Authorization Grid Detail, Effective March 1, 2026
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Defines prior authorization, notification, and utilization review requirements across inpatient, outpatient, behavioral health, DME, home health, imaging, and other services for Fidelis Care Medicaid, Child Health Plus (CHP) and HealthierLife plans (partial document — Part 1 of 3). Includes delegated reviewers and special program-specific rules.
No material clinical/coverage changes — the authorization grid content is informational and ongoing; no new material policy changes were listed.
Coverage Summary & Scope
Payer: Fidelis Care. This policy applies to Medicaid, Child Health Plus (CHP) and HealthierLife plans and defines prior authorization, notification, and utilization review requirements across inpatient, outpatient, behavioral health, DME, home health, imaging, pharmacy and other services. The grid is effective March 1, 2026 (document header) and identifies covered plan lines as NYM (Medicaid), CHP and HealthierLife.
Delegated reviewers include Evolent (NIA) for delegated radiology, oncology/outpatient drug review, musculoskeletal/orthopedic management, and therapy prior authorization programs, and TurningPoint Healthcare Solutions, LLC for specified ENT and cardiac surgical procedure reviews. Coverage stance: mixed — many behavioral health outpatient services no longer require prior authorization but numerous inpatient, outpatient surgical, diagnostic, DME, imaging and pharmacy items do require prior authorization or have special notification/waiver rules.
Authorization & Utilization Review Criteria
General Authorization Requirements
Authorization and utilization review requirements as specified below:
- Out-of-network and inpatient: Any Medicaid, CHP and HealthierLife service provided by a nonparticipating provider/facility/physician requires authorization.
- Inpatient admissions: All inpatient admissions require an authorization. Emergency room services or any emergent service required to provide stabilization do not require authorization; post-stabilization services and inpatient admissions after ER require authorization.
New fax number for Inpatient ER notifications: 833-663-1602.
- Medical necessity review: All facility admissions are reviewed for medical necessity.
- Transplants: All solid organ and bone marrow/tissue transplants require authorization at the time of the transplant evaluation (includes listed CPT/procedure codes).
See transplant code list in grid.
- Rehabilitation services: Inpatient Rehabilitation Services (acute, sub-acute and skilled nursing rehabilitation) require prior authorization.
- Orthopedic and spinal procedures: Orthopedic surgical and spinal procedures performed inpatient or outpatient require prior authorization; Musculoskeletal Management Program delegated to Evolent (NIA).
- TurningPoint delegated surgeries: Certain surgical categories (ENT, Cardiac, and other delegated CPT lists) have prior authorization delegated to TurningPoint Healthcare Solutions, LLC.
OASAS Licensed Inpatient Substance Use Disorder (In-State, In-Network)
Effective 01/01/2020 — conditions where authorization and concurrent review are waived or limited:
OASAS Licensed Inpatient SUD (In-State, In-Network)
- No prior auth in-network OASAS SUD: Inpatient SUD services provided by NY State OASAS-licensed, participating in-network facilities are not subject to prior authorization review.
- Concurrent review waiver and notification: No concurrent utilization review during first 28 days of inpatient admission provided facility notifies Fidelis Care of admission and initial treatment plan within two business days via OASAS Appendix A and LOCADTR submission to fax 833-663-1608 or LOCADTR@fideliscare.org.
- Daily clinical review and consultation: Facility must perform daily clinical review (not required to run LOCADTR every day) and periodically consult with Fidelis Care starting on or just prior to day 14 to ensure LOCADTR use.
- Post-28-day review: Inpatient SUD services may be subject to utilization review after day 28 or upon discharge using LOCADTR.
- Discharge plan: Prior to discharge, facility must provide written discharge plan and indicate whether post-discharge services are secured or reasonably available.
- Retro review: All services may be retrospectively reviewed for clinical necessity.
OASAS/Out-of-State or Non-Participating Facilities for SUD
Authorization and concurrent review requirements for other facilities:
Providers may contact Behavioral Health with questions; contact info in grid.
OMH Licensed Inpatient Mental Health Treatment (In-State, In-Network)
Effective 06/01/2021 — prior authorization waived except for patients meeting triggers; additional rule for under 18 effective 01/01/2020:
- No prior auth with required notification: Inpatient mental health treatment provided by OMH-licensed hospitals in NY State are not subject to prior authorization provided the facility notifies the insurer within 2 business days of admission (phone or fax).
OMH trigger list (any)
- AOT: Individuals subject to a current Assisted Outpatient Treatment (AOT) court order
- Recent AOT: Individuals who had an AOT court order that expired within the past five years
- High utilization: (1) Three or more psychiatric inpatient hospitalizations in prior 12 months; OR (2) Four or more psychiatric ED visits in prior 12 months; OR (3) Three or more medical inpatient hospitalizations in prior 12 months
- Early readmission: Individuals readmitted to any mental health inpatient unit within 30 days of discharge from prior mental health inpatient admission
- Long stay: Individuals not meeting above triggers whose length of stay exceeds 30 days (concurrent review from Day 31 onwards)
- Under-18 special rule: For members under 18 in-network and OMH-licensed: no prior authorization and no concurrent review during first 14 days if facility notifies Fidelis within two business days using OMH Two-Day Notification and Initial Treatment Plan form, performs daily clinical review, and participates in periodic consultation with Fidelis Care.
- Out-of-network: All inpatient mental health services provided by out-of-network facilities are subject to concurrent review throughout the admission.
Behavioral Health - Outpatient Services Authorization Exceptions and Requirements
Authorization removed for most outpatient behavioral health; exceptions listed require authorization or notification:
- Partial Hospitalization requires utilization review only for members meeting OMH triggers (same trigger list as inpatient mental health); out-of-network partial hospitalization subject to concurrent review throughout admission.
- Intensive Outpatient Treatment: No prior authorization for first seven days; additional days require authorization; utilization review only for members meeting OMH triggers; out-of-network services subject to concurrent review.
- ABA: Applied Behavior Analysis (ABA) covered for members under 21 with ASD or Rett Syndrome; referral required from specified licensed clinicians; providers must be LBA/CBAA or specified individuals enrolled in NYS Medicaid; Prior Authorization required from Behavioral Health (ABA authorization request form).
- Continuing Day Treatment (H2012): First 7 service days do not require authorization; additional days require authorization.
- PROS and ACT: Personalized Recovery Oriented Services (PROS) prior authorization not required effective 02/01/2022. Assertive Community Treatment (ACT & Youth ACT H0040): effective 06/01/23 providers no longer need Fidelis prior authorization; SPOA process for placement.
- IPRT and HCBS: Intensive Psychiatric Rehabilitation Treatment (IPRT H2012K) and Home and Community Based Services (HCBS) eligibility/notification rules apply; HCBS intake/service delivery prior auth not required effective 01/01/23 for adult HealthierLife plan.
- CORE Services: CORE services available without prior authorization effective 02/01/2022; Service Initiation Form required within 3 business days of first service visit.
- CFTSS: Children and Family Treatment & Support Services (CFTSS): specified services listed with concurrent review required at/after the 4th visit for several services; some codes have no authorization requirements (CI).
- Children's HCBS & Respite: Children's Home and Community Based Services require notification prior to initial appointment and have limits/processes for respite services; short-term respite must be in-person; per-calendar-year unit limits apply and exceedance requires medical necessity documentation.
- 29-I Facility CLHRS/OLHRS: Core Limited Health Related Services (CLHRS) delivered by 29-I facilities: No Utilization Review will be conducted for CLHRS; OLHRS listed will not have Utilization Review when delivered by 29-I Facilities; 29-I facilities providing CFTSS or Children's HCBS remain subject to authorization as outlined.
- Family & Group Psychotherapy: Family Psychotherapy (90847) and Group Psychotherapy (90853) covered; authorization required. Effective 01/01/2026, notification and concurrent review required for Group Psychoeducation beyond initial 30 visits per calendar year. SUD group/family psychotherapy and 29-I providers not subject to authorization for group/family psychotherapy.
Outpatient Surgery Authorization List
Outlined CPT/HCPCS codes and categories that require prior authorization in outpatient settings (Part 1 of list):
- Skin surgery and ambulatory POS rules: Many skin surgery treatments removed from auth when performed in office/POS11 or POS22; ambulatory surgery POS24 codes (long list) continue to require authorization; certain codes require authorization regardless of POS (listed A-/Q-codes).
- Eyelid & ocular surgery codes listed require authorization (65760-65775 series and related codes).
- Facial cosmetic/septoplasty/rhinoplasty: Facial cosmetic and rhinoplasty codes listed require authorization (21120-21296, 30400-30450, etc.).
- Vascular procedures: Vascular/vein procedures listed require authorization (36465-36478, 37241-37244, 37718-37785, etc.).
- CAR-T therapy requires authorization (Q2058, 38225-38228).
- Delegations to Evolent/TurningPoint: Certain outpatient orthopedic/spinal procedures delegated to Evolent (NIA) and ENT/Cardiac delegated to TurningPoint; if delegated, requests should be directed to the vendor.
Outpatient & DME Services - Diagnostic Testing, DME, Home Health, Hospice, Imaging
Authorization requirements and special rules for outpatient diagnostics, DME, home health and imaging:
- Diagnostic testing requiring auth: Diagnostic testing (sleep studies including home sleep studies; BRCA and other genetic testing; wireless capsule endoscopy and motility; gastroenterology procedures with POS-specific auth rules; proprietary laboratory analyses U-codes; other services G0330, G0571, 42975, 64567, 87182-87183, 97037) require authorization as noted. Authorization not required for CPT 81244, 81329, 81331, 81336, 81420; CPT 81329 and 81336 combined limit 1 per lifetime.
- Drug testing: G0480 requires authorization.
- Donor breast milk: T2101 (Donor Breast Milk) requires authorization only when given in an outpatient setting.
- Home health approvals: Home Health Care approvals are based on medical need for skilled services; numerous HCPCS/T codes require authorization and specific billing units.
- PERS and CDPAS: PERS requires authorization. Consumer Directed Personal Assistance services (CDPAS) require authorization.
- Hospice submission rules: Hospice requests for Medicaid members should be submitted to Fidelis Care; CHP requests to Fidelis Care; coverage nuances for members enrolled in Hospice prior to Oct 1, 2013 described in grid.
- Imaging - OB ultrasounds and delegation: Imaging Studies: First 4 OB ultrasounds can be performed without authorization; five or more ultrasounds for a normal pregnancy require authorization; OB ultrasounds for high-risk pregnancy (specified O09 & O36 codes) do not require authorization. Prior authorization for radiology services delegated to Evolent (NIA); cardiac ultrasounds delegated to TurningPoint.
Imaging Studies Authorization Rules
Authorization requirements for obstetric (OB) ultrasounds and other imaging services:
- OB ultrasound counts: The first 4 OB ultrasounds can be performed without an authorization. Five or more ultrasounds for a normal pregnancy require authorization.
Normal pregnancy diagnosis codes listed (Z32.01, Z33.1, Z34.x series).
- High risk pregnancy exception: OB ultrasounds for a high risk pregnancy (O09 & O36 code ranges listed) do not require authorization.
High risk diagnosis code ranges provided in grid.
- Radiology delegation: Prior authorization for radiology services has been delegated to Evolent (NIA); cardiac ultrasounds delegated to TurningPoint; many ultrasounds (non-OB pelvic, abdominal, fetal echocardiograms) may not require prior authorization and full CPT list available on payer site.
DXA and TBS Scans Authorization Rules
Authorization rules and age/diagnosis-based exceptions for DXA scans (77080/77081) and TBS codes:
Physical, Occupational, and Speech Therapy Authorization Rules
Prior authorization requirements for PT/OT/ST in various settings and timing for submission:
- Scope and vendor: Effective 10/1/2021, Home & Outpatient PT, OT, and ST performed after the initial evaluation require prior authorization through Evolent (NIA). Home therapy requires authorization for the initial evaluation.
- Exclusions from program: Program excludes PT/OT/ST performed in Inpatient, Emergency Room, Skilled Nursing Facility/Sub-Acute Rehab, or during an Observation stay.
- All other billed codes require auth: All other billed procedure codes, even if on same date as initial evaluation, require authorization prior to billing.
- Submission timeframes: Authorization request must be sent to Evolent (NIA) within 1 business day for outpatient setting or 2 business days for home health setting if submitting claims using codes other than designated initial evaluation CPT codes; for inpatient settings submit to Fidelis within 1 business day.
- POS 31 & 32 fax: For therapy services provided in Inpatient settings POS 31 & 32 prior authorization requests are to be faxed to 833-663-1611.
- Non-therapy providers (MD, DO, DPM, etc.) should request prior authorization for all services after the initial evaluation directly through Fidelis Care.
Podiatry Services
Authorization and coverage notes for podiatry:
Code 11719 is non-covered for Medicaid when rendered by a physician per Medicaid Fee Schedule; when rendered by a facility using POS 11 it is covered and requires prior authorization.
Therapeutic Services and Specific Procedure Rules
Therapeutic services that require authorization or are non-covered, including lists of CPT/HCPCS and coverage exclusions:
- Listed therapeutic services: Phototherapy, Hyperbaric Oxygen Therapy, Pain Management Codes (injections/TENS/etc.), Interventional Pain Management and neuromodulation codes, Topical oxygen, Radiation Therapy (delegated to Evolent), Ambulatory continuous glucose monitoring (95249), Radiofrequency Ablation of Uterine Fibroids (58674), Bronchial Thermoplasty (31660,31661), Vision Therapy (92066,95919) — require authorization or are listed in grid.
- Non-covered for Low Back Pain: Prolotherapy; therapeutic facet joint steroid injections in the lumbar/sacral regions; therapeutic injections of steroids into intervertebral discs; continuous or intermittent traction — not covered for Low Back Pain diagnosis.
Long Term Home Health Care Services
Coverage and authorization for long-term home health services and home-delivered meals for Medicaid Managed Care enrollees transitioning from LTHHCP:
Adult Day Health Care (ADHC/AADHC)
Authorization requirements for adult day health care programs:
DME and Erectile Dysfunction Services
Authorization and exclusion details for DME and ED-related treatments:
Listed codes include 37788, 37790, 54400-54411, 54416-54417, L7900, L7902 as subject to coverage rules and authorization.
Self-Management Training and Smoking Cessation
Coverage limits and authorization for DSMT, ASMT, and smoking cessation counseling:
- ASMT: Asthma Self-Management Training (ASMT): No authorization required for S9441, S9445, S9446 when billed with diagnosis codes J45x; newly diagnosed or medically complex members allowed up to 10 hours in continuous 6-month period; medically stable up to 1 hour; group sessions limited to no more than eight patients.
Services Provided by Outside Vendors — Authorization Contacts
External vendors handling authorizations for specialized services and certain transport codes:
Pharmacy and Medicaid Pharmacy List Rules
Pharmacy benefit transition, delegation for oncology drug PA, exclusions, Appendix I submission routing, and J-code non-coverage example:
- NYRx transition: Effective April 1, 2023, Fidelis Medicaid Managed Care and HARP members receive pharmacy benefits through NYRx (Medicaid FFS Pharmacy Program); physician-administered drugs on Medicaid Pharmacy List are available through NYRx.
- Evolent oncology PA delegation: Oncology medications and supportive agents require prior authorization from Evolent before dispensation or administration for Medicaid Managed Care and HARP (medical benefit only), excluding Child Health Plus; requests via Evolent portal or 1-888-999-7713 option 1.
- Excluded categories from Evolent review: A list of drug categories excluded from Evolent review provided (e.g., Antibiotics; Bone Marrow/Stem Cell Transplants/CAR-T; Cablivi; Controlled Substances; Genetic Lab Testing; Hemophilia Drugs; Immune Globulins; Inpatient Drug Requests; Radiopharmaceuticals; Surgeries).
- Appendix I submission routing: Appendix I lists codes that require prior authorization and should be submitted to the Pharmacy Team electronically via e-fax 1-844-235-5090 (Appendix I not related to Evolent program).
- J-code non-coverage example: Certain J7xxx/J0xxx codes are non-covered when billed with specific diagnoses; example: J7318-J7333 hyaluronic acid J-codes are non-covered when billed with M17.x (osteoarthritis of the knee) when paired with CPT 20610.
Codes Requiring Prior Authorization / Special Handling
| 32850 | Thoracic organ transplant procedure (example) |
| 32851 | Thoracic organ transplant procedure (example) |
| 32852 | Thoracic organ transplant procedure (example) |
| 32853 | Thoracic organ transplant procedure (example) |
| 32854 | Thoracic organ transplant procedure (example) |
| 32855 | Thoracic organ transplant procedure (example) |
| 32856 | Thoracic organ transplant procedure (example) |
| 33930 | Cardiac transplant (example) |
| 33931 | Cardiac transplant (example) |
| 33932 | Cardiac transplant (example) |
| Laparoscopic codes | Various CPT codes for laparoscopic procedures; many are outpatient within 24 hours and may not require inpatient authorization if performed in-network |
| Thyroid surgery codes | Examples: 60240, 60252 (refer to auth grid for exceptions) |
| Inpatient OMH notification codes | Facilities must notify within 2 business days; inpatient OMH admissions generally not subject to prior auth when meeting statutory criteria |
| OASAS RRSY services | Residential Rehabilitation Services for Youth codes and program-level billing; not subject to prior auth for in-network NY facilities per policy |
| DME supplies | Durable medical equipment and supplies may require prior auth depending on MLTC/product; refer to auth grid |
| Associated device HCPCS | HCPCS device codes associated with delegated CPTs (e.g., TurningPoint or Evolent approvals) are reviewed with the primary procedure |
| J-codes (appendix) | Certain J-/C-/Q- codes may have non-coverage or special handling; see Appendix I and program-specific lists |
| OB ultrasound DX lists | Diagnosis code requirements for obstetric ultrasound - refer to OB-specific auth criteria |
What Providers Must Do
Obtain authorization for inpatient admissions
Obtain authorization for all inpatient admissions. Emergency stabilization does not require authorization but post-stabilization inpatient admissions do. Notify via fax for inpatient/ER notifications.
- Fax for Inpatient ER notifications: 833-663-1602
Transplant authorization at evaluation
Obtain prior authorization at the time of the transplant evaluation for all solid organ and bone marrow/tissue transplants. Refer to the listed transplant CPT/procedure codes when submitting the authorization request.
OASAS Inpatient SUD notification and documentation
For in‑network OASAS‑licensed inpatient SUD: notify Fidelis within two business days of admission and submit the OASAS Appendix A Notification Form and the LOCADTR medical necessity tool (fax or email). Facilities must perform daily clinical review, consult with Fidelis around day 14 regarding LOCADTR use, and provide a written discharge plan prior to discharge indicating whether post‑discharge services are secured or reasonably available.
- Submit OASAS Appendix A Notification Form and LOCADTR to fax 833-663-1608 or LOCADTR@fideliscare.org
- Use the LOCADTR clinical review tool/perform daily clinical review (not necessarily LOCADTR daily)
- Notify/consult with Fidelis starting on or just prior to day 14
- Provide written discharge plan prior to discharge and indicate whether post-discharge services are secured or reasonably available
OMH licensed inpatient notification
OMH‑licensed inpatient mental health facilities must notify Fidelis within two business days of admission by phone or fax. For in‑network OMH facilities admitting members under age 18, submit the OMH Two‑Day Notification and Initial Treatment Plan form within two business days to avoid concurrent review during the first 14 days; perform daily clinical review and participate in periodic consultation with Fidelis.
- Submit OMH Two-Day Notification and Initial Treatment Plan form to fax 833-561-0094 or email Mental_Health_Admission@fideliscare.org within two business days for under‑18 in‑network admissions
Behavioral Health authorization submission
Behavioral Health prior authorization requests (TMS, psychological testing, ABA, family/group beyond thresholds, etc.) should be submitted via the Behavioral Health contact channels or using the specified forms.
- Email: qhcmbh@fideliscare.org (Behavioral Health) or chmmc@fideliscare.org for members under 21 as noted
- Fax: 833-561-0098 (Behavioral Health) or 833-663-1604 for children's requests as indicated
- Phone: 1-888-FIDELIS (1-888-343-3547) follow prompts or extension 16072
- Use ABA authorization request form: https://www.fideliscare.org/Portals/0/Providers/FormsApplications/Applied-Behavioral-Analysis-Treatment-Report.pdf
DXA and OB ultrasound authorization rules
DXA (77080/77081) and OB ultrasound authorization is not required when specific age and diagnosis/frequency exceptions are met (DXA two‑year intervals for listed ages/diagnoses; first four OB ultrasounds for normal pregnancy). For other situations, authorization is required. See attached diagnosis lists for OB and DXA exceptions.
- Refer to OB ultrasound diagnosis code lists (Z32.01, Z33.1, Z34.x for normal pregnancy; O09/O36 ranges for high‑risk pregnancy exceptions)
- Refer to DXA rules: women >65 and men >70 with Z13.820 or specified diagnosis lists for ages 51–69/51–64
Submit ABA prior authorization
Applied Behavior Analysis (ABA) services for eligible members under age 21 require prior authorization from Behavioral Health. Use the Fidelis ABA authorization request form and ensure member eligibility and referral from an approved clinician.
- Use ABA authorization request form: provided link in policy
- Members eligible: under 21 with ASD and/or Rett Syndrome; referral from specified licensed clinicians required
Partial and intensive outpatient authorization timing
Partial hospitalization and intensive outpatient rules: partial hospitalization utilization review is conducted only for members meeting OMH triggers. Intensive outpatient requires no prior authorization for the first seven days; additional service days require authorization. OMH trigger criteria apply for utilization review.
- First 7 days of intensive outpatient: no prior authorization required; days beyond 7 require authorization
- Partial hospitalization: utilization review only for members meeting OMH triggers (AOT, recent high utilization, readmission within 30 days, or length of stay >30 days)
- Contact Behavioral Health: 1-888-FIDELIS ext 16072
Radiology services prior authorization
Radiology prior authorization for delegated codes is handled by Evolent (NIA); certain cardiac ultrasounds are delegated to TurningPoint. Verify the payer CPT list and route requests to the delegated reviewer as specified.
- Radiology PA delegated to Evolent (NIA)
- Cardiac ultrasounds (and some CPTs) delegated to TurningPoint — verify TurningPoint list on payer site
- Always confirm CPT lists on the payer's authorization page
Therapy (PT/OT/ST) authorization and timing
Home & outpatient PT/OT/ST after the initial evaluation require prior authorization through Evolent (NIA). Initial evaluation in home therapy requires authorization. Submit authorization requests within 1 business day for outpatient or 2 business days for home health when billing codes beyond the initial evaluation. For POS 31 & 32 (SNF/Sub‑acute rehab) fax prior authorization to the specified number.
- Send outpatient authorization requests to Evolent within 1 business day when billing beyond the initial evaluation
- Send home health authorization requests within 2 business days when billing beyond the initial evaluation
- For therapy services in POS 31 & 32 fax prior authorization to 833-663-1611
- CPT 92610 and 92611 do not require prior authorization
Pharmacy oncology prior authorization
Oncology medications and supportive agents (medical benefit) require prior authorization from Evolent before dispensing or administration for Medicaid Managed Care and HARP members (excludes Child Health Plus). Requests are submitted via Evolent's portal or phone. The oncology pharmacy benefit transitioned to NYRx effective 4/1/2023 for pharmacy claims; some oncology items remain under Evolent review as detailed.
- Submit oncology PA requests to Evolent via portal (https://um.newcenturyhealth.com) or call 1-888-999-7713, option 1
- Oncology pharmacy transitioned to NYRx on 4/1/2023 (pharmacy benefit)
- CHP line of business: oncology requests continue to be submitted to Fidelis Care
Appendix I prior authorization submissions
Appendix I codes require prior authorization submissions to the Pharmacy Team via electronic fax. Appendix I authorizations are separate from Evolent programs.
- Submit Appendix I prior authorization requests to Pharmacy Team e-fax: 1-844-235-5090
- Note: Appendix I is not related to the Evolent oncology review
Prior Authorization Required for Listed Codes
Providers must obtain prior authorization before billing the listed J‑, Q‑, and S‑ HCPCS codes and other codes identified on the payer authorization grid; verify the code table and obtain PA prior to billing.
- Refer to the code tables/Appendix lists in the grid when requesting authorization
- Obtain PA prior to billing for listed J‑, Q‑, S‑ and other HCPCS/CPT codes
UM Voicemail Requirements for Provider Contact
Voicemail messages related to Utilization Management may only be left if the provider's voicemail is HIPAA‑compliant; greetings must identify the mailbox owner and organization and state that the mailbox is confidential and can receive PHI. If not HIPAA‑compliant, only a generic message requesting a callback will be left and a second direct contact attempt will be made per the Department of Health Reasonable Effort Policy.
Background and Definitions
This authorization grid aligns with New York State OMH and OASAS guidance and best-practice manuals: OMH-licensed inpatient mental health facilities and OASAS-licensed inpatient SUD facilities have specific notification, waiver, and utilization review triggers per NYS guidance rather than routine prior authorization.
Fidelis delegates certain prior authorization programs to third parties: the Musculoskeletal Management Program and radiology/oncology/therapy reviews have been transitioned to Evolent (NIA), and prior authorization for specified ENT and cardiac surgical procedures has been delegated to TurningPoint Healthcare Solutions, LLC (delegated CPT/HCPCS lists apply).
Where applicable, the grid aligns services and supply billing to New York State Fee-for-Service rules and programs — for example, pharmacy benefits for Medicaid/HARP transitioned to the NYRx (NYS FFS Pharmacy Program) effective 4/1/2023 and certain physician-billed DME supplies were transitioned to NYS FFS per the Medicaid DME Program Manual.
OASAS: New York State Office of Addiction Services and Supports — licensing body for substance use disorder treatment (used to determine prior authorization and concurrent review waivers for in‑state, in‑network inpatient SUD).
OMH: New York State Office of Mental Health — licensing body for mental health services (used to determine prior authorization and utilization review triggers and notification processes for OMH‑licensed facilities).
POS: Place of Service codes (examples: POS 11 = office, 22 = outpatient, 24 = ambulatory surgery center, 19 = off‑campus outpatient hospital) — used to determine authorization requirements for many outpatient procedures and gastroenterology rules.
LOCADTR: Level of Care for Alcohol and Drug Treatment Referral — the OASAS clinical review tool (LOCADTR) required for inpatient SUD notification, periodic review, discharge planning, and retrospective/continued stay review when applicable.
AOT: Assisted Outpatient Treatment — court order status that is a trigger for utilization review under OMH rules.
Evolent (NIA): External utilization management vendor delegated to review prior authorizations for radiology, oncology outpatient drugs, therapy services and the Musculoskeletal Management Program per the grid.
NYRx: New York Medicaid Fee‑for‑Service Pharmacy Program (FFS) — the pharmacy benefit program receiving Fidelis Medicaid/HARP pharmacy benefits effective 4/1/2023; certain physician‑administered drugs and pharmacy prior authorization workflows reference NYRx.
Revision History
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