CurrentFidelis CarePolicy N/A

Oncology medications and supportive agents prior review by Evolent (New Century Health)

Fidelis Care Essential Plan and Qualified Health Plans require review by Evolent (formerly New Century Health/NCH) before oncology medications and supportive agents are dispensed or administered for members (adults 18+; pediatric membership included starting 7/1/2022). The policy lists out-of-scope items and a comprehensive list of HCPCS/J/Q codes that require prior authorization/review.

Policy Summary

PayerFidelis Care

PolicyOncology medications and supportive agents prior review by Evolent (New Century Health)

Policy CodePolicy N/A

Change TypeClarified scope (pediatrics & clinical trials)

Effective DateN/A

Next Review DateN/A

Key ActionSubmit all oncology regimens to New Century Health (my.newcenturyhealth.com or 1-888-999-7713, option 1) prior to dispensing or administration; include the entire regimen to avoid denial.

SourceLink

POLICY UPDATE CHANGES

Pediatric membership and clinical trials to be included for NCH review starting 7/1/2022.

1Prior review required

100+HCPCS/J/Q codes listed

18+Out-of-scope categories listed

Policy summary

Fidelis Care requires external review by Evolent (formerly New Century Health/NCH) for oncology medications and supportive agents prior to dispensing or administration for members covered under the Essential Plan and Qualified Health Plans; providers must submit requests via NCH’s portal (my.newcenturyhealth.com) or by calling 1-888-999-7713, option 1. This requirement applies to adult members (age 18+) initially, and pediatric membership and clinical trial reviews are included starting 7/1/2022.

Prior review requirement

Oncology medications and supportive agents require review by Evolent (NCH) before dispensing or administration:

ALL of the following

Member is covered under Fidelis Care Essential Plan or Qualified Health Plan
Medication or supportive agent is an oncology medication or supportive agent
Review/authorization request submitted to New Century Health via my.newcenturyhealth.com or by calling 1-888-999-7713 option 1 prior to dispensing/administration
Submit the entire oncology regimen to NCH; omissions may result in a denial
Explicit operational requirement
Age applicability
- Member age 18 years or older (initial scope)
- Pediatric membership included starting 2022-07-01; clinical trials may be submitted starting 2022-07-01

HCPCS / J / Q code groups requiring review

HCPCS/Codes requiring prior authorization / review by NCHHCPCSCovered

C9095	TEBENTAFUSP-TEBN INJ
C9155	EPCORITAMAB-BYSP INJ
C9163	INJECTION TALQUETAMAB-TGVS
C9165	INJECTION ELRANATAMAB-BCMM
C9293	GLUCARPIDASE
J0185	APREPITANT INJECTION (listed in group with other codes)
J0207	AMIFOSTINE 500 MG INJ
J0208	SODIUM THIOSULFATE
J0594	BUSULFAN 1 MG INJ
J0641	LEVOLEUCOVORIN CALCIUM INJECTION

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What providers must do

Prior Authorization

Prior review/authorization required by New Century Health

Submit all oncology regimens for any oncology medication/supportive agent to New Century Health prior to dispensing or administration. Requests can be submitted via the NCH web portal or by phone. Review/authorization is required before dispensing or administration.

Submit at my.newcenturyhealth.com
Or call 1-888-999-7713, option 1
Review required prior to dispensing/administration

Documentation Required

Submit entire oncology regimen

Providers must include the entire oncology regimen when submitting to NCH. Any omissions may result in a denial.

Emphasize: submit entire oncology regimen
Omissions may result in a denial

Billing Rule

Do not submit out-of-scope requests to NCH

Do not submit requests for items that are out of scope for New Century Health; those requests follow alternate approval workflows instead of NCH submission.

Examples: Antibiotics; Bone marrow, stem cell transplants, CAR-T; Controlled substances; Equipment requests (infusion pumps); Genetic lab testing and laboratory services; Hemophilia drugs; Immune globulins; Inpatient drug requests; Iron preparations; Pain medications; Radiopharmaceuticals; Surgeries/surgical procedures; Sickle cell diagnoses
Follow alternate approval workflows for these items (do not submit to NCH)