings, electric heat pads and hot water bottles, surgical stockings, protective helmets, wigs, insulin pumps and infusion pumps.
T2101 (Donor Breast Milk) requires authorization only when given in an outpatient setting.

Prior Authorization

Outpatient Therapy Authorization

Outpatient therapy (PT, OT, ST) rules: initial evaluations in office or facility do not require prior authorization, but all subsequent services after the initial evaluation require prior authorization through Evolent (NIA). In-home initial evaluations require authorization. Providers must follow submission timelines and routing requirements.

Effective 10/1/2021, all outpatient therapy after initial evaluation requires prior authorization through Evolent (NIA).
Initial therapy evaluation in office/facility does not require PA; initial home evaluation does require PA.
CPT codes 92610 and 92611 do not require prior authorization.
For therapy services in inpatient settings (POS 31 & 32), send PA requests to fax 833-663-1611 (formerly 716-803-8307).
Rehabilitation and Habilitation benefits limited to 60 visits per condition per plan year (combined therapies).

Prior Authorization

Rehab and Radiation Authorization

Cardiac and pulmonary rehabilitation delivered outpatient and radiation therapy services require prior authorization; radiation therapy authorization has been delegated to Evolent (NIA).

Cardiac rehab codes: S9472, 93797, G0422, G0423, rev code 0943 — authorization required for outpatient delivery.
Pulmonary rehab codes: G0237-G0239, S9473, rev code 0943 — authorization required for outpatient delivery.
Radiation therapy prior authorization delegated to Evolent (NIA).

Prior Authorization

Pharmacy / Oncology Authorization

Oncology medications and supportive agents require prior authorization from Evolent before dispensing or administration in outpatient settings; Evolent may implement utilization controls. Some categories are excluded from Evolent review and should be sent to Fidelis Pharmacy team.

Submit oncology-related requests via Evolent Web portal (https://um.newcenturyhealth.com/) or by calling 1-888-999-7713, option 1.
Excluded from Evolent review: antibiotics, bone marrow/stem cell transplants, CAR-T, certain specified drug categories, inpatient drug requests, genetic lab testing, hemophilia drugs, immune globulins, radiopharmaceuticals, surgeries/procedures, and others listed in the policy.
Pharmacy PA submissions: e-fax 1-844-235-5090 for non-Evolent pharmacy requests; see Appendix I for codes requiring PA.

Prior Authorization

Codes Requiring Prior Authorization (Appendix I)

Codes listed in Appendix I require prior authorization before services are rendered or billed. Claims submitted with HCPCS J-codes and other listed miscellaneous codes without prior authorization may be denied.

Appendix I contains extensive J-code and HCPCS listings that require PA (the appendix is authoritative for those codes).
Diagnosis-linked PA: some Appendix I entries are grouped with disease designations indicating PA may be diagnosis-specific — follow appendix pairing of codes and diagnoses.

Documentation Required

ASD Authorization Documentation

Autism Spectrum Disorder (ASD) authorizations: DME speech generation equipment and Applied Behavior Analysis (ABA) require authorization; an attestation of ASD diagnosis must be provided at time of request by a licensed physician or psychologist.

Authorization required for DME speech generation equipment.
Authorization required from Behavioral Health for ABA.
Attestation of ASD diagnosis must be provided at time of request by a licensed physician or psychologist.

Documentation Required

Enteral Therapy Documentation

Enteral therapy (HCPCS B4034-B4162) requires authorization. A written order from a physician or licensed provider must state the enteral formula is medically necessary and effective as a disease-specific treatment (examples: inherited metabolic disorders, Crohn's disease, GER with failure to thrive, chronic intestinal pseudo-obstruction, multiple severe food allergies).

Benefit applies to nutritional supplements for diseases such as phenylketonuria, branched-chain ketonuria, galactosemia, homocystinuria.
Non-prescription enteral formulas for home use require a written order stating medical necessity and disease-specific effectiveness.

Prior Authorization

SUD Authorization for Out-of-Network/Out-of-State Providers

Out-of-state or out-of-network providers must request authorization for outpatient substance use disorder services that are otherwise in-network/in-state exceptions. In-network, in-state outpatient SUD services listed (office visits, therapy, clinic visits, IOP, outpatient rehab, opioid treatment programs) do not require authorization when provided in-network/in-state; out-of-network or out-of-state providers remain subject to authorization requirements.

Effective January 1, 2020, in-network/in-state outpatient SUD services do not require provider notification, prior authorization, or concurrent review.
Out-of-state or out-of-network providers must request authorization for these services.

Step Therapy

Step Therapy — Not Specified

No explicit step therapy rules are stated in the provided excerpt of this policy.

Step therapy: not specified in this section.

Prior Authorization

Diagnosis-linked Prior Authorization

Diagnosis-linked prior authorization: Appendix I groups some codes with disease designations indicating that authorization may be diagnosis-specific. Providers must follow Appendix I pairings of codes and diagnoses when submitting PA requests.

Appendix I may indicate diagnosis-specific PA requirements — the appendix is authoritative for these mappings.

Prior Authorization

Intensive Outpatient Review Triggers

Intensive outpatient and partial hospitalization admissions are subject to utilization review and will be limited to members who meet NYS OMH Best Practice Manual criteria (triggers include AOT status, high utilization of inpatient/ED services, recent readmission, or length of stay exceeding specified thresholds). Out-of-network facilities are subject to concurrent review throughout admission.

Triggers include: current or recent (within 5 years) AOT court order; 3+ psychiatric inpatient hospitalizations in prior 12 months OR 4+ psychiatric ED visits in prior 12 months OR 3+ medical inpatient hospitalizations in prior 12 months; readmission within 30 days of prior mental health inpatient discharge; or length of stay >30 days (concurrent review from Day 31 onward).
Submission channels for members under 21: email chmmc@fideliscare.org, fax 833-663-1604, or call 1-888-FIDELIS and follow Children's Medicaid prompts.

NotificationFacilities must notify insurer within 2 business days of admission

Intensive Outpatient Treatment (IOP)

Definition (IOP)Intensive Outpatient Treatment (IOP) includes revenue codes 905 or 912, CPT 90899, S9480, or HCPCS H2013 when provided by OMH‑licensed programs

When UR appliesUtilization review (admission and concurrent stay) applies only when OMH triggers are met (AOT, high utilization, readmission, LOS >30 days)

Concurrent review for OON providersIOP services provided by out‑of‑network facilities are subject to concurrent review throughout the admission

Transcranial Magnetic Stimulation (TMS)

TMS definitionTranscranial Magnetic Stimulation (TMS) covered with authorization required for CPT 90867‑90869

Adult MDD criteriaMembers >18 may be eligible when TMS is delivered using an FDA‑cleared device per labeled indications, with confirmed MDD and failure of multiple medication and evidence‑based psychotherapy trials

Request methodsRequests may be submitted via email, fax, or phone to Behavioral Health authorization contacts

Prior Authorization (PA)

Prior Authorization (PA) — definitionA payer‑required approval obtained before a service or drug is provided to ensure coverage; Appendix I identifies codes subject to PA

Appendix I roleAppendix I enumerates specific J‑codes, miscellaneous and HCPCS codes tied to drug names/descriptions that require prior authorization

Billing consequenceClaims billed with listed J‑codes and miscellaneous codes require prior authorization prior to billing; failure may trigger denial or retrospective review