Prior Authorization and Utilization Management for Facility, Surgical, Outpatient, Behavioral Health, Diagnostic, and DME Services
Defines which inpatient admissions, inpatient/outpatient procedures, behavioral health services, diagnostic tests, and DME require prior authorization or are carved out for Fidelis Care members in New York State; affects providers submitting authorization requests and facilities delivering these services.
No material clinical or coverage changes in this revision.
Coverage Criteria and Carve-Outs
Authorization and behavioral health carve-outs
Covered when authorization is obtained and medical necessity is demonstrated per plan review
Providers should use designated fax for Inpatient ER notifications (see provider guidance).
Facility must perform daily clinical review, periodically consult with Fidelis Care starting near day 14, and provide a written discharge plan prior to discharge.
Inpatient mental health services for members age 18 and older require prior authorization and are subject to concurrent review; out‑of‑state and out‑of‑network facilities require prior authorization for all ages.
Service-specific prior authorization criteria
Covered when ALL of the following are met for each service-specific group and authorization is approved
Some CPTs/procedures have delegated review (e.g., TurningPoint, Evolent); providers must direct prior authorization requests to the delegated vendor when applicable.
TMS (CPT 90867, 90868, 90869) requires use of an FDA‑cleared device, confirmed diagnosis of major depressive disorder, and failure of multiple medication and evidence‑based psychotherapy trials in the current episode; authorization requests follow behavioral health contact procedures.
Some genetic testing CPTs (81220, 81329, 81336, 81420) do not require authorization; CPT 81220 has a lifetime limit of 1 and CPTs 81329/81336 have a combined lifetime limit of 1.
Outpatient and Home Therapy Authorization
Covered when authorization requirements are followed
Initial evaluations in office or facility do not require PA, but subsequent billed therapy procedure codes (even on same date) require PA; home therapy initial evaluations do require authorization. Follow delegated submission timelines: outpatient setting within 1 business day to Evolent, home health within 2 business days, inpatient settings to Fidelis Care within 1 business day or via designated fax for inpatient therapy.
Medical Nutrition Therapy
Covered when diagnosis and visit limits are met
Diagnoses must match the listed diabetes or renal disease ICD‑10 codes in the policy.
Diabetes Self-Management Training
Covered when billing and provider certification requirements are met
These services no longer require prior authorization when billed with G0108/G0109.
Imaging Studies Authorization
Authorization conditions for imaging
Delegated radiology prior authorization is managed by Evolent (NIA) for many imaging services; refer to delegated lists for other ultrasounds and imaging CPTs.
Out-of-network Coverage for Specific Medicare Advantage Plans
Covered when ALL of the following are met
Additional co‑pays and deductibles may apply; other plans or lack of authorization may not be covered or may incur different cost‑sharing.
In-network, in-state behavioral health carve-outs apply when specific notification and documentation requirements are met. OASAS-licensed inpatient SUD facilities in New York State that participate in the Fidelis Care network are not subject to prior authorization and are exempt from concurrent utilization review for the first 28 days of an admission 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 specified. Facilities must perform daily clinical review and periodically consult with Fidelis Care beginning on or just prior to day 14; services may be reviewed after day 28 or retrospectively.
Similarly, OMH-licensed inpatient mental health treatment for members under age 18 at in-state, in-network OMH hospitals is not subject to prior authorization and not subject to concurrent review for the first 14 days if the facility: (1) notifies Fidelis Care of admission and the initial treatment plan within two (2) business days using the OMH Two-Day Notification and Initial Treatment Plan form, (2) performs daily clinical review, and (3) participates in periodic consultation to confirm use of the plan’s approved clinical review criteria. Adult (age 18+) inpatient mental health admissions and out-of-state or out-of-network facilities remain subject to prior authorization and concurrent review.
The policy lists specific therapeutic services that are not covered for members with a diagnosis of Low Back Pain. These exclusions include prolotherapy and therapeutic injections of steroids into intervertebral discs. The document also states that topical oxygen is not a covered service (see related NMN entry).
Several sections provide detailed pharmacy and J-code mappings intended to guide billing and PA submission; these chunks focus on code-to-drug mappings and dosage breakpoints. There are no explicit coverage exclusions stated in these mapping excerpts — the content is presented as billing/code cross-reference material to be used when requesting authorization or submitting claims.
Large Medicare-labeled J-code mapping tables are included to assist providers with code-to-product identification for billing and prior authorization. These excerpts map specific J-codes to drug names and supply descriptors but do not themselves state explicit coverage exclusions; providers should use the mapped J-code when requesting authorization or submitting claims for the referenced products.
Out-of-network coverage under this policy is limited. Services rendered out-of-network are covered only when an authorization has been obtained and only for the specified Medicare Advantage products: the Medicare Advantage Flex Plan (003) and the Medicare Advantage without RX (001). Additional co-pays and deductibles may apply.
The behavioral health coding section explicitly identifies CPT 96110 as a non-covered service. Other services not listed as non-covered may still be subject to medical necessity review and require prior authorization where specified in the policy.
Topical oxygen therapy is specifically identified in the policy as not a covered service (not medically necessary). This statement is explicit in the therapeutic services exclusions.
The pharmacy mapping and code tables in these excerpts do not include explicit 'not medically necessary' declarations. Their content is limited to drug-to-code cross references and related billing descriptors.
This later Medicare mapping excerpt likewise contains code-to-product mappings and billing descriptors; it does not include explicit statements that services are 'not medically necessary.'
Codes, Mappings, and Limits
| J1561 | Injection, triamcinolone acetonide, not otherwise specified |
| J1096 | Injection, midazolam, per 1 mg (example mapping) |
| J1566 | Injection, methylprednisolone acetate, per 40 mg (example mapping) |
| J1568 | Injection, betamethasone acetate and betamethasone sodium phosphate, per 6 mg (example mapping) |
| J1202 | Injection, buprenorphine extended release, mapping to J1202 |
| J1203 | Injection, buprenorphine extended release (alternate), mapping to J1203 |
| J1246 | Injection, buprenorphine/naloxone, per unit (example mapping) |
| J1299 | Injection, unspecified drug, used as placeholder mapping |
| J1301 | Injection, burosumab-twza (Crysvita) mapping |
| J1302 | Injection, onabotulinumtoxinA (Botox) mapping |
Provider Actions, Notifications, and Authorization Processes
Authorization requirement for inpatient and listed outpatient/DME services
All inpatient admissions require prior authorization. Fidelis Care does not require authorization for emergency room services or emergent stabilization, but post-stabilization services and inpatient admissions following ER care do require authorization. All facility admissions are reviewed for medical necessity. Failure to obtain required authorization for inpatient admissions or many facility services may result in denial of payment.
- New fax number for Inpatient ER: 833-663-1602 (formerly 347-868-6411)
- All inpatient facility services — medical, substance abuse, and behavioral health — require authorization
- Inpatient rehabilitation (acute, sub-acute, skilled nursing rehab) requires authorization when skilled services are provided
Transplant authorization
All solid organ and bone marrow/tissue transplants require authorization at the time of transplant evaluation. Submit requests before proceeding with evaluation/placement.
Vendor-delegated surgical prior authorization
Certain surgical prior authorization programs are delegated to vendor partners (Evolent/NIA, TurningPoint). When a CPT code is delegated, associated HCPCS/device codes are typically included in the delegated review. Follow delegated vendor instructions for submission and use the vendor code lists.
- Musculoskeletal Management Program (orthopedic/spinal) transitioned to Evolent (NIA) effective 1/1/24 — see vendor list for codes
- TurningPoint Healthcare Solutions, LLC: delegated review for certain ENT, orthopedic, spinal, and other surgical procedures — associated HCPCS reviewed by TurningPoint
- Ears/Nose/Throat (ENT) and Cardiac surgical prior auth may be delegated — refer to respective delegated lists
Outpatient surgery prior authorization (examples)
Specific outpatient surgical procedures require prior authorization. Where codes are delegated to a vendor (e.g., TurningPoint or Evolent), submit authorization requests to that vendor per the delegation guidance.
- Bariatric surgery: 43770-43774, 43888 (note: S2083 no longer requires authorization as of 8/1/22)
- Blepharoplasty: 15820-15823
- Breast reconstruction: 11920-11971, 19300, 19316-19342, 19355, 19370-19396
- Skin surgery: 15011, 15012; 11730 requires auth when billed with REV codes 0360, 0361, 0490
- Ambulatory surgery POS 24 codes that continue to require auth: 10040, 11300-11313, 11400-11471, 11721
- Dermal injections for Facial Lipodystrophy Syndrome (Q2026, Q2027, G0429) require auth and limited coverage criteria
- Abdominoplasty/lipectomy/panniculectomy: 15830, 15832-15839, 15847, 15876-15879
- Reduction mammoplasty: 19300, 19318
- Facial cosmetic, septoplasty, rhinoplasty and related codes: 21120-21296, 30400-30450, 30465-30520, 30620-30802, 30999, 31298, Q2028
- Vascular/vein procedures: 36465-36479, 36482-36483, 37241-37244, 37718-37785
- Spinal surgery: 20932-20934, 22867-22870, 62380
- Speech processor implants: 69716, 69719, 69726, 69727
- Esophageal procedures: 43284, 43497
- CAR-T therapy: 38225-38228
- Urology: 51721, 53865, 53866, 55881, 55882
- Other listed device/product codes (e.g., C1600-C1604, C1737, C7556-C7560, C9807, 23140, 60660-60661) require prior authorization
Behavioral health prior authorization
Most outpatient behavioral health services no longer require authorization, but selected services remain subject to prior authorization. Follow the submission instructions and forms specified for testing and specialty programs.
- Psychological/Neuropsychological testing: 96116, 96121, 96130-96139, 96146 — authorization required; submit on the Psychological/Neuropsychological testing request form
- Developmental Pediatric testing: 96112, 96113 — authorization required (96110 non-covered)
- Outpatient ECT: 90870 — authorization required
- Partial Hospitalization: revenue codes 912, 913, 944, 945; HCPCS H0035 — authorization required
- Intensive Outpatient Treatment: bill type 131, revenue 905 or 912, CPT 90899, S9480, HCPCS H2013 — authorization required
- Transcranial Magnetic Stimulation (TMS): CPT 90867, 90868, 90869 — covered with authorization; members must meet FDA device labeling, confirmed MDD diagnosis, and failure of multiple medication and evidence-based psychotherapy trials during the current episode
- Behavioral Health prior auth requests: email qhcmbh@fideliscare.org, fax 833-561-0098, or call 1-888-FIDELIS and follow Behavioral Health prompts (ext. 16072)
Diagnostic and DME prior authorization
Outpatient diagnostic testing, certain gastroenterology procedures, wireless capsule/endoscopy, infectious agent detection, penile prosthesis, select therapies, and many DME/orthotics require prior authorization. Some specific DME and orthotic codes are listed as not requiring authorization — verify code-level rules before submitting.
- Diagnostic testing examples: Sleep studies (including home sleep studies), Wireless Capsule Endoscopy (91110-91111), Wireless Motility Capsule (91112-91113), Infectious agent detection by DNA/RNA (87483), Penile prosthesis (54405), Other services: 97037, A9607
- Gastroenterology procedures that require authorization when performed in POS 19 or 22 if an office or ASC is available: 43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270; 43290 requires authorization in any POS
- DME: extensive lists of codes that do not require authorization (see code lists). Other DME and orthotic codes require authorization — check the specific code
- Outpatient Home Therapy (PT/OT/ST) after the initial evaluation requires prior authorization through Evolent (NIA) effective 10/1/2021; initial evaluations may not require auth but follow-up billed codes do
- Some orthotic codes are explicitly listed as not requiring authorization; other orthotics/DME do require authorization
Prior authorization required for listed services
Prior authorization is required for many listed outpatient diagnostic, procedure, imaging, DME and therapy services. Delegated reviews (Evolent/TurningPoint) cover many Part B services — check the payer or vendor code lists to determine where to submit the request.
- Radiology prior authorization delegated to Evolent (NIA); a full list of CPT codes requiring authorization is available from the vendor
- Outpatient PT/OT/ST after initial evaluation requires authorization via Evolent (NIA); non-therapy providers should request prior authorization for all services after the initial evaluation directly through Fidelis Care
- For therapy services in inpatient POS 31 & 32, send prior authorization to fax 833-663-1611 (formerly 716-803-8307)
Use mapped J-codes for billing/prior authorization
When requesting prior authorization or billing Part B drugs, use the mapped HCPCS/J-codes and the payer's code mappings. The coding listings in this section are provided for billing and prior authorization reference; they do not by themselves establish clinical criteria or PA requirements.
- Use the mapped J-code when requesting prior authorization or when billing Medicare Part B-covered drugs
- The document contains extensive J-code to drug name mappings and pharmacy supply/dispensing fee descriptors (e.g., per 90 days, per 30 days); reference these when preparing PA requests or claims
- J-code mappings do not by themselves indicate whether prior authorization is required — check payer rules and program-specific guidance (e.g., Evolent oncology program, Part B step therapy policy)
Step therapy references
Some drugs and therapies are subject to step therapy or other pharmacy program requirements. Refer to Fidelis Care's Part B Step Therapy Policy and the formulary/prior authorization pages for up-to-date lists. Oncology medications and supportive agents require prior authorization via Evolent for participating providers.
- For drugs requiring step therapy, see the Part B Step Therapy Policy link on the Fidelis website
- Oncology medications/supportive agents require PA from Evolent (portal my.newcenturyhealth.com or call 1-888-999-7713, option 1) before dispensing or administration
- Self-administered medications are covered under the pharmacy benefit — check formulary and benefit rules
Out-of-network authorization
Out-of-network services require authorization for certain Medicare Advantage plans. Coverage may be available but additional cost sharing applies — verify plan-specific requirements before scheduling care.
- Out-of-network services are covered with an authorization for Medicare Advantage Flex Plan (003) and Medicare Advantage without RX (001)
- Additional co-pays and deductibles may apply for out-of-network services
Voicemail compliance affects UM communication
Voicemail mailbox greetings for providers must be HIPAA-compliant to permit detailed UM messages. If not compliant, Utilization Management will leave only a generic message requesting a call back and will make a second attempt as required by Department of Health reasonable effort rules.
- Voicemail greeting must identify the mailbox owner and organization, state the mailbox is confidential, and say PHI may be left
- If voicemail is HIPAA-compliant, UM will leave a detailed message; otherwise UM leaves a generic message and requests callback
- UM will make a second attempt to reach the provider directly when notifying of a UM determination
OASAS notification and documentation
OASAS-licensed in-state inpatient Substance Use Disorder (SUD) facilities participating in Fidelis Care's network are not subject to prior authorization and have limited concurrent review during the first 28 days, provided they notify Fidelis Care within two business days using the OASAS Appendix A and LOCADTR tool. Out-of-state, out-of-network, or non‑OASAS‑licensed facilities must request prior authorization and are subject to concurrent review.
- Facility must fax/email OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool to fax 833-663-1608 or LOCADTR@fideliscare.org within two business days
- Inpatient SUD facilities must perform daily clinical review and consult with Fidelis Care starting on or just prior to day 14 to ensure LOCADTR use
- Inpatient SUD services may be subject to utilization review after day 28 or upon discharge; facilities must provide written discharge plan prior to discharge
Where and how to submit PA requests
Where and how to submit prior authorization requests depends on service type. Delegated vendor programs require using vendor portals/faxes; non‑therapy providers submit to Fidelis. Follow the specific instructions for oncology, pharmacy, behavioral health, therapy, and inpatient requests.
- Outpatient PT/OT/ST after initial evaluation: prior authorization through Evolent (NIA) — vendor portal/contact per Evolent guidance
- Non-therapy providers (MD/DO/DPM) should request prior authorization for services after the initial evaluation directly through Fidelis Care
- Oncology medication PA requests: Evolent Web portal my.newcenturyhealth.com or call 1-888-999-7713, option 1
- Pharmacy injectable (non-oncology) PA requests: send electronically via fax to 1-844-235-5090 (as of 10/1/2023)
- Behavioral Health PA requests (including TMS): email qhcmbh@fideliscare.org, fax 833-561-0098, or call 1-888-FIDELIS and follow Behavioral Health prompts (ext. 16072)
- For therapy services in inpatient POS 31 & 32: prior auth fax 833-663-1611
This section is a pharmacy coding table
This section contains pharmacy coding tables and drug-to-J-code mappings for Medicare Part B billing and prior authorization reference. Use these mappings to identify correct J-codes and associated dispensing/supply fee descriptors when preparing PA requests or claims.
- Extensive J-code lists map HCPCS/J-codes to drug names and supply descriptors — consult when requesting PA or billing
- Examples include pharmacy dispensing/supplying fees (per 30 days, per 90 days) and program-specific Q-codes
- These coding lists do not by themselves establish PA triggers — always cross-check payer program guidance
Policy Background and Scope
This utilization management policy defines authorization requirements across inpatient admissions, outpatient surgical and diagnostic procedures, behavioral health services, and select therapeutic and DME items. All inpatient admissions require authorization and facility admissions are reviewed for medical necessity. Specific carve-outs exist for in-state OASAS inpatient SUD (first 28 days without PA) and OMH inpatient mental health for members under 18 (first 14 days without PA) provided timely notification and required documentation are submitted. Service-specific prior authorization applies to listed outpatient surgeries and diagnostic procedures; certain therapeutic services (for example, prolotherapy and steroid injections into intervertebral discs) are expressly not covered for members with Low Back Pain, and topical oxygen is listed as not covered. Out-of-network coverage is limited to the specified Medicare Advantage plans when authorized.
Definitions and Clinical Tools
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