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ModifiedFidelis CarePolicy N/A

Authorization & Utilization Review — Facility, Behavioral Health, and SUD Services (Coverage Criteria)

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Governs prior authorization, utilization review, and related operational requirements for Fidelis Care Medicaid (and select lines) services in New York State, including inpatient, outpatient surgical, transplant, behavioral health, and SUD settings. Affects participating and nonparticipating providers/facilities rendering these services.

Policy Summary

PayerFidelis Care

PolicyAuthorization & Utilization Review — Facility, Behavioral Health, and SUD Services (Coverage Criteria)

Policy CodePolicy N/A

Change TypeMultiple material updates (delegations, ABA coverage, utilization-review triggers)

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for all inpatient admissions (post-stabilization) and for listed codes/items before billing; follow specific submission forms and fax numbers per service.

SourceLink

POLICY UPDATE CHANGES

Applied Behavior Analysis (ABA) services provided by LBAs and supervised CBAAs are included in the Medicaid managed care benefit effective January 1, 2023 for members under 21 with ASD or Rett Syndrome.

Prior authorization is no longer required for Personalized Recovery Oriented Services (PROS) effective February 1, 2022.

ACT services (H0040) will not require prior authorization from Fidelis Care effective 6/1/23; SPOA process governs assignment and referrals.

For Partial Hospitalization and Intensive Outpatient programs delivered by OMH-licensed NYS programs, utilization review is required and specific high-utilization and AOT-related clinical triggers are listed.

Many Home & Community Based Services and CORE services do not require prior authorization when eligibility and enrollment criteria are met; some HCBS intake/services do not require prior authorization effective specified dates.

Auth requiredAll inpatient admissions (except ED stabilization)

28dInpatient SUD exemption (in‑network NY OASAS)

14dOMH inpatient under-18 no concurrent review

EvolentMusculoskeletal PA delegate

TurningPointENT/Cardiac PA delegate

90867-69TMS authorization required

Coverage and Medical Necessity Criteria

Partial Hospitalization and Intensive Outpatient Criteria

Utilization review (admission and concurrent/continued stay) criteria for Partial Hospitalization (PHP) and Intensive Outpatient (IOP) programs operated by OMH-licensed programs in New York State. Criteria below reflect NYS OMH Best Practice Manual triggers used to determine which members require prior authorization or ongoing concurrent review.

ALL of the following

Partial Hospitalization (PHP) - Admission/Coverage Triggers
- Individuals subject to a current Assisted Outpatient Treatment (AOT) court order.
- Individuals who had an AOT court order that expired within the past five years.
- Individuals with high utilization of inpatient or emergency department (ED) services in the past year as evidenced by: (1) Three (3) or more psychiatric inpatient hospitalizations in the prior 12 months; OR (2) Four (4) or more psychiatric ED visits in the prior 12 months; OR (3) Three (3) or more medical inpatient hospitalizations in the prior 12 months.
- Individuals who are readmitted to any mental health inpatient unit within thirty (30) days of discharge from a prior mental health inpatient admission.
- Individuals not meeting any of the above triggers whose length of stay exceeds 30 days (concurrent review from Day 31 onwards).
Operational/Network Rules for Partial Hospitalization
- All partial hospitalization mental health services provided by out-of-network facilities are subject to concurrent review throughout the admission.
- Providers with questions may call Fidelis Care during regular business hours at 1-888-FIDELIS (1-888-343-3547), extension 16072 for Behavioral Health.
- Requests for members under 21 may be submitted by email to chmmc@fideliscare.org, by fax (New: 833-663-1604), or by calling 1-888-FIDELIS and following prompts for Children's Medicaid.

ALL of the following

Intensive Outpatient (IOP) - Initial Authorization and Early Services
- No prior authorization is required for the first seven (7) days of service for IOP; additional service days beyond the first seven require authorization.
- This exception applies to IOP services provided by OMH-licensed programs in New York State and documented with revenue codes 905, 906, or 912; CPT 90899; S9480; or HCPCS H2013.
Intensive Outpatient (IOP) - Admission/Concurrent Review Triggers
- Individuals subject to a current Assisted Outpatient Treatment (AOT) court order.
- Individuals who had an AOT court order that expired within the past five years.
- Individuals with high utilization of inpatient or emergency department (ED) services in the past year as evidenced by: (1) Three (3) or more psychiatric inpatient hospitalizations in the prior 12 months; OR (2) Four (4) or more psychiatric ED visits in the prior 12 months; OR (3) Three (3) or more medical inpatient hospitalizations in the prior 12 months.

Code Lists and Appendix I Mappings

Outpatient Surgery CPT Codes (selected)CPTCovered

10060	Incision and drainage, skin and subcutaneous tissue
11100	Biopsy of skin, subcutaneous tissue and/or mucous membrane
11900	Insertion or removal of therapeutic, prophylactic, or diagnostic implant
17000	Destruction of premalignant lesions
20600	Arthrocentesis, aspiration and/or injection; major joint or bursa
20605	Arthrocentesis, aspiration and/or injection; intermediate joint or bursa
20610	Arthrocentesis, aspiration and/or injection; small joint or bursa
50300	Cystourethroscopy with removal of foreign body from bladder
50305	Cystourethroscopy with removal of calculus
50320	Transurethral removal of foreign body

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Outpatient Surgery CPT Codes — Eyelid / Ocular & Cosmetic (additional)CPTCovered

10040	Incision and removal of foreign body
11200	Removal of skin tags
11201	Removal of skin tags, multiple
15769	Muscle repair / complex wound repair codes (range)
15820	Blepharoplasty; lower eyelid
15821	Blepharoplasty; lower eyelid, complicated
15822	Blepharoplasty; upper eyelid
15823	Blepharoplasty; upper eyelid, complicated
15830	Abdominoplasty
15832	Lipectomy

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Behavioral Health CPT/HCPCS CodesmixedCovered

96110	Developmental screening
96112	Developmental testing
96113	Developmental testing
96116	Neurobehavioral status exam
96121	Standardized cognitive performance testing
96130	Psychological testing evaluation services
96131	Psychological testing evaluation services
96132	Neuropsych testing evaluation
96133	Neuropsych testing evaluation
96136	Psychological test administration and scoring

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Partial Hospitalization (PHP) CodesRevenueCovered

4349	Partial Hospitalization rate code group
4350	Partial Hospitalization rate code
4351	Partial Hospitalization rate code
4352	Partial Hospitalization rate code
4353	Partial Hospitalization rate code
4354	Partial Hospitalization rate code
4355	Partial Hospitalization rate code
4356	Partial Hospitalization rate code
4357	Partial Hospitalization rate code
4358	Partial Hospitalization rate code

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Intensive Outpatient (IOP) CodesmixedCovered

Revenue 905	IOP revenue code
Revenue 906	IOP revenue code
Revenue 912	IOP/behavioral health revenue code
CPT 90899	Unlisted psychiatric service (used for IOP)
S9480	Intensive outpatient program, per diem
H2013	Intensive outpatient services (HCPCS)

Continuing Day Treatment, ACT, CORE & HCBS CodesmixedCovered

H2012	Continuing day treatment
H0040	Assertive Community Treatment (ACT)
H2017	Psychosocial Rehabilitation
H0036	Community Psychiatric Support & Treatment
H0038	Family/Youth Peer Support Services
T2017	Habilitation and Residential Support Services
T2015	Pre-Vocational Services
T2019	Transitional Employment
H2023	Supported Employment
H2025	Supported Employment

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Children & Family Treatment and Support Services (CFTSS) CodesmixedCovered

90791	Psychiatric diagnostic evaluation
H0004	Behavioral health counseling and therapy
H2011	Comprehensive community support services
90882	Environmental intervention for behavioral health
H0036	CPST
H2017	PSR
H0038	FPSS / YPSS
H2001	Crisis Intervention
S9484	Crisis Intervention (HCPCS)

TMS CPT Codes (Authorization Required)CPTCovered

90867	Transcranial magnetic stimulation plus psychotherapy
90868	TMS daily psychotherapy
90869	TMS subsequent daily treatment

Imaging / DXA / TBS CodesCPT

77080	Dual-energy X-ray absorptiometry (DXA), axial skeleton
77081	DXA, other than axial skeleton
77089	Bone mass, TBS
77090	Bone mass, TBS
77091	Bone mass, TBS
77092	Bone mass, TBS

OB Pregnancy / High-Risk Ultrasound ICD-10 CodesICD-10Covered

O09.00	Supervision of pregnancy with history of infertility, unspecified trimester
O09.01	...
O09.02	...
O09.03	...
O09.1	Supervision of high-risk pregnancy, unspecified
O09.10	...
O09.11	...
O09.12	...
O09.13	...
O09.211	Supervision of pregnancy with other poor reproductive or obstetric history

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Therapeutic / Procedural CodesCPTCovered

20526	Injection(s); tendon sheath, ligament, or ganglion cyst
20550	Injection(s); single tendon sheath, or ligament
20551	Injection(s); each additional tendon or ligament
20552	Injection(s); single or multiple trigger point(s)
20553	Injection(s); trigger point, additional
21073	Reconstructive procedures
61736	Stereotactic ablation
63622	Spinal fusion adjunct
64400	Injection, anesthetic agent; stellate ganglion
64553	Insertion of neurostimulator lead

Appendix I: HCPCS/CPT/J-codes Requiring Prior Authorization (excerpt)mixedCovered

C9047	caplacizumab-yhdp (Cablivi) and mapping variants
C9145	aprepitant aponvie inj / vutrisiran mapping
C9166	secukinumab IV mapping
C9167	apadamtase alfa mapping
C9168	mirkizumab-mrkz mapping
C9169	nogapendekin alfa mapping
C9170	tarlatamab-dlle mapping
C9172	fidanacogene elaparvovec mapping
C9293	glucarpidase (Voraxaze) mapping
C9399	unclassified drugs/biologics

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Required Provider Actions and Submission Instructions

Prior Authorization

Obtain prior authorization for all inpatient admissions

All inpatient admissions require prior authorization; emergency room stabilization services do not require prior authorization but post-stabilization inpatient admissions do. Failure to obtain prior authorization for inpatient admissions (except ER stabilization) may result in claim denial or retrospective review. Use the new inpatient ER fax 833-663-1602 when submitting notifications.

Obtain prior authorization before inpatient admission except for ER stabilization.
If admission follows ER stabilization, obtain authorization for the inpatient stay.
Use fax 833-663-1602 for Inpatient ER notifications.

Prior Authorization

Authorize transplants at evaluation

All solid organ and bone marrow/tissue transplant procedures require authorization at the time of the transplant evaluation; a broad list of transplant CPTs is provided in the policy and claims may be denied if authorization is not obtained.

Admission Criteria by Setting

acute/sub-acute/SNF admission criteria

Acute/Sub-Acute/SNF admission authorization: All acute inpatient facility services and inpatient rehabilitation services require prior authorization when medically necessary; inpatient admissions are reviewed for medical necessity and prior authorization is required except for ER stabilization services.

Medical rehabilitation can be completed at an acute or sub-acute level of care.

Inpatient SUD admission criteria

Inpatient SUD admission: In-network, NY OASAS-licensed inpatient SUD facilities must notify Fidelis Care within two business days of admission and the initial treatment plan (OASAS Appendix A + LOCADTR); if notification and required processes are completed, prior authorization and concurrent review are not required for the first 28 days; services may be reviewed after day 28 or on discharge. Out-of-state or out-of-network facilities must request prior authorization and are subject to concurrent review throughout the admission.28 days

Facilities must perform daily clinical review and consult with Fidelis Care starting on or near day 14; fax/email options and LOCADTR submission instructions provided in policy.

Continued Stay and Concurrent Review Criteria

Inpatient mental health / Partial hospitalization continued stay criteria

OMH continued stay triggers: Continued stay utilization review for OMH-licensed inpatient and partial hospitalization services is required only if the member meets trigger criteria: current or recent AOT orders, high utilization in prior 12 months (3+ psych inpatient OR 4+ psych ED OR 3+ medical inpatient), readmission within 30 days, or length of stay exceeding 30 days (concurrent review from Day 31).See triggers

Partial hospitalization provided by out-of-network facilities is subject to concurrent review throughout admission.

Partial Hospitalization / Intensive Outpatient continued stay criteria

Concurrent Review After Day 30: If length of stay exceeds 30 days, concurrent review is required from Day 31 onward for Partial Hospitalization and Intensive Outpatient programs; for Intensive Outpatient, the first seven days of service do not require prior authorization but additional days require authorization.Day 31+ for concurrent review; first 7 days no auth for IOP

Day Limits, Exemptions and Short-Term Allowances

Inpatient SUD concurrent review exemption period

Exemption periodIn-network, NY OASAS‑licensed inpatient SUD services are exempt from prior authorization and concurrent utilization review for the first 28 days of an admission when the facility notifies Fidelis Care of the admission and initial treatment plan within two business days and performs required clinical review/consultation.

Notification requirementFacility must notify Fidelis Care within two business days using the OASAS Appendix A Notification Form and may fax/email LOCADTR to 833-663-1608 or LOCADTR@fideliscare.org.

Clinical review toolFacilities must perform daily clinical review and periodically consult with Fidelis Care starting on or just prior to day 14 to ensure LOCADTR use; this does not require running every LOCADTR module daily.

Post‑28 day reviewServices may be subject to utilization review after day 28 or upon discharge using the LOCADTR clinical review tool.

Inpatient mental health concurrent review exemption period (under-18 OMH in-network rule)

Key Terms and Definitions

LOCADTR clinical review tool used for Inpatient SUD medical necessity and utilization review (definition entry)

LOCADTR definitionLOCADTR is the clinical review tool used to assess medical necessity for inpatient SUD; facilities may fax/email LOCADTR outputs to Fidelis Care (LOCADTR@fideliscare.org) as part of notification and review.

Use timingLOCADTR is used to determine ongoing medical necessity after the 28‑day exemption period and to inform discharge planning.

Submission channelOASAS Appendix A Notification Form and LOCADTR may be faxed to 833-663-1608 (formerly 646-829-1421).

OMH-developed form required to notify Fidelis Care within two business days for certain OMH inpatient admissions

Form nameOMH 'Two‑Day Notification and Initial Treatment Plan' form is the OMH‑developed form required for notification to Fidelis Care for qualifying OMH inpatient admissions.

Background and Scope

This policy governs prior authorization, utilization review, and operational requirements for Fidelis Care Medicaid (and select related lines) in New York State across inpatient, outpatient surgical, transplant, behavioral health, and substance use disorder settings. It reflects state‑specific delegations, notification timelines (for example, OMH and OASAS two‑day notification processes), and code‑level prior authorization requirements; providers should follow the listed notification and authorization processes to avoid claim denials or retrospective review.

Policy Summary

PayerFidelis Care

PolicyAuthorization & Utilization Review — Facility, Behavioral Health, and SUD Services (Coverage Criteria)

Policy CodePolicy N/A

Change TypeMultiple material updates (delegations, ABA coverage, utilization-review triggers)

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for all inpatient admissions (post-stabilization) and for listed codes/items before billing; follow specific submission forms and fax numbers per service.

SourceLink

On This Page

Individuals who are readmitted to any mental health inpatient unit within thirty (30) days of discharge from a prior mental health inpatient admission.

Individuals not meeting any of the above triggers whose length of stay exceeds 30 days (concurrent review from Day 31 onwards).

Operational/Network Rules for IOP

All intensive outpatient mental health services provided by out-of-network facilities are subject to concurrent review throughout the admission.
Providers with questions may call Fidelis Care during regular business hours at 1-888-FIDELIS (1-888-343-3547), extension 16072 for Behavioral Health.

Request transplant authorization at the time of transplant evaluation.

Refer to the transplant CPT list in the policy when submitting the PA.

Prior Authorization

Use Evolent (NIA) for musculoskeletal prior authorizations (effective 1/1/24)

Orthopedic and spinal surgical procedures require prior authorization; effective 1/1/24 the Musculoskeletal Management Program was transitioned to Evolent (NIA) for delegated review of applicable codes and associated devices.

Submit PA requests per Evolent (NIA) instructions for delegated orthopedic/spinal CPTs and associated HCPCS devices.
Check the delegated code list in Section II/G when preparing authorizations.

Prior Authorization

Route ENT and cardiac prior auths to TurningPoint (delegated)

ENT and cardiac surgical procedure prior authorizations have been delegated to TurningPoint Healthcare Solutions, LLC; if a CPT is delegated to TurningPoint, submit the prior authorization per TurningPoint's process and note that associated devices (HCPCS) will also be reviewed by TurningPoint.

Route PA requests for delegated ENT and cardiac CPTs to TurningPoint per the delegated code list.
Include associated HCPCS device codes in the submission to TurningPoint when applicable.

Prior Authorization

Prior authorization required for listed outpatient surgery CPTs

Specified outpatient surgery CPTs listed in the Outpatient Surgery section require prior authorization when performed in the indicated settings (including certain ambulatory surgery centers); follow the code-specific PA requirements in Section III and submit authorization prior to billing.

Obtain PA for listed outpatient surgery CPTs when performed in the specified place of service (see Section III lists).
Note special rules (e.g., some codes require PA in any place of service; some require PA only if performed in freestanding ASCs).

Documentation Required

Behavioral health: obtain PA for testing exceptions

Most outpatient behavioral health services do not require authorization; however, exceptions such as psychological/neuropsychological testing and specified developmental pediatric testing still require prior authorization and must be submitted on the designated testing request form.

Submit PA for psychological/neuropsychological testing CPTs (e.g., 96116, 96121, 96130–96133, 96136–96139, 96146) using the testing request form.
Submit PA for developmental pediatric testing CPTs 96112 and 96113 as required.

Prior Authorization

Partial hospitalization: submit utilization review when OMH triggers met

Partial hospitalization programs are subject to utilization review (admission and continued stay) only when members meet specified OMH clinical triggers per the NYS OMH Best Practice Manual; concurrent review applies from Day 31 for stays that exceed 30 days and out-of-network partial hospitalization is subject to concurrent review throughout the admission.

Submit utilization review requests when member meets AOT, high-utilization, readmission, or length-of-stay >30 days triggers.
Be aware out-of-network facilities remain subject to concurrent review for the entire admission.

Prior Authorization

Prior authorization required for TMS (CPT 90867–90869)

Transcranial Magnetic Stimulation (TMS) CPT codes 90867, 90868, and 90869 require prior authorization; requests may be submitted by email, fax (833-561-0098), or phone following Behavioral Health routing.

Ensure TMS eligibility documents show age >18 and failure of multiple medication and psychotherapy trials during the current episode.
Submit PA requests via qhcmbh@fideliscare.org, fax 833-561-0098, or 1-888-FIDELIS (follow Behavioral Health prompts).

Prior Authorization

First seven IOP/Continuing Day Treatment days exempt from PA; obtain PA thereafter

Intensive Outpatient (IOP) and Mental Health Continuing Day Treatment programs do not require prior authorization for the first seven service days; any additional service days beyond the initial seven require prior authorization.

No PA needed for service days 1–7; obtain PA for day 8 onward.
For Continuing Day Treatment (H2012) follow the same first-seven-day exemption and submit PA as required thereafter.

Billing Rule

Obtain authorization for specified MLTC DME supply codes

For MLTC members, specific DME supply codes require authorization and benefit limits follow the Medicaid DME Program Manual; confirm codes (e.g., A4335, A4554, T45xx series) and submit PA before billing.

Obtain PA for MLTC-only supply codes listed (A4335, A4554, T4521–T4543, etc.).
Apply Medicaid DME Program Manual benefit limits when requesting authorization.

Prior Authorization

OB ultrasounds: obtain PA for ≥5 in normal pregnancy; radiology delegated to Evolent

OB ultrasound rules: the first four OB ultrasounds for a normal pregnancy may be performed without authorization; five or more OB ultrasounds for a normal pregnancy (specified ICD-10 Z32.01, Z33.1, Z34.xx series) require prior authorization. Radiology prior authorization has been delegated to Evolent (NIA).

No PA required for up to 4 OB ultrasounds for normal pregnancy diagnosis codes listed.
Obtain PA for five or more OB ultrasounds for normal pregnancy; high-risk pregnancy diagnosis codes listed do not require authorization.
Route radiology PAs to Evolent (NIA) per delegation.

Documentation Required

DXA/TBS exceptions and therapy PA routing (Evolent + fax for SNF/Sub-Acute)

DXA scans (CPT 77080/77081) have age- and diagnosis-based exceptions allowing one scan every two years without authorization for specified patient groups; therapy services (home & outpatient PT/OT/ST) performed after the initial evaluation require prior authorization through Evolent (NIA), and inpatient SNF/Sub-Acute Rehab therapy PAs must be faxed to 833-663-1611.

No PA required for one 77080/77081 every two years for listed age/diagnosis groups; other requests require PA.
Submit outpatient/home PT/OT/ST PAs to Evolent (NIA) after the initial evaluation; home therapy initial evaluation also requires authorization.
For therapy in POS 31 & 32 (SNF/Sub-Acute), fax PA requests to 833-663-1611.

Prior Authorization

Obtain PA for specified therapeutic and oncology procedure/medication codes

Selected therapeutic, procedural, device, and oncology medication codes require prior authorization (examples include 95249, 58674, 31660/31661 and other listed CPT/HCPCS); oncology medications and supportive agents require prior authorization through Evolent (NCH) for Medicaid Managed Care and HARP (medical benefit) except where excluded.

Obtain PA for listed therapeutic/procedural/device codes prior to administration or billing.
Submit oncology medication PA requests per Evolent (NCH) instructions; see Evolent Oncology Program auth grid for specifics.

Documentation Required

Submit prior authorization for Appendix I codes before billing

Appendix I enumerates numerous HCPCS/CPT/J- and S-codes that require prior authorization; providers must submit PA requests for those codes to the Pharmacy Team via e-fax 1-844-235-5090 or follow the Evolent instructions for oncology items.

Verify whether the code appears in Appendix I before rendering service.
Submit PA requests for Appendix I codes to the Pharmacy Team via e-fax 1-844-235-5090, or follow Evolent routing for oncology requests.

Denial Risk

PA required for drugs/items mapped to Appendix I J-/HCPCS codes

Prior authorization is required for the drugs and items mapped to the HCPCS/J-codes listed in Appendix I; claims billed with those codes may be denied if PA was not obtained prior to billing.

Obtain PA for any service/drug mapped to Appendix I J-/G-/S-codes prior to claim submission.
Claims for Appendix I codes submitted without PA may be subject to denial.

Documentation Required

Follow PA process for appendix J-code groupings mapped to agents

Appendix I includes J-code groups mapped to specific agents (examples shown in the policy, e.g., multiple J72xx/J73xx/J92xx entries); providers must follow the PA process for the specific J-code and associated drug product listed—failure to obtain PA may result in denial.

Identify the exact J-code and mapped agent in Appendix I when requesting PA.
Follow the PA submission routing (Pharmacy Team e-fax or Evolent for oncology) for J-code medications.

Prior Authorization

Obtain PA for listed J- and S- codes in Appendix I before billing

The Appendix I listing includes numerous J‑ and S‑codes (partial extracts shown) that require prior authorization before billing; providers must obtain authorization for these HCPCS/J- and S-codes to avoid denial.

Check Appendix I partial lists (e.g., J9118, J9210, J9271, S0081, etc.) to confirm PA requirements prior to providing services.
Do not bill these codes without documented PA.

Billing Rule

20610 non-covered when billed with specified hyaluronic acid J‑codes for knee OA

Procedure 20610 is non-covered when billed with specified hyaluronic acid J-codes for osteoarthritis of the knee (ICD-10 M17 series); in all other situations 20610 does not require authorization.

Do not bill 20610 together with HA J-codes for knee osteoarthritis (M17 series) — 20610 is non-covered in that combination.
When 20610 is billed outside those HA/J-code combinations, no PA is required.

Step Therapy

Include prior medication and psychotherapy trial failures in TMS PA requests

TMS eligibility requires documentation of failure to respond to multiple trials of medication and evidence-based psychotherapy during the current episode; this treatment history must be included in the authorization request.

Include documentation of failed medication trials and psychotherapy during the current episode when submitting TMS PA.
Confirm member is ≥18 and TMS will be administered per FDA-labeled indications.

Note

Use Evolent auth grid for oncology medication PA and step therapy details

Evolent (NCH) maintains an oncology review list and authorization grid for oncology-related medications; providers should consult Evolent program pages for step therapy and authorization specifics rather than relying on the appendix alone.

Refer to the Evolent Oncology Program auth grid on Fidelis Care’s provider resources for current oncology PA criteria and step therapy rules.
Do not send oncology pharmacy requests to Evolent if they are listed as excluded from Evolent review per policy.

Documentation Required

When J-codes map to multiple agents, request PA for the specific drug/HCPCS listed

Appendix mappings associate certain J-codes with multiple related drug products (examples include J9118 mapped to calaspargase pegol‑mknl and others); when a J-code maps to multiple agents, follow the PA process for the specific drug/HCPCS listed in Appendix I.

When a J-code has multiple mapped agents in Appendix I, specify the exact agent and corresponding HCPCS/J-code in the PA request.
Follow Pharmacy Team or Evolent routing based on the drug category.

Documentation Required

OMH 2‑day notification and initial treatment plan submission for under‑18 admissions

For OMH‑licensed inpatient mental health admissions of members under 18, the facility must notify Fidelis Care of the admission and submit the OMH 'Two‑Day Notification and Initial Treatment Plan' form within two business days, perform daily clinical review, and participate in periodic consultation; meeting these requirements exempts the first 14 inpatient days from prior authorization and concurrent utilization review.

Fax the OMH Two‑Day form to 833-561-0094 or email Mental_Health_Admission@fideliscare.org within two business days of admission.
Ensure daily clinical review and periodic consultation occur to qualify for the 14‑day no‑review exemption.

Documentation Required

OASAS: 2‑day admission notification, LOCADTR submission, and discharge plan requirements

For in‑state, in‑network OASAS‑licensed Inpatient SUD admissions, the facility must notify Fidelis Care of the admission and initial treatment plan within two business days using the OASAS Appendix A Notification Form and the LOCADTR tool; timely notification and required processes exempt the first 28 days from prior authorization and concurrent utilization review.

Fax/email the OASAS Appendix A form and LOCADTR tool to 833-663-1608 or LOCADTR@fideliscare.org within two business days.
Perform daily clinical review and consult with Fidelis Care starting on/near day 14; provide a written discharge plan before discharge.

Documentation Required

Use required ABA, CORE, and HCBS forms and submit within specified timeframes

ABA authorizations require submission using the Fidelis ABA Treatment Report form. CORE Service Initiation Forms must be submitted within 3 business days of first service. Short‑term respite beyond annual limits requires LPHA attestation and the NYS DOH Children's HCBS Authorization and Care Manager Notification form; submit forms per the policy fax/email addresses to avoid claims delays.

Submit ABA PA using the Fidelis ABA Treatment Report form (link provided in policy).
Email CORE Service Initiation Form to QHCMHARPBH@FidelisCare.org or fax 833-561-0089 within 3 business days of first visit.
For short‑term respite beyond 14 days/year, include LPHA attestation and the NYS DOH Children's HCBS Authorization form to SM_Childrens_HCBS@fideliscare.org or fax 833-663-1604.

Billing Rule

Fax inpatient SNF/Sub‑Acute therapy prior auths to 833‑663‑1611

Prior authorization requests for therapy services provided in inpatient SNF/Sub‑Acute Rehab settings (POS 31 & 32) must be faxed to 833-663-1611; non‑therapy providers should submit PA requests for services after the initial evaluation directly to Fidelis Care.

Fax inpatient SNF/Sub‑Acute therapy PA requests to 833-663-1611.
Non‑therapy providers (MD/DO/DPM) submit PAs for services after initial evaluation through Fidelis Care per standard channels.

Documentation Required

Submit pharmacy and Appendix I PA requests via e‑fax 1‑844‑235‑5090 (or Evolent for oncology)

Pharmacy prior authorization requests, including those for Appendix I codes, should be submitted to the Pharmacy Team via e‑fax 1‑844‑235‑5090; most oncology medication requests are processed via Evolent (NCH) per the oncology program instructions.

E‑fax pharmacy PA requests to 1-844-235-5090.
For oncology‑related medication PAs, follow Evolent (NCH) portal/phone routing as specified in Section IX.

Documentation Required

Obtain PA for Appendix I codes before claim submission

Providers must obtain prior authorization for services billed using the codes listed in Appendix I before submitting claims; claims submitted for Appendix I codes without prior authorization may be denied.

Verify Appendix I status before performing or billing the service.
Secure documented PA prior to claim submission to avoid denials.

Documentation Required

Obtain J‑code and drug‑specific prior authorization from Appendix I before billing

Specific J‑codes and drug products enumerated in Appendix I require prior authorization before billing; providers must obtain these authorizations for the exact J‑code/drug listed to ensure coverage.

Request PA for the exact J‑code and associated drug product as listed in Appendix I.
Do not assume PA for one mapped agent covers other agents within the same J‑code group—specify the agent.

Documentation Required

Maintain HIPAA‑compliant voicemail for UM determinations

When Fidelis UM leaves voicemail messages regarding determinations, the provider must maintain a HIPAA‑compliant voicemail greeting that identifies the mailbox owner, organization name, and states the mailbox is confidential and that PHI may be left; otherwise, UM will leave only a generic callback request.

Ensure voicemail greeting meets HIPAA requirements (identify owner, organization, confidentiality, PHI allowed).
If voicemail is not HIPAA‑compliant, expect only a generic message and request to call back.

Denial Risk

Denial risk: inpatient admissions without PA

Failure to obtain prior authorization for any inpatient admission (except emergency department stabilization services) may trigger a denial or retrospective review; obtain and document authorization before inpatient services to mitigate denial risk.

Obtain PA prior to inpatient admission when not an ER stabilization event.
Document authorization details to support claims and avoid retrospective denials.

Denial Risk

Denial risk: transplant services without authorization

Transplant procedures require authorization at the time of the transplant evaluation; omission of authorization may result in claim denial—ensure authorization is secured and documented prior to transplant services.

Obtain transplant PA at evaluation and retain authorization documentation.
Refer to the policy's transplant CPT list when submitting the PA request.

Denial Risk

Concurrent review and denial risk for out‑of‑network partial hospitalization/IOP

Partial hospitalization and intensive outpatient services provided by out‑of‑network facilities are subject to concurrent review throughout the admission; failure to meet OMH Best Practice triggers may lead to non‑authorization or denial.

If services are delivered by out‑of‑network facilities, anticipate concurrent review for the entire admission.
Ensure documentation meets OMH clinical trigger criteria to support continued stay reviews.

Denial Risk

Denial risk: ≥5 OB ultrasounds for normal pregnancy without PA

Five or more OB ultrasounds for a normal pregnancy (specified ICD‑10 Z32.01, Z33.1, Z34.xx series) require prior authorization; failure to obtain authorization for five or more ultrasounds may result in denial.

Obtain PA for a fifth and subsequent OB ultrasound for normal pregnancy diagnosis codes listed.
High‑risk pregnancy diagnosis codes listed do not require authorization for OB ultrasounds.

Denial Risk

Denial risk: DXA billed outside allowed age/diagnosis/frequency without PA

DXA scans billed outside the specified age/diagnosis groups or outside the one‑every‑two‑years frequency require prior authorization and may be denied if not authorized; confirm age and diagnosis codes before performing the service.

Verify patient age/diagnosis meet the no‑PA exception (e.g., women >65 or men >70 with Z13.820, or listed diagnosis groups for ages 51–69/51–64).
Obtain PA for DXA requests outside the exception criteria to avoid denial.

Denial Risk

Denial risk: billing listed J‑/G‑/S‑codes without PA

Claims for drugs or procedures billed with the J‑, J7xxx, G‑ and related HCPCS/S‑codes listed in Appendix I require prior authorization; submission without required prior authorization may trigger claim denial.

Confirm Appendix I status before service; obtain PA for listed J‑/G‑/S‑codes prior to billing.
Claims submitted for Appendix I codes without PA are at risk for denial.

Denial Risk

Denial risk: listed J‑codes billed without drug‑specific PA

Claims for the J‑codes and specific drugs enumerated in Appendix I may be denied if prior authorization was not obtained; providers must secure drug‑specific authorizations for those J‑codes before rendering or billing the service.

Obtain J‑code/drug‑specific PA from Pharmacy Team or via Evolent for oncology items.
Retain authorization documentation to support claim adjudication.

Inpatient mental health admission criteria

Inpatient mental health (OMH) admission: OMH-licensed inpatient mental health admissions in-network are not subject to prior authorization review except when members meet specified clinical triggers; for members under 18 in-network, no prior authorization and no concurrent review during the first 14 days if the facility completes the OMH two-business-day notification form, performs daily clinical review, and participates in periodic consultation. Out-of-network inpatient mental health services remain subject to concurrent review throughout the admission.14 days for under-18 exemption

Notification fax/email and contact details specified in policy.

Partial Hospitalization (OMH-licensed programs) admission criteria

Partial Hospitalization (OMH-licensed) admission: Admission to partial hospitalization programs will be reviewed only for individuals who meet triggers per the NYS OMH Best Practice Manual: current or recently expired AOT order (within 5 years); high utilization (3+ psych inpatient OR 4+ psych ED OR 3+ medical inpatient in prior 12 months); readmission within 30 days; or expected length of stay exceeding 30 days (concurrent review from Day 31).see high utilization threshold

Rate and HCPCS codes (rate codes 4349–4363, revenue 912/913, H0035, S9484) apply; out-of-network programs are subject to concurrent review throughout the admission.

SNF | Nursing Facility | Sub-Acute Rehab admission criteria

SNF / Nursing Facility / Sub-Acute Rehab admission: Therapy and skilled services in SNF/Sub-Acute Rehab settings require prior authorization where indicated; prior authorization requests for therapy services in inpatient settings POS 31 & 32 should be faxed to 833-663-1611. Non-therapy providers should request prior authorization for services after the initial evaluation directly through Fidelis Care.

This entry describes submission process and prior authorization requirement for inpatient therapy services rather than specific clinical admission triggers.

Out-of-network programs remain subject to concurrent review throughout the admission.

Exemption period (under‑18, in‑network)OMH‑licensed inpatient mental health admissions for members under 18 are not subject to prior authorization or concurrent review during the first 14 days if the facility meets notification and documentation requirements.

Two‑day notification formFacility must submit the OMH 'Two‑Day Notification and Initial Treatment Plan' form to Fidelis Care by fax (New: 833-561-0094) or email to Mental_Health_Admission@fideliscare.org within two business days of admission.

Daily review & consultationFacility must perform daily clinical review and participate in periodic consultation with Fidelis Care to ensure use of OMH‑approved evidence‑based clinical review criteria appropriate to patient age.

IOP / Continuing Day Treatment initial authorization exemption — first 7 service days no prior authorization required

Initial authorization exemptionIntensive Outpatient (IOP) and Mental Health Continuing Day Treatment: no prior authorization required for the first 7 service days; additional days require authorization.

Codes referencedRevenue codes 905/906/912; CPT 90899; HCPCS S9480; HCPCS H2013 (IOP).

Request methodsRequests for continuing services can be made via Fidelis Care Behavioral Health contacts as specified (email/fax/phone).

Children's HCBS Respite short-term annual limit without documented medical necessity

Annual short‑term respite limitShort‑term Planned and Crisis Respite services may not exceed 14 days (1,344 15‑minute units) per calendar year without documented medical necessity.

Beyond‑limit documentationRespite beyond these limits must be supported by medical necessity via an LPHA Attestation form plus the NYS DOH Children's HCBS Authorization and Care Manager Notification form submitted to SM_Childrens_HCBS@fideliscare.org or fax 833-663-1604.

Submission timingHCBS Authorization and Notification Form should be submitted prior to rendering service to prevent claims processing disruptions; Plan of Care must be submitted by C-YES and Health Home providers.

Timing and submission

Must be completed and submitted within two business days of admission by fax (New: 833-561-0094) or email to Mental_Health_Admission@fideliscare.org.

Related obligationsFacility must also perform daily clinical review and participate in periodic consultation to ensure use of OMH‑approved clinical review criteria.

High utilization definition — prior utilization thresholds that constitute high utilization

High utilization — psychiatric inpatientThree (3) or more psychiatric inpatient hospitalizations in the prior 12 months constitutes high utilization.

High utilization — psychiatric EDFour (4) or more psychiatric emergency department visits in the prior 12 months constitutes high utilization.

High utilization — medical inpatientThree (3) or more medical inpatient hospitalizations in the prior 12 months constitutes high utilization.

ABA eligibility — diagnosis and provider-type definition for ABA coverage

Covered diagnosesApplied Behavior Analysis (ABA) is available for members under age 21 diagnosed with autism spectrum disorder and/or Rett Syndrome per DSM‑5.

Provider typesServices must be provided by Licensed Behavior Analysts (LBA) or Certified Behavior Analyst Assistants (CBAA) working under LBA supervision, and providers must be enrolled in NYS Medicaid.

Referral requirementMember must be referred by a NYS‑licensed physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner, or physician assistant; prior authorization required from Behavioral Health using the Fidelis ABA Treatment Report form.

Normal pregnancy (authorization context) — ICD-10 code list defining normal pregnancy

Normal pregnancy ICD‑10 codesNormal pregnancy indicated by ICD‑10 codes such as Z32.01, Z33.1, Z34.00–Z34.03, Z34.80–Z34.83, Z34.9–Z34.93 (these designate normal pregnancy for OB ultrasound authorization rules).

Authorization thresholdThe first 4 OB ultrasounds for these normal pregnancy diagnosis codes can be performed without authorization; five or more require authorization.

High‑risk pregnancy exceptionOB ultrasounds for listed high‑risk pregnancy diagnosis codes do not require authorization.

DXA scans — definition and frequency exceptions for DXA CPTs 77080/77081

DXA CPTs and frequencyCPT codes 77080 and 77081 (DXA) are allowed without prior authorization once every two years for specified age/diagnosis groups (e.g., women >65 or men >70 with Z13.820, and other listed diagnosis groups for ages 51–69/51–64).

Age/diagnosis exceptionsAuthorization not required when accompanied by the specified diagnosis codes for the defined age groups; requests outside these groups require authorization.

TBS codesTBS scan CPTs listed include 77089, 77090, 77091, 77092.

Prior authorization — definition entry describing PA concept in policy

Prior authorization definitionPrior authorization is payer approval obtained before a service is rendered to ensure coverage for the specific code or item; providers must obtain authorization for services billed using codes listed in Appendix I before claim submission.

Appendix I requirementAppendix I enumerates HCPCS/CPT/J‑codes that require prior authorization and maps many codes to specific agents; claims for these codes may be denied without prior authorization.

Submission channelsPharmacy/Appendix I prior auth requests should be submitted to the Pharmacy Team or via specified Evolent/Evolent (NCH) processes for oncology items as indicated in the policy.