CurrentFidelis CarePolicy N/A

Fidelis Care Ears, Nose, & Throat (ENT) Surgeries Management Program

Defines prior authorization and management processes for selected ear, nose, and throat (ENT) surgeries for Fidelis Care members in New York, detailing provider responsibilities and TurningPoint handling of utilization management.

Policy Summary

PayerFidelis Care

PolicyEars, Nose, & Throat (ENT) Surgeries Management Program

Policy CodePolicy N/A

Change TypeNew program launchdelegation of prior authorization

Effective DateOct 4, 2021

Next Review DateN/A

Key ActionObtain prior authorization from TurningPoint for listed ENT procedures before providing services.

SourceLink

POLICY UPDATE CHANGES

Launch of a new Fidelis Care Ears, Nose, & Throat (ENT) Surgeries Management Program effective October 4, 2021.

TurningPoint Healthcare Solutions, LLC will handle prior authorization for medical necessity and length of stay for specified ENT procedures.

List of ENT procedures requiring authorization (e.g., tonsillectomy, rhinoplasty, sinus surgery, cochlear implant, tympanostomy, thyroidectomy, FESS).

Oct 4, 2021program start date (pending NY approval)

1delegated UM vendor

≥10ENT procedure types listed

Multiple

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Authorization & Coverage Criteria for ENT Procedures

Authorization required for listed ENT procedures

Covered when ALL of the following administrative conditions are met

Authorization Conditions: (1) Procedure is one of the listed ENT surgeries and (2) prior authorization is obtained from TurningPoint for medical necessity and length of stay when applicable

Applies across inpatient, outpatient, physician office, and in-home settings; emergency-related procedures do not require authorization

Emergency-related procedures are excluded from the prior authorization requirements for the listed ENT surgeries. The policy specifies that Emergency Related Procedures do not require authorization, and providers should not seek prior approval for procedures performed in true emergency situations.

Impacted Procedure Codes

Impacted CPT Codes (referenced)mixed

see website list

Impacted CPT codes are provided on Fidelis Care website (document references a list but does not enumerate codes in the notice).

Provider Responsibilities & Authorization Process

Prior Authorization

Prior Authorization Required

Prior authorization is required for the listed ENT procedures. Fidelis Care has delegated prior authorization for medical necessity and appropriate length of stay (when applicable) to TurningPoint Healthcare Solutions, LLC. Providers must obtain authorization before scheduling or performing procedures except in emergencies.

Affected procedures include (not exhaustive): Tonsillectomy and/or Adenoidectomy; Tympanostomy/Tympanoplasty/Myringotomy; Rhinoplasty/Septoplasty; Sinus Surgery; Functional Endoscopic Sinus Surgery; Balloon Dilation; Laryngoscopy/Laryngoplasty; Cochlear Implant; Thyroidectomy/Parathyroidectomy; Esophagoscopy.

Documentation Required

Provider Actions

It is the responsibility of the ordering/provider to obtain prior authorization and to verify authorization has been received before rendering services. Providers should ensure documentation supports medical necessity and any requested length of stay.

Confirm member eligibility and product (e.g., Medicaid, Medicare Advantage, Essential Plan, Child Health Plus, Qualified Health Plans) before submission.
Coordinate with facility/ancillary providers to include required clinical documentation with the authorization request.

Key Terms & Peer-to-Peer Process

inv-09: Peer-to-Peer Engagement

DefinitionPeer-to-Peer Engagement: A process where a TurningPoint physician of the same specialty engages the ordering provider to validate the clinical appropriateness of the requested ENT procedure.

PurposeTo support additional clinical discussion when authorization requests require validation of procedure appropriateness specific to the patient’s condition.

When usedApplied for authorization requests that require additional clinical discussion to validate medical necessity or appropriateness of the requested ENT procedure.

Who participatesA TurningPoint physician of the same specialty and the ordering/provider who requested authorization.

Program contextPart of the Fidelis Care ENT Surgeries Management Program managed by TurningPoint Healthcare Solutions, effective Oct 4, 2021.

Program Background

This notice introduces a utilization management program for selected Ears, Nose, & Throat (ENT) surgeries intended to promote patient safety and cost-effective care. The program delegates prior authorization for medical necessity and appropriate length of stay to TurningPoint Healthcare Solutions and covers procedures across inpatient, outpatient, physician office, and in-home settings. Providers are responsible for obtaining prior authorization when required and for following TurningPoint intake procedures via web portal, telephone, or facsimile.