COVID-19 UPDATE - OpenPayer

Policy summary and scope

Payer: Fidelis Care. Policy title: COVID-19 update — prior authorization and coding guidelines (Part 1). This update consolidates COVID-19–related authorization and coding guidance and reiterates that all inpatient admissions require authorization, while emergency room stabilization does not require authorization but post-stabilization services and subsequent inpatient admissions do and will be reviewed for medical necessity.

The document lists delegated prior authorization vendors and programs (for example, TurningPoint and Evolent (NIA)) with associated code lists and device review responsibilities, routing instructions and vendor contact points (see delegated prior authorization programs). It also documents that select Behavioral Health services are being carved into the MAP Medicaid benefit effective 1/1/2023 and includes numerous operational routing changes, including updated fax numbers and delegated reviewer assignments.

Authorization and coverage criteria

Inpatient admission and emergency services

Inpatient admission and emergency services — summary and operational routing.

All inpatient admissions require prior authorization. Emergency room services and any emergent service required to provide stabilization of an emergent condition do not require authorization. Fidelis Care requires authorization of post-stabilization services and any inpatient admissions after emergency room services are completed; facility admissions are reviewed for medical necessity.

Operational contact: New fax number for Inpatient ER routing is 833-663-1602 (formerly 347-868-6411).

Inpatient facility services requiring authorization

Inpatient facility services that require authorization — includes transplant evaluation and inpatient rehabilitation.

All inpatient facility services (medical, substance use, and behavioral health admissions) require authorization.

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

Transplants: All solid organ and bone marrow (hematopoietic stem cell) transplants require authorization at the time of transplant evaluation. Examples of related CPT/Codes include (but are not limited to) 32850-32856, 33930-33946, 38204-38215, 38230-38242, 44133, 44136, 47133-47147, 48160, 48550-48556, 50300-50380, 50547, 65710-65757. (This is a non-exhaustive list; provider should request auth at evaluation.)

OASAS licensed Inpatient SUD

OASAS-licensed in-state inpatient substance use disorder (SUD) treatment — notification, exemption period, LOCADTR requirements, and retrospective review.

Effective 01/01/2020: Inpatient detoxification, inpatient rehabilitation and inpatient residential treatment services provided by New York State facilities that are licensed/certified/authorized by OASAS and participating in the Fidelis Care provider network are not subject to authorization review by Fidelis Care for the first twenty-eight (28) days of the inpatient admission provided the facility notifies Fidelis Care of the inpatient admission and the initial treatment plan within two (2) business days of admission.

Notification methods: The facility may fax or email the OASAS Appendix A Notification Form and OASAS LOCADTR Medical Necessity Tool to fax number 833-663-1608 (formerly 646-829-1421) or via LOCADTR submission to the Fidelis Care LOCADTR intake (LOCADTR@fideliscare.org).

During the first 28 days the facility must perform daily clinical review of the patient. This does not require the facility to run a LOCADTR concurrent review module every day but facilities must use LOCADTR to inform periodic clinical review and to determine medical necessity. Facilities must periodically consult with Fidelis Care (beginning no later than the 14th day of treatment) to ensure appropriate application of the LOCADTR tool.

Prior to discharge, facilities must provide the member and Fidelis Care with a written discharge plan determined using LOCADTR and must indicate that services included in the discharge plan are secured or reasonably available. All services (including those within the first 28 days) may be reviewed retrospectively to assess clinical necessity.

OMH licensed Inpatient Mental Health Treatment

OMH-licensed inpatient mental health treatment rules for under-18 and adult members.

Effective 01/01/2020: Inpatient mental health treatment for members under age 18 provided by OMH-licensed hospitals in New York State participating in the Fidelis Care provider network are not subject to authorization review by Fidelis Care and are not subject to concurrent utilization review for the first fourteen (14) days of the inpatient admission provided the facility: (1) notifies Fidelis Care of both the admission and the initial treatment plan within two (2) business days of admission by completing the OMH Two-Day Notification and Initial Treatment Plan form and submitting it to Fidelis Care by fax to 833-561-0094 (formerly 718-896-1784) or by email to MentalHealthAdmission@fideliscare.org; (2) performs daily clinical review of the patient; and (3) participates in periodic consultation with Fidelis Care to ensure use of the evidence-based clinical review criteria approved by OMH.

Inpatient mental health services for members age 18 and older require authorization review by Fidelis Care and are subject to concurrent review throughout the admission.

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

Operational contact: For questions call 1-888-FIDELIS (1-888-343-3547), extension 16072 for Behavioral Health.

Delegated prior authorization programs

Delegated prior authorization programs and associated device review responsibilities.

Musculoskeletal Management Program (including certain orthopedic and spinal surgical procedures) transitioned to Evolent (NIA) effective 01/01/2024. For a list of CPT codes requiring authorization under this delegation, providers should reference the Evolent (NIA) delegated code list.

TurningPoint Healthcare Solutions, LLC has been delegated prior authorization for specified ENT, cardiac, and certain outpatient orthopedic/spinal surgical procedure code sets. For a list of codes requiring authorization under TurningPoint, providers should reference the TurningPoint delegated code lists.

Associated devices (HCPCS codes) tied to CPT codes delegated to a vendor (Evolent or TurningPoint) will also be reviewed by the same vendor for medical necessity.

Behavioral Health — outpatient and testing

Behavioral Health — outpatient testing, procedures, and intensive programs requiring authorization.

Testing: Certain psychological/neuropsychological testing services require prior authorization. (Providers should refer to the Behavioral Health testing authorization list for specific CPT/HCPCS codes.)

Electroconvulsive Therapy (ECT) and Transcranial Magnetic Stimulation (TMS): Authorization is required for ECT and TMS services — clinical documentation supporting medical necessity must be submitted as part of the authorization request.

Intensive outpatient programs (IOP) / Intensive outpatient treatment: These programs require authorization. Billing detail: when IOP/IO is provided, follow applicable procedure codes and place-of-service rules; verify submission of units/sessions per the plan's IOP billing guidance.

Behavioral Health carve-in (effective 1/1/2023)

Behavioral Health carve-in effective 01/01/2023.

Effective 01/01/2023: Behavioral Health services were carved in — Fidelis Care administers coverage and utilization management for behavioral health services under the plan as of the effective carve-in date.

A crosswalk mapping behavioral health service responsibilities and code alignments exists to support the carve-in transition (refer to the internal crosswalk document; no need to reproduce the table here).

Pharmacy, Part B drugs and oncology medications

Pharmacy — Part B drugs, enteral therapy, oncology medications and step therapy expectations.

Part B drugs and physician-administered medications may require prior authorization; providers should submit requests with clinical documentation demonstrating medical necessity.

Enteral therapy: certain enteral nutrition products billed with HCPCS codes require prior authorization. Providers should follow the enteral therapy HCPCS authorization list when requesting coverage.

Oncology medications (including some physician-administered oncology drugs) are managed through Evolent (NIA) — prior authorization is required and clinical supporting documentation should be submitted to the delegated vendor.

Step therapy: Where step therapy applies, medications may require trial of preferred alternatives before coverage of non-preferred agents is approved; prior authorization submissions should document prior trials or clinical rationale for exceptions.

Out-of-network coverage for Medicare Advantage plans

Out-of-network (OON) coverage requirements for referenced Medicare Advantage plans.

For referenced Medicare Advantage plans within this policy, out-of-network inpatient admissions or services require prior authorization. Members and providers should confirm OON authorization requirements prior to service when possible.

Cost implication: Authorization of out-of-network services does not guarantee in-network benefit levels; members may be subject to higher cost-sharing for OON services as defined by their Medicare Advantage benefit design.

New technology / experimental

New technology and experimental treatments.

Prior authorization is required for new, investigational, or experimental treatments and technologies. Coverage decisions are based on medical necessity and evidence supporting safety and effectiveness; requests should include clinical evidence and rationale.

If a treatment is determined to be experimental or not medically necessary based on review of the evidence, authorization will be denied.

Outpatient surgery, outpatient & DME authorizations, home health, podiatry, counseling, and UM voicemail requirements

Additional required coverage items consolidated from the source: outpatient surgery and DME authorizations; home health and outpatient home therapy; podiatry and therapeutic services; counseling and education services; utilization management voicemail requirements.

Outpatient surgery prior authorization — code highlights: A broad set of outpatient surgical CPT/HCPCS codes require prior authorization when performed in ambulatory surgery centers or other outpatient settings. Examples from the policy include (non-exhaustive): 15011, 15012; bariatric 43770-43774, 43888; blepharoplasty 15820-15823; breast reconstruction 11920-11971, 19300, 19316-19342, 19355, 19370-19396; ear repair/piercing 69300, 69090; eyelid & ocular surgery 65760-65769, 67903-67911, 66991, 68841; certain dermatologic, cosmetic, facial, rhinoplasty, septoplasty, reduction mammoplasty (19300,19318), vascular and spinal codes (20932-20934, 22867-22870, 62380), esophageal 43284, 43497, urology 51721, 53865-53866, 55881-55882, CAR-T therapy 38225-38228, and other specified HCPCS such as C1600-C1604, C1737, C7556-C7560, C9807. Certain codes continue to require authorization regardless of place of service (e.g., 11200, 11201, 11719, 15769-15829, 17340-17999). Providers must reference the full outpatient surgery prior authorization lists to determine applicability.

Outpatient and DME prior authorization: Durable medical equipment and certain outpatient services require prior authorization per plan policy. Associated HCPCS devices tied to delegated CPT codes are reviewed by the same vendor (Evolent or TurningPoint) if the CPT is delegated. Enteral therapy items billed with HCPCS require prior authorization (see enteral therapy section above).

Provider-impact summary and required actions

Prior Authorization

Obtain authorization for inpatient admissions

All inpatient admissions require prior authorization. Fidelis Care does not require authorization of emergency room services or any emergent service required to provide stabilization of an emergent condition. Authorization is required for post-stabilization services and inpatient admissions once ER services are completed. Note: New fax number for Inpatient ER notifications is 833-663-1602 (formerly 347-868-6411).

Exception: ER emergent stabilization services do NOT require prior authorization; inpatient admissions after stabilization do.
New inpatient ER fax: 833-663-1602 (formerly 347-868-6411).

Prior Authorization

Transplant authorization at evaluation

All solid organ and bone marrow transplants require authorization at the time of the transplant evaluation. Providers must obtain authorization when the patient is evaluated for transplant.

Code lists and billing rules

Transplant-related CPT codes (authorization required at transplant evaluation)CPTCovered

32850
32851
32852
32853
32854
32855
32856
33930
33931
33932

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Transplant-related CPT codes (authorization required at transplant evaluation) - duplicate group summaryCPTCovered

No codes listed

Outpatient surgery codes requiring prior authorization (examples)CPTCovered

15011
15012
43770	Bariatric
43771	Bariatric
43772	Bariatric
43773	Bariatric
43774	Bariatric
43888	Bariatric
15820	Blepharoplasty
15821	Blepharoplasty

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Outpatient surgery codes requiring prior authorization (examples) - delegated lists noteCPTCovered

No codes listed

Behavioral health testing and procedure codes (authorization required)mixedCovered

96116	Psych testing
96121	Psych testing
96130	Neuropsych testing
96131	Neuropsych testing
96132	Neuropsych testing
96133	Neuropsych testing
96136	Psych testing
96137	Psych testing
96138	Psych testing
96139	Psych testing

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Behavioral health testing and procedure codes (authorization required) - notemixedCovered

No codes listed

Imaging and radiology codes highlightedCPT|RevenueCovered

77089	TBS scan
77090	TBS scan
77091	TBS scan
77092	TBS scan
43235	GI endoscopic procedure (authorization conditional by POS 19/22; not required in POS 11 or 24)
43239	GI endoscopic procedure
43248	GI procedure
45378	Colonoscopy/therapeutic (authorization conditional by POS 19/22; not required in POS 11 or 24)
45380	Colonoscopy (authorization conditional by POS)
45384	Colonoscopy (authorization conditional by POS)

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Imaging and radiology codes highlighted - POS conditional noteCPT|RevenueCovered

No codes listed

Wireless capsule endoscopy and motilityCPTCovered

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

Wireless capsule endoscopy and motility - auth requiredCPTCovered

No codes listed

DME codes not requiring authorization (examples)HCPCS

A4239
A4287
A4341
A4342
A4457
A4560
A4604
A4670
A6533
A4468	explicitly listed as not requiring authorization

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DME codes not requiring authorization (examples) - noteHCPCS

No codes listed

Enteral therapy HCPCS requiring authorizationHCPCSCovered

B4034-B4162

range of enteral formulas/disposable items requiring authorization (Part B services)

Enteral therapy HCPCS requiring authorization - noteHCPCSCovered

No codes listed

Selected J/C codes and J-code mapping examples (pharmacy/infusion)HCPCSCovered

C9047	listed with numeric mappings to J-codes
C9145	listed with numeric mappings to J-codes
C9167	listed with numeric mappings to J-codes
C9168	listed with numeric mappings to J-codes
C9173	listed with numeric mappings to J-codes
C9293	listed with numeric mappings to J-codes
G0516	insertion of implant mapping to J0571 etc.
G0517	removal mapping to J0572 etc.
J0129	adalimumab and mapping examples in list
J0172	aducanumab mapping example

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Selected J/C codes and J-code mapping examples (pharmacy/infusion) - mapping noteHCPCSCovered

No codes listed

HCPCS J-codes listed (Medicare section)HCPCS

J7295	Segesterone acetate and ethinyl estradiol
J7296	Ethinyl estradiol and etonogestrel
J7297	levonorgestrel-releasing intrauterine (Kyleena)
J7298	levonorgesteral-releasing intrauterine (Liletta)
J7300	levonorgesteral-releasing intrauterine (Mirena) / intrauterine copper contracept
J7304	levonorgestrel-releasing intrauterine (Skyla)
J7306	contraceptive hormone patch
J7307	levonorgestrel implant system (Implanon)
J7308	aminolevulinic acid 20% (Levulan kerastick)
J7311	fluocinolone acetonide intravitreal implant (Retisert)

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HCPCS J-codes listed (Medicare section) - Medicare mapping contextHCPCS

No codes listed

Q-codes and miscellaneous supply/dispenser feesHCPCS

Q0138	Miscellaneous chemotherapy ferumoxytol (non-ESRD) and related mappings
Q0155	Pharmacy supply fee and related mappings
Q0511	initial immunosuppressive drug(s) Pharmacy supply fee for oral
Q0512	Pharmacy supply fee for subsequent prescription in a 30-day
Q0513	Pharmacy dispensing fee for inhalation drug(s); per 30 days
Q0514	Pharmacy dispensing fee for inhalation drug(s); per 90 days
Q0521	Pharmacy supplying fee for HIV pre-exposure prophylaxis FDA approved days/prescription
Q2041	Pharmacy supplying fee related mapping entries
Q2042	Pharmacy supplying fee related mapping entries
Q2043	Q-code mapping (e.g., teclistamab -> Q2043)

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Q-codes and miscellaneous supply/dispenser fees - noteHCPCS

No codes listed

Certain GI endoscopic and colonoscopy CPTs (examples: 43235, 43239, 43248, 45378, 45380, 45384, 45385 and related small bowel codes 46255/46260/46270) require authorization only when performed in Place of Service 19 or 22 if an office-based POS or ambulatory surgery center is available; these services do not require authorization when performed in POS 11 or 24. CPT 43290 requires authorization in any place of service. For genetic testing related exceptions, CPTs 81220, 81329, 81336, and 81420 do not require authorization; CPT 81220 has a lifetime limit of 1, and CPTs 81329 and 81336 have a combined lifetime limit of 1.

DME, orthotics, home therapy and sleep/diagnostic rules

Operational routing and billing details

Operational routing updates include new fax numbers for specific programs: Inpatient ER fax 833-663-1602; OASAS inpatient SUD notification fax 833-663-1608; OMH two-day notification fax 833-561-0094; and prior authorization requests for therapy services in inpatient settings to fax 833-663-1611.

Delegated reviewer assignments and vendor contacts: TurningPoint Healthcare Solutions, LLC handles prior authorization for delegated ENT, cardiac and certain orthopedic/spinal CPTs (and reviews associated HCPCS devices); Evolent (NIA) handles the Musculoskeletal Management Program, radiation therapy, home therapy (PT/OT/ST) prior authorization, and oncology medication prior authorization per their program routing. Vision prior authorizations are handled by Davis Vision (1-800-601-3383).

For transportation and related authorization/billing guidance, refer to the Transportation Provider Manual as noted in the vendor services section.

Note

Vendor-specific prior authorization contacts

Vendor‑specific contacts and supplemental resources: vision prior authorizations are handled by Davis Vision and transportation requirements are referenced in the Transportation Provider Manual.

Davis Vision prior auth contact: 1-800-601-3383.
See Transportation Provider Manual for transportation prior authorization/billing guidance.

Key terms and abbreviations

Definitions

POSPlace of Service

OASASNew York State Office of Addiction Services and Supports

OMHNew York State Office of Mental Health

LOCADTRLevel of Care and Demand Tool for Addiction/Behavioral Health clinical review

UMUtilization Management

PHIPersonal Health Information

Thresholds, limits and notable numeric rules

Thresholds / Limits

OASAS concurrent review exemptionFirst 28 days without concurrent utilization review if facility notifies Fidelis within 2 business days and meets LOCADTR and notification requirements

OMH concurrent review exemption (under 18)First 14 days without concurrent utilization review if facility notifies Fidelis within 2 business days using OMH Two‑Day Notification and Initial Treatment Plan and meets other conditions

DSMT allowance10 hours (20 units) in a continuous 12‑month period (no authorization required when billed with G0108/G0109)

MNT visits without authorization8 visits per year for Medical Nutrition Therapy (codes 97802/97803 or G0270/G0271)

CPT 81220 lifetime limitCPT 81220 has a lifetime limit of 1 (CPT 81329 and 81336 have a combined lifetime limit of 1)

Common questions and contact points

Urgent authorization & delegated vendor contacts

Fax/email & voicemail/HIPAA guidance for OASAS/OMH notifications

Document changes and effective dates

2025-03-01medicare_mapping_effectiveLatest

Medicare mappings section effective 2025-03-01 (Medicare J-/C-/Q-code and mapping list included)