CurrentFidelis CarePolicy N/A

COVID-19 UPDATE - Authorization and Coding Guidelines

Defines Fidelis Care prior authorization requirements, delegated reviewers, lists of CPT/HCPCS codes requiring authorization or not, special rules for inpatient admissions, behavioral health and substance use services carve-in (effective Jan 2023), outpatient/DME/imaging/therapy authorization rules, and pharmacy prior authorization/delegation details. This is part 1 of 2 and covers many service categories and code lists.

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE - Authorization and Coding Guidelines

Policy CodePolicy N/A

Change TypeOperational / Authorization update

Effective Date

Next Review Date

Key ActionProviders must obtain authorization for all inpatient admissions; emergency stabilization does not require authorization but post-stabilization inpatient admissions do and will be reviewed for medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material changes — brief indicates has_material_change=false and provides no discrete policy updates.

MultipleService categories with auth rules

Jan 1 2023Behavioral Health carve-in effective

Oct 1 2021NIA therapy/radiology auth effective

Apr 1 2023DME codes A4341/A4342 no PA effective

Coverage Summary

This policy defines Fidelis Care prior authorization and coding guidance for a broad set of services related to COVID-19 updates and operational changes. It covers multiple service categories including inpatient (medical, substance use disorder, behavioral health, rehabilitation), outpatient procedures and surgery, behavioral health outpatient and testing, durable medical equipment (DME), imaging, therapy (home and outpatient PT/OT/ST), and pharmacy (Medicare Part D/Part B and delegated oncology reviews).

The policy notes delegated prior authorization reviewers and vendors: TurningPoint Healthcare Solutions, LLC for specified surgical categories and associated devices, National Imaging Associates, Inc. (NIA) for radiology and outpatient/home therapy prior authorization, and New Century Health (NCH) for oncology medication prior authorization. It also documents special notification/exception rules for state-licensed facilities licensed by OASAS and OMH with limited authorization/concurrent review exceptions when facility notification and required forms are submitted within specified timelines.

This document is part 1 of 2 and provides the scope summary, lists of CPT/HCPCS codes and code groups that require or do not require authorization, delegations, and operational timing instructions for submissions and notifications.

Quick-reference thresholds & effective dates for key rules

OB ultrasound thresholdFirst 4 OB ultrasounds can be performed without authorization; five or more require authorization

BRCA/genetic testing lifetime limitsCPT 81220 authorization not required; lifetime limit = 1. CPTs 81329 and 81336 combined authorization-except limit = 1 per lifetime

NIA outpatient/home therapy effective dateOutpatient/home PT/OT/ST prior authorization delegated to NIA effective for DOS on/after 10/01/2021 (announcement dated 9/20/2021)

Behavioral Health carve-in effective dateBehavioral Health services carved into MAP Plan benefit package effective January 1, 2023

DME A4341/A4342 PA changeEffective 4/01/2023 codes A4341 and A4342 are new and do not require prior authorization

Authorization and Medical Necessity Rules

Inpatient Admissions and Emergency Services

Covered when authorization rules below are met:

ALL of the following

All inpatient admissions require an authorization.
Emergency room services or emergent services for stabilization do not require authorization; post-stabilization services and inpatient admissions after ER completion require authorization and are reviewed for medical necessity.

Specific inpatient categories requiring authorization

Authorization required for:

ANY of the following inpatient categories

Code Lists and Authorization Status

Transplant CPT codes requiring authorizationCPTCovered

32850
32851
32852
32853
32854
32855
32856
33930
33931
33932

1–10 of 74

1/8

Outpatient surgery codes requiring authorization (selected lists)CPTCovered

15820	Blepharoplasty
15821	Blepharoplasty
15822	Blepharoplasty
15823	Blepharoplasty
43770	Bariatric
43771	Bariatric
43772	Bariatric
43773	Bariatric
43774	Bariatric
43888	Bariatric

1–10 of 43

1/5

Behavioral health testing codes requiring authorizationCPTCovered

96116	Psychological testing (requires auth)
96121	Psychological testing (requires auth)
96130	Neuropsych testing (requires auth)
96131	Neuropsych testing (requires auth)
96132	Neuropsych testing (requires auth)
96133	Neuropsych testing (requires auth)
96136	Psych/Neuropsych testing (requires auth)
96137	Psych/Neuropsych testing (requires auth)
96138	Psych/Neuropsych testing (requires auth)
96139	Psych/Neuropsych testing (requires auth)

1–10 of 15

1/2

Intensive Outpatient and Program-related codesmixedCovered

H0035	Intensive outpatient HCPCS
90899	CPT (listed for program billing mapping)
S9480	Service code (listed for program billing mapping)

Wireless capsule & motility capsuleCPTCovered

91110	Wireless capsule endoscopy
91111	Wireless capsule endoscopy
91112	Wireless motility capsule
91113	Wireless motility capsule

Genetic testing CPT exceptions (no auth required)CPT

81220	Authorization not required; lifetime limit 1
81329	Authorization not required; combined limit with 81336 = 1 lifetime
81336	Authorization not required; combined limit with 81329 = 1 lifetime
81420	Authorization not required

DME codes not requiring authorizationHCPCSCovered

V5266
A4341	Effective 4/1/23 - no PA
A4342	Effective 4/1/23 - no PA

Orthotic codes not requiring authorization (selected list)HCPCSCovered

A4565
A8000
A8001
L0220
L0861
L0970
L1040
L1050
L1060
L1080

1–10 of 45

1/5

Therapy and imaging CPTs delegated to NIA or requiring authorizationmixedCovered

92610	Speech - does not require authorization (exception)
92611	Speech - does not require authorization (exception)
77089	TBS scan
77090	TBS scan
77091	TBS scan
77092	TBS scan

Examples of imaging/procedure codes requiring authorization in specific POSCPTCovered

43235	Requires auth in POS19/22 when office/ASC available
43239	Requires auth in POS19/22 when office/ASC available
43248	Requires auth in POS19/22 when office/ASC available
45378	Requires auth in POS19/22 when office/ASC available
45380	Requires auth in POS19/22 when office/ASC available
45384	Requires auth in POS19/22 when office/ASC available
45385	Requires auth in POS19/22 when office/ASC available
46255	Requires auth in POS19/22 when office/ASC available
46260	Requires auth in POS19/22 when office/ASC available
46270	Requires auth in POS19/22 when office/ASC available

Provider Actions & Requirements

Prior Authorization

Obtain prior authorization for inpatient admissions

Providers must obtain prior authorization for all inpatient admissions. Emergency room services or any emergent service required to provide stabilization do not require authorization. However, post-stabilization services and inpatient admissions after completion of emergency room services require authorization and will be reviewed for medical necessity.

Prior Authorization

Transplant authorization at evaluation

All solid organ and bone marrow tissue transplants require authorization at the time of the transplant evaluation. (See listed transplant CPT codes requiring authorization.)

Background and Definitions

Background: This Fidelis Care policy provides COVID-19 related updates and broad authorization and coding guidelines across inpatient, outpatient, behavioral health, DME, imaging, therapy, and pharmacy services. It explicitly states that all inpatient admissions require authorization while emergency stabilization does not, and it lists solid organ and bone marrow transplant CPT codes that require authorization at the time of transplant evaluation.

The policy documents delegations and vendor responsibilities: prior authorization for specified surgical categories (ENT, cardiac, certain orthopedic/spinal procedures) has been delegated to TurningPoint, and radiology, radiation therapy, and outpatient/home therapy prior authorization have been delegated to NIA. Pharmacy oncology medication prior authorization for participating providers is handled by New Century Health.

The policy also notes state regulatory exceptions: in‑state, in‑network OASAS‑licensed inpatient SUD facilities are not subject to authorization or concurrent utilization review for the first 28 days provided the facility notifies Fidelis within 2 business days and submits OASAS Appendix A and the LOCADTR tool; similarly, OMH‑licensed inpatient mental health hospitals in NY for members under 18 are not subject to authorization or concurrent review for the first 14 days if the OMH two‑day notification and initial treatment plan form is submitted within 2 business days and required clinical review/consultation steps are followed.

Term	Definition
OASAS	Office of Addiction Services and Supports (New York State) — facilities licensed/certified by OASAS have specific authorization exceptions per policy (in‑network, in‑state OASAS licensed facilities are not subject to authorization review and not subject to concurrent utilization review during the first 28 days provided timely notification and LOCADTR submission).
OMH	Office of Mental Health (New York State) — OMH licensed hospitals have specific authorization exceptions for members under 18 per policy (in‑network NY OMH licensed hospitals participating in Fidelis network are not subject to authorization or concurrent review during the first 14 days if facility submits OMH Two‑Day Notification and Initial Treatment Plan and meets clinical review/consultation requirements).
NIA	National Imaging Associates, Inc. — third‑party prior authorization vendor to which Fidelis has delegated prior authorization for radiology services and for outpatient/home therapy services (effective 10/1/2021 for outpatient home therapy PT/OT/ST).
TurningPoint	TurningPoint Healthcare Solutions, LLC — delegated prior authorization reviewer for certain surgical categories (ENT, cardiac, certain orthopedic/spinal procedures) and associated devices; requests for CPTs delegated to TurningPoint should be directed to TurningPoint.
NCH	New Century Health (NCH) — delegated prior authorization reviewer for oncology medications and supportive agents for participating providers; oncology PA requests for participating providers must be submitted via the NCH portal or phone.

Revision History

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE - Authorization and Coding Guidelines

Policy CodePolicy N/A

Change TypeOperational / Authorization update

Effective Date

Next Review Date

SourceLink

On This Page

All inpatient facility services: Medical, Substance Abuse, and Behavioral Health admissions require authorization.

Inpatient Rehabilitation Services (acute, sub-acute, skilled nursing rehabilitation) require authorization; acute and sub-acute authorized when skilled services are provided.

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

Includes list of CPTs in source.

OASAS Licensed Inpatient Substance Use Disorder Treatment

Exceptions and requirements for in-state OASAS-licensed facilities:

Effective 01/01/2020: In-network, in-state OASAS licensed facilities participating in Fidelis network are not subject to authorization review and not subject to concurrent utilization review during first 28 days, provided facility notifies Fidelis within 2 business days of admission and initial treatment plan using OASAS Appendix A and LOCADTR tool.

Facility may fax/email OASAS Appendix A and LOCADTR to provided contacts; services may be reviewed retrospectively.

Facility must perform clinical review, periodically consult with Fidelis starting on/near 14th day, and notify whether discharge services are secured/available. Services may be reviewed retrospectively.

Prior to discharge, provide written discharge plan per LOCADTR.

Out-of-state, non-OASAS-licensed, or out-of-network facilities must request authorization and are subject to concurrent review throughout admission.

OMH Licensed Inpatient Mental Health Treatment (members <18)

Exceptions effective 01/01/2020:

Inpatient mental health treatment for members under 18 provided by OMH licensed hospitals in NY participating in Fidelis network are not subject to authorization and not subject to concurrent utilization review during first 14 days if: facility notifies Fidelis within 2 business days via OMH 'Two-Day Notification and Initial Treatment Plan' form; performs daily clinical review; participates in periodic consultation with Fidelis using approved evidence-based clinical review criteria.

Submit form by fax or email to specified contacts.

Inpatient mental health services for age 18 and older require prior authorization.

Out-of-network providers must request prior authorization for inpatient mental health treatment for members of all ages and are subject to concurrent review.

Delegation to TurningPoint Healthcare Solutions, LLC

Certain surgical categories delegated to TurningPoint:

Prior authorization for ENT surgical procedures delegated to TurningPoint; associated devices (HCPCS) also reviewed by TurningPoint.

Refer to TurningPoint delegated CPT list in source.

Prior authorization for Cardiac surgical procedures delegated to TurningPoint; associated devices reviewed by TurningPoint.

Certain orthopedic and spinal surgical procedures delegated to TurningPoint.

Outpatient surgery authorization categories

The following outpatient procedures require authorization (lists of CPT ranges/codes):

Listed outpatient procedure groups

Blepharoplasty: 15820, 15821, 15822, 15823
Bariatric surgery: 43770, 43771, 43772, 43773, 43774, 43888
Note: S2083 no longer requires authorization as of 8/1/22.
Breast reconstruction: 11920-11971, 19300, 19316-19342, 19355, 19370-19396
Skin surgery (ambulatory POS24): 10040, 11300, 11301, 11471, 11721
These CPTs continue to require authorization when completed as ambulatory surgery (POS24).
Dermal injections (Facial Lipodystrophy): Q2026, Q2027, G0429
Require authorization; coverage limited to individuals with HIV and secondary diagnosis of depression.
ASC billing exceptions: 10060, 11100, 11900, 17000, 20600, 20605, 20610
If billed from freestanding ASC (bill type 0831) require authorization; CPT 20610 non-covered when billed with M17.9.
Codes requiring auth any POS: 11200, 11201, 11719, 15769-15829, 17340-17999
These codes continue to require authorization for any place of service.
Ear repair/ear piercing: 69300, 69090
Ocular/eyelid surgery: 65760-65769
Abdominoplasty/panniculectomy: 15830-15839, 15847, 15876-15879
Facial cosmetic/septoplasty/rhinoplasty: 21120-21296, 30400-30450, 30465-30520, 30620-30802, 30999, 31298, C9749, Q2028
For CPTs delegated to TurningPoint, direct requests to TurningPoint.
Reduction mammoplasty: 19300, 19318
Vascular procedures: 36465, 36466, 36483, 37241-37244, 37718-37785
Speech Processor Implant: 69716, 69719, 69726, 69727
Spinal surgery: 20932-20934, 22867-22870, 62380
Esophageal procedures: 43284, 43497

Behavioral Health - Outpatient and Testing

Authorization requirements for behavioral health outpatient services and testing:

Authorization requirement removed from all outpatient behavioral health services except specified CPTs which continue to require authorization: 96116, 96121, 96130-96133, 96136-96139, 96146. Requests must be submitted on Psychological/Neuropsychological testing request form.

Developmental Pediatric Testing requires authorization for 96112 and 96113. Note: 96110 is a non-covered service.

Authorization required for 90870.

Behavioral Health Intensive Outpatient & Revenue/CPT mappings

Codes and bill types requiring authorization or listed for IOP/IOP-like services:

Intensive Outpatient Treatment revenue codes: 912, 913, 944, 945; HCPCS H0035.

Bill type 131, Revenue code 905 or 912, CPT 90899, S9480, HCPCS H2013 (listed for certain programs).

Outpatient & DME services requiring prior authorization

Outpatient procedures, diagnostics, DME and other services needing prior authorization:

Sleep studies, including home sleep studies require prior authorization.

Diagnostic testing including breast cancer/BRCA and other genetic testing require authorization except CPTs 81220, 81329, 81336, 81420 (authorization not required for these; 81220 lifetime limit 1; 81329 & 81336 combined limit 1 per lifetime).

Wireless capsule endoscopy: 91110, 91111; Wireless motility capsule: 91112, 91113 require authorization.

Certain procedures require authorization if performed in POS 19 and 22 when office/ASC available: 43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270. Authorization not required when performed in POS 11 or 24.

Infectious agent detection by DNA or RNA: 87483 requires authorization.

Authorization required for 43290 when performed in any place of service.

Penile prosthesis: 54405 requires authorization.

Durable Medical Equipment (DME)

Authorization exceptions and rules:

Certain DME codes do not require authorization: V5266.

Effective 4/1/23, codes A4341 and A4342 are new and do not require prior authorization.

Listed orthotic codes do not require authorization (selected list includes A4565, A8000, A8001, L0220, L0861, L0970, L1040, L1050, L1060, L1080, L1085, L1120, L1240, L1250, L1260, L1270, L1280, L1290, L1620, L1630, L1650, L1660, L1810, L2182, L2184, L2190, L3650, L3710, L3913, L3919, L3921, L3923, L3925, L3929, L3995, L8010, L8035, L8300, L8310, L8320, L8330, L8400, L8410, L8415, L8417).

Other DME and orthotic codes require authorization.

Home Health Care & Outpatient Therapy

Authorization rules and delegation effective dates:

Effective 9/20/2021 for dates of service on/after 10/1/2021: Outpatient Home Therapy (PT, OT, ST) services performed by a therapy provider require prior authorization through National Imaging Associates, Inc. (NIA). Initial evaluations require authorization; CPTs 92610 and 92611 do not require authorization.

Office or facility based initial evaluations do not require authorization but other billed procedure codes on same date do require authorization.

Outpatient therapy after initial evaluation requires authorization through NIA; office/facility initial evaluations do not require authorization but all other billed procedure codes on same date do require prior authorization.

Authorization request submission timing: within 1 business day for outpatient or 2 business days for home health setting; inpatient settings to Fidelis within 1 business day. For services provided in inpatient POS 31 & 32 prior auth requests to be sent to 716-803-8307.

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

Imaging Studies

Authorization and limits:

First 4 OB ultrasounds can be performed without authorization; five or more require authorization. OB ultrasounds for high risk pregnancy require authorization per listed diagnosis codes.

Prior authorization for radiology services has been delegated to NIA (except cardiac ultrasounds delegated to TurningPoint).

A full list of CPT codes requiring authorization is available via link.

TBS scans listed: 77089, 77090, 77091, 77092.

Podiatry Services

Authorization rules:

Authorization is no longer required for general podiatric services; authorization requirements still apply to individual services indicated on the grid and rendered by podiatrists.

Therapeutic Services and Procedure-level rules

Authorization and coverage exclusions:

Chiropractic and phototherapy services (CPTs listed) and hyperbaric oxygen therapy are subject to rules; specific pain management codes (20526, 20550-20553, 21073, 27096, 62263-62264, 62273, 62280-62281) are subject to authorization rules; codes 63622 and 63688 do not require authorization for requests from orthopedic specialties.

Non-covered services for members with diagnosis of Low Back Pain include therapeutic injections of steroids into intervertebral discs, prolotherapy, and topical oxygen (not covered).

Ambulatory continuous glucose monitoring noted (95249) in context of not-covered/limited services.

Radiation therapy services prior authorization delegated to NIA; other listed procedures (e.g., radiofrequency ablation of uterine fibroids 58674; bronchial thermoplasty 31660, 31661) are listed with authorization/coverage details.

Counseling, Medical Nutrition Therapy, DSMT

Coverage and authorization rules:

Medical nutrition therapy covered with a diagnosis of diabetes (E13.8, E13.9, O24.410, O24.414). Eight visits per year covered without authorization using codes 97802 or 97803 or G0270 and G0271.

Diabetes Self-Management Training (DSMT): Members allowed 10 hours/20 units in a continuous 12-month period; services provided by certified providers and no longer require authorization.

New Technology/Experimental Treatment

Prior authorization requirement:

Prior authorization is required and approval is based on medical necessity for new technology/experimental treatments.

Pharmacy Prior Authorization and Delegation

Medicare Part D and other pharmacy rules:

All covered Medicare Part D drugs must be prescribed for medically accepted indications (FDA or Medicare-approved compendia); formulary and PA criteria available on Fidelis website.

Enteral therapy HCPCS B4034-B4162 require authorization (Part B benefit).

Oncology medications and supportive agents require prior authorization from New Century Health (NCH) for participating providers before dispensing/administration; PA can be requested via NCH web portal or phone.

Certain injectable non-oncology codes require authorization for participating and non-participating providers; submit PA requests to Fidelis Pharmacy Team via e-fax 1-877-882-5892.

Documentation Required

OASAS/OMH notification requirements

OASAS-licensed in-network facilities and OMH-licensed in-network hospitals have specific notification requirements in lieu of prior authorization during the limited initial days of admission.

OASAS: Notify Fidelis within 2 business days of admission and fax or email the OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool to 646-829-1421 or LOCADTR@fideliscare.org.
OMH: Submit the OMH 'Two-Day Notification and Initial Treatment Plan' form to Fidelis within 2 business days by fax to 718-896-1784 or email to Mental_HealthAdmission@fideliscare_org.

Prior Authorization

Delegate prior authorization to TurningPoint or NIA when indicated

Prior authorization for certain surgical categories and imaging/therapy has been delegated to third-party vendors. Requests for CPTs delegated to TurningPoint or NIA should be directed per the delegation instructions.

TurningPoint: delegated for ENT surgical procedures, cardiac surgical procedures, and certain orthopedic/spinal surgical procedures; associated devices (HCPCS) also reviewed by TurningPoint.
NIA: delegated for radiology, radiation therapy, and outpatient/home therapy (PT/OT/ST) prior authorization per instructions.

Documentation Required

Timing for authorization notifications/submissions

Authorization and notification timing varies by setting: specific short timelines apply for OASAS/OMH notifications and for submission of authorization requests in outpatient, home health, and certain inpatient settings.

Billing Rule

Freestanding ASC billing rule

When the listed CPTs are performed in a freestanding ambulatory surgery center billed with bill type 0831, an authorization is required. Note that CPT 20610 for hyaluronic acid joint injection is non-covered when billed with diagnosis code M17.9.

Affected CPTs: 10060, 11100, 11900, 17000, 20600, 20605, 20610
Bill type 0831 requirement for authorization when performed in freestanding ASC
CPT 20610 is non-covered when billed with M17.9

Prior Authorization

Pharmacy prior authorization submission

Non-oncology injectable prior authorization requests for both participating and non-participating providers must be submitted to the Fidelis Pharmacy Team via e-fax. Oncology prior authorizations for participating providers are handled via New Century Health.

Non-oncology injectable PA e-fax: 1-877-882-5892
Oncology PA for participating providers: New Century Health portal (my.newcenturyhealth.com) or phone 1-888-999-7713, option 1

Documentation Required

Discharge planning for Inpatient SUD

For inpatient substance use disorder (Inpatient SUD) in OASAS-licensed facilities, prior to discharge the facility must provide a written discharge plan to the member and Fidelis using the LOCADTR clinical review tool and must indicate whether the services in the discharge plan are secured or reasonably available.

Use the LOCADTR clinical review tool to determine and document the discharge plan.
Indicate to Fidelis whether discharge services are secured or reasonably available prior to discharge.