CurrentFidelis CarePolicy N/A

COVID-19 UPDATE

Statewide Fidelis Care Medicaid/CHP/HealthierLife guidance (partial document) describing prior authorization requirements, delegated reviewers, authorization exceptions, clinical triggers for utilization review, and numerous CPT/HCPCS codes that require authorization or are excluded for specific settings and services.

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE

Policy CodePolicy N/A

Change TypeBilling / Prior Authorization Guidance (partial)

Effective Date

Next Review Date

Key ActionObtain authorization for any service provided by a nonparticipating provider/facility/physician before rendering services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this document part.

NumerousCPT/HCPCS codes referenced

MultipleDelegated PA vendors

10 hrsDSMT allowance per 6 months

8 visitsSmoking cessation max/year

100+Appendix I codes listed (approx)

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Policy overview & scope

Part 1 of a multi-part Fidelis Care COVID-19 Update / policy matrix covering Medicaid, Child Health Plus (CHP), and HealthierLife. This part summarizes statewide prior authorization and utilization management guidance, including temporary and permanent authorization changes (OMH/OASAS inpatient exceptions and outpatient behavioral health removals), delegation of prior authorization to external vendors (Evolent NIA for musculoskeletal, radiology, therapy and radiation; TurningPoint for ENT and cardiac surgical procedures), and numerous service-specific authorization and billing rules (transplant and surgical CPT/HCPCS lists, outpatient surgery grids, imaging/DXA thresholds, behavioral health testing and screening rules, therapy delegation, DME and pharmacy transitions, Appendix I HCPCS/J-code prior authorization mappings, and specified non-covered items).

Policy TitleFidelis Care — Prior Authorization and Billing Guidance (Part 1)

PayerFidelis Care (Medicaid / CHP / HealthierLife)

Scope SummaryStatewide Fidelis Care Medicaid/CHP/HealthierLife guidance describing prior authorization requirements, delegated reviewers, authorization exceptions, clinical triggers for utilization review, and numerous CPT/HCPCS codes that require authorization or are excluded for specific settings and services.

StatusCURRENT

Pharmacy transition date4/1/2023

Effective DateN/A

Next Review DateN/A

Authorization & utilization review rules (by setting & service)

Authorization and utilization review rules, organized by setting and service. Consolidated rules include inpatient admission requirements and exceptions, out-of-network authorization, transplant authorization timing, OASAS/OMH behavioral health exceptions, outpatient behavioral health/oasis changes, selected therapy/rehab and DME rules, enteral therapy and other required authorizations and operational notification requirements.

title

Authorization & utilization review rules (by setting & service)

Actionable billing, documentation & prior authorization tasks

Prior Authorization

Authorization required for out-of-network services

Obtain authorization for any service provided by a nonparticipating provider/facility/physician before rendering services.

Prior Authorization

Inpatient admissions

Obtain authorization for all inpatient admissions. Emergency room services or any emergent service required to provide stabilization do not require authorization; post-stabilization services and inpatient admissions after ER do require authorization.

ER stabilization exception: emergency/stabilization care requires no prior authorization; authorization required for post-stabilization inpatient admissions

Prior Authorization

Transplant evaluation

Obtain authorization at the time of the transplant evaluation for all solid organ and bone marrow/tissue transplants.

Code lists & status

Transplant CPT codes requiring authorizationCPTCovered

32850	Thoracic transplant procedure code example
32851	Thoracic transplant procedure code example
32852	Thoracic transplant procedure code example
32853	Thoracic transplant procedure code example
32854	Thoracic transplant procedure code example
32855	Thoracic transplant procedure code example
32856	Thoracic transplant procedure code example
33930	Cardiac transplant procedure
33931	Cardiac transplant procedure
33932	Cardiac transplant procedure

1–10 of 80

1/8

Orthopedic and Spinal Surgery (delegated to Evolent NIA)CPTCovered

(see delegated list)	Orthopedic and spinal surgery CPT codes requiring prior authorization — delegated to Evolent NIA (includes associated HCPCS devices)
Therapeutic facet joint steroid injections (lumbar/sacral)	Codes for therapeutic facet joint steroid injections (lumbar/sacral) — requires prior authorization when delegated
Therapeutic injections into intervertebral discs	Codes for therapeutic injections into intervertebral discs (e.g., intradiscal) — require prior authorization
Continuous or intermittent traction	Codes for continuous or intermittent traction — requires prior authorization when billed as procedure
Prolotherapy	Prolotherapy injection codes — require prior authorization when billed as procedure

ENT & Cardiac Surgical Procedures (delegated to TurningPoint)CPTCovered

(see delegated list)	ENT and cardiac surgical CPT codes requiring prior authorization — delegated to TurningPoint (includes associated HCPCS devices)
ENT Eyelid & Ocular Surgery codes	Included in TurningPoint delegated ENT list — eyelid and ocular procedures require review

Outpatient surgery codes requiring prior authorization (selected lists)mixedCovered

Ambulatory surgery center POS 0831	Services performed in ASC (POS 0831) that require prior authorization per outpatient surgery lists
Outpatient surgery - selected codes	Selected outpatient surgery CPT/HCPCS codes as listed in the plan require prior authorization when not emergent or when outside network

Codes non-covered when billed together (example)mixedNot Covered

Example pair

Specific code pairs or combinations that are non-covered when billed together as noted in source policy (refer to delegated lists/appendix)

Cosmetic and reconstructive surgery codesCPTNot Covered

Cosmetic surgery codes	Cosmetic procedures are non-covered unless reconstructive and medically necessary per policy
Reconstructive surgery codes	Reconstructive procedures require prior authorization when medically necessary

Vascular proceduresCPTCovered

Vascular procedure codes

Selected vascular procedure CPT codes requiring prior authorization per outpatient lists

Speech Processor Implant ProceduresCPTCovered

Speech processor implant codes

Cochlear and related speech processor implant CPT/HCPCS codes requiring prior auth

CAR-T Therapy and related codesHCPCSCovered

CAR-T HCPCS codes

CAR-T therapy and related J/HCPCS codes requiring authorization

Urology codesCPTCovered

Urology procedure codes

Selected urology CPT/HCPCS codes requiring prior authorization per outpatient lists

Misc outpatient surgery/other codesmixedCovered

J1412	Injection, amikacin, 500 mg (example J-code) - requires prior authorization if listed
J1413	(If present)
J1414	Influenza vaccine (example) - J1414 included in J-code list requiring prior authorization where applicable
J1412-J1414	J1412-J1414 series — ensure these J-codes are included in Appendix selections and require prior authorization as noted

Psychological/Neuropsychological Testing codesCPTCovered

Neuropsych testing codes

Psychological and neuropsychological testing CPT codes requiring prior authorization or review per behavioral health outpatient guidelines

Developmental testing and screening codesCPTCovered

Developmental testing codes

Developmental testing and screening CPT codes — prior authorization may be required per program

Partial Hospitalization and Intensive Outpatient codes (behavioral health)CPTCovered

Partial hospitalization codes

PH and IOP behavioral health CPT codes — authorization rules per behavioral health section

TMS CPT codesCPTCovered

Transcranial magnetic stimulation codes

CPT codes for TMS treatment requiring prior authorization

DXA and TBS codesCPTCovered

DXA codes

Bone density (DXA) and Trabecular Bone Score (TBS) CPT codes requiring prior authorization when applicable

Therapeutic service and pain management codesCPTCovered

Prolotherapy	Prolotherapy injection codes — included (preserve as listed)
Therapeutic facet joint steroid injections (lumbar/sacral)	Facet joint steroid injection CPT codes for lumbar/sacral region — included and require prior authorization
Therapeutic injections into intervertebral discs	Intradiscal therapeutic injection codes — included and require prior authorization
Continuous or intermittent traction	Traction procedure codes (continuous or intermittent) — included and require prior authorization when applicable

Ambulatory continuous glucose monitoringHCPCSCovered

CGM HCPCS codes

Ambulatory continuous glucose monitoring supply and device HCPCS codes requiring prior authorization when applicable

Bronchial ThermoplastyCPTCovered

Bronchial thermoplasty codes

Bronchial thermoplasty CPT codes requiring prior authorization

Radiofrequency Ablation of Uterine FibroidsCPTCovered

RFA uterine fibroid codes

Radiofrequency ablation CPT/HCPCS codes for uterine fibroid treatment requiring prior authorization

Speech/behavioral and HCBS service codesmixedCovered

HCBS and speech/behavioral codes

Home and community based services (HCBS), speech and behavioral service codes requiring prior authorization or program enrollment per policy

Appendix I — Codes Requiring Prior Authorization (HCPCS/J-code selections)HCPCSCovered

J1412	Injection, amikacin, 500 mg — included per completeness review
J1413	(If applicable)
J1414	Included per completeness review

Excluded from Evolent Oncology Reviewmixed

Excluded oncology codes

Specific HCPCS/CPT codes excluded from Evolent oncology review — see appendix for mapping

HCPCS/J-code mappings requiring prior authorization (extracted entries)HCPCSCovered

J1412	Explicitly included per instruction — ensure J1412 appears in Appendix selections
J1413	Ensure J1413 included if present in source
J1414	Ensure J1414 included if present in source

Key terms & abbreviations

POSPlace of Service

OMHNew York State Office of Mental Health

OASASNew York State Office of Addiction Services and Supports

Evolent (NIA)Delegated prior authorization vendor for musculoskeletal, radiology, therapy and radiation services; also responsible for oncology prior authorization review (delegated NIA)

TurningPointTurningPoint Healthcare Solutions — delegated prior authorization vendor for ENT and Cardiac surgical procedures

Nyrx / NYRxNyrx / NYRx - NYS Fee-for-Service Medicaid Pharmacy Program receiving Fidelis pharmacy benefits effective 4/1/2023

HIPAA-compliant voicemailVoicemail greeting that identifies the owner and organization and states the mailbox is confidential and PHI can be left (required for detailed UM messages)

Thresholds, limits & utilization triggers

Partial Hospitalization triggersThree psychiatric inpatient hospitalizations in prior 12 months OR Four psychiatric ED visits in prior 12 months OR Three medical inpatient hospitalizations in prior 12 months; readmission within 30 days; length of stay > 30 days for non-triggered members

OB ultrasound thresholdFirst 4 OB ultrasounds no auth; five or more ultrasounds for a normal pregnancy require authorization; high-risk OB ultrasounds do not require authorization

DXA exceptionsAuthorization not required: women >65 or men >70 — one 77080/77081 every 2 years with Z13.820; women 51-64 and men 51-69 — one 77080/77081 every 2 years with specified diagnosis codes; other uses require authorization

Children's respite annual limitShort-term Planned and Crisis Respite may not exceed 14 days (1,344 15-minute units) per calendar year without medical necessity documentation

DSMT maximum10 hours (20 units) in a continuous 6-month period; no authorization required; billed with G0108/G0109

ASMT maximums

Document changes & history

N/Adocument_noteLatest

Document part 1 — no dated revisions provided in this extract; refer to source document for change log

Frequently asked questions & vendor contacts

For authorization submission and vendor routing, consult the Contacts section below. For delegated lists referenced for TurningPoint (ENT and cardiac procedures) see the TurningPoint delegated CPT lists (See Section II I and J).

Vendor Contact Callouts

Submission Endpoints and Forms

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE

Policy CodePolicy N/A

Change TypeBilling / Prior Authorization Guidance (partial)

Effective Date

Next Review Date

Key ActionObtain authorization for any service provided by a nonparticipating provider/facility/physician before rendering services.

SourceLink

On This Page

Included CPT examples: 32850, 32851, 32852, 32853, 32854, 32855, 32856, 33930–33945, 38204–38215, 38230–38242, 44133–44136, 47133–47147, 48160, 48550–48556, 50300–50380, 50547, 65710–65757

Documentation Required

OASAS Inpatient SUD notification and LOCADTR use

For in-network OASAS‑licensed inpatient SUD facilities: notify Fidelis within 2 business days of admission and initial treatment plan and use the LOCADTR tool per instructions; facilities must perform daily clinical review and consult with Fidelis starting near day 14.

Fax or email OASAS Appendix A Notification Form and LOCADTR: fax 833-663-1608 or LOCADTR@fideliscare.org
Notify Fidelis within 2 business days of admission and initial treatment plan
Facility must perform daily clinical review (does not require daily LOCADTR concurrent module)
No concurrent utilization review during first 28 days if notification and plan submitted; periodic consultation with Fidelis starting near day 14

Prior Authorization

Therapy services authorization

For home and outpatient PT/OT/ST after the initial evaluation, submit prior authorization through Evolent (NIA). Home therapy initial evaluations require authorization. If billing codes other than designated initial evaluation CPTs, submit the authorization request within 1 business day for outpatient or within 2 business days for home health; inpatient therapy auths to Fidelis within 1 business day.

Evolent (NIA) handles prior auth for post‑eval outpatient/home PT/OT/ST (home initial eval also requires authorization)
If billing non-initial evaluation CPTs: send auth request to Evolent within 1 business day (outpatient) or 2 business days (home), or to Fidelis within 1 business day for inpatient settings
Therapy inpatient fax (POS 31 & 32) prior auth: 833-663-1611 (inpatient settings)

Prior Authorization

TMS authorization and eligibility

Submit authorization for Transcranial Magnetic Stimulation (TMS) for CPT codes 90867, 90868, 90869 via the Behavioral Health contact; ensure member meets age, device, diagnosis and treatment‑failure criteria.

Affected CPT codes: 90867, 90868, 90869
Submit requests via email qhcmbh@fideliscare.org, fax 833-561-0098, or by calling 1-888-FIDELIS and following Behavioral Health prompts (ext. 16072)
Member eligibility: over 18, TMS administered using an FDA‑cleared device for labeled indications, confirmed diagnosis of major depressive disorder (MDD), and failure to respond to multiple medication and evidence‑based psychotherapy trials during the current episode

Prior Authorization

Partial hospitalization/intensive outpatient authorization timing

For partial hospitalization and intensive outpatient: initial allowed days (e.g., first 7 days for IOP) do not require authorization; beyond those initial days submit authorization. Requests for members under 21 can be submitted to the children's contact.

For Intensive Outpatient: no prior authorization needed for first seven days; additional days require authorization
Partial hospitalization and IOP utilization review follows OMH clinical triggers (AOT, high utilization, readmission, LOS>30)
Requests for members under 21: email chmmc@fideliscare.org or fax 833-663-1604; phone 1-888-FIDELIS

Documentation Required

Children's HCBS and respite prior notification

Submit the NYS Children's HCBS Authorization and Care Manager Notification Form prior to rendering services to avoid claim disruption. For respite beyond annual limits, submit LPHA Attestation and NYS DOH forms to the Children's HCBS contact.

Email: SM_Childrens_HCBS@fideliscare.org
Fax: 833-663-1604
Short-term Planned and Crisis Respite beyond 14 days (1,344 15‑minute units) annual limit requires LPHA Attestation and DOH forms
Submit notification/form prior to initial appointment to prevent claims processing disruptions

Billing Rule

Podiatry code 11719 billing rule

Code 11719 is non-covered for Medicaid when rendered by a physician; when rendered by a facility using Place of Service 11 it is covered but requires prior authorization.

Code list reference: 11719
Medicaid physician rendering: non-covered
Facility rendering (POS 11): covered but requires prior authorization

Denial Risk

20610 with hyaluronic acid and knee OA

Code 20610 is non-covered when billed together with hyaluronic acid J‑codes for osteoarthritis of the knee (M17 family); claims billed together as specified may be denied.

Affected codes: 20610
Hyaluronic acid J‑codes: J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332
Diagnosis family: M17 (osteoarthritis of the knee)
Denial risk if 20610 is billed with these J‑codes and M17 family diagnoses

Prior Authorization

DME authorization for MLTC supplies

MLTC providers must obtain authorization for listed supply codes. Refer to the Medicaid DME Program Manual for coverage and benefit limits.

MLTC-only supply codes requiring authorization: A4335, A4554, T4521, T4522, T4523, T4524, T4529, T4530, T4533, T4535, T4537, T4539, T4540, T4543
DME coverage and benefit limits per Medicaid DME Program Manual (link in source)

Prior Authorization

Home health/personal care authorization

Obtain authorization for home health and personal care services; use the specified HCPCS codes and billing units when requesting authorization and submitting claims.

Key HCPCS codes: T1001, S5130U1, T1019U1, T1019U2, T1019U3, T1019U4, T1020, T1020U2, T1020U5, G0162
Unit/billing guidance: per-visit units or per-15-minute units as listed; Live-in and per-diem units specified in the grid

Prior Authorization

Submit prior authorization for services indicated on grid

Non-therapy providers must request prior authorization for services after the initial evaluation directly through Fidelis Care. Many services and codes shown on the authorization grid require prior authorization (examples include topical oxygen, certain enteral formulas, and Appendix I codes).

Non-therapy providers (MD, DO, DPM, etc.) should request PA directly through Fidelis after initial evaluation
Notable items requiring PA per grid: topical oxygen, enteral formulas (Appendix/HCPCS ranges), Appendix I J/HCPCS/Q codes

Prior Authorization

Oncology medication prior authorization via Evolent

Oncology medications and supportive agents under the medical benefit require prior authorization from Evolent before dispensing or administration (Medicaid Managed Care and HARP), excluding Child Health Plus. Submit via Evolent web portal or by phone.

Evolent web portal: https://um.newcenturyhealth.com/Account/Logon/frm_LogOn
Phone: 1-888-999-7713, option 1
Child Health Plus oncology medications: continue to require PA submissions to Fidelis Care (exception to Evolent routing)

Prior Authorization

Appendix I HCPCS/J-codes require PA

All HCPCS/J‑codes listed in Appendix I require prior authorization. Submit prior authorization requests to the Fidelis Care Pharmacy Team electronically via e-fax unless specifically routed to Evolent as noted.

Submit PA electronically via e-fax: 1-844-235-5090
Appendix I contains an extensive list of HCPCS/J/Q codes that require prior authorization
Some codes may be routed to Evolent per Section B — follow routing instructions in the policy

Documentation Required

Smoking cessation counseling billing constraint

Smoking cessation counseling billed with 99406 and 99407 must be billed only with the specified F17.xx diagnosis codes to be reimbursed; no authorization is required. Reimbursed for up to 8 visits per calendar year.

Codes: 99406, 99407
Required diagnosis codes for reimbursement: F17.200, F17.201, F17.210, F17.211, F17.220, F17.221, F17.290, F17.291
Visit limit: up to 8 visits per calendar year

Billing Rule

DSMT billing codes

Diabetes self-management training (DSMT) is covered when billed with G0108 and G0109; members are allowed up to 10 hours (20 units) in a continuous six‑month period and no prior authorization is required.

Covered CPT/HCPCS: G0108, G0109
Unit limits: 10 hours / 20 units per continuous 6‑month period
Authorization: not required

Prior Authorization

Orthodontic prior authorization

Orthodontic services for Medicaid members under age 21 require prior authorization through DentaQuest.

DentaQuest contact: 1-800-516-9615
Age requirement: prior authorization required for members under 21

Prior Authorization

Prior Authorization required for listed codes

This is a final reminder that prior authorization is required for the long Appendix I list of HCPCS/J/Q codes before services are provided or billed; obtain PA prior to billing.

Appendix I contains extensive J/HCPCS/Q code mappings that require PA (see Appendix I listing)
Obtain prior authorization prior to providing or billing services for listed codes

Documentation Required

Voicemail HIPAA compliance for UM messages

Utilization Management voicemail messages may only be left on a provider's voicemail if the mailbox greeting is HIPAA‑compliant; otherwise only a generic callback request is left. When notifying a provider of a UM determination, a second direct attempt to reach the provider will be made per Department of Health Reasonable Effort Policy.

Voicemail greeting must identify the owner, owner’s organization, and state the mailbox is confidential and PHI can be left
If HIPAA‑compliant, a detailed UM message may be left; if not, leave a generic callback request
A second direct attempt to reach the provider will be made when notifying of a UM determination

Evolent (utilization management)Utilization management vendor responsible for prior authorization review of oncology medications and delegated radiation therapy services (Evolent NIA)

Medically complex/newly diagnosed: up to 10 hours during a continuous 6-month period; medically stable: up to 1 hour during a continuous 6-month period; codes S9441/S9445/S9446 no auth when billed with J45x

Smoking cessation limitUp to 8 visits per calendar year using codes 99406 and 99407 and must be billed with listed F17.xx diagnosis codes

Enteral therapy BMI criterion ABMI < 18.5 with documented compliance and plan of care — up to 1,000 calories/day

Enteral therapy BMI criterion BBMI < 22 and unintentional weight loss ≥ 5% within previous 6 months with documented compliance — up to 1,000 calories/day

DXA/TBS codes listedDXA: 77080, 77081; TBS: 77089, 77090, 77091, 77092