Prior Authorization Required for Listed Services

Prior authorization is required for the services and codes listed below. Failure to obtain required prior authorization may result in claim denial or retrospective review. When prior authorization is required, submit requests to the delegated vendor when indicated (Evolent/TurningPoint/other) or to Fidelis Care per the routing instructions in each callout.

• All inpatient admissions require authorization except emergency room stabilization services; post-stabilization inpatient care requires authorization.
• Outpatient surgical procedures enumerated in Sections II–III require prior authorization (see code lists and delegated vendors).
• Certain orthopedic/spinal, ENT, and cardiac surgical procedure prior authorizations have been delegated to Evolent (NIA) or TurningPoint — follow delegated routing for those CPTs.

Psychological/Neuropsychological Testing — Authorization Submission Requirements

Psychological and neuropsychological testing codes require authorization. All requests must be submitted using the Fidelis Psychological/Neuropsychological Testing request form and include clinical documentation supporting test selection and indications.

• Affected CPTs include: 96116, 96121, 96130-96131, 96132-96133, 96136-96139, 96146.
• Attach completed test request form and relevant clinical notes/diagnoses.
• Use delegated routing only if stated elsewhere; otherwise submit to Fidelis per testing form instructions.

Developmental Pediatric Testing — Authorization Rules and Documentation

Developmental pediatric testing and screening have specific authorization rules. Code 96112 and 96113 require authorization. CPT 96110 (developmental screening) does not require authorization (except for CHP) but must be billed with the appropriate screening diagnosis and documented per guidance.

• 96112, 96113 — Authorization required.
• 96110 — No authorization required (excluding Child Health Plus). When billed, use diagnosis Z13.41 (autism screen) OR Z13.42 (screening for global developmental delays) and document use of a standardized validated screening tool, scoring, and recommendations.
• Developmental screening frequency: follow Bright Futures/AAP periodicity — ASD screening up to twice in first three years (beginning at 18 months); global developmental delay screening up to once per year in first three years.

TMS Prior Authorization — CPTs 90867-90869

Transcranial Magnetic Stimulation (TMS) is a covered service but requires prior authorization for the listed CPT codes and medical necessity criteria must be met.

• Authorization required for CPT 90867, 90868, 90869.
• Requests may be submitted via email to qhcmbh@fideliscare.org, fax 833-561-0098, or by calling 1-888-FIDELIS and following Behavioral Health prompts (ext. 16072).
• Members must be >18, have FDA-cleared device used per labeled indications, a confirmed diagnosis of major depressive disorder, and failure of appropriate medication and evidence-based psychotherapy trials during the current episode.

DME Prior Authorization — DME/Supplies Routing and MLTC Specifics

Durable medical equipment (DME) and certain supply codes require prior authorization; refer to NYS DME Manual and program-specific routing. MLTC-specific supply codes also require authorization.

• DME coverage and benefit limits follow the Medicaid DME Program Manual: https://www.emedny.org/ProviderManuals/DME/index.aspx.
• Effective 4/1/23 select DME supplies billed by physicians (POS 12/14) were transitioned to NYS Fee-for-Service (NYRx); check the Medical Supply Procedure Codes list for those supplies.
• For MLTC members, the following supply HCPCS require authorization: A4335, A4554, T4521-T4524, T4529, T4530, T4533, T4535, T4537, T4539, T4540, T4543.
• Personal Emergency Response Systems (PERS) and Consumer Directed Personal Assistance Services (CDPAS) require authorization.
• Submit DME authorization requests per Fidelis routing unless otherwise directed in the DME manual or member line of business guidance.

Imaging Prior Authorization — Delegation to Evolent and Specific Rules

Many imaging services require prior authorization. Radiology prior authorization has been delegated to Evolent (NIA) for a broad set of radiology CPTs; certain ultrasounds and DXA/TBS rules and exceptions apply.

• Prior authorization delegated to Evolent (NIA) for radiology services — follow Evolent routing where indicated.
• OB ultrasound rules: first four OB ultrasounds do not require authorization; five or more for a normal pregnancy require authorization. OB ultrasounds for high-risk pregnancies do not require authorization.
• DXA (77080/77081) — no authorization for specified age/diagnosis groups (women >65, men >70, and select age/diagnosis criteria for ages 51–69/51–64); other uses require authorization.
• Therapy services (PT/OT/ST) after the initial evaluation require prior authorization through Evolent (NIA) for home/outpatient settings; home therapy initial evaluations require authorization and inpatient/home timing rules apply (see therapy callout).

Prior Authorization for Imaging/Therapeutic/Pain Management Services and Not Covered Low Back Pain Services

Prior authorization is required for many imaging, therapeutic, and pain management services and for specific procedure codes. Some pain and therapeutic services are not covered for low back pain diagnoses.

• Therapeutic services requiring authorization include phototherapy, hyperbaric oxygen, pain management injections and interventional pain codes (see list).
• Pain management and interventional codes include 20526, 20550-20553, 21073, 27096, 62263-62327, 64400-64530, 64553-64595, 64600-64610, 64618-64640 and interventional codes 63650, 63655, 63661-63664, 63685, 63688, and related device HCPCS.
• Not covered for members with diagnosis of Low Back Pain: prolotherapy; therapeutic facet joint steroid injections in lumbar/sacral regions (with or without CT guidance); therapeutic intradiscal steroid injections; continuous or intermittent traction.
• Topical oxygen and specified other therapeutic services require prior authorization.

Oncology Medication and Appendix I Prior Authorization Routing

Oncology medications and many drug administration/HCPCS (Appendix I) codes require prior authorization and have specific routing. Evolent manages oncology medication prior authorizations for most Medicaid/HARP members; Appendix I requests are routed to Fidelis Pharmacy.

• Oncology medications and supportive agents — prior authorization required via Evolent (https://um.newcenturyhealth.com) for Medicaid Managed Care and HARP medical benefit (excludes Child Health Plus).
• Appendix I lists HCPCS/CPT/J/Q/S/Q99x codes that require prior authorization; submit Appendix I prior authorization requests to Fidelis Pharmacy Team by e-fax 1-844-235-5090 unless excluded per section B.
• Appendix I is distinct from the Evolent oncology program; certain oncology-related requests remain under Evolent — follow section-specific routing instructions.
• HCPCS S codes are benefit exclusions except S0013, S0189, S0190, S0191, S9435; consult Appendix I and pharmacy guidance for S-code handling.

Appendix I — Codes Requiring Prior Authorization (Submission and Denial Risk)

Appendix I enumerates numerous J-, Q-, C-, G-, J7xxx, Q5xxx, Q9xxx, and S-code groups that require prior authorization before billing. These codes must have prior authorization submitted and approved to avoid denial. Appendix I also contains codes that are non-covered when billed with specific diagnoses.

• Appendix I is the authoritative list of medication and drug administration HCPCS/CPT codes that require PA prior to claim submission; examples include numerous J-codes (e.g., J0401, J0641…), Q-codes, C-codes, G0516/G0517, J7xxx series, and many oncology-related J9xxx/J92xx series.
• Some Appendix I HCPCS for medications not FDA-approved (e.g., J1726) are benefit exclusions.
• Certain HCPCS (e.g., J7318–J7333 series) are non-covered when billed with specific musculoskeletal diagnoses (see policy for code/diagnosis pairs).
• Maximum unit edits apply to all HCPCS regardless of PA status; verify units against Fidelis Maximum Units policy.

Documentation for Prior Authorization-Required Codes

For services and codes that require prior authorization, ensure supporting documentation is submitted with the PA request and retain it for claims support. For Appendix I drug administration codes and other PA-required codes, include clinical indication, dosing/units, frequency, and relevant prior treatments.

• Appendix I J- and Q- code administrations require PA submissions to Fidelis Pharmacy via e-fax 1-844-235-5090 unless routed to Evolent per oncology program guidance.
• Include: clinical notes, diagnosis, prior therapy history, proposed dosing/units, expected duration, and site of administration.
• Incomplete documentation or lack of PA may result in claim denial or retrospective medical necessity review.

Therapy Prior Authorization Timing and Routing

Outpatient therapy prior authorization timing and routing: after the initial evaluation, outpatient/home therapy requires prior authorization through Evolent (NIA) with specific submission timeframes; inpatient therapy routing differs.

• Home and outpatient PT/OT/ST (after the initial evaluation) require prior authorization through Evolent (NIA).
• If submitting claims using codes other than designated initial evaluation CPT codes, an authorization request must be sent to Evolent (NIA) within 1 business day for outpatient settings or within 2 business days for the home health setting.
• For therapy services provided in inpatient settings (POS 31 & 32), prior authorization requests are to be faxed to 833-663-1611.
• CPT 92610 and 92611 (specified speech codes) do not require prior authorization.

Home Health and Consumer-Directed Services — Authorization and Documentation

Home health and consumer-directed services require authorization and documentation supporting skilled needs, and certain consumer-directed HCPCS/unit rules apply.

• Home health approvals are based on documented medical need for skilled services.
• Consumer Directed Personal Assistance (CDPAS) and Consumer Direct services require authorization and must be billed using the specified HCPCS (e.g., T1019U6–T1020U7) and unit conventions.
• For Children's HCBS and respite exceeding program limits, submit LPHA attestation and NYS DOH forms (Children's HCBS Authorization and Care Manager Notification) prior to service delivery to avoid claim disruptions. Submit forms to SM_Childrens_HCBS@fideliscare.org or fax 833-663-1604.

OMH and OASAS Notification and Documentation to Avoid Concurrent Review

Providers must follow OMH and OASAS notification and documentation processes to avoid concurrent review during the initial inpatient periods and to ensure proper claims handling.

• OMH licensed inpatient mental health (members <18): facility must notify Fidelis Care of admission and initial treatment plan within two business days using OMH 'Two-Day Notification and Initial Treatment Plan' form; submit by fax 833-561-0094 or email Mental_Health_Admission@fideliscare.org. No concurrent utilization review during first 14 days if requirements met.
• OASAS licensed inpatient SUD: facility must notify Fidelis Care and submit OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool within two business days to fax 833-663-1608 or LOCADTR@fideliscare.org to avoid concurrent review for the first 28 days. Facilities must provide discharge plan prior to discharge and indicate whether services in the discharge plan are secured/available.
• Facilities must perform daily clinical review and participate in periodic consultation with Fidelis starting near day 14 for SUD and day 14 for OMH to ensure appropriate use of clinical review criteria.

Voicemail Compliance for UM Messages

Utilization Management (UM) voicemail messages containing PHI may be left only if the provider voicemail is HIPAA-compliant. Mailbox greetings must identify owner and organization and state confidentiality and PHI acceptance.

• If voicemail is HIPAA-compliant, UM will leave a detailed message. If not, a generic message requesting callback will be left.
• When attempting UM determinations, Fidelis will make a second direct contact attempt per DOH Reasonable Effort Policy.

Ensure PA is obtained for listed services and codes before billing

Prior authorization is required for the services and codes listed in the policy; providers must follow the policy's routing and submission instructions to obtain PA prior to service or billing.

• All inpatient admissions require authorization (emergent stabilization excluded).
• Appendix I and sections II–V list numerous CPT/HCPCS/J/Q/S codes that require PA.