CurrentFidelis CarePolicy N/A

Authorization Grid Detail, Effective March 1, 2026

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.

Policy Summary

PayerFidelis Care

PolicyAuthorization Grid Detail, Effective March 1, 2026

Policy CodePolicy N/A

Change TypeN/A

Effective Date03/01/2026

Next Review DateN/A

Key ActionObtain authorization for all inpatient admissions; emergency stabilization does not require authorization but post-stabilization inpatient admissions do (fax Inpatient ER notifications to 833-663-1602).

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — the authorization grid content is informational and ongoing; no new material policy changes were listed.

MultipleService categories with auth rules

ManyCodes listed requiring authorization

2Delegated reviewers (Evolent, TurningPoint)

ConditionalBehavioral health outpatient mostly no auth (exceptions)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

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.

Quick thresholds and limits

OMH/Partial hospitalization triggers (high utilization)>=3 psych inpatient hospitalizations OR >=4 psych ED visits OR >=3 medical inpatient hospitalizations in prior 12 months

Inpatient SUD concurrent review waiver periodFirst 28 days (no concurrent utilization review if facility notifies within 2 business days and other conditions met)

OB ultrasound count (normal pregnancy)First 4 ultrasounds without authorization; 5 or more require authorization

DXA repeat intervalOne 77080 or 77081 every 2 years for specified age/diagnosis groups (women >65, men >70; women 51–64 and men 51–69 with listed diagnoses)

DSMT (Diabetes Self-Management Training)10 hours (20 units) in a continuous 6-month period

Smoking cessation visitsUp to 8 visits per calendar year using codes 99406 + 99407 (must bill with specified F17.x dx codes)

Children's short-term respite annual limit1,344 15-minute units (14 days) per calendar year unless medical necessity documented

Group Psychoeducation / Group Psychotherapy thresholdNotification and concurrent review required beyond initial 30 visits per calendar year (effective 01/01/2026)

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.

Codes Requiring Prior Authorization / Special Handling

Transplant CPT/Procedure CodesCPTCovered

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)

1–10 of 79

1/8

Outpatient Surgery / Common CPT ExamplesCPT

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)

Behavioral Health Codes / OMH/OASAS ExceptionsCPT

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, Prosthetics, Orthotics, and Supplies (MLTC / ED)HCPCS

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-code / J-/C-/Q- Non-Coverage / Special Handling FragmentsmixedNot Covered

J-codes (appendix)

Certain J-/C-/Q- codes may have non-coverage or special handling; see Appendix I and program-specific lists

OB Ultrasound / Pregnancy Diagnosis CodesICD-10

OB ultrasound DX lists

Diagnosis code requirements for obstetric ultrasound - refer to OB-specific auth criteria

What Providers Must Do

Prior Authorization

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

Prior Authorization

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.

Documentation Required

OASAS Inpatient SUD notification and documentation

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.

Revision History

Policy Summary

PayerFidelis Care

PolicyAuthorization Grid Detail, Effective March 1, 2026

Policy CodePolicy N/A

Change TypeN/A

Effective Date03/01/2026

Next Review DateN/A

SourceLink

On This Page

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:

Out-of-State or Non-Participating Facilities for SUD: Facilities outside New York State, not OASAS-licensed/certified/authorized by OASAS, or outside Fidelis Care's network must request prior authorization for Inpatient SUD services and are subject to concurrent review throughout the admission.

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:

Psychological/Neuropsych Testing: Psychological/Neuropsychological Testing requires authorization for listed CPT codes and requests must use the testing request form (96116, 96121, 96130-96139, 96146).
Developmental Pediatric Testing (96112, 96113) requires authorization; 96110 does not require authorization (excluding CHP) and has billing/diagnosis and frequency rules per 'First Three Years of Life' guidance.
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.
Transcranial Magnetic Stimulation (TMS): TMS Covered; Authorization Required for CPT 90867, 90868, 90869 with additional clinical criteria (adult, FDA-cleared device, confirmed MDD, failure of multiple medication + psychotherapy trials).
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):

Bariatric surgery requires authorization for 43770, 43772, 43773, 43774 (S2083 no longer requires authorization as of 8/1/22).
Blepharoplasty requires authorization for 15820, 15821, 15822, 15823.
Breast reconstruction/mammoplasty: Breast Reconstruction/Mammoplasty requires authorization for 11920-11971, 19300, 19301, 19316-19342, 19355, 19357, 19370-19396.
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).
Freestanding ASC preauth: Certain procedures require preauthorization if performed in freestanding ambulatory surgery centers (bill type 0831): 10060, 11100, 17000, 20600, 20605.
CPT 20610 non-coverage condition: CPT 20610 is non-covered when billed with hyaluronic acid J-codes (J7318-J7333) and diagnosis of osteoarthritis of the knee (M17 series); otherwise no authorization required for 20610.
Ear repair/piercing: Ear repair/ear piercing codes 69300 and 69090 require authorization.
Eyelid & ocular surgery codes listed require authorization (65760-65775 series and related codes).
Abdominoplasty/panniculectomy: Abdominoplasty/lipectomy/panniculectomy codes listed require authorization (15830, 15832-15839, 15847, 15876-15879).
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.).
Speech processor implant: Speech Processor Implant Procedures require authorization (69716, 69719, 69726, 69727).
Spinal surgery codes listed require authorization (20932-20934, 22867-22870, 62330-62331, 62380, 63032).
Esophageal procedures 43284 and 43497 require authorization.
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.
Gastroenterology POS rules: Gastroenterology procedures require authorization if performed in POS 19 and 22 when an office or ASC is available; not required in POS 11 or 24; 43290 and 43889 require authorization in any POS.
Proprietary lab U-codes: Proprietary Laboratory Analysis U-codes listed require authorization (0340U, 0493U, 0600U-0613U).
Drug testing: G0480 requires authorization.
DME coverage and NYRx transition: DME coverage per Medicaid DME Program Manual; specific supplies billed by physician POS12 or 14 for Medicaid/HARP transitioned to NYS FFS (NYRx) effective 4/1/23; MLTC-only supply codes require authorization (A4335, A4554, T4521-T4543 series).
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:

Women >65 and Men >70: Authorization not required when billed for women age > 65: one 77080 or 77081 every two years when accompanied by diagnosis code Z13.820; and for men age > 70 with Z13.820.
Women 51-64 and Men 51-69: Authorization not required for women age 51-64 and men age 51-69: one 77080 or 77081 every two years when accompanied by any of the diagnosis codes on the attached list referenced in the grid.
Other DXA requests: Requests for 77080/77081 for any other age group or any other diagnosis require authorization.
TBS scans CPT codes 77089, 77090, 77091, 77092 are listed and require authorization per grid.

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.
Initial evaluation codes: CPT codes 92610 and 92611 do not require prior authorization.
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:

Podiatry Services: Authorization is no longer required for podiatric services generally; individual services indicated on the grid and rendered by podiatrists may still require authorization.

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:

Long Term Home Health Care Services: Home Delivered Meals (S5170) are covered with an authorization for Medicaid Managed Care enrollees who transitioned from the Medicaid Fee-for-Service LTHHCP and were receiving these services at time of transition.

Adult Day Health Care (ADHC/AADHC)

Authorization requirements for adult day health care programs:

Adult Day Health Care (ADHC/AADHC): Authorization is required for any new ADHC/AADHC patient. Prior authorization is required for the initial assessment, up to two visits. Members already enrolled as of 8/1/13 may remain in current care plan for up to 90 days; continuation beyond 90 days reviewed for medical necessity.

DME and Erectile Dysfunction Services

Authorization and exclusion details for DME and ED-related treatments:

DME and Erectile Dysfunction Services: DME, services, and pharmaceutical treatment for erectile dysfunction are listed; these items and services are not covered for registered sex offenders.

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:

DSMT: Diabetes Self-Management Training (DSMT): Members allowed 10 hours/20 units in a continuous 6-month period; provided by certified providers and no longer require authorization; codes G0108 and G0109.
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.
Smoking Cessation Counseling: No authorization required; reimbursed for up to 8 visits per calendar year using sum of codes 99406 and 99407, billed ONLY with specific F17.x diagnosis codes.

Services Provided by Outside Vendors — Authorization Contacts

External vendors handling authorizations for specialized services and certain transport codes:

Services Provided by Outside Vendors — Authorization Contacts: Orthodontic services for Medicaid members under age 21 require prior authorization by DentaQuest (1-800-516-9615). Vision prior authorizations handled by Davis Vision (1-800-601-3383). Transportation codes A0430, A0431, A0435, A0436 require authorization.

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.

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

Prior Authorization

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

Prior Authorization

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

Prior Authorization

DME/MLTC supply authorization

Obtain authorization for MLTC‑only DME supply codes listed; follow Medicaid DME Manual and NYRx transition guidance for supplies billed by physicians in POS 12/14.

A4335
A4554
T4521
T4522
T4523
T4524
T4529
T4530
T4533
T4535
T4537
T4539
T4540
T4543

Documentation Required

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

Billing Rule

20610 non-coverage condition

CPT 20610 is non‑covered when billed with listed hyaluronic acid J‑codes and a diagnosis of osteoarthritis of the knee (M17 series). Otherwise 20610 does not require authorization.

Affected J‑codes: J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332
Osteoarthritis ICD‑10: M17 and listed M17.x codes

Prior Authorization

Authorization for proprietary lab tests

Obtain prior authorization for proprietary laboratory analysis U‑codes listed; include these U‑codes on authorization requests.

0340U
0493U
0600U
0601U
0602U
0603U
0604U
0605U
0606U
0607U
0608U
0609U
0610U
0611U
0612U
0613U

Prior Authorization

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

Prior Authorization

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

Prior Authorization

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

Prior Authorization

DXA and TBS authorization

DXA and TBS prior authorization: DXA CPTs 77080 and 77081 may be performed without authorization under specified age/diagnosis/frequency exceptions; TBS codes and additional DXA requests require authorization. TBS CPTs listed include 77089–77092.

DXA CPTs: 77080, 77081
TBS CPTs: 77089, 77090, 77091, 77092
Requests outside the specified age/diagnosis criteria require authorization

Prior Authorization

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

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

Billing Rule

Smoking cessation billing restriction

Smoking cessation counseling codes 99406 and 99407 are reimbursed only when billed with specified tobacco‑use diagnosis codes and are limited to eight visits per calendar year for Medicaid members.

Bill codes 99406 and 99407 only with diagnosis codes F17.200, F17.201, F17.210, F17.211, F17.220, F17.221, F17.290, F17.291
Limit: up to 8 visits per calendar year

Billing Rule

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

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

Documentation Required

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.

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.