Fidelis Care Prior Auth & Coverage Update

Coverage & Medical Necessity Criteria

Inpatient Admission Criteria

Covered when ALL of the following are met

Inpatient admissions require authorization: All inpatient admissions require authorization; emergency room stabilization services do not require prior authorization but post-stabilization inpatient admissions do require authorization.

All facility admissions are reviewed for medical necessity; inpatient rehabilitation (acute, sub-acute, and skilled nursing rehabilitation) requires authorization.

OASAS Inpatient Substance Use Disorder

Special handling for OASAS licensed inpatient SUD

Initial OASAS inpatient SUD: Fidelis will not conduct prior authorization review for the initial 14 days of OASAS-licensed inpatient detoxification, inpatient rehabilitation, or inpatient residential treatment; providers must notify Fidelis within 48 hours by fax or email using the OASAS Appendix A Notification Form and OASAS LOCADTR Medical Necessity Tool.14 days

All services remain subject to periodic consultation and potential utilization review after day 14 or upon discharge; out-of-state and out-of-network providers must still request authorization.

Pediatric Behavioral Health Authorization Exemptions

Pediatric behavioral health service visit-count exemptions

ASD services: No prior authorization is required for the first seven days of Autism Spectrum Disorder (ASD) services; additional service days require authorization. Authorization is required for Applied Behavioral Analysis and for DME speech-generation equipment, and attestation of an ASD diagnosis must be provided at the time of request.7 days

State expansions for CHP members include additional supports and DME items to assist speech performance.

CFTSS authorization rules: For Children and Family Treatment & Support Services (CFTSS) other than crisis intervention, Fidelis will not conduct authorization review for the first 3 visits; concurrent review and authorization are required prior to the 4th visit.3 visits

Providers must submit the CFTSS Authorization Request Form by email or fax or contact Fidelis by phone.

Outpatient & DME Authorization Criteria

Outpatient and DME services requiring authorization

Outpatient diagnostics and procedures: Sleep studies (including home sleep studies), certain diagnostic testing and genetic testing (note: CPT 81220, 81329, and 81336 do not require authorization and have lifetime limits), wireless capsule endoscopy (91110, 91111), and specified gastroenterology procedures require prior authorization; authorization is not required when these services are performed in specified places of service (for some items POS 11 or 24).see coding thresholds

Some gastroenterology procedures require authorization when performed in POS 19 or 22 if an office-based or ambulatory surgery center is available.

Home Health Care - Medical necessity

Home Health Care approvals

Home care approvals are based on documented medical need for skilled nursing or therapy services; personal care services, Personal Emergency Response System (PERS), and Consumer Directed Personal Assistance Services (CDPAS) require authorization.

Applies to Medicaid and Managed Long Term Care (MLTC); hospice submission rules vary by enrollment date.

Outpatient Therapy - Coverage and limits

Outpatient therapy coverage

Therapy authorization: Initial PT, OT, and ST evaluations do not require authorization, but all subsequent outpatient therapy services and any other billed procedure codes after the initial evaluation require prior authorization through National Imaging Associates (NIA) effective 10/1/2019; this excludes PT/OT/ST performed in inpatient settings, ER, SNF, or during an observation stay.

Non-therapy providers should request authorization for services after the initial evaluation directly through Fidelis.

Visit limits: Medicaid and MLTC are limited to 20 Occupational Therapy and Speech Therapy visits per calendar year; Physical Therapy is limited to 40 visits per calendar year effective 7/1/2018. CHP has no visit limit.OT/ST = 20/year; PT = 40/year

Services received at home are not included in this restriction.

Enteral Therapy - Medical necessity

Enteral therapy coverage conditions

Enteral therapy indications: Enteral therapy (HCPCS B4034–B4162) is covered when ANY of the following apply: (1) tube-fed individuals who can only obtain nutrition through a tube; (2) individuals with inborn metabolic disorders requiring specific nutritional formulas not available by other means; (3) children under age 21 who require medical formulas due to growth and development factors; or (4) adults with HIV/AIDS or other disease/condition who are oral-fed and meet supplemental nutrition criteria.

Benefit limits and authorization required; pharmacy supplies do not require authorization and supplies are not covered for CHP.

Enteral BMI/weight criteria: For supplemental nutrition coverage, beneficiaries must require supplemental nutrition, demonstrate documented compliance with an appropriate medical and nutritional plan of care, and meet one of the following BMI/weight-loss criteria: BMI <18.5 (up to 1,000 calories per day) OR BMI <22 with documented unintentional weight loss of ≥5% within the prior 6 months (up to 1,000 calories per day).BMI <18.5 OR BMI <22 + ≥5% unintentional weight loss

Documentation of clinical indication, BMI, and weight-loss data or evidence of need for tube feeding/total nutritional support should be supplied with requests.

Covered populations for enteral formulas

Enteral formulas (HCPCS B4034-B4162) are covered when ANY of the following beneficiary categories apply and medical criteria are met:

Covered beneficiary categories: 1) Tube-fed individuals who can only obtain nutrition through a tube; 2) Individuals with inborn metabolic disorders requiring specific nutritional formulas not available through other means; 3) Children under age 21 who require medical formulas due to growth and development factors; 4) Adults with HIV infection, AIDS, or HIV-related illness (or other disease/condition) who are oral-fed and meet supplemental nutrition criteria.

See supplemental and total nutritional support criteria for additional medical requirements.

Supplemental nutrition coverage criteria

Coverage when ALL of the following supplemental nutrition criteria are met (for oral-fed beneficiaries in category 4 above):

Supplemental nutrition criteria: A) Beneficiary requires supplemental nutrition and demonstrates documented compliance with an appropriate medical and nutritional plan of care; AND B) Beneficiary has BMI under 18.5 (up to 1,000 calories per day).BMI <18.5

Alternative pathway: BMI <22 plus ≥5% unintentional weight loss in the prior 6 months (up to 1,000 cal/day) as documented.

Total nutritional support criteria

Coverage for total nutritional support:

Total nutritional support: Beneficiary requires total nutritional support, has a permanent structural limitation that prevents chewing of food, AND placement of a feeding tube is medically contraindicated.

Documentation of medical contraindication to feeding tube placement is required for approval of total nutritional support.

CPT code 20610 is specifically identified as non‑covered when billed with certain diagnosis codes in ambulatory surgery/ASC billing scenarios. Providers should not expect coverage for claims that pair 20610 with those disallowed diagnosis combinations and must confirm appropriate coding and place of service prior to billing.

Therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT fluoroscopic guidance) and therapeutic injections of steroids into intervertebral discs are listed as not covered for members with a diagnosis of Low Back Pain. The policy also lists related pain management procedures (e.g., trigger point injections, spinal injections) and indicates continuous or intermittent traction and other specified therapeutic services are excluded for that diagnosis group.

Pharmacy supplies do not require prior authorization. Note that enteral and pharmacy supplies are not covered for CHP members — providers must refer to the member’s benefit plan to confirm CHP exclusions and coverage details.

CPT code 96110 is explicitly listed as a non‑covered service in the behavioral/neuropsychological testing section and should not be submitted for coverage.

Several therapeutic services commonly used for low back pain are identified as not covered when the member’s diagnosis is Low Back Pain. These exclusions include lumbar/sacral facet joint steroid injections, steroid injections into intervertebral discs, continuous or intermittent traction, and other listed pain management therapies; providers should verify alternative, covered treatment options prior to delivery.

Certain oncology drugs (for example, J9035, J9355, J9306) are noted as being available through the medical benefit without prior authorization; clinical criteria for agents such as Xolair are available on the provider portal. Confirm drug‑specific coverage rules and billing instructions on the portal before submission.

Relevant Procedure & HCPCS/CPT Code Lists

Transplant-related CPT rangesCPTCovered

32850-32856	listed transplant CPT ranges
33930-33945	listed transplant CPT ranges
38204-38215	listed transplant CPT ranges
38230-38242	listed transplant CPT ranges
44133-44136	listed transplant/related CPT ranges
47133-47147	listed transplant/related CPT ranges
48160	listed transplant/related CPT
48550-48556	listed transplant/related CPT ranges
50300-50380	listed transplant/related CPT ranges
50547	listed transplant/related CPT

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Selected outpatient surgery codes requiring authorizationCPT | HCPCSCovered

43770-43775	Bariatric surgery
S2083	Bariatric related HCPCS
15820-15823	Blepharoplasty
11920-11971	Breast reconstruction
19300	Breast surgery
19316-19342	Breast reconstruction ranges
19355	Breast reconstruction
19370-19396	Breast reconstruction/related

Ambulatory/ASC specific codesCPTCovered

10040	Ambulatory procedure requiring authorization in POS 24
11300-11313	Certain skin lesion excision codes
11400-11471	Skin repair codes
11721	Paronychia procedures
10060	Incision and drainage codes requiring auth for ASC bill type 0831
11100	Biopsy codes for ASC auth list
11900	Excision of benign lesion
17000	Destruction of benign lesions
20600	Aspiration/injection procedures
20605	Aspiration/injection procedures

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Behavioral health and testing codesCPT | HCPCSCovered

96116	Neuropsych testing code requiring authorization
96121	Psych testing requiring authorization
96130-96139	Psych/neuropsych testing range
96146	Testing code
96112	Psych testing request code (authorization required)
96113	Psych testing request code (authorization required)
90870	Outpatient ECT
H0035	Partial hospitalization HCPCS
S9484	Partial hospitalization HCPCS
H2012	Mental health continuing day treatment

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Sleep, diagnostic, and gastroenterology procedures requiring authorizationCPTCovered

91110	Wireless capsule endoscopy
91111	Wireless capsule endoscopy
43235	Esophagogastroduodenoscopy procedure
43239	Esophageal procedure
43248	Gastroenterology procedure
45378	Colonoscopy with biopsy
45380	Therapeutic colonoscopy
45384	Colonoscopy with removal
45385	Colonoscopy with removal
46255	Anorectal manometry/related

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HCBS and pediatric behavioral service codesHCPCS | CPTCovered

H0036	Community Psychiatric Support and Treatment (CPST)
H0038	Peer support services (FPSS/YPSS)
H2017	Psychosocial Rehabilitation (PSR)
H0045	Short Term Crisis Respite / Intensive Crisis Respite
H0040	Assertive Community Treatment (ACT)
T2017	Habilitation and Residential Support Services
T2015	Pre-Vocational Services
T2019	Transitional Employment
T2013	Education Support Services
H2023	Supported Employment

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Outpatient procedure CPTs requiring authorization in some settingsCPT

91110	Wireless capsule endoscopy
91111	Wireless capsule endoscopy

Gastroenterology CPTs requiring authorization in POS 19/22CPT

43235	Esophagogastroduodenoscopy procedures
43239	Esophagogastroduodenoscopy procedures
43248	Esophagogastroduodenoscopy procedures
45378	Colonoscopy with biopsy +/- therapy
45380	Colonoscopy therapeutic
45384	Colonoscopy with polypectomy
45385	Colonoscopy with polypectomy
46255	Anoscopy procedures
46260	Anoscopy procedures
46270	Anoscopy procedures

Pain management / therapeutic injection codesCPT

20526	Trigger point injection
20550	Injection procedure for tendon sheath
20551	Injection procedure for tendon sheath
20552	Injection procedure for tendon sheath
20553	Injection procedure for tendon sheath
62263	Spinal injection
62264	Spinal injection

Telehealth codes requiring authorizationCPT

G2010	Remote evaluation of recorded video and/or images
G2012	Brief communication technology-based service

Enteral therapy HCPCS group requiring authorizationHCPCS

B4034-B4162

Enteral formulas and disposable items

Podiatry authorization exceptionICD-10

Diabetes diagnosis (claim level)

Required on claim to exempt podiatry from authorization

DME supply codes requiring authorization for MLTCHCPCS

A4335	DME supply code (requires auth for MLTC)
A4554	DME supply code (requires auth for MLTC)
T4521	DME supply code (requires auth for MLTC)
T4522	DME supply code (requires auth for MLTC)
T4523	DME supply code (requires auth for MLTC)
T4524	DME supply code (requires auth for MLTC)
T4529	DME supply code (requires auth for MLTC)
T4530	DME supply code (requires auth for MLTC)
T4533	DME supply code (requires auth for MLTC)
T4535	DME supply code (requires auth for MLTC)

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Behavioral and asthma/smoking counseling codesCPT | HCPCSCovered

G0108	Group-based counseling
G0109	Individual counseling
S9441	Asthma education
S9445	Asthma education
S9446	Asthma education
98960	Education and training for self-management
98961	Education and training for self-management
98962	Education and training for self-management
99406	Smoking cessation counseling intermediate
99407	Smoking cessation counseling intensive

Enteral HCPCS codes describedHCPCSCovered

B4034-B4162

Enteral therapy HCPCS codes (enteral formulas/disposables)

Drug and injectable HCPCS codes requiring authorizationHCPCSCovered

Multiple J-, C-, G- HCPCS codes	Numerous injectable and drug HCPCS codes (examples in text: J0135, J0221, J0178, J0222, J0129, J0565, J0567, ... and many others listed across chunks 37-51). Authorization required except where noted.
B4088	Exception noted (B4088 does not require authorization)

Special-note codes / medical benefitmixed

CPT 20610 or 20611	Codes referenced for billing when certain coverage applies
J9035, J9355, J9306	Bevacizumab (Avastin), Trastuzumab (Herceptin), Pertuzumab (Perjeta) — available through the medical benefit without prior authorization

BRCA genetic testing lifetime limits

CPT 81220Lifetime limit: 1 per member

CPT 81329Combined lifetime limit of 1 when billed with CPT 81336

CPT 81336Combined lifetime limit of 1 when billed with CPT 81329

Provider Authorization, Submission & Documentation Requirements

Prior Authorization

Inpatient admissions — Prior authorization required

All inpatient admissions require prior authorization. Emergency services that stabilize the emergent condition do not require prior authorization, but post-stabilization inpatient services and any subsequent inpatient admissions after emergency care do require authorization. Failure to obtain authorization for inpatient admissions and post-stabilization inpatient services may result in non-coverage.

All facility admissions are reviewed for medical necessity
Inpatient rehabilitation (acute, sub-acute, skilled nursing) requires prior authorization
Inpatient substance use disorder rehabilitation requires prior authorization

Prior Authorization

Transplants — Authorization at evaluation

All solid organ and bone marrow transplants require authorization at the time of the transplant evaluation.

Example related CPT ranges (not exhaustive): 32850-32856, 33930-33945, 38204-38215, 38230-38242, 44133-44136, 47133-47147, 48160, 48550-48556, 50300-50380, 50547, 65710-65757

Admission & Initial Stay Criteria

SNF | acute inpatient | sub-acute inpatient

SNF / acute / sub-acute admission authorization: All inpatient facility admissions (including SNF, acute inpatient, and sub-acute inpatient) require prior authorization and are reviewed for medical necessity; inpatient rehabilitation services (acute, sub-acute, and skilled nursing rehabilitation) require authorization.

Emergency stabilization services are exempt until post-stabilization inpatient care.

Inpatient SUD

Inpatient SUD admission handling: Initial 14 days of OASAS-licensed inpatient detoxification, inpatient rehabilitation, or inpatient residential treatment do not require prior authorization provided the provider notifies Fidelis within 48 hours; services are subject to periodic consultation and may be subject to utilization review after day 14 or upon discharge.14 days

Out-of-state and out-of-network providers must request authorization as required.

Continued Stay / Ongoing Treatment Criteria

Inpatient SUD continued stay criteria

OASAS inpatient SUD continued stay: During the initial 14 days of OASAS inpatient SUD, providers and the plan must engage in periodic consultation; services may be subject to utilization review after day 14 or upon discharge.after 14 days

Community-based pediatric behavioral services continued stay criteria

CFTSS continued stay: For CFTSS (other than crisis intervention), concurrent review and authorization are required prior to the 4th visit; no authorization or concurrent review is required for the first 3 visits.prior to 4th visit

ADHC continued stay criteria

Initial Day Limits & Visit Exemptions

Inpatient SUD day limit

Initial coverage periodInitial 14 days of OASAS licensed inpatient SUD treatment do not require prior authorization

Provider notificationProviders must notify Fidelis Care of each admission within 48 hours using OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool

Post-14-day reviewServices are subject to periodic consultation and utilization review after day 14 or upon discharge

Behavioral health / ASD day limit

Initial exemptionFirst 7 service days of ASD-related services do not require prior authorization

Additional daysService days beyond the first 7 require prior authorization

Policy Background & Scope

This policy describes Fidelis Care prior authorization and medical‑necessity review requirements across multiple care settings. It requires prior authorization for all inpatient admissions (post‑stabilization inpatient care) while identifying timely access exceptions such as the initial 14 days of OASAS‑licensed inpatient substance use disorder treatment and initial visit exemptions for certain pediatric behavioral health services (e.g., ASD). The document also specifies prior authorization rules for outpatient procedures, DME, enteral therapy (HCPCS B4034‑B4162), outpatient therapy visit limits, and pharmacy/ injectable drugs, and provides submission contacts, delegated authorization arrangements, and documentation requirements to support review and coverage determinations.

Key Definitions

OASAS licensed inpatient SUD treatment

DefinitionInpatient detoxification, inpatient rehabilitation, or inpatient residential treatment licensed by OASAS

Initial authorization handlingFidelis Care will not conduct prior authorization review for the initial 14 days of these OASAS-licensed services

Notification requirementProviders must notify Fidelis within 48 hours and submit LOCADTR and Appendix A forms; out-of-state/out-of-network providers must still request authorization

CFTSS

PopulationChildren and Family Treatment & Support Services (CFTSS) for Medicaid recipients under age 21

Initial-visit exemptionFidelis will not conduct authorization review for the first 3 CFTSS visits (no concurrent review for crisis intervention)

OpenPayer

Prior Authorization and Medical Necessity Requirements for Inpatient, Outpatient, Behavioral Health, and Post‑Acute Services

Coverage & Medical Necessity Criteria

Relevant Procedure & HCPCS/CPT Code Lists

Provider Authorization, Submission & Documentation Requirements

Admission & Initial Stay Criteria

Continued Stay / Ongoing Treatment Criteria

Initial Day Limits & Visit Exemptions

Policy Background & Scope

Key Definitions