Fidelis Care prior auth & coverage update

Coverage Criteria

Inpatient Admission Coverage

Covered when ALL of the following are met

Inpatient admissions: All inpatient admissions require authorization and are reviewed for medical necessity

Acute inpatient facility services benefits are unlimited when medically necessary

OASAS Inpatient SUD

OASAS-licensed Inpatient SUD coverage terms

OASAS inpatient SUD initial period: Inpatient SUD provided by NYS OASAS-licensed participating facilities do not require prior authorization and are not subject to concurrent utilization review during the first 28 days if the facility notifies Fidelis Care within two business days and provides the LOCADTR initial treatment plan28 days

Facilities must perform daily clinical review and consult with Fidelis Care by around day 14; services may be subject to utilization review after day 28 or upon discharge

OMH Inpatient Mental Health (Under 18)

OMH-licensed inpatient mental health (members under 18)

OMH inpatient MH initial period: Inpatient mental health treatment for members under 18 provided by OMH-licensed in-network hospitals do not require authorization review and are not subject to concurrent utilization review during the first 14 days if the facility 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 and participates in periodic consultation14 days

Inpatient mental health services for age 18 and older do require prior authorization and are subject to concurrent review

Behavioral Health Initial Coverage

Behavioral health and ASD/CFTSS initial visit policies

ASD and certain behavioral services initial period: No prior authorization is required for the first 7 days for ASD services and for specified outpatient behavioral services (e.g., certain OP SUD, IPRT, and others as noted); additional service days beyond the initial period require authorization from Behavioral Health7 days (varies by service)

Authorization is required for applied behavioral analysis and some DME; providers should follow Behavioral Health submission channels for continued services

Outpatient Surgery Coverage

Outpatient surgical procedures

Outpatient procedure authorization: Specific outpatient surgical and ambulatory procedures listed by CPT/HCPCS ranges (e.g., blepharoplasty 15820-15823; bariatric 43770-43775, S2083; breast reconstruction 11920-11971, 19300-19396; specified skin surgery codes; certain ambulatory surgery center procedures) require prior authorization

Some outpatient procedures performed within 24 hours should not be billed as inpatient; select orthopedic/spinal authorization responsibilities have been delegated to TurningPoint for certain dates of service

CFTSS Initial and Crisis Rules

CFTSS coverage and authorization rules

CFTSS initial visits: For CFTSS (excluding Crisis Intervention), Fidelis Care will not conduct prior authorization review for the first 3 visits; concurrent review and submission of the CFTSS Authorization Request Form are required beginning with the 4th visitfirst 3 visits

Providers must submit the CFTSS Authorization Request Form by email or fax for the 4th visit and beyond

Crisis Intervention services have no authorization or concurrent review requirementnone

Crisis Intervention codes include H20O1, S9484, S9485

Behavioral Health Program Authorization

Behavioral health program authorization requirements for children/youth

Services requiring prior auth and concurrent review: Partial Hospitalization Program, Assertive Community Treatment (ACT), Continuing Day Treatment, PROS, and Inpatient Psychiatric Services require prior authorization and concurrent review for the specified age groups (commonly under 21 or ages 18-20 depending on service)per service

Requests for members under age 21 may be submitted via designated email, fax (347-690-7362) or by phone to Fidelis Care children's Medicaid line

Imaging and Outpatient Therapy

Imaging and outpatient therapy authorization policies

Radiology and imaging: Many radiology services require authorization through eviCore; OB ultrasounds: the first 4 ultrasounds are allowed without authorization, while five or more for a normal pregnancy require authorization (high-risk pregnancy exemptions listed by diagnosis codes)OB ultrasounds: >4

DXA scans and other imaging have age- and diagnosis-based authorization rules as specified

Outpatient PT/OT/ST: Effective 10/1/2019, all outpatient therapy services (PT/OT/ST) after the initial evaluation require prior authorization through National Imaging Associates (NIA); initial evaluations do not require authorizationpost-initial evaluation

Excludes therapy performed in inpatient, ER, SNF, or observation stays; non-therapy providers should request authorization directly through Fidelis Care

DME & Home Health

DME and home health authorization

DME supplies for MLTC: For MLTC members, selected DME supply codes require authorization (list provided in the DME Program Manual and document); DME coverage follows Medicaid DME Program Manual benefit limitsper manual

Disposable items and supplies are covered for Medicaid but not for CHP lines of business; select supply codes listed (e.g., A4335, A4554, T4521-T4524, etc.) require authorization for MLTC

Home health skilled services: Home care approvals are based on the medical need for skilled services; Personal Emergency Response Systems (PERS), Consumer Directed Personal Assistance Services (CDPAS), and Personal Care Services require authorizationmedical necessity

Codes, billing units and requirements for nursing assessment and levels of personal care are specified in the document

ASMT, Smoking Cessation, Counseling Limits

Behavioral and supportive service limits and authorization exceptions

Asthma Self-Management Training: Members with newly diagnosed or medically complex asthma may receive up to 10 hours of ASMT during a continuous six-month period; medically stable members may receive up to 1 hour in six months; authorization is not required for listed ASMT codes when billed with J45x diagnoses10 hours per 6 months

Group sessions allowed up to 8 patients

Smoking Cessation Counseling: Smoking cessation counseling is reimbursed for up to 8 visits per calendar year using codes 99406 and 99407 and must be billed with diagnosis codes F17.200 or F17.201; no authorization is required8 visits per calendar year

Medicaid billing criteria must be met

Counseling Services: Members are allowed 10 hours (20 units) of counseling services in a continuous 6-month period provided by certified providers; these services are covered when billed with G0108 and G0109 and no longer require authorization

Enteral Therapy Coverage Criteria

Covered when ALL of the following apply for the respective beneficiary group

Enteral therapy eligibility groups: One of: (1) tube-fed individuals who can only obtain nutrition through a tube; (2) individuals with inborn metabolic disorders requiring specific formulas not otherwise available; (3) children under 21 who require medical formulas due to growth and development factors; (4) adults with diagnosis of HIV/AIDS or related illness who are oral-fed and require supplemental nutrition and meet BMI/weight-loss criteria, or adults requiring total nutritional support with a permanent structural limitation preventing chewing and for whom feeding tube placement is contraindicated.see BMI/weight loss thresholds

Enteral formulas and disposable items in HCPCS range B4034-B4162 require authorization for covered beneficiaries; pharmacy supplies do not require authorization

CPT code 96110 is explicitly listed as a non‑covered developmental testing code and should not be billed as a covered outpatient behavioral health testing service.

Several procedures and interventions commonly used for Low Back Pain are identified as not covered. These include prolotherapy; therapeutic steroid injections into intervertebral discs; facet joint steroid injections in the lumbar and sacral regions (with or without CT fluoroscopic guidance); and continuous or intermittent traction. The policy also references multiple pain‑management CPT/HCPCS codes in this non‑covered context.

Pharmacy supplies do not require prior authorization. Note that supplies are not covered for CHP members per the benefit plan; providers should refer to the member’s specific plan benefits for CHP supply coverage details.

Certain oncology J‑codes are designated as exceptions and are available through the medical benefit without prior authorization. Specifically, J9035 (Avastin), J9355 (Herceptin), and J9306 (Perjeta) are noted as available without PA. Other biologics (for example, Xolair) remain subject to PA and associated clinical criteria on the provider portal.

Services that are typically completed within 24 hours and are considered inpatient‑only procedures will not be approved at an inpatient level of care when billed as inpatient; such services should be billed and reviewed as outpatient when clinically appropriate.

Topical oxygen is identified as requiring prior authorization and therefore is not covered without that authorization. The policy also lists select pain management codes and procedures that are not covered for members with a diagnosis of Low Back Pain when performed by non‑orthopedists.

In the provided excerpts there are no additional items explicitly described as not medically necessary; the text instead documents coverage limits, authorization requirements, and specific non‑covered services where indicated.

Coding

Transplant codes requiring authorizationCPTCovered

32850-32856	Transplant-related codes (document list)
33930-33945	Transplant-related codes (document list)
38204-38215	Transplant-related codes (document list)
38230-38242	Transplant-related codes (document list)
44133-44136	Transplant-related codes (document list)
47133-47147	Transplant-related codes (document list)
48160	Transplant-related code (document list)
48550-48556	Transplant-related codes (document list)
50300-50380	Transplant-related codes (document list)
50547	Transplant-related code (document list)

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Outpatient surgery and ambulatory codes requiring authorizationCPT | HCPCSCovered

15820-15823	Blepharoplasty
43770-43775	Bariatric surgery
S2083	Bariatric-related HCPCS
11920-11971	Breast reconstruction and related
19300,19316-19342,19355,19370-19396	Breast reconstruction/mammoplasty codes
10040	Skin surgery code (authorization may be required)
11300-11313	Skin surgery codes
11400-11471	Skin surgery codes
11721	Skin procedure code
10060	Ambulatory surgery center code requiring auth

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Psychological and developmental testingCPTCovered

96116,96121,96130-96133,96136-96139,96146	Psychological/Neuropsychological testing codes requiring authorization
96112,96113	Developmental pediatric testing codes requiring authorization
96110	Developmental testing code listed as non-covered

Behavioral health and HCBS service codesCPT | HCPCSCovered

H0036	Community Psychiatric Support and Treatment (CPST)
H2017	Psychosocial Rehabilitation (PSR)
T2017	Habilitation and Residential Support Services
H0045	Short Term Crisis Respite
H0038	Empowerment Services / Family Peer Support
H0040	Assertive Community Treatment (ACT)
H2012	Intensive Psychiatric Rehabilitation Treatment / Continuing Day Treatment
S9480	Substance Use Disorder Intensive Outpatient Treatment
A0160	Provider Travel Supplement
H0035, S9484	Other behavioral health HCPCS codes referenced

Children & Family Treatment Service CodesmixedCovered

90791	OLP - Other Licensed Practitioner
HOO04	OLP code listed in CFTSS
H2011	OLP code listed in CFTSS
90882	OLP code listed in CFTSS
H2017	PSR - Psychosocial Rehabilitation
H0036	CPST - Community Psychiatric Supports and Treatment
H0038	FPSS / YPSS - Family/Youth Peer Support Services
H20O1	CI Crisis Intervention (note possible OCR/S text variants)
S9484	Crisis Intervention
S9485	Crisis Intervention

Outpatient / Diagnostic / GI / Genetic CodesCPTCovered

81220	BRCA testing (authorization not required; lifetime limit 1)
81329	Genetic testing (authorization not required; combined lifetime limit 1 with 81336)
81336	Genetic testing (authorization not required; combined lifetime limit 1 with 81329)
91110	Wireless Capsule Endoscopy
91111	Wireless Capsule Endoscopy
43235	Gastroenterology procedure requiring authorization in POS 19/22 when office/ASC available
43239	Gastroenterology procedure requiring authorization in POS 19/22 when office/ASC available
43248	Gastroenterology procedure requiring authorization in POS 19/22 when office/ASC available
45378	Gastroenterology procedure requiring authorization in POS 19/22 when office/ASC available
45380	Gastroenterology procedure requiring authorization in POS 19/22 when office/ASC available

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Imaging / Therapeutic / Pain Management / CGM CodesCPT

77080	DXA scan
77081	DXA scan
20526	Therapeutic procedure / injection
20550	Therapeutic procedure / injection
20551	Therapeutic procedure / injection
20552	Therapeutic procedure / injection
20553	Therapeutic procedure / injection
62263	Pain management / injection
62264	Pain management / injection
62273	Pain management / injection

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Home Health / Personal Care / ED CodesmixedCovered

T1019	Personal care / Level I previous HCPCS (up to 03/31/2018)
S5130U1	Personal care / Level I new HCPCS (effective 04/01/2018)
T1020	Personal care / Level II previous HCPCS (up to 03/31/2018)
G0162	Nursing supervision
L7900	DME/pharmaceutical treatment for erectile dysfunction
54360	ED related procedure
54400	ED related procedure
54401	ED related procedure
54402	ED related procedure
54405	ED related procedure

Counseling / ASMT / Smoking Cessation / LTHHCP CodesCPT | HCPCSCovered

G0108	Counseling service code (per text)
G0109	Counseling service code (per text)
S9441	Asthma self-management training
S9445	Asthma self-management training
S9446	Asthma self-management training
98960	Asthma self-management training / education
98961	Asthma self-management training / education
98962	Asthma self-management training / education
99406	Smoking cessation counseling
99407	Smoking cessation counseling

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Smoking Cessation Counseling codes and DXCPT | ICD-10Covered

99406	Smoking cessation counseling (intermediate)
99407	Smoking cessation counseling (intensive)
FI7.200	Diagnosis code referenced for SCC
FI7.201	Diagnosis code referenced for SCC

Enteral Therapy HCPCSHCPCSCovered

B4034-B4162

Enteral formulas/disposable items

J/HCPCS codes requiring authorization (partial list)HCPCS | J-codesCovered

J0129	abatacept (Orencia) and related code mappings
J0135	adalimumab (Humira) mapping
J0178	aflibercept (Eylea) mapping
J0179	brolucizumab-dbll mapping
J0180	algalsidase beta (Fabrazyme) mapping
J0725	chorionic gonadotropin mapping
J7314	fluocinolone acetonide intravitreal implant (Yutiq) mapping
J7318	hyaluronan (Durolane) mapping
J7320	hyaluronan (Genvisc) mapping
J7331	hyaluronan (Synojoynt) mapping

OASAS Inpatient SUD no-concurrent-review period — first 28 days

PolicyOASAS-licensed inpatient SUD services are not subject to prior authorization and are not subject to concurrent utilization review during the first 28 days of the inpatient admission provided the facility notifies Fidelis Care of the admission and initial treatment plan within two business days.

Notification requirementFacility must notify Fidelis Care within two (2) business days and may fax/email the OASAS Appendix A Notification Form and LOCADTR tool to the listed contacts.

Daily clinical reviewFacilities must perform daily clinical review and periodically consult with Fidelis Care on or just prior to the 14th day to ensure LOCADTR use.

Provider Actions & Authorization Process

Prior Authorization

Outpatient surgery prior authorization — Selected outpatient surgical and procedure codes require prior authorization

Selected outpatient surgical and procedure codes require prior authorization. Providers must obtain authorization for listed ambulatory surgery and outpatient procedures to avoid claim denials.

Blepharoplasty: CPT 15820-15823
Bariatric surgery: CPT 43770-43775, S2083
Breast reconstruction: CPT 11920-11971, 19300, 19316-19342, 19355, 19370-19396
Selected skin surgery codes (POS 24) continue to require authorization: 10040, 11300-11313, 11400-11471, 11721
Freestanding ambulatory surgery center (bill type 0831) codes requiring authorization: 10060, 11100, 11900, 17000, 20600, 20605, 20610 (note: 20610 non-covered with certain diagnoses)

Prior Authorization

Psych testing prior authorization — Authorization required for specified psychological/neuropsychological and developmental testing codes

Authorization is required for specified psychological, neuropsychological, and developmental testing codes. Submit requests using the Psychological/Neuropsychological testing request form.

Admission Criteria

SNF | LTACH | IRF | inpatient

General facility admissions: All inpatient and facility admissions require prior authorization and medical necessity review; emergency stabilization services do not require authorization but post-stabilization inpatient admissions do

inpatient SUD

OASAS facility admission notification: OASAS-licensed in-network facilities must notify Fidelis Care within two business days of admission and provide the LOCADTR initial treatment plan to avoid prior authorization for the first 28 days2 business days

Notification via fax or email using Appendix A and LOCADTR

inpatient mental health

Continued Stay Criteria

inpatient behavioral health/SUD

Periodic consultation and review: OASAS and OMH facilities must periodically consult with Fidelis Care (around day 14 for SUD) to ensure use of LOCADTR/approved clinical review criteria; services may be subject to utilization review after the initial no-review period14 days (consultation); 28 days (SUD review)

Concurrent utilization review resumes after initial period or for out-of-network/out-of-state facilities

ADHC / day health

ADHC continuation: Authorization is required for any new ADHC/ADHCIAADHC patient and for the initial assessment (up to two visits); continuation beyond transitional enrollment periods will be reviewed for medical necessityper authorization

Members enrolled as of 8/1/13 remain in current care plan for up to 90 days; continuation beyond 90 days requires review

Discharge Criteria

For OASAS‑licensed inpatient Substance Use Disorder (SUD) treatment provided by participating, in‑network New York State facilities, Fidelis Care does not require prior authorization and does not perform concurrent utilization review for the first 28 days of the admission provided the facility notifies Fidelis Care within two business days and submits the required LOCADTR/Appendix A information. Facilities must perform daily clinical review and consult with Fidelis Care by approximately day 14, and prior to discharge must provide a LOCADTR‑based written discharge plan indicating whether post‑discharge services are secured or reasonably available.

Long‑term home health transition services such as Medical Social Services (S9127) and Home Delivered Meals (S5170) are covered for Medicaid managed care enrollees who transitioned from the LTHHCP program, but these services require prior authorization as specified for transitioned members.

Time & Visit Limits

inpatient and outpatient behavioral health day limits — OASAS SUD 28 days; OMH inpatient (<18) 14 days; various BH services often first 7/14/30 days

OASAS inpatient SUDNo concurrent utilization review for the first 28 days when facility notifies Fidelis Care within two business days and provides LOCADTR documentation.

OMH inpatient (<18)No concurrent utilization review for the first 14 days when facility notifies Fidelis Care within two business days using OMH Two-Day Notification and Initial Treatment Plan form.

Behavioral health initial periodsVarious behavioral health services often have initial no-auth/no-concurrent-review windows (commonly first 7 days; some SUD services have 14 or 30 day initial periods depending on service).

outpatient / home-based therapy visit limits — OT/ST 20 visits/year; PT 40 visits/year

OT/ST limitOT and ST: 20 visits per calendar year (Medicaid/MLTC).

Definitions

OASAS Inpatient SUD definition — Inpatient detox, rehab and residential treatment provided by NYS OASAS-licensed facilities

DefinitionOASAS Inpatient SUD includes inpatient detoxification, inpatient rehabilitation and inpatient residential treatment services provided by New York State OASAS-licensed facilities participating in Fidelis Care network.

Authorization exceptionThese services are not subject to prior authorization and not subject to concurrent utilization review during the first 28 days if notification requirements are met.

Notification mechanismFacility may fax/email OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool to the provided contacts.

OMH-licensed inpatient mental health (members <18) — Inpatient mental health treatment for members under 18 at OMH-licensed hospitals

DefinitionOMH-licensed inpatient mental health for members under 18: inpatient mental health treatment provided by OMH-licensed hospitals in New York State that participate in the Fidelis network.

Background

This policy defines Fidelis Care’s utilization management approach for inpatient, post‑acute and related services: admissions and facility stays are reviewed for medical necessity and generally require prior authorization; special statutory or regulatory provisions (for example, OASAS‑licensed inpatient SUD and OMH‑licensed inpatient mental health for members under 18) provide time‑limited waivers of prior authorization and concurrent review when notification and reporting requirements are met; and a range of outpatient procedures, imaging, therapy, enteral nutrition, and many J/HCPCS drugs require prior authorization through designated processes.

OpenPayer

Authorization requirements for inpatient, outpatient, and behavioral health services