CurrentFidelis CarePolicy N/A

Prior Authorization and Utilization Review Requirements for Inpatient and Outpatient Services

Governs Fidelis Care authorization, utilization review, and coding requirements for various inpatient and outpatient medical and behavioral health services for Fidelis Care members (New York State focus). Affects participating and nonparticipating providers and facilities.

Policy Summary

PayerFidelis Care

PolicyPrior Authorization and Utilization Review Requirements for Inpatient and Outpatient Services

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 procedures and medications listed (including Appendix I J‑codes) before scheduling or dispensing when required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7IOP initial no-authorization period (days)

28OASAS SUD concurrent review exemption (days)

14OMH inpatient notification period for <18 (days)

30Concurrent review begins after (days)

3Psych inpatient high-utilization trigger

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4Psych ED high-utilization trigger

Coverage and Utilization Review Criteria

OMH inpatient mental health utilization review triggers

Utilization review for OMH licensed inpatient mental health treatment will be conducted only for members who meet the following clinical criteria per NYS OMH Best Practice Manual:

OMH inpatient review triggers: Individuals who had an AOT court order that expired within the past five years; Individuals subject to a current Assisted Outpatient Treatment (AOT) court order; Individuals with high utilization of inpatient or emergency department (ED) services in the past year evidenced by: (1) Three (3) or more psychiatric inpatient hospitalizations in the prior 12 months; OR (2) Four (4) or more psychiatric ED visits in the prior 12 months; OR (3) Three (3) or more medical inpatient hospitalizations in the prior 12 months; Individuals whose length of stay exceeds 30 days (concurrent review from day 31 onwards); Individuals readmitted to any mental health inpatient unit within thirty days of discharge.see text

Applies to OMH licensed hospitals in New York State

Partial hospitalization utilization review triggers

Utilization review for partial hospitalization mental health treatment for OMH licensed programs will be conducted only for members who meet the following criteria:

Partial hospitalization review triggers: Individuals subject to a current Assisted Outpatient Treatment (AOT) court order; Individuals who had an AOT court order that expired within the past five years; Individuals with high utilization of inpatient or emergency department (ED) services in the prior 12 months evidenced by: (1) Three (3) or more psychiatric inpatient hospitalizations; OR (2) Four (4) or more psychiatric ED visits; OR (3) Three (3) or more medical inpatient hospitalizations; Individuals readmitted to any mental health inpatient unit within thirty days of discharge; Individuals whose length of stay exceeds 30 days (concurrent review from day 31 onwards).see text

Applies to OMH licensed partial hospitalization programs

Intensive outpatient utilization review triggers

Utilization review for intensive outpatient mental health treatment for OMH licensed programs will be conducted only for members who meet the following criteria:

Intensive outpatient review triggers: Individuals subject to a current Assisted Outpatient Treatment (AOT) court order; Individuals who had an AOT court order that expired within the past five years; Individuals with high utilization of inpatient or emergency department (ED) services in the prior 12 months evidenced by: (1) Three (3) or more psychiatric inpatient hospitalizations; OR (2) Four (4) or more psychiatric ED visits; OR (3) Three (3) or more medical inpatient hospitalizations; Individuals readmitted to any mental health inpatient unit within thirty days of discharge; Individuals whose length of stay exceeds 30 days (concurrent review from day 31 onwards).see text

First seven days of intensive outpatient do not require authorization; additional days require authorization

Partial hospitalization / Intensive Outpatient coverage criteria

Partial hospitalization and intensive outpatient services provided by OMH-licensed programs are subject to utilization review and are covered when member meets NYS OMH Best Practice criteria:

High-utilization or AOT triggers: Member meets ANY of the following: current Assisted Outpatient Treatment (AOT) court order; AOT court order expired within past five years; three (3) or more psychiatric inpatient hospitalizations in the prior 12 months; three (3) or more medical inpatient hospitalizations in the prior 12 months; four (4) or more psychiatric ED visits in the prior 12 months; readmission to mental health inpatient within 30 days of discharge.see listed counts

Triggers start concurrent review; otherwise concurrent review from day 31 onwards applies.

TMS medical necessity criteria

Transcranial Magnetic Stimulation (TMS) is covered with prior authorization when ALL criteria below are met:

TMS coverage requirements: Member is older than 18 years; TMS is administered using an FDA‑cleared device in accordance with FDA 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 of illness.age>18

Prior authorization required for CPT codes 90867, 90868, 90869.

ACT eligibility and placement

Assertive Community Treatment (ACT) authorization/placement is managed via SPOA process effective 6/1/23:

ACT process: Provider must submit the application for ACT to the local Single Point of Access (SPOA); SPOA confirms eligibility and urgency and manages referral list and assignment to an ACT team; Fidelis authorization is not required for ACT services using code H0040 effective 6/1/23.

Follow local SPOA process per NYS guidance.

DXA scan coverage and authorization

DXA scans (CPT 77080/77081) coverage and authorization rules as provided

Women >65: One 77080 or 77081 every (as listed) when accompanied by diagnosis code Z13.820.age >65

Authorization not required for this age/diagnosis combination as listed in source.

Men >=70: One 77080 or 77081 every two years when accompanied by diagnosis code Z13.820.age >=70

Authorization not required for this age/diagnosis combination as listed in source.

Women 51-64: One 77080 or 77081 every two years when accompanied by any diagnosis codes on the attached list.age 51-64

Therapeutic services — covered/ not covered

Therapeutic services listed with authorization requirements and non-covered items for low back pain.

Therapeutic services listed: Selected pain management and therapeutic procedure codes (including injections, TENS, other therapeutic services) require prior authorization as indicated; topical oxygen requires authorization; radiation therapy prior authorization has been delegated to Evolent (NIA); ambulatory continuous glucose monitoring (95249) is listed.per code

See code list in source for specific CPT/HCPCS codes.

Not covered for Low Back Pain: Therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT guidance); prolotherapy; therapeutic injections of steroids into intervertebral discs; continuous or intermittent traction are not covered for members with a diagnosis of Low Back Pain.diagnosis = Low Back Pain

Explicit non‑covered items listed in source.

Behavioral and self-management services coverage

Behavioral health and self-management training coverage summaries.

Counseling services: Members are allowed 10 hours (20 units) in a continuous 6‑month period; services must be provided by certified providers and no longer require authorization when billed with codes G0108/G0109.10 hours per 6 months

Source: Counseling services section.

Asthma self-management training (ASMT): ASMT may be provided individually or in groups (up to 8 patients). Authorization is not required for S9441, S9445, S9446 when billed with diagnosis codes J45x. Newly diagnosed or medically complex asthma: up to 10 hours in a continuous 6‑month period; stable asthma: up to 1 hour in a continuous 6‑month period.diagnosis J45x; up to 10 or 1 hour per 6 months

Source: ASMT section.

Smoking cessation counseling reimbursed up to 8 visits per calendar year using codes 99406 and 99407 billed with diagnosis code F17.200; no authorization required for Medicaid members.

Pharmacy coverage and oncology PA

Pharmacy benefit transition and oncology medication authorization requirements.

Pharmacy benefit transition: Effective April 1, 2023, members enrolled in Fidelis Care Medicaid Managed Care and HARP plans will receive pharmacy benefits through NYRx (Medicaid FFS). Providers should check NYRx for formulary and coverage updates.effective 2023-04-01

Source: Pharmacy section.

Oncology medications and supportive agents billed to pharmacy or administered in-office/outpatient require prior authorization from Evolent (formerly New Century Health) before dispensing or administration for Medicaid Managed Care and HARP members; Child Health Plus oncology medications continue to require authorization to Fidelis Care.oncology meds require PA

Source: Pharmacy/Oncology sections.

In-state, in-network OASAS-licensed inpatient substance use disorder (SUD) facilities and OMH-licensed inpatient mental health hospitals have limited prior authorization and concurrent review requirements when notification and documentation conditions are met. For OASAS inpatient SUD services, facilities participating in Fidelis Care’s network are not subject to authorization review and are exempt from concurrent utilization review for the first 28 days of an admission provided the facility notifies Fidelis Care and submits the OASAS Appendix A Notification Form and LOCADTR tool within two business days and performs required daily clinical review and periodic consultation with Fidelis Care (chunk describes required LOCADTR use and notification). Facilities outside NYS, not OASAS-licensed, or not in-network must request authorization and remain subject to concurrent review throughout the stay (see source).

Certain Home and Community-Based Services (HCBS), Intensive Psychiatric Rehabilitation Treatment (IPRT/H2012), and CORE services do not require prior authorization when members meet the stated eligibility/enrollment criteria and the service initiation procedures are followed. Effective January 1, 2023, authorization is not required for intake or initial service delivery for specified HCBS/IPRT services when eligibility is confirmed per the plan and enrollment rules.

Several therapeutic and pain-management procedures require authorization, however the policy explicitly lists items that are not covered for members with a diagnosis of Low Back Pain. Non-covered items include: therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT guidance), prolotherapy, therapeutic steroid injections into intervertebral discs, and continuous or intermittent traction. Topical oxygen and other listed therapeutic services may require prior authorization as noted.

Most S‑codes in Appendix I are treated as benefit exclusions. Exceptions explicitly retained as covered include S0013, S0190, S0191, and S9435. Note that oral medications billed under the prescription benefit will transition to New York State Fee‑for‑Service (NYRx) effective 4/1/2023 for certain member lines (Medicaid/HARP), and providers must follow the pharmacy submission instructions in Appendix I for codes requiring prior authorization.

Specific hyaluronan J‑codes in the J73xx family (for example J7318–J7333 and related entries shown in the appendix) are listed as non‑covered when billed with the diagnosis MI7.0. Providers should verify diagnosis coding before billing, as claims combining these J‑codes with MI7.0 will be treated as non‑covered per the policy language.

Appendix I indicates that prior authorization requirements for certain J‑ and S‑codes vary by member type and by indication. Specifically, the appendix notes that authorization is not required for ophthalmic indications for the listed codes; providers should follow the appendix guidance for member‑type exceptions and indication‑based authorization rules.

CPT code 20610 (injection into joint/ bursa) is identified as non‑covered when billed in conjunction with listed hyaluronic acid J‑codes (e.g., J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332) and a diagnosis of osteoarthritis of the knee. Claims combining 20610, the hyaluronan J‑codes, and knee OA will be processed as not covered under the policy.

Obstetrical ultrasound limits are specified: the first four (4) OB ultrasounds for a normal pregnancy may be performed without prior authorization; a normal pregnancy with five (5) or more ultrasounds requires authorization. High‑risk pregnancy ultrasound services identified in the policy do not require authorization. Requests for imaging outside the allowed counts, ages, or diagnoses should be submitted for authorization per imaging prior‑authorization rules.

For members with a diagnosis of Low Back Pain, the policy specifies that a number of therapeutic procedures are not medically necessary and therefore not covered. These explicitly include lumbar/sacral facet joint steroid injections (with or without CT guidance), prolotherapy, steroid injections into intervertebral discs, and continuous or intermittent traction. Other therapeutic services listed in the pain management section may require prior authorization as described elsewhere in the policy.

Codes and Billing Classifications

Transplant and major surgery CPTsCPTCovered

32850	Example transplant-related CPT from list
33930	Example cardiac/transplant CPT from list
38204	Bone marrow transplant related CPT
44133	Bowel resection CPT appearing in transplant/major surgery list
65710	Ophthalmic CPT range referenced

Outpatient surgery CPTs requiring authorizationCPTCovered

43770	Laparoscopic bariatric procedure CPT
15820	Blepharoplasty CPT
11920	Breast reconstruction CPT range
36465	Vascular/vein procedure CPT
69716	Speech processor implant CPT
43284	Esophageal procedure CPT
20932	Spinal surgery/orthopedic CPT

Developmental and psychological testing codesCPT

96110	Developmental screening (no authorization for CHP excluding) — must be billed with Z13.4 or Z13.42 per Medicaid guidance
96112	Developmental testing - authorization required
96116	Psychological testing CPT
96121	Psychological testing CPT

Behavioral health partial and intensive outpatient codesmixedCovered

4362	Partial hospitalization code
4363	Partial hospitalization code
H0035	HCPCS for partial hospitalization
S9484	HCPCS for partial hospitalization
H2013	HCPCS for intensive outpatient
90899	CPT code for intensive outpatient (unspecified psychotherapy)

Intensive Outpatient Codesmixed

Revenue 905	IOP revenue code
Revenue 906	IOP revenue code
Revenue 912	IOP revenue code
CPT 90899	IOP unspecified psychotherapy/procedure
S9480	IOP service code
HCPCS H2013	Structured outpatient addiction or co-occurring disorder treatment program

Behavioral Health HCBS/Community CodesHCPCS

H2012	Mental Health Continuing Treatment / IPRT reference
H0040	Assertive Community Treatment (ACT)
H2017	Psychosocial Rehabilitation
H0036	Community Psychiatric Support and Treatment (CPST)
H0038	Empowerment Services / Peer Supports / Family/Youth Peer Support
A0160	Provider Travel Supplement

TMS CPT Codes requiring authorizationCPT

90867	TMS with mapping for surgical/other complex codes (per document)
90868	TMS subsequent management
90869	TMS maintenance

Outpatient & Procedure Codes Requiring AuthorizationCPT

91110	Wireless capsule endoscopy
91111	Wireless capsule endoscopy additional
91112	Wireless motility capsule
91113	Wireless motility capsule additional
43235	Esophagoscopy/other upper GI procedure
43239	Upper GI procedure
43248	Esophagogastroduodenoscopy with intervention
45378	Colonoscopy with biopsy
45380	Colonoscopy with removal of tumor
45384	Colonoscopy with ablation

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DME codes requiring authorization for MLTCHCPCS

A4335	DME supply code
A4554	DME supply code
T4521	DME supply code
T4522	DME supply code
T4523	DME supply code
T4524	DME supply code
T4529	DME supply code
T4530	DME supply code
T4533	DME supply code
T4535	DME supply code

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DXA scanningCPT

77080	DXA scan CPT code
77081	DXA scan CPT code

DXA scan codesCPTCovered

77080	DXA scan, axial skeleton; single or first radiologic area, bone density study
77081	DXA scan, each additional radiologic area (List II codes — as presented)

Therapeutic and special procedure codesmixedCovered

20526	Injection, therapeutic, tendon sheath, ligament, or ganglion cyst
20550	Injection(s); single tendon sheath, or ligament
20551	Injection(s); single or multiple trigger point(s)
20552	Injection(s); other codes listed under pain management
20553	Injection(s); other
21073	Injection related code listed
27096	Injection or procedure code listed
62263	Injection epidural; lumbar
62264	Injection epidural; lumbar with catheter
62273	Injection other spinal

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Erectile dysfunction DME/services/pharmaceutical codesmixed

37788	Erectile dysfunction related procedure
37790	Erectile dysfunction related procedure
54400	Repair of penile fracture
54401	Repair of penile fracture
54405	Other penile surgery codes listed
54408	Other penile surgery codes listed
54410	Other penile surgery codes listed
54411	Other penile surgery codes listed
54416	Other penile surgery codes listed
54417	Other penile surgery codes listed

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Appendix I — HCPCS/J/G/C codes requiring prior authorization (partial list)mixedCovered

C9047	caplacizumab-yhdp (Cablivi) and mapping entries in Appendix I
C9145	aprepitant aponvie inj and mapping entries in Appendix I
C9167	apadamtase alfa and mapping entries in Appendix I
C9168	mirkizumab-mrkz and mapping entries in Appendix I
C9169	nogapendekin alfa and mapping entries in Appendix I
C9170	tarlatamab-dlle and mapping entries in Appendix I
C9172	fidanacogene elaparvovec and mapping entries in Appendix I
C9293	glucarpidase Voraxaze and mapping entries in Appendix I
C9399	unclassified drugs/biologics and mapping entries in Appendix I
G0516	implant insertion mapping entries in Appendix I

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Asthma Self-Management Training codesHCPCSCovered

S9441	Asthma self-management training, individual
S9445	Asthma self-management training, group
S9446	Asthma self-management training, other

Smoking cessation counseling codesCPTCovered

99406	Tobacco use cessation counseling intermediate
99407	Tobacco use cessation counseling intensive

Counseling Services codesHCPCSCovered

G0108	Counseling services code
G0109	Counseling services code

Codes (sample start of list)HCPCS

J0593
J0135
J0172

Codes (continued list)HCPCS

J0200
J0205
J0218

Codes (further continuation)HCPCS

J1447
J1559
J7190

Codes with drug names as listedHCPCS

J7312	dexamethasone intravitreal implant (Ozurdex) referenced
J7320	hylauronan products referenced
J7327	hylauronan (Monovisc)

Appendix I - selected J-codes (part)HCPCSCovered

J8522
J7321
J7322
J7323
J7324
J7325
J7326
J7327

Appendix I - additional J-codes (part)HCPCSCovered

J9217
J9223
J9225
J9226
J9227
J9228
J9229
J9245
J9247
J9248

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Appendix I - S-codes and othersHCPCSCovered

S0145
S0148
S0155
S0156
S0157
S0160
S0169
S0170
S0172
S0174

Developmental screening timing (96110 reimbursement ages)

Reimbursed screening codeCPT 96110 reimbursed in the first three years of life when billed with Z13.4 or Z13.42 per AAP/Bright Futures schedule (screening at 9, 18, and 30 months; ASD screening at 18 and 24 months)

Authorization statusNo prior authorization required for 96110 (excludes Child Health Plus members)

Prior Authorization and Provider Routing

Prior Authorization

IOP prior authorization

Intensive Outpatient (IOP) services: No authorization is required for the first seven days of service. Additional IOP service days require prior authorization. Submit authorization requests for IOP using revenue codes 905, 906, or 912; CPT 90899; S9480; or HCPCS H2013. Concurrent review will be conducted for IOP provided by OMH‑licensed programs only when members meet NYS OMH clinical trigger criteria (see partial hospitalization/IOP criteria).

First 7 days: no prior authorization required
Subsequent days: prior authorization required
Billing/codes: revenue 905, 906, 912; CPT 90899; S9480; HCPCS H2013

Prior Authorization

Outpatient diagnostic prior authorization

Outpatient diagnostic procedures (sleep studies, wireless capsule endoscopy, select GI procedures, BRCA/genetic tests, and other diagnostic testing) require prior authorization per code and place-of-service rules. Examples: sleep studies (including home), wireless capsule endoscopy (91110, 91111) and wireless motility capsule (91112, 91113). Certain procedures performed in POS 19 or 22 require authorization only when an office or ambulatory surgery center (POS 11 or 24) is available; check service-specific notes (e.g., 43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270). Authorization is required for 43290 in any POS. Submit outpatient diagnostic authorization requests to Fidelis Care per standard submission channels.

Background and Scope

Scope: This policy governs Fidelis Care’s prior authorization, utilization review, and coding requirements for a broad set of inpatient and outpatient services with an emphasis on behavioral health and related services in New York State. It covers OASAS‑licensed inpatient substance use disorder treatment and OMH‑licensed inpatient mental health treatment (including partial hospitalization and intensive outpatient programs), procedural and imaging prior‑authorization rules, pharmacy and oncology medication routing, DME and therapeutic service authorization, and Appendix I code‑level prior‑authorization requirements. The document describes state‑specific exemptions (for in-network OASAS/OMH facilities when notification and LOCADTR/Two‑Day forms are submitted), delegated authorization arrangements, member‑type exceptions, and the effective dates for program transitions (for example pharmacy benefit changes effective 4/1/2023 and ACT placement change effective 6/1/23).

Key Definitions and Tools

LOCADTR — tool for OASAS inpatient SUD utilization review and discharge planning

LOCADTR purposeLOCADTR is the clinical medical necessity tool used for OASAS inpatient SUD utilization review and discharge planning (facilities must use LOCADTR and submit forms to Fidelis Care)

Notification timingOASAS facilities must notify Fidelis Care of admission and initial treatment plan within two business days and may fax/email the OASAS Appendix A Notification Form and LOCADTR tool

Concurrent review windowIn-state, in-network OASAS inpatient SUD services are exempt from concurrent utilization review for the first 28 days provided notification and LOCADTR use requirements are met

AOT — Assisted Outpatient Treatment references

AOT definition/useAssisted Outpatient Treatment (AOT) court orders (current or expired within the past five years) are triggers for utilization review for OMH inpatient, partial hospitalization, and intensive outpatient services

Policy Summary

PayerFidelis Care

PolicyPrior Authorization and Utilization Review Requirements for Inpatient and Outpatient Services

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 procedures and medications listed (including Appendix I J‑codes) before scheduling or dispensing when required.

SourceLink

On This Page

Authorization allowance per source.

Men 51-69: One 77080 or 77081 every two years when accompanied by any diagnosis codes on the attached list.age 51-69

Authorization allowance per source.

Other ages/diagnoses: Requests for CPT 77080 or 77081 for any other age group or any other diagnosis will require prior authorization.other

Requests outside listed groups require authorization.

Source: Smoking cessation section.

Frequency limitsASD screening (validated tool) reimbursed up to twice in the first three years beginning at 18 months; global developmental screening reimbursed up to once per year in the first three years

High-utilization inpatient/ED triggers

Psychiatric inpatient triggerThree or more psychiatric inpatient hospitalizations in the prior 12 months

Psychiatric ED triggerFour or more psychiatric emergency department visits in the prior 12 months

Medical inpatient triggerThree or more medical inpatient hospitalizations in the prior 12 months

Respite annual limit

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

Beyond-limit requirementRespite beyond annual limits requires medical necessity documentation (LPHA Attestation form) and prior authorization/workflow submission

Delivery requirementsRespite must be in-person (no telehealth/telephone) and delivered in allowable settings per HCBS guidance

Child Health Plus enteral therapy applicability date

Applicability date for CHP enteral therapyEnteral therapy HCPCS codes B4034–B4162 require authorization for Child Health Plus effective 4/1/2023

Enteral therapy scopeApplies to tube-fed individuals, inborn metabolic disorders, children under 21 needing medical formula for growth/development, and other listed clinical indications

Supplies notePharmacy supplies do not require authorization; some supplies are not covered for Child Health Plus per benefit plan

ASMT hours for stable asthma

ASMT hours — newly diagnosed/complexUp to 10 hours of Asthma Self-Management Training (ASMT) during a continuous six-month period for newly diagnosed or medically complex asthma

ASMT deliveryASMT may be provided individually or in groups (up to 8 patients); codes S9441/S9445/S9446; authorization not required when billed with J45x

Eligible membersIncludes pregnant women with newly diagnosed or medically complex asthma as specified

ASMT hours for newly diagnosed/medically complex asthma

ASMT hours — newly diagnosed/medically complexUp to 10 hours of Asthma Self-Management Training (ASMT) during a continuous six-month period for newly diagnosed or medically complex asthma

Authorization and codesAuthorization not required for S9441, S9445, S9446 when billed with diagnosis J45x

Group sizeGroup sessions limited to no more than eight patients

per-interval qualifiers (per-30/60/90-day qualifiers referenced)

Per-interval qualifiers presentAppendix I lists multiple codes that include per-30-day, per-60-day, and per-90-day qualifiers for drug or supply coverage frequency

Appendix referenceSee Appendix I code entries (e.g., J9319 per 60-days) for specific per-interval limits and mapping

Prior authorization implicationPer-interval qualifiers may affect authorization and dispensing frequency; check specific J‑code entry in Appendix I

Sleep studies (including home) require prior authorization
Wireless capsule endoscopy: 91110, 91111; wireless motility: 91112, 91113
Some GI procedures require PA in POS 19/22 when office/ASC available: 43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270
43290 requires authorization in any POS
BRCA/genetic testing: note exceptions (81220, 81329, 81336, 81420 not requiring PA)

Prior Authorization

Therapeutic and special procedure prior authorization

Therapeutic and special procedures often require prior authorization; some categories are delegated. Pain management and injection procedures, hyperbaric oxygen, topical oxygen, ambulatory continuous glucose monitoring, radiation therapy, radiofrequency ablation of uterine fibroids, bronchial thermoplasty, vision therapy, and other specialized procedures are subject to PA or delegated review. Note exclusions and non‑covered items (e.g., certain low‑back pain injections).

Pain management/injection codes: 20526, 20550–20553, 21073, 27096, 62263–62290, 62320–62327, 64629
Hyperbaric oxygen and topical oxygen require PA
Ambulatory CGM: 95249
Radiation therapy PA delegated to Evolent (NIA) — see delegated list
Radiofrequency ablation of uterine fibroids: 58674
Bronchial thermoplasty: 31660, 31661
Vision therapy: 92066, 95919
Several therapeutic services may be non‑covered for low back pain (facet joint injections, prolotherapy, intradiscal steroid injections, continuous traction)

Prior Authorization

Appendix I prior authorization codes

Appendix I contains the long list of HCPCS/J‑codes and associated drugs that require prior authorization. Providers must check Appendix I for whether a given HCPCS or J‑code requires PA and follow the Pharmacy submission instructions for those codes.

Appendix I lists HCPCS/J‑codes (e.g., many J‑codes and C/G/Q codes) that require prior authorization
Use Appendix I to identify the associated drug/product for each code before submitting PA

Prior Authorization

Codes requiring prior authorization (J/HCPCS)

Use of listed HCPCS and J‑codes may trigger a prior authorization requirement for the drug or biologic. Many oncology‑related J‑codes and other J‑codes in Appendix I require PA before dispensing or administration; pharmacy and outpatient infusion requests may be routed to Evolent (New Century Health) where applicable.

Listed HCPCS/J‑codes in Appendix I generally require PA prior to dispensing or administration
Oncology medications/supportive agents require PA via Evolent (NCH) for most Medicaid/HARP members (see oncology routing)
Child Health Plus oncology pharmacy PA continues to be submitted to Fidelis Care

Prior Authorization

Delegated prior authorization for surgical codes

Delegated prior authorization for many surgical codes: certain musculoskeletal, orthopedic, spinal, ENT and cardiac surgical procedure authorizations have been delegated to third‑party vendors (for example, Evolent (NIA) for Musculoskeletal Management and TurningPoint for many surgical specialties). When a CPT code is delegated, submit PA requests to the delegated vendor. If a CPT code is delegated, associated devices/HCPCS codes will also be reviewed by the delegate.

Musculoskeletal (orthopedic/spinal) authorization delegated to Evolent (NIA) effective 1/1/24 — check Evolent delegated CPT list
TurningPoint Healthcare Solutions handles many ENT and cardiac surgical PAs — check TurningPoint delegated CPT list
If a CPT code is delegated, associated HCPCS/device codes are reviewed by the same delegate

Prior Authorization

Partial hospitalization concurrent review triggers

Partial hospitalization concurrent review triggers: Utilization Review for partial hospitalization mental health treatment is conducted only for members meeting NYS OMH Best Practice trigger criteria (examples include AOT status, high inpatient/ED utilization, multiple recent psychiatric inpatient admissions or ED visits). Members not meeting triggers whose length of stay exceeds 30 days will enter concurrent review from day 31 onward. Submit requests per Behavioral Health contact channels.

Triggers include AOT court order, 3+ psychiatric inpatient hospitalizations in prior 12 months, 4+ psychiatric ED visits in prior 12 months, readmission within 30 days, and similar high‑utilization markers
Concurrent review begins day 31 for members without specified triggers
Questions: call 1‑888‑FIDELIS and use the Behavioral Health extension

Prior Authorization

DXA scan age/diagnosis authorization

DXA scan age/diagnosis authorization rules: Coverage without prior authorization is available for specific age/diagnosis combinations; requests for DXA (77080, 77081) outside these age/diagnosis combinations require authorization.

Women >65: one DXA (77080/77081) every two years when accompanied by appropriate diagnosis (e.g., Z13.820)
Men ≥70: one DXA every two years with appropriate diagnosis
Women 51–64 and men 51–69: one DXA every two years when accompanied by any of the qualifying diagnosis codes (see policy list)
Any DXA for ages/diagnoses not covered above requires prior authorization

Denial Risk

Therapeutic services authorization / coverage risk

Therapeutic services carry authorization and coverage risk: many therapeutic procedures (e.g., injections, pain procedures, hyperbaric oxygen, radiation therapy) require PA and some are delegated. Some procedures are specifically non‑covered for certain diagnoses (e.g., several injections for low back pain). Verify medical necessity and submit supporting documentation to avoid denials.

Pain management injections and TENS codes subject to PA and medical necessity review
Radiation therapy PA delegated to Evolent (NIA) — follow delegated process
Topical oxygen and other specialized therapies require PA
Certain services are non‑covered for specific diagnoses (e.g., low back pain)

Prior Authorization

Prior authorization required for listed J‑codes and associated drugs

Prior authorization is required for the listed J‑codes and associated drugs in Appendix I. Pharmacy authorization requests for codes in Appendix I should be submitted electronically or via e‑fax to the Fidelis Pharmacy Team at 1‑844‑235‑5090 unless the specific oncology/oncology‑related agent is routed to Evolent (NCH/Evolent Oncology Program). Refer to the oncology program routing guidance for Evolent submissions.

Pharmacy e‑fax for Appendix I PA submissions: 1‑844‑235‑5090 (unless routed to Evolent)
Oncology pharmacy PA for many agents is managed by Evolent (NCH) — check the Evolent Oncology Program auth grid
Do not send excluded categories (see policy) to Evolent

Documentation Required

Use of listed HCPCS/J‑codes may trigger prior authorization

Use of listed HCPCS/J‑codes may trigger prior authorization and must be documented: when submitting authorization requests or claims for codes from Appendix I or other listed HCPCS/J‑codes, include clinical documentation that supports medical necessity and links the code to the specific drug/product and indication.

Include medication name, dose, frequency, diagnosis, and supporting clinical notes when requesting PA for J/HCPCS codes
For oncology biologics, include prior lines of therapy and relevant pathology/genetics as applicable

Prior Authorization

OMH two‑day notification for inpatient under 18

OMH Two‑Day Notification for inpatient under‑18 mental health admissions: For OMH‑licensed inpatient mental health treatment for members under age 18 in NYS, facilities must notify Fidelis Care of the admission and initial treatment plan within two business days using the OMH Two‑Day Notification and Initial Treatment Plan form. Send by fax to 833‑561‑0094 (new) or by email to MentalHealthAdmission@fideliscare.org. If criteria are met, the first 14 days are not subject to concurrent review.

Notify Fidelis within two business days of admission and initial treatment plan using OMH Two‑Day Notification form
Fax: 833‑561‑0094 (new) — formerly 718‑896‑1784
Email: MentalHealthAdmission@fideliscare.org
First 14 days: no concurrent utilization review if notification requirements met

Prior Authorization

OASAS notification requirements

OASAS notification for inpatient SUD: For OASAS‑licensed inpatient SUD facilities in NYS, facilities are not subject to PA 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 business days using the OASAS Appendix A Notification Form and LOCADTR tool submission. Fax or email forms to 833‑663‑1608 or LOCADTR@fideliscare.org.

Notify Fidelis within two business days using OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool
Fax/email: 833‑663‑1608 (new) or LOCADTR@fideliscare.org
First 28 days: not subject to authorization or concurrent UR if notification and initial plan submitted

Documentation Required

CORE service initiation documentation

CORE service initiation documentation: CORE services do not require prior authorization, but the Service Initiation Form must be submitted within 3 business days of the first service visit. Submit the form by email to QHCMHARPBH@fideliscare.org or fax to 833‑561‑0089 (new).

CORE Services: no PA required
Service Initiation Form required within 3 business days of first visit
Submit to QHCMHARPBH@fideliscare.org or fax 833‑561‑0089

Prior Authorization

Non‑therapy provider authorization routing

Non‑therapy provider authorization routing: Non‑therapy providers (MD, DO, DPM, etc.) should request authorization for services after the initial therapy evaluation directly through Fidelis Care using the standard Fidelis authorization channels (phone, fax, email) rather than the therapy vendor routing.

Non‑therapy providers must submit PA requests directly to Fidelis Care
Therapy services (post‑evaluation) are routed to Evolent (NIA) per program rules; home therapy initial evals require PA

Prior Authorization

Pharmacy authorization submission

Pharmacy authorization submission: For PA requests related to Appendix I HCPCS/J‑codes and other pharmacy‑reimbursable drugs, submit electronically or via e‑fax to Fidelis Care Pharmacy at 1‑844‑235‑5090 unless the request is managed by Evolent (NCH/Evolent Oncology Program). Oncology pharmacy requests for Evolent‑managed agents must follow the Evolent submission process (visit their auth grid or call the Evolent number).

Fidelis Pharmacy e‑fax for PA submissions: 1‑844‑235‑5090
Oncology medication PA: many agents routed to Evolent (NCH) — check Evolent Oncology Program guidance and use their submission channels

Documentation Required

Documentation of codes requiring authorization

Documentation of codes requiring authorization: When requesting authorization for codes listed in Appendix I or other PA‑required codes, include the specific code(s), associated drug or device, clinical indication, relevant prior treatments, supporting clinical notes, and any applicable diagnostic test results to substantiate medical necessity.

Provide code(s), drug/device name, dose, frequency, diagnosis, prior therapies, and supporting clinical documentation
Failure to provide adequate documentation may result in denial or delayed review

Documentation Required

UM voicemail HIPAA requirements

UM voicemail HIPAA requirements: UM messages may be left only if the provider voicemail is HIPAA‑compliant. Mailbox greeting must identify the mailbox owner and organization and state that the mailbox is confidential and PHI may be left. If not HIPAA‑compliant, UM will leave a generic message requesting a callback and will make a second attempt to reach the provider directly as required by DoH Reasonable Effort Policy.

Voicemail mailbox greeting must identify owner and organization and state PHI may be left
If voicemail not HIPAA‑compliant, only a generic message will be left and a callback requested
A second attempt to reach the provider directly will be made per DOH policy

Note

Member‑type authorization notes

Member‑type authorization notes: Authorization requirements vary by member line of business. Examples: OASAS/OMH exceptions apply for in‑state licensed facilities and specific time windows (OMH under‑18 first 14 days; OASAS first 28 days). Some authorizations are not required for certain lines (e.g., certain S codes/exceptions, CHP vs NYM/HARP differences for pharmacy/DME). Always verify member type (Medicaid, HARP, CHP, MLTC) and follow the line‑of‑business rules when submitting PA requests.

OMH/ OASAS inpatient notification exceptions apply only for OMH/OASAS‑licensed NYS participating network facilities
Oncology pharmacy PA routing differs by line of business (Evolent for Medicaid/HARP; Fidelis for Child Health Plus)
DME and supply PA rules vary by program and member type (see DME manual and MLTC list)
Some authorizations are required for specific member types only; verify before submission

Application across settingsAOT presence applies as a review trigger for OMH-licensed inpatient, partial hospitalization, and IOP programs per NYS OMH Best Practice Manual

Provider actionProviders should identify AOT status on admission/authorization requests to support utilization review determinations

High-utilization (psychiatric) — definition/trigger summary

High-utilization summaryHigh-utilization is defined as any of: >=3 psychiatric inpatient hospitalizations in prior 12 months; >=4 psychiatric ED visits in prior 12 months; or >=3 medical inpatient hospitalizations in prior 12 months

Readmission triggerReadmission to any mental health inpatient unit within 30 days of discharge also qualifies as a utilization trigger

Concurrent review timingIf none of the high-utilization/AOT triggers apply, concurrent review begins when length of stay exceeds 30 days (from day 31 onward)

ABA (members under 21 with ASD or Rett Syndrome) eligibility

ABA eligibility criteriaMembers under age 21 with a diagnosis of Autism Spectrum Disorder and/or Rett Syndrome per DSM-5 may be eligible for Applied Behavioral Analysis (ABA)

Provider/referral requirementMember must be referred by a NYS licensed physician, psychologist, psychiatric nurse practitioner, pediatric NP, or physician assistant

Authorization processPrior authorization required from Behavioral Health for ABA; requests submitted using the ABA authorization request form