CurrentFidelis CarePolicy N/A

Prior Authorization and Utilization Review Requirements (Inpatient, Outpatient, Behavioral Health, DME, and Select Procedures)

Defines services that require prior authorization, notification, or utilization review for Fidelis Care members (primarily New York State), including inpatient admissions, transplants, select outpatient surgeries, behavioral health services, and certain DME and diagnostic testing. Affects providers requesting authorization for these services.

Policy Summary

PayerFidelis Care

PolicyPrior Authorization and Utilization Review Requirements (Inpatient, Outpatient, Behavioral Health, DME, and Select Procedures)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for all inpatient admissions and for listed transplants, outpatient procedures, behavioral health services, selected DME, and certain diagnostic tests as specified.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Inpatientrequire authorization

At evaluationtransplant auth timing

ExemptOMH inpatient MH (NYS, <18)

First 28 daysOASAS Inpatient SUD (NYS, in-network)

60rehab/habilitation limit

Coverage and Medical Necessity Criteria

Inpatient admissions

Covered when authorization obtained

Inpatient admissions: All inpatient admissions require authorization.

Emergency services for stabilization do not require authorization, but post‑stabilization inpatient admissions and all facility admissions are reviewed for medical necessity. Inpatient rehabilitation (acute, sub‑acute, skilled nursing) requires prior authorization.

OASAS Inpatient SUD

In‑network, NYS OASAS licensed inpatient SUD services are exempt from prior authorization under specified conditions

OASAS Inpatient SUD exemption: Inpatient detoxification, inpatient rehabilitation and inpatient residential treatment services provided by New York State facilities licensed/certified/authorized by OASAS and participating in Fidelis Care's network are not subject to prior authorization review.28 days

No concurrent utilization review during the first 28 days provided the facility notifies Fidelis Care within 2 business days and submits the OASAS Appendix A Notification Form and LOCADTR tool. Facilities must perform daily clinical review and periodically consult with Fidelis Care starting on or just prior to day 14. Services may be subject to utilization review after day 28 and may be reviewed retrospectively.

OMH Inpatient Mental Health

OMH‑licensed inpatient mental health treatment in NYS — utilization review triggers and age‑based exemptions

Triggers for utilization review (all ages): Utilization review (prior authorization/concurrent review) will be conducted for individuals who meet any of the following: subject to a current AOT court order; had an AOT order that expired within 5 years; high utilization defined as 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 to any mental health inpatient unit within 30 days of discharge; or length of stay exceeds 30 days (concurrent review begins Day 31).see triggers

Only members meeting these triggers will have utilization review.

Age‑based exemption (members under 18): For members under 18, in‑network OMH licensed hospitals are not subject to prior authorization and Fidelis Care will not conduct concurrent review during the first 14 days provided the facility notifies Fidelis Care of the admission and initial treatment plan within 2 business days (using the OMH Two‑Day Notification and Initial Treatment Plan form), performs daily clinical review, and participates in periodic consultation with Fidelis Care.14 days

Out‑of‑network facilities remain subject to concurrent review throughout the admission.

Behavioral Health Outpatient Coverage Criteria

Behavioral health outpatient services require authorization per listed codes and forms

Psychological/Neuropsychological testing: Authorization is required for listed CPT codes (96116, 96121, 96130‑96133, 96136‑96139, 96146). Requests must be submitted on the Psychological/Neuropsychological testing request form.

Developmental testing codes 96112/96113 require authorization; CPT 96110 is non‑covered.

Partial Hospitalization / Intensive Outpatient: Partial hospitalization (revenue codes 912/913/944/945; HCPCS H0035) and intensive outpatient treatment (revenue 905/912; CPT 90899; S9480; H2013) require utilization review and will be conducted only for members who meet NYS OMH Best Practice Manual clinical criteria (AOT, recent AOT within 5 years, high utilization, readmission within 30 days, or LOS>30).see OMH triggers

Out‑of‑network services are subject to concurrent review throughout admission.

ASD services: Authorization is required for DME speech generation equipment and for Applied Behavior Analysis (ABA) through Behavioral Health. An attestation of ASD diagnosis by a licensed physician or psychologist must be provided at time of request.

Benefit limits and authorization criteria

Covered when ALL of the following are met (as stated in policy segments):

Home Health Care: Home care approvals are based on medical need for skilled services.40 visits/plan year

Benefit maximum is 40 visits per plan year.

Hospice Care: Hospice care must be provided as part of a NY‑certified Hospice Care program.210 days

When medically necessary, coverage is available for up to 210 days.

Rehabilitation / Habilitation: Outpatient rehabilitation and habilitation services are limited by visit counts.60 visits/condition/plan year

CPT code 20610 is explicitly listed as non-covered when used for joint injection of hyaluronic acid for the treatment of osteoarthritis of the knee (diagnosis codes include M17.0, M17.10–M17.12, M17.2, M17.30–M17.32, M17.4, M17.5, M17.9).

Developmental pediatric testing billed with CPT code 96110 is identified in the policy as a non-covered service; by contrast related developmental testing codes 96112 and 96113 require authorization.

For members with a diagnosis of Low Back Pain, the policy lists specific services that are not covered: (a) prolotherapy; (b) therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT fluoroscopic guidance); (c) therapeutic injections of steroids into intervertebral discs; and (d) continuous or intermittent traction.

The policy states that orthotics are not covered. It also provides lists of DME codes that do not require authorization and notes that other DME and certain supplies do require authorization, but orthotics are specifically excluded from coverage.

Many surgical and medical procedures that are completed within 24 hours will not be approved at an inpatient level of care. These procedures should be billed as outpatient when performed within the Fidelis Care network; examples include certain laparoscopic procedures and thyroid surgery completed within 24 hours. A referenced list of inpatient-only procedures is provided in the policy.

In addition to the previously listed non-covered low back pain services, the policy reiterates that a set of therapeutic and pain management procedures are addressed under therapeutic services and identifies exceptions (for example, 63622 and 63688 do not require authorization for requests from orthopedic specialties). However, for members with a diagnosis of Low Back Pain the specific exclusions listed remain non-covered as detailed above.

Code Lists and Coding Rules

Transplants — CPT/Procedure codes requiring prior authorizationCPTCovered

32850	Thoracic transplant procedure (example listed)
32851	Thoracic transplant procedure (example listed)
32852	Thoracic transplant procedure (example listed)
32853	Thoracic transplant procedure (example listed)
32854	Thoracic transplant procedure (example listed)
32855	Thoracic transplant procedure (example listed)
32856	Thoracic transplant procedure (example listed)
33930	Heart transplant; orthotopic (cardiac transplantation) — code listed as requiring authorization
33931	Heart transplant; transfer of donor heart (related transplant code)
33932	Cardiac transplantation, associated procedure

1–10 of 80

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Provider Submission, Authorization, and Notification Requirements

Denial Risk

Inpatient Authorization Required

All inpatient admissions require prior authorization. Emergency department stabilization services do not require prior authorization; however post-stabilization services and any inpatient admission following ER services do require authorization. All facility admissions are reviewed for medical necessity. Note: New fax number for inpatient/ER notifications is 833-663-1602.

Applies to all acute inpatient facility services and inpatient rehabilitation (acute, sub-acute, skilled nursing rehabilitation).

Denial Risk

Transplants: Authorization at Evaluation

All solid organ and hematopoietic cell (bone marrow) transplants require authorization at the time of transplant evaluation. Lack of authorization may result in claim denial.

Policy Background and Scope

This policy documents Fidelis Care's operational prior authorization and utilization review requirements across inpatient, outpatient, behavioral health, transplant, diagnostic testing, and DME services for members (primarily New York State). Key scope points: all inpatient admissions require authorization; OMH‑licensed inpatient mental health and OASAS‑licensed inpatient SUD programs have state-specific notification and limited concurrent review exemptions when facility notification requirements are met (for OASAS: no concurrent review for the first 28 days with a two business‑day notification; for OMH members under 18: no concurrent review during the first 14 days with required two business‑day notification); numerous outpatient surgeries, behavioral health outpatient services, certain DME, diagnostic and therapeutic procedures, and many HCPCS/J‑codes listed in Appendix I require prior authorization per the code lists in this policy.

Defined Terms and Operational Definitions

OASAS Licensed Inpatient SUD definition

DefinitionInpatient substance use disorder treatment services provided in New York State by facilities licensed, certified, or otherwise authorized by OASAS and participating in Fidelis Care's provider network

Prior authorization stanceIn-network OASAS licensed inpatient SUD services are not subject to prior authorization review by Fidelis Care

Notification and documentationFacility must notify Fidelis Care within 2 business days and may fax/email OASAS Appendix A Notification Form and LOCADTR tool to the specified contacts; facilities must perform daily clinical review and consult with Fidelis Care starting on or just prior to day 14

OMH Licensed Inpatient Mental Health Treatment definition

DefinitionInpatient mental health treatment provided by OMH-licensed hospitals in New York State

Policy Summary

PayerFidelis Care

PolicyPrior Authorization and Utilization Review Requirements (Inpatient, Outpatient, Behavioral Health, DME, and Select Procedures)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

State‑expanded ASD benefits include increased case management, certain DME, and ABA.

The 60‑visit limit applies to all therapies combined per condition per plan year (rehabilitation and habilitation).

Cardiac and Pulmonary Rehabilitation: Authorization is required for outpatient cardiac and pulmonary rehabilitation services and associated codes.authorization required

Cardiac rehab codes include S9472, 93797, 93798, G0422, G0423, rev code 0943; pulmonary rehab codes include G0237‑G0239, G0424, S9473, rev code 0943.

Representative CPT codes include (but are not limited to): 32850–32856, 33930–33941, 38204–38215, 44133–44136, 47133–47147, 48160, 48550–48556, 50300–50380, 50547, 65710–65757. Request authorization at time of transplant evaluation.

Prior Authorization

Outpatient Surgery and Procedures: Prior Authorization

Selected outpatient surgeries and procedures require prior authorization before scheduling or billing. Confirm place of service requirements — some codes require authorization only when performed in ambulatory surgery settings.

Bariatric surgery: 43770–43775 (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: many office procedures (POS 11/22) do not require auth; when performed as ambulatory surgery (POS 24) the following CPTs require auth: 10040, 11300–11313, 11400–11471, 11721. Codes that require auth in any place of service include: 11200, 11201, 11719, 15769–15829, 17340–17999.
CPT 20610: non-covered for hyaluronic acid knee injections for osteoarthritis (diagnoses M17.*).
Additional categories: ear repair (69300, 69090); eyelid/ocular surgery (65760–65775, 66987–66991, 67900–67911, 68841); abdominoplasty/panniculectomy (15830–15879, 15847, 15876–15879); reduction mammoplasty (19300, 19318); facial cosmetic/septoplasty/rhinoplasty (21120–21296, 30400–30520, 30620–30802, 30999, 31298, C9749, Q2028).
Certain vascular, spinal, esophageal, cochlear/speech processor implant, orthopedic and cardiac procedures have delegated prior authorization to TurningPoint Healthcare Solutions — follow delegated submission instructions.

Prior Authorization

Outpatient Diagnostic Testing and Imaging: Authorization

Authorization is required for many outpatient diagnostic tests and some DME items. Prior authorization for certain radiology services and radiology/utilization review has been delegated to National Imaging Associates (NIA).

Diagnostic testing requiring authorization includes: sleep studies (including home sleep studies), genetic testing/BRCA (exceptions noted for CPTs 81220, 81329, 81336, 81420), wireless capsule endoscopy (91110–91111) and motility capsule (91112–91113), selected gastroenterology procedures (see policy for POS-specific rules).
OB ultrasound: first four ultrasounds for a normal pregnancy do NOT require authorization; five or more require authorization. OB ultrasounds for high-risk pregnancy do not require authorization.
Radiology prior authorization has been delegated to NIA; a full CPT list of radiology codes requiring authorization is available via the insurer resources.
Certain imaging (e.g., TBS scans 77089–77092) require authorization.

Prior Authorization

DME and Supplies: Authorization

Durable Medical Equipment (DME) rules: some DME codes do not require prior authorization; many others do and certain supplies require authorization. Verify status before ordering.

DME codes that do NOT require prior authorization include (partial list): E0130, E0135, E0168, E0182, E0184, E0235, E0274, E0305, E0310, E0424, E0431, E0434, E0439, E0570, E0575, E0580, E0602, E0603, E0621, E0655, E0660, E0776, E0890, E0900, E0942, E2361, E2363, L0130–L0200 series (select codes), L1652, L1902, L2132, L2134, L2136, L3100, L3221, L3762, L4350, L7360–L7366, S8421, S8424, V5266. Effective 4/1/23 new codes that do not require PA include: A4341, A4342, A4560, A6590, A6591, A7049, E0677, E0711, K1035, L8678.
Other DME items that require authorization include orthotics (not covered) and supplies such as compression garments/stockings, electric heat pads, hot water bottles, surgical stockings, protective helmets, wigs, insulin pumps/infusion pumps. Blood glucose monitors/testing supplies (A4253, A9275, E0607, E2100, E2101) are covered through the member's prescription drug benefit.
When in doubt submit a PA request for DME prior to claim submission to avoid denial.

Prior Authorization

Therapy and Selected Procedures: Authorization and Timing

Therapy services (PT/OT/ST) and select therapeutic procedures require prior authorization for continuation beyond initial evaluations and for many billed procedure codes. Some programs and code sets are delegated to NIA.

Effective 10/1/2021: All outpatient therapy (PT/OT/ST) services after the initial evaluation require prior authorization through NIA. Initial office/facility evaluations do NOT require PA, but any other billed codes (even on same date) require authorization prior to billing.
For home health therapy, submit authorization within 2 business days; for outpatient settings submit within 1 business day. For inpatient settings, send to Fidelis within 1 business day; for POS 31 & 32 (SNF/Sub-Acute Rehab) fax prior auth to 833-663-1611.
Therapeutic services requiring authorization include phototherapy (96567, 96573–96574, 96900, 96910–96913, 96920–96922), hyperbaric oxygen (99183, C1300), pain management/injection codes (20526, 20550–20553, 21073, 27096, 62263–62327, 63622, 63688, 64400–64595, 64600–64640, etc.; note 63622 and 63688 do not require authorization when requested by orthopedic specialties), cardiac and pulmonary rehab (S9472, 93797–93798, G0422–G0424, G0237–G0239, S9473).
Some procedures are not covered for low back pain (e.g., prolotherapy, lumbar facet joint steroid injections, intradiscal steroid injections, traction).

Prior Authorization

Codes Requiring Prior Authorization (Appendix I)

Prior authorization is required for the extensive list of codes in Appendix I. Missing prior authorization for services listed in the Appendix may result in claim denial. Review the Appendix for HCPCS/J- and CPT-level codes that are subject to prior authorization.

Appendix I contains a comprehensive, frequently-updated list of codes (C-, J-, Q-, S-, and various CPT/HCPCS codes) that require prior authorization. Examples include numerous high-cost drugs/biologics (J-codes), cancer/infusion drugs (J90xx–J93xx series), and specialty device/drug codes. Providers must consult the Appendix or the online resources for the current authorized-code lists before providing services.

Documentation Required

ASD Documentation and Authorization

Autism Spectrum Disorder (ASD) services require specific documentation and authorization: diagnosis attestation and authorization for certain services are required.

DME speech generation equipment requires authorization.
Applied Behavior Analysis (ABA) requires authorization from Behavioral Health.
An attestation of ASD diagnosis must be provided at the time of request by a licensed physician or psychologist.

Documentation Required

Voicemail and HIPAA Requirements for UM Communication

Utilization Management voicemail/HIPAA requirements: detailed UM messages may only be left if the provider voicemail is HIPAA-compliant. Otherwise a generic message will be left and a callback requested. The UM team will make a second direct contact attempt per Department of Health Reasonable Effort Policy.

Voicemail greetings must identify the mailbox owner and organization and state the mailbox is confidential and PHI may be left.
If mailbox is HIPAA-compliant a detailed UM message will be left; if not, only a generic message will be left.
A second direct attempt to contact the provider will be made when notifying of a UM determination.

Utilization review scopeOMH-licensed inpatient mental health treatment is not subject to prior authorization for all ages, but utilization review is conducted only for members who meet specific clinical triggers (AOT status, high utilization, readmission within 30 days, or LOS>30)

Pediatric exemptionFor members under 18 in-network, no prior authorization and no concurrent review during the first 14 days provided facility submits Two-Day Notification and Initial Treatment Plan within 2 business days and performs daily clinical review

Normal pregnancy OB ultrasound definition

ScopeOB ultrasounds coded for routine prenatal care (diagnosis codes Z32.01, Z33.1, Z34.xx) for a normal pregnancy

Authorization ruleFirst four (4) ultrasounds for a normal pregnancy do not require authorization; five (5) or more require authorization

High-risk pregnanciesUltrasounds for specified high-risk pregnancy diagnosis codes do not require authorization

Initial therapy evaluation definition

DefinitionOffice or facility-based initial evaluations for Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST)

Authorization for initial evalInitial office or facility-based PT/OT/ST evaluations do not require prior authorization; initial therapy evaluation in the home does require authorization

Subsequent servicesAll therapy services provided after the initial evaluation require prior authorization through NIA; if claims use codes other than initial evaluation CPT codes, authorization must be requested within 1 business day for outpatient or 2 business days for home health