CurrentFidelis CarePolicy CP.FC.01

Clinical Policy: Denial of Medicaid Non-Covered Benefits

Policy Summary

PayerFidelis Care

PolicyClinical Policy: Denial of Medicaid Non-Covered Benefits

Policy CodePolicy CP.FC.01

Change TypeAnnual administrative updates

Effective DateApr 1, 2025

Next Review Date

Key ActionQHCM will review the NY State DOH monthly Medicaid Updates newsletters and determine applicability, reviewing EPSDT-related non-covered benefits for medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added 'LOB: Medicaid and CHIP' to header and updated handbook revision date references.

Added under section II 'd. Services not covered as listed in Fidelis Care Medicaid Managed Care Member Handbook revised October 2024'.

1Applies to Lines of Business

21EPSDT age cutoff (years)

MonthlyDOH newsletter review frequency

Coverage Summary

Defines which NY State Medicaid-declared non-covered benefits Fidelis Care New York will deny and the process for review and denial for Medicaid and CHIP members, including consideration of EPSDT/Summary Periodicity Schedule (AAP Periodicity Schedule) and medical necessity. Applies to Medicaid and CHIP members; EPSDT age cutoff: 21 years. QHCM will review NY State DOH Medicaid Updates monthly to identify published non-covered benefits.

Medical Necessity Criteria

Medically Appropriate and Covered

Covered when ALL of the following are met:

ALL of the following

Listed by NY State as a non-covered benefit
A condition discovered by screening listed on the Summary Periodicity Schedule and American Academy of Pediatrics (AAP) Periodicity Schedule
Meets medical necessity

Not Medically Appropriate and Not Covered

Not covered in any of the following situations:

ANY of the following

Listed by NY State as a non-covered benefit AND a condition discovered by screening listed on the Summary Periodicity Schedule and AAP Periodicity Schedule AND does not meet medical necessity
Listed by NY State as a non-covered benefit AND is NOT a condition discovered by screening listed on the Summary Periodicity Schedule and AAP Periodicity Schedule
Listed by NY State as a non-covered benefit AND the member exceeds 21 years of age
Services not covered as listed in Fidelis Care Medicaid Managed Care Member Handbook revised October 2024

Provider Actions & Operational Steps

Documentation Required

Monthly DOH newsletter review

QHCM will review the NY State DOH monthly Medicaid Updates newsletters for published DOH Medicaid non-covered benefits and determine applicability.

Prior Authorization

Medical necessity review for EPSDT-related non-covered benefits

If the non-covered benefit relates to a condition discovered by screening on the Summary Periodicity Schedule/AAP Periodicity Schedule, QHCM will review it for medical necessity before making a coverage determination.

Denial Risk

Administrative denial for non-EPSDT conditions

If the non-covered benefit does NOT relate to a condition discovered by screening on the Summary Periodicity Schedule/AAP Periodicity Schedule, it will be administratively denied as not a covered benefit.

Definitions & Background

Policy governs how Fidelis Care NY treats NY State-declared Medicaid non-covered benefits. Benefits listed by NY State as non-covered may still be provided when ALL of the following are met: (a) listed by NY State as a non-covered benefit, (b) the condition was discovered by screening listed on the Summary Periodicity Schedule/AAP Periodicity Schedule, and (c) it meets medical necessity. Exceptions under EPSDT apply only for members under age 21.

Situations that are not covered include: the benefit is listed by NY State as non-covered and is a condition discovered by screening but does not meet medical necessity; the benefit is listed by NY State as non-covered and is not a condition discovered by screening on the Summary Periodicity Schedule/AAP Periodicity Schedule; the benefit is listed by NY State as non-covered and the member is older than 21 years; and services listed as not covered in the Fidelis Care Medicaid Managed Care Member Handbook (revised October 2024).

Process: QHCM will review the DOH monthly newsletters for published DOH Medicaid non-covered benefits, determine if the non-covered benefit relates to a condition discovered by screening on the Summary Periodicity Schedule/AAP Periodicity Schedule, and if it does, review it for medical necessity before coverage determination. If it does not, it will be administratively denied as not a covered benefit.

EPSDT: Early and Periodic Screening, Diagnostic and Treatment services — Medicaid benefit for children and adolescents under age 21.

Medicaid non covered benefit: Services that NY State Medicaid has determined it will not cover in some or all circumstances.

Summary Periodicity Schedule / AAP Periodicity Schedule: Screening services schedule (Bright Futures/AAP) used to identify conditions discovered by screening; providers must follow the most current Bright Futures/AAP Recommendations for Preventive Pediatric Health Care.

QHCM: Quality Health Care Management — the Fidelis Care entity responsible for reviewing DOH updates (monthly) and determining applicability of NY State-declared non-covered benefits.

Revision History

4/25revisedLatest

Added 'LOB: Medicaid and CHIP' to header. Updated date of revision to Fidelis Care Medicaid Managed Care Member Handbook in section II d. References reviewed and updated. (Annual review; non-material administrative edits)

4/24revised

Added under section II 'd. Services not covered as listed in Fidelis Care Medicaid Managed Care Member Handbook revised November 2023'. References reviewed and updated. (Annual review; administrative update)

4/24revised

Annual review. Added under section II 'd. Services not covered as listed in Fidelis Care Medicaid Managed Care Member Handbook revised November 2023'. References reviewed and updated. (Administrative update)

2/23revised

Annual review. References updated; Changed font; changed Centene to Fidelis Care. (Administrative edits)

9/20revised

Removed EPSDT table. (Administrative update)