Fidelis Care Prior Auth & Coverage Update

Coverage Criteria and Medical Necessity Rules

Inpatient admission authorization

Covered when ALL of the following are met

Inpatient Admissions: All inpatient facility services (medical, substance abuse, and behavioral health) require prior authorization; emergency room stabilization does not require prior authorization but post-stabilization services and inpatient admissions do

All facility admissions are reviewed for medical necessity

OASAS inpatient SUD carve-out

Special carve-out (OASAS-licensed in-network NYS facilities)

OASAS Inpatient SUD: Inpatient detoxification, inpatient rehabilitation and inpatient residential treatment services provided by OASAS-licensed in-network New York State facilities are not subject to prior authorization or 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 and uses the LOCADTR tool for periodic review; services may be subject to review after day 28 or retrospectively28 days

Facilities outside NYS, not OASAS-licensed, or out-of-network must request prior authorization and are subject to concurrent review throughout admission

OMH inpatient mental health carve-out for minors

Special carve-out (OMH-licensed in-network NYS hospitals for under-18 members)

OMH Inpatient Mental Health (<18): Inpatient mental health treatment for members under 18 at OMH-licensed New York State participating hospitals is not subject to prior authorization or concurrent utilization review for the first 14 days provided the facility: (1) notifies Fidelis Care of the admission and initial treatment plan within two business days using the OMH Two-Day Notification and Initial Treatment Plan form; (2) performs daily clinical review; and (3) participates in periodic consultation with Fidelis Care to ensure use of approved clinical review criteria14 days

Inpatient mental health for age 18+ and out-of-state/out-of-network providers require prior authorization and concurrent review

Behavioral health outpatient authorization exceptions

Behavioral health outpatient coverage stance

Outpatient Behavioral Health: Authorization requirement removed for all outpatient behavioral health services except specified services which continue to require authorization: psychological/neuropsychological testing (96116, 96121, 96130-96133, 96136-96139, 96146), developmental pediatric testing (96112, 96113; 96110 non-covered), outpatient ECT (90870), partial hospitalization (H0035; revenue codes 912, 913, 944, 945), and intensive outpatient treatment (90899, S9480, H2013; bill type 131, revenue codes 905/912)

Authorization requests for testing should be submitted on the designated Psychological/Neuropsychological testing request form; see code lists for details

Behavioral health services coverage by program/setting

Coverage status by service and program/setting

Psychiatric Inpatient: MAP Medicaid (beginning Jan 2023): Hospital = Covered (Medicare subject to 190-day lifetime maximum); Freestanding status varies by program and timeframe

OMH regulation referenced

Mental Health Outpatient Treatment and Rehabilitative Services: MAP Medicaid (beginning Jan 2023): Hospital and Freestanding = Covered; Medicare: Hospital and Freestanding = Covered

OMH Part 599

Assertive Community Treatment (ACT): MAP Medicaid entries vary; Medicare entries in this excerpt indicate Not Covered for ACT in hospital and freestanding settings

OMH Part 508

Continuing Day Treatment (CDT):

Medical Nutrition Therapy

Medical Nutrition Therapy (MNT) coverage when diagnosis is diabetes or renal disease

MNT coverage: Medical nutrition therapy by a licensed nutrition provider is covered for members with diabetes (extensive ICD-10 diabetes code list) or renal disease (I12.0, I12.9, N18.1-N18.6, N18.9, N28.9, N29, Z48.22, Z94.0)

Eight visits per year are covered without authorization using codes 97802, 97803, G0270 or G0271

Diabetes Self-Management Training

Diabetes Self-Management Training (DSMT)

DSMT coverage: Members are allowed 10 hours / 20 units in a continuous 12-month period; services must be provided by certified providers and are covered when billed with codes G0108 and G0109; prior authorization is not required10 hours/20 units per 12 months

No prior authorization required

Therapeutic Services

Therapeutic services coverage stance

Therapeutic services requiring prior authorization: A listed group of therapeutic procedure codes and services (phototherapy, chiropractic, hyperbaric oxygen, pain management injections and neuraxial procedures, radiofrequency ablation, bronchial thermoplasty, vision therapy, etc.) are subject to prior authorization; exceptions noted (e.g., 63622 and 63688 do not require authorization for requests from orthopedic specialties)

Some services are explicitly not covered for Low Back Pain (prolotherapy; therapeutic injections of steroids into intervertebral discs); topical oxygen is not covered

Oncology medication PA

Oncology and select infused drugs

Oncology medications and supportive agents require prior authorization from New Century Health (NCH) for participating providers before dispensing or administration; PA can be requested via the NCH web portal or by phone

Oncology requests by nonparticipating providers will be reviewed by Wellcare By Fidelis Care as directed

Enteral Therapy

Enteral therapy

Enteral therapy: Enteral formulas and disposable items described by HCPCS codes B4034-B4162 require prior authorization and apply to Medicare Part B services

Authorization and coverage prerequisites

Covered when authorization obtained and submission rules followed

Authorization submission: Prior authorization requests for pharmacy and other listed services must be submitted electronically via e-fax to the Pharmacy Team at 1-877-882-5892

Oncology requests by nonparticipating providers will require review by Wellcare By Fidelis Care at the same fax number

Out-of-network Medicare Advantage: Out-of-network services are covered with an authorization for the Medicare Advantage Flex Plan (003) and the Medicare Advantage without RX (001)

Additional copays and deductibles may apply

Unlisted/Temporary codes: All services billed with 'Unlisted' or 'Temporary' codes (such as C-codes) require prior authorization

Lack of authorization may result in denial

Many surgical and medical procedures that are completed within 24 hours are not appropriate for inpatient level of care and therefore will not be approved as inpatient admissions. When these services are performed and billed as outpatient (for example, ambulatory surgery or office-based procedures in POS 11 or 22), prior authorization requirements follow the outpatient rules in this policy rather than inpatient authorization. Providers should verify place-of-service billing and submit prior authorization requests accordingly to avoid retrospective denials.

Topical oxygen is explicitly stated in the policy as not a covered service. Providers should not submit prior authorization requests for topical oxygen because the service is excluded from coverage.

Reiterating exclusions: the policy identifies topical oxygen as a non‑covered service. This exclusion applies regardless of the setting and should be considered when evaluating treatment plans and claim submission.

For members with a diagnosis of Low Back Pain, the policy lists specific services that are not covered. These include prolotherapy and therapeutic injections of steroids into intervertebral discs. Additionally, certain outpatient procedures (see outpatient surgery section) may require authorization depending on place of service; confirm coding and setting before submission.

Prior authorization submission instructions for pharmacy-administered drugs are provided: requests must be sent electronically via e-fax to 1-877-882-5892. The outpatient surgery section lists procedure groups and CPT/HCPCS codes that require prior authorization; consult the code lists in this policy when preparing requests to ensure correct code-level routing.

Out-of-network services may be covered for certain Medicare Advantage plans when an authorization is obtained. Specifically, the Medicare Advantage Flex Plan (003) and Medicare Advantage without RX (001) cover out-of-network services with prior authorization; however, additional copays and deductibles may apply and providers should confirm member benefit details before rendering services.

CPT code 20610 (joint injection) is addressed by the policy: when billed for hyaluronic acid injections with qualifying osteoarthritis diagnosis codes (examples include M17.0, M17.10–M17.12, M17.2, M17.30–M17.32, M17.4, M17.5, M17.9), the service is listed as non‑covered. Providers must ensure accurate diagnosis coding; hyaluronic acid injections billed with these M17 osteoarthritis codes will be denied.

Examples of services explicitly listed as not covered in the policy include: prolotherapy, therapeutic injections of steroids into intervertebral discs for Low Back Pain, and topical oxygen. The outpatient surgery section also notes certain procedure codes and place-of-service combinations that carry specific coverage limitations or non‑coverage designations.

The policy explicitly lists therapeutic injections and prolotherapy among services not covered for members with a diagnosis of Low Back Pain. These treatments are treated as exclusions and will be denied when billed for that diagnosis.

The policy includes extensive code lists and groups for prior authorization scope and pharmacy routing. For pharmacy-administered agents, submit prior authorization requests by e-fax to 1-877-882-5892. For outpatient surgical and procedure codes, refer to the outpatient surgery code lists in the policy to determine whether prior authorization is required and where requests should be submitted.

Code Lists and Billing Identifiers

Outpatient surgery and ambulatory procedures requiring prior authorization (selected)CPTCovered

43770	Laparoscopic sleeve gastrectomy
43771	Revision/other bariatric
43772	Bariatric procedure
43773	Bariatric procedure
43774	Bariatric procedure
43888	Laparoscopic gastric bypass
10040	Incision and drainage (abscess)
11300-11307	Skin lesion excision (selected codes require PA in ASC POS 24)
11308-11313	Further excision codes requiring PA in ASC POS 24
11200	Removal of skin tags (continues to require auth)

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Office-based dermatologic procedures still requiring PA if done in ASC (POS 24)CPTCovered

10060	I&D of skin and subcutaneous tissue
11100	Biopsy of skin, subcutaneous tissue
11900	Excision of pilonidal cyst
17000	Destruction of premalignant lesions
20600	Arthrocentesis
20605	Arthrocentesis with injection
20610	Arthrocentesis with injection large joint

Ear/ocular and related procedures requiring PACPTCovered

69300	Repair of the external ear
69090	Removal of foreign body from ear
65760-65775	Ocular adnexa procedures range
66987-66991	Vitrectomy/ocular procedures
67900-67911	Eyelid ptosis/lagophthalmos procedures
68841	Tympanostomy

Additional skin surgery codes requiring PA in ASC (explicit list)CPTCovered

11300	Excision, pilonidal cyst etc.
11301	Excision code
11302	Excision code
11303	Excision code
11304	Excision code
11305	Excision code
11306	Excision code
11307	Excision code
11308	Excision code
11309	Excision code

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Codes exempt/always require authorization regardless of POSCPTCovered

11200	Removal of skin tags
11201	Removal of skin tags
11719	Nail procedure requiring auth

Non-covered or place-of-service caveatsmixedNot Covered

20610 (with OA dx M17.x)

Non-covered for hyaluronic acid joint injection with specified osteoarthritis diagnosis codes

Psychological / Neuropsychological and Developmental testing codesCPTCovered

96116	Neurobehavioral status exam
96121	Neurobehavioral status exam, reassessment
96130	Psychological testing evaluation
96131	Psychological testing evaluation add-on
96132	Neuropsych test evaluation
96133	Neuropsych test evaluation add-on
96136	Psychological or neuropsych test administration & scoring
96137	Psych test admin add-on
96138	Psych testing admin & scoring, each 30 minutes
96139	Psych testing admin add-on

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Authorization requirementmixed

Authorization is required. All requests should be submitted on the Psychological/Neuropsychological testing request form.

Outpatient ECTCPTCovered

90870

Electroconvulsive therapy (ECT)

Partial Hospitalization (Mental Health) - Revenue & HCPCSmixedCovered

Revenue 912	Partial hospitalization
Revenue 913	Partial hospitalization
Revenue 944	Partial hospitalization
Revenue 945	Partial hospitalization
HCPCS H0035	Partial hospitalization service

Intensive Outpatient TreatmentmixedCovered

Bill type 131	Intensive outpatient bill type
Revenue 905 or 912	Revenue codes for IOP
CPT 90899	Unlisted psychiatric service
S9480	Intensive outpatient code
HCPCS H2013	Community psychiatric treatment

Selected diagnostic and procedure CPT/HCPCS requiring prior authorization (sample)CPTCovered

43235	Esophagogastroduodenoscopy with dilation
43239	EGD with other procedure
43248	EGD with sphincterotomy
45378	Colonoscopy with biopsy
45380	Colonoscopy with removal of tumor
45384	Colonoscopy, other
45385	Colonoscopy with ablation
46255	Hemorrhoidectomy
46260	Hemorrhoid procedure
46270	Hemorrhoid ligation

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DME and orthotics not requiring prior authorization (sample list)HCPCS

A4604	Ostomy pouch
E0130	Walker
E0135	Walker
L0130	Knee orthosis
L0140	Knee orthosis
L0150	Knee orthosis
L0170	Ankle/foot orthosis
L0190	Ankle/foot orthosis
V2624	Breast prosthesis

Imaging, therapy and other codes with specific PA notesmixed

77089-77092	TBS scans
95249	Ambulatory continuous glucose monitoring
92066	Vision therapy
95919	Vision therapy
OB ultrasound rule	First 4 OB ultrasounds no auth; 5+ for normal pregnancy require auth (see ICD-10 list)

Phototherapy and related therapeutic CPT codesCPT

96567	Phototherapy
96573	Phototherapy
96574	Phototherapy
96900	Phototherapy
96910	Phototherapy
96912-96913	Phototherapy codes

Pain management injection codesCPT

20526	Trigger point injection
20550	Injection tendon sheath
20551	Injection joint
20552	Injection(s)

Epidural/neuraxial injection and catheter codesCPT

62263-62264	Epidural injection
62273	Injection/infusion
62280-62282	Catheter-related codes

Spinal implant / neurostimulator codesCPT

63650	Percutaneous implantation of neurostimulator lead
64553-64595	Neurostimulator system procedures (selection)

Nerve injection and destruction codesCPT

64600-64640	Destruction of peripheral nerve
64628-64629	Destruction of sensory nerve
64582-64583	Nerve procedures

Vision therapy codesCPT

92066

Vision therapy

Diagnosis codes supporting Medical Nutrition Therapy coverage (diabetes/renal)ICD-10Covered

Extensive list

See policy: E08.*, E09.*, E10.*, E11.*, E13.*, O24.*, O99.* and renal disease codes I12.0, I12.9, N18.1-N18.6, N18.9, N28.9, N29, Z48.22, Z94.0

MNT billing codes allowed without authorizationCPTCovered

97802	Medical nutrition therapy initial assessment
97803	Medical nutrition therapy re-assessment
G0270	MNT group; 30 minutes
G0271	MNT follow-up

DSMT codes (no authorization required)CPTCovered

G0108	DSMT individual; 30 minutes
G0109	DSMT group; 30 minutes

Continuous Glucose Monitor / Ambulatory CGMHCPCSCovered

95249

Ambulatory continuous glucose monitor—professional

Enteral therapy HCPCS codes (require authorization)HCPCS

B4034-B4162

Enteral formulas and supplies—require authorization (Part B)

Pharmacy / Infused drug HCPCS / J-code sample groupings (partial list)HCPCSCovered

J0129	Abatacept (Orencia) mapping
J0135	Adalimumab (Humira) mapping
J0172	Aducanumab / other mappings
J0218	Oligonucleotide therapies mapping
J2326	Nusinersen mapping
J7320-J7333	Hyaluronan product mappings
J9354-J9395	High-cost oncology biologics mapping (partial)
C-codes / Q-codes	Selected C/Q mappings referenced in policy (e.g., C9047-C9051, Q0138, Q0510- Q5131)

Provider Steps, Submission Channels, and Prior Authorization Delegation

Prior Authorization

Prior Authorization Required

Prior authorization required for the listed surgical services and for all inpatient facility admissions. All facility admissions are reviewed for medical necessity; failure to obtain required authorization may result in denial. Transplants require authorization at the time of transplant evaluation.

All inpatient facility services (medical, substance use, behavioral health) require authorization.
Transplants (solid organ and bone marrow/tissue) require authorization at time of transplant evaluation — includes listed CPT ranges and examples.

Prior Authorization

Delegated Prior Authorization to TurningPoint

Prior authorization for specified ENT, certain orthopedic/spinal, cardiac and other surgical procedures has been delegated to TurningPoint Healthcare Solutions, LLC. If a CPT code is delegated to TurningPoint, associated devices (HCPCS codes) will also be reviewed by TurningPoint for medical necessity.

Delegated areas include: ENT procedures, certain outpatient orthopedic and spinal surgical procedures, and cardiac surgical procedures (see policy lists).

Policy Background and Scope

This policy governs Fidelis Care utilization management processes across a broad range of services, including inpatient admissions, solid organ and bone marrow/tissue transplants, behavioral health services (inpatient and outpatient), outpatient surgeries, and delegated prior authorization areas. It documents state-specific carve-outs: OASAS‑licensed in‑network New York facilities have an initial 28‑day carve‑out for inpatient SUD admissions with required notification and LOCADTR use, and OMH‑licensed in‑state hospitals have an initial 14‑day carve‑out for inpatient mental health admissions for members under age 18 with a two‑day notification requirement. The policy also specifies submission channels (e-fax 1-877-882-5892 for pharmacy PA), delegation to third‑party reviewers for selected surgical categories, and that out‑of‑network Medicare Advantage coverage may be available with authorization (additional copays/deductibles may apply).

Key Terms and Regulatory Tools

LOCADTR — clinical review tool (OASAS inpatient SUD)

DefinitionLOCADTR is the OASAS LOCADTR Medical Necessity Tool used for clinical review of inpatient SUD admissions and discharge planning

Facility requirementOASAS-licensed inpatient SUD facilities must submit LOCADTR and use it for periodic review and for discharge planning

Submission methodsFacilities may fax or email the OASAS Appendix A Notification Form and LOCADTR to 646-829-1421 or LOCADTR@fideliscare.org

Two-Day Notification and Initial Treatment Plan (OMH inpatient <18)

Form purposeThe OMH 'Two-Day Notification and Initial Treatment Plan' form must be completed and submitted within two business days for OMH-licensed inpatient mental health admissions for members under 18

Submission channels

OpenPayer

Prior Authorization and Utilization Review Policy (Inpatient, Outpatient, Behavioral Health, Pharmacy & Related Services)

Coverage Criteria and Medical Necessity Rules

Code Lists and Billing Identifiers

Provider Steps, Submission Channels, and Prior Authorization Delegation

Policy Background and Scope

Key Terms and Regulatory Tools