CurrentFidelis CarePolicy N/A

COVID-19 UPDATE

Provides updated authorization, utilization review, and billing rules across inpatient, outpatient surgery, behavioral health, diagnostic testing, DME, imaging, therapeutic services, pharmacy and vendor services for Fidelis Care members (New York State focus). It lists CPT/HCPCS codes requiring prior authorization, codes excluded from authorization, delegated reviewers, and operational notification/fax numbers.

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE

Policy CodePolicy N/A

Change TypeConsolidation/Operational update

Effective Date

Next Review Date

Key ActionObtain prior authorization for inpatient admissions and specified services and submit requests to delegated vendors (Evolent, TurningPoint, New Century Health) or Fidelis as indicated.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — this update consolidates authorization, utilization review, delegation, code lists, and operational contacts but does not introduce a discrete material policy change.

manyPrior Authorization Code Entries

delegatedExternal Delegations

NYPrimary Geographic Focus

limitedInpatient SUD/OMH no-PA periods noted

Listed Codes Requiring PA (approx.)

1Voicemail UM Communication Rule

Policy Summary & Scope

Background: Fidelis Care COVID-19 update consolidates prior authorization, utilization review and operational guidance across multiple service lines and confirms delegations to external vendors (Evolent, TurningPoint, New Century Health). The guidance focuses on New York State and includes state-specific exceptions for OMH- and OASAS‑licensed facilities.

Scope summary: Applies to inpatient admissions and concurrent review, outpatient surgery and ambulatory procedures, behavioral health services (including OMH/ OASAS notification and limited no-PA periods), durable medical equipment (DME) and supplies, imaging and diagnostic testing, therapeutic/pain management services, and pharmacy/enteral therapy. Delegated reviewers noted include Evolent (musculoskeletal management, radiology, outpatient therapy, radiation, oncology review via New Century Health/Evolent), TurningPoint (ENT and cardiac surgical procedures), and New Century Health / Evolent for oncology medications. High‑level services impacted: inpatient (all admissions and specific inpatient programs), outpatient surgery, behavioral health (testing, partial hospitalization, IOP, TMS), DME (lists of no-PA and PA items), and pharmacy (enteral therapy, oncology meds requiring vendor review).

Inpatient Admissions & Emergency Services

Prior Authorization

COVERAGE

Covered when ALL of the following are met:

OMH & OASAS Licensed Facilities — NY State Exceptions

OASAS Licensed Inpatient Substance Use Disorder (Inpatient SUD)

Prior authorization and concurrent review exceptions for in-state OASAS-licensed inpatient SUD facilities (NY State):

Effective 01/01/2020: In-state OASAS-licensed and in-network Inpatient SUD services are not subject to prior authorization review.

No concurrent utilization review during first 28 days of admission provided facility notifies Fidelis Care of admission and initial treatment plan within 2 business days.28 days

Facility may fax/email OASAS Appendix A Notification Form and LOCADTR tool to fax 833-663-1608 or LOCADTR@fideliscare.org.

Facilities must perform daily clinical review; periodic consultation with Fidelis Care starting on or just prior to day 14 to ensure LOCADTR use.day 14

Delegated Prior Authorization Programs & Vendor Contacts

Delegated Prior Authorization Programs

Certain specialty prior authorizations are delegated to external vendors:

Musculoskeletal Management Program (orthopedic & spinal surgical procedures) delegated to Evolent (NIA) effective 1/1/24; if CPT delegated to Evolent, associated HCPCS devices will also be reviewed by Evolent.1/1/24

ENT surgical procedures prior authorization delegated to TurningPoint Healthcare Solutions, LLC; associated HCPCS reviewed by TurningPoint when CPT delegated.

Cardiac surgical procedures prior authorization delegated to TurningPoint Healthcare Solutions, LLC; associated HCPCS reviewed by TurningPoint when CPT delegated.

Radiation therapy prior authorization delegated to Evolent (NIA).

Outpatient Surgery Prior Authorization (Selected Items)

Outpatient Surgery Prior Authorization (selected items)

Outpatient procedures and code groups requiring prior authorization (listing is not exhaustive):

Outpatient surgery categories and examples: Bariatric surgery: 43770-43775 (S2083 no longer requires authorization as of 8/1/22). Blepharoplasty: 15820-15823. Breast reconstruction: 11920-11971, 19300, 19316-19342, 19355, 19370-19396. Skin surgery: 15011, 15012; selected skin/ambulatory codes and POS rules listed. Ambulatory surgery center preauth for 10060, 11100, 11900, 17000, 20600, 20605. 20610 non-covered when billed with hyaluronic acid J-codes (J7318, J7320-J7332) for knee osteoarthritis; otherwise no auth for 20610. Ear repair: 69300, 69090. Eyelid/ocular surgery: 65760-65775, 66683, 66987-66991, 67900-67911, 68841. Abdominoplasty/lipectomy/panniculectomy: 15830, 15832-15839, 15847, 15876-15879. Reduction mammoplasty: 19300, 19318. Facial cosmetic/septoplasty/rhinoplasty: 21120-21296, 30465-30520, 30620-30802, 30999, 31298, Q2028. Vascular procedures: 36465-36479, 36482-36483, 37241-37244, 37718-37785. Spinal Surgery: 20932-20934, 22867-22870, 62380. Speech Processor Implants: 69716, 69719, 69726, 69727. Esophageal procedures: 43284, 43497. CAR-T Therapy: 38225-38228. Urology: 51721, 53865, 53866, 55881, 55882. Other listed C-codes and surgical codes require authorization.

Delegated outpatient surgery CPTs: Certain outpatient orthopedic and spinal surgical procedures prior authorization delegated to Evolent (NIA). For CPT codes delegated to TurningPoint, prior authorization requests should be directed to TurningPoint as noted.

Behavioral Health — Outpatient Services

Prior authorization and utilization review rules for outpatient behavioral health services:

Testing & assessments: Psychological/Neuropsychological Testing requires authorization: 96116, 96121, 96130-96133, 96136-96139, 96146. Developmental Pediatric Testing requires authorization: 96112, 96113 (96110 is non-covered).

Requests submitted on designated testing request form.

Partial Hospitalization/IOP & ECT: Outpatient ECT: 90870 requires authorization. Partial Hospitalization (MH): revenue 912, 913, 944, 945 and HCPCS H0035 — utilization review only for members meeting OMH Best Practice triggers. Intensive Outpatient Treatment: RC 905/912, CPT 90899, S9480, HCPCS H2013 — utilization review only for members meeting OMH Best Practice triggers.

ASD & Residential: Autism Spectrum Disorder: Authorization required for DME speech generation equipment and for Applied Behavior Analysis; attestation of ASD diagnosis must be provided by licensed physician or psychologist at time of request. Residential treatment CPT 1001-1002 and HCPCS H0017-H0019, H2036 require authorization.

Diagnostic Testing & Imaging

Authorization rules for diagnostic testing and imaging services:

Sleep studies & genetic testing: Sleep studies including home sleep studies require authorization. BRCA and other genetic testing require authorization except CPT 81220, 81329, 81336, 81420 which do not require authorization. CPT 81220 lifetime limit = 1; CPT 81329 and 81336 combined limit = 1 per lifetime.lifetime limits as stated

Wireless capsule & selected GI: Wireless Capsule Endoscopy: 91110-91111 and Wireless Motility capsule 91112-91113 require authorization. Selected GI procedures require authorization when performed in POS 19 and 22 if office/ASC available: 43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270. Authorization not required in POS 11 or 24. 43290 requires authorization in any POS.POS-based rules

OB ultrasound & TBS:

Durable Medical Equipment (DME) & Supplies

Durable Medical Equipment (DME) and Supplies

Authorization rules and lists for DME codes:

DME codes NOT requiring authorization (selected list): List of DME HCPCS codes that do NOT require an authorization (A4239, A4287, A4341, A4342, A4457, A4468, A4541, A4560, A6590, A6540, A6591, A7021, A7049, E0130, E0135, E0168, E0182, E0184, E0235, E0274, E0305, E0310, E0424, E0431, E0434, E0439, E0492, E0562, E0570, E0575, E0580, E0601, E0602, E0603, E0621, E0655, E0660, E0677, E0711, E0776, E0890, E0900, E0942, E1390, E2001, E2361, E2363, K1035, K1036, L0130, L0140, L0150, L0160, L0170, L0172, L0174, L0180, L0190, L0200, L0642, L1652, L1681, L1902, L2132, L2134, L2136, L2210, L3100, L3221, L3702, L3762, L4350, L5991, L7360, L7362, L7364, L7366, L8678, S8421, S8424, V5010, V5020, V2625, V2626, V5266).

4/1/24 additions: Effective 4/1/24 additional codes not requiring PA: A4271, A4438, A4564, A4593, A4594, E0152, E0736.4/1/24

Supplies requiring authorization:

Therapeutic & Pain Management Services

Therapeutic Services

Authorization and coverage rules for therapeutic and pain management services:

Phototherapy & HBOT: Phototherapy (96567, 96573-96574, 96900, 96910, 96912-96913, 96920-96922) requires authorization. Hyperbaric Oxygen Therapy (99183) requires authorization.

Pain management & interventional: Pain management injection and related codes (20526, 20550-20553, 21073, 27096, 62263-62290, 62320-62327, 64400-64595, 64600-64640, 64582-64583, 64628-64629) require authorization. Interventional Pain Management codes (63650, 63655, 63661-63664, 63685, 63688 and HCPCS C1778, C1787, C1883, C1897) require authorization.

Not covered for low back pain: Not covered for members with diagnosis of Low Back Pain: prolotherapy; therapeutic facet joint steroid injections in lumbar/sacral regions; steroid injections into intervertebral discs; continuous or intermittent traction.

Outpatient Therapy (PT/OT/ST) Prior Authorization Rules

Authorization requirements, limits and submission timelines:

Initial evaluation: Initial PT/OT/ST evaluations do not require prior authorization (office or facility based). CPT 92610 and 92611 do not require prior authorization.

Post-evaluation outpatient services: Effective 10/1/2021: All outpatient PT, OT, ST services after the initial evaluation require prior authorization through Evolent (NIA). If services beyond initial evaluation are billed, authorization request must be sent to Evolent within 1 business day for outpatient, within 2 business days for home health, or to Fidelis within 1 business day for inpatient settings.1 business day outpatient; 2 business days home health

Therapy benefit limits: Rehabilitation and Habilitation — 60 visits per condition per plan year (all therapies combined). Non-therapy providers should request prior authorization directly through Fidelis Care.

Podiatry, Chiropractic & Diabetes Self-Management

Podiatry & Chiropractic Services

Authorization rules for podiatry and chiropractic services:

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

Chiropractic codes requiring prior authorization: 98940, 98941, 98942, 98943 and revenue code 0940.

Diabetes Self-Management Training (DSMT)

Coverage and limits:

DSMT coverage and limits: Members allowed 10 hours/20 units in a continuous 12-month period; services must be provided by certified providers and no longer require authorization. Covered when billed with codes G0108 and G0109.10 hours / 20 units per 12-month period

Pharmacy, Enteral Therapy & Oncology Medication Prior Auth

Pharmacy and Enteral Therapy

Pharmacy prior authorization rules and exclusions:

Formulary updates & enteral therapy: Monthly formulary updates available on Fidelis Care website pharmacy services page. Enteral therapy HCPCS B4034-B4162 require authorization for therapeutic nutritional formulas and specified indications; written order must state medical necessity.

Oncology meds via Evolent/NCH: Oncology medications and supportive agents require prior authorization from Evolent (formerly New Century Health) before dispensing or administration; requests via New Century Health web portal or 1-888-999-7713 option 1.

Appendix I not related to NCH program; check NCH auth grid on website.

Items excluded from Evolent review: List of items excluded from Evolent (NCH) review (do not send): antibiotics; bone marrow/stem cell transplants, CAR-T; Cablivi; controlled substances; equipment requests (infusion pumps); genetic lab testing; hemophilia drugs; immune globulins; inpatient drug requests; iron preparations; pain medications; radiopharmaceuticals; surgeries; sickle cell diagnoses.

Code Lists (Selected groups)

High-Impact Provider Actions

Note

Top operational provider actions — prioritized

Prioritized operational callouts — key provider actions grouped for quick operational use.

Obtain prior authorization for inpatient admissions and specified services; ER emergent stabilization does not require PA; inpatient ER fax: 833-663-1602.
Use delegated vendors and submission portals: Evolent portal; TurningPoint for ENT/cardiac; New Century Health portal or 1-888-999-7713 (opt 1); Pharmacy e-fax 1-844-235-5090.
Notification requirements for OMH/OASAS facilities: notify within 2 business days using OMH Two‑Day Notification form (fax 833-561-0094 or email Mental_Health_Admission@fideliscare.org) or OASAS Appendix A/LOCADTR (fax 833-663-1608 or LOCADTR@fideliscare.org); periodic consultation timelines (OASAS day ~14).
20610 non-coverage condition: do not bill 20610 with hyaluronic acid J-codes (J7318, J7320–J7332) for M17 series diagnoses; that combination is non-covered.
ASD attestation requirement: include licensed physician or psychologist attestation of ASD diagnosis at time of request for ABA or DME speech generation equipment.
Outpatient therapy submission timelines and limits: outpatient PT/OT/ST after initial evaluation require PA via Evolent; submit within 1 business day for outpatient, 2 business days for home health; therapy limit 60 visits per condition per plan year.

Definitions & Acronyms

Document Changes & History

01/01/2020policy_effective_date

Effective 01/01/2020: In-state OASAS‑licensed in-network inpatient SUD services not subject to prior authorization and no concurrent review during first 28 days if facility notifies Fidelis within 2 business days.

01/01/2020policy_effective_date

Effective 01/01/2020: Inpatient mental health treatment for members under age 18 at OMH‑licensed in‑network hospitals not subject to prior authorization and no concurrent review during first 14 days with required notification.

06/01/2021policy_effective_date

Effective 06/01/2021: Inpatient mental health treatment at OMH‑licensed hospitals (all ages) in NY State not subject to prior authorization; facility must notify insurer within 2 business days.

Services may be subject to utilization review after 28 days or upon discharge using LOCADTR; prior to discharge facility must provide written discharge plan and indicate whether services are secured/available.after 28 days

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

OMH Licensed Inpatient Mental Health Treatment

Authorization/concurrent review rules for OMH-licensed hospitals in NY State:

No-PA for OMH licensed hospitals: Effective 06/01/2021: Inpatient mental health treatment at OMH licensed hospitals in NY State are not subject to prior authorization review.

Facility must notify insurer within 2 business days: call 1-888-FIDELIS ext 16072 or fax 833-561-0094 (formerly 718-896-1784).

Utilization review will be conducted only for members meeting ANY of the following

Individuals subject to a current Assisted Outpatient Treatment (AOT) court order.
Individuals who had an AOT court order that expired within the past five years.5 years
Individuals with high utilization in prior 12 months: (1) three or more psychiatric inpatient hospitalizations OR (2) four or more psychiatric ED visits OR (3) three or more medical inpatient hospitalizations.12 months
Individuals readmitted to any mental health inpatient unit within 30 days of prior discharge.30 days
Individuals not meeting above triggers whose length of stay exceeds 30 days (concurrent review from Day 31 onwards).>30 days

Under-18 provisions: Effective 01/01/2020: Inpatient mental health treatment for members under age 18 at OMH-licensed in-network hospitals are not subject to prior authorization; no concurrent review during first 14 days if facility: i) notifies within 2 business days using OMH Two-Day Notification and Initial Treatment Plan form (fax 833-561-0094 or email Mental_Health_Admission@fideliscare.org), ii) performs daily clinical review, iii) participates in periodic consultation to ensure evidence-based review criteria use. Out-of-network inpatient mental health services are subject to concurrent review throughout admission.14 days

Documentation Required

Behavioral health and SUD notification requirements

OMH and OASAS-licensed facility notification rules: facilities must notify Fidelis Care within 2 business days using the specified forms and channels. Required forms: OMH Two-Day Notification and Initial Treatment Plan form (for OMH) and OASAS Appendix A plus the LOCADTR tool (for OASAS). Fax and email contacts provided; facilities must perform daily clinical review and participate in periodic consultation (starting on or just prior to day 14 for OASAS) with Fidelis Care.

OMH Two-Day Notification and Initial Treatment Plan form — fax 833-561-0094 or email Mental_Health_Admission@fideliscare.org (OMH; 2-business-day notification).
OASAS Appendix A Notification Form and LOCADTR tool — fax 833-663-1608 or LOCADTR@fideliscare.org (OASAS; 2-business-day notification).
Facilities perform daily clinical review; periodic consultation with Fidelis Care starting on or just prior to day 14 (OASAS).

Documentation Required

Voicemail / HIPAA-compliant voicemail requirement for UM messages

UM voicemail messages: provider voicemail must be HIPAA-compliant to receive detailed UM messages. Voicemail greeting must identify mailbox owner, organization, and state that mailbox is confidential and PHI may be left. If voicemail is not HIPAA-compliant, UM will leave a generic message requesting callback and will make a second direct attempt per Department of Health Reasonable Effort Policy.

Ensure voicemail greeting identifies owner and organization and states mailbox is confidential and can accept PHI.
If voicemail not HIPAA-compliant: generic message only; request callback and UM will attempt direct contact again per Reasonable Effort Policy.

Outpatient therapy (PT/OT/ST after initial eval) prior authorization via Evolent (NIA) effective 10/1/2021.10/1/2021

Prior Authorization

Use delegated vendors and submission portals

Use delegated vendors and submission portals for prior authorization where indicated. Submit requests via vendor portals or vendor contact lines; pharmacy Appendix I items may be submitted via pharmacy e-fax.

Evolent portal for delegated musculoskeletal, radiology, outpatient therapy, radiation, and oncology reviews (per delegation notes).
TurningPoint contacts for ENT and cardiac surgical procedure delegations (see TurningPoint delegated lists).
New Century Health (Evolent/NCH) oncology medication portal: https://um.newcenturyhealth.com/Account/Logon or phone 1-888-999-7713 (option 1).
Pharmacy e-fax for Appendix I items: 1-844-235-5090.
DentaQuest (orthodontic/major dental) 1-800-516-9615; Davis Vision 1-800-601-3383.

Operational notes: When prior authorization for a CPT code is delegated to a vendor, associated HCPCS/device codes are reviewed by that same vendor (e.g., CPTs delegated to Evolent — including the Musculoskeletal Management Program effective 1/1/24 — will have associated HCPCS reviewed by Evolent; CPTs delegated to TurningPoint will have associated HCPCS reviewed by TurningPoint).

Effective dates and program delegations called out in the brief: Musculoskeletal Management to Evolent effective 1/1/24; Outpatient therapy (PT/OT/ST after initial evaluation) prior authorization via Evolent effective 10/1/21; Radiation therapy prior authorization delegated to Evolent (NIA). Oncology medication review is handled by New Century Health (now Evolent/NCH) per the pharmacy section and submission portal guidance.

See Section II-G and II-I/II-J references.

Billing Rule

20610 non-coverage when billed with hyaluronic acid J‑codes + M17 diagnoses

20610 is non-covered when billed together with specified hyaluronic acid J-codes for knee osteoarthritis (M17 series diagnoses). If 20610 is billed with those J-codes and an M17 diagnosis, the service is non-covered; in all other situations 20610 does not require authorization.

Hyaluronic acid J-codes referenced: J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332

TMS: Transcranial Magnetic Stimulation (TMS) covered with authorization required for CPT 90867, 90868, 90869; requests via email qhcmbh@fideliscare.org, fax 833-561-0098 or 1-888-FIDELIS ext 16072. Members over 18 eligible when FDA-cleared device, confirmed MDD, and failure of multiple trials of medication plus evidence-based psychotherapy in current episode.

Documentation Required

ASD attestation requirement

When requesting ASD-related services (Applied Behavior Analysis or DME speech generation equipment), include attestation of ASD diagnosis at the time of request. Attestation must be provided by a licensed physician or psychologist.

Prior Authorization

TMS authorization (CPT 90867–90869)

Transcranial Magnetic Stimulation (TMS) requires prior authorization for CPT codes 90867–90869. Authorization requests must include required clinical documentation: use of an FDA‑cleared device per labeled indications, confirmed diagnosis of major depressive disorder (MDD), and documentation of failure of multiple medication trials plus evidence‑based psychotherapy during the current episode.

CPT codes: 90867, 90868, 90869
Documentation: FDA‑cleared device use; confirmed MDD diagnosis; prior trials of multiple medications and evidence‑based psychotherapy during current episode

OB ultrasounds: first 4 for normal pregnancy do not require authorization; five or more ultrasounds for a normal pregnancy require authorization (dx Z32.01, Z33.1, Z34.xx, Z34.80-Z34.83, Z34.9-Z34.93). OB ultrasounds for high-risk pregnancy (O09 and O36 series codes) do not require authorization. TBS scans (77089-77092) require authorization.

Other imaging: Penile prosthesis 54405 and other listed services such as 97037 require authorization. Prior authorization for radiology services delegated to Evolent (NIA); many ultrasounds do not require prior auth per CPT list.

Billing Rule

OB ultrasound authorization rule — first 4 no-PA; 5+ require PA

OB ultrasound rule: for a normal pregnancy the first four ultrasounds do not require prior authorization; five or more ultrasounds require authorization. High‑risk pregnancy ultrasounds (listed O09/O36 codes) do not require authorization. Relevant diagnosis codes provided for normal pregnancy.

No-PA for first 4 OB ultrasounds (normal pregnancy).
PA required for 5 or more ultrasounds (normal pregnancy).
Normal pregnancy diagnosis codes referenced: Z32.01, Z33.1, Z34.00–Z34.03, Z34.80–Z34.83, Z34.9–Z34.93

Other DME codes require authorization. Supplies requiring authorization include compression garments/stockings, electric heat pads, surgical stockings, protective helmets, wigs, insulin pumps, insulin infusion pumps.

Prior Authorization

Other DME codes and supplies require authorization

Other DME and supply items generally require prior authorization unless listed as no-PA. Examples of supplies that require authorization include compression garments/stockings, electric heat pads, surgical stockings, protective helmets, wigs, insulin pumps, and insulin infusion pumps.

Compression garments / compression gradient stockings
Electric heat pads and hot water bottles
Surgical stockings
Protective helmets
Wigs
Insulin pumps and insulin infusion pumps

Cardiac/Pulmonary rehab & other: Cardiac and Pulmonary Rehabilitation delivered outpatient require authorization (Cardiac: S9472, 93797, G0422, G0423, rev code 0943; Pulmonary: G0237-G0239, S9473, rev code 0943). Radiation therapy prior authorization delegated to Evolent (NIA). Ambulatory continuous glucose monitoring (95249) requires authorization. Radiofrequency ablation of uterine fibroids (58674) and Bronchial Thermoplasty (31660, 31661) require authorization. Other therapeutic codes listed (61736, 61737; Vision Therapy: 92066, 95919) require authorization as indicated.

Prior Authorization

Cardiac & pulmonary rehab — prior authorization required (outpatient)

Cardiac and pulmonary rehabilitation delivered outpatient require prior authorization. Relevant codes include cardiac rehab codes S9472, 93797, G0422, G0423 (and rev code 0943) and pulmonary rehab codes G0237–G0239 and S9473.

Cardiac rehab codes: S9472, 93797, G0422, G0423, rev code 0943
Pulmonary rehab codes: G0237, G0238, G0239, S9473, rev code 0943

Prior Authorization

Outpatient therapy submission timelines and limits

Outpatient therapy submission timelines: after the initial evaluation, outpatient PT/OT/ST require prior authorization via Evolent (NIA). If services beyond the initial evaluation are billed, submit the authorization request to Evolent within 1 business day for outpatient settings (within 2 business days for home health); inpatient requests go to Fidelis within 1 business day. Initial evaluations do not require prior authorization. Therapy visit limits apply.

Submit outpatient therapy PA to Evolent (NIA) within 1 business day when billed beyond initial evaluation.
Home health therapy PA submission within 2 business days.
Inpatient therapy PA submissions to Fidelis within 1 business day.
Therapy limits: Rehabilitation and Habilitation — 60 visits per condition per plan year (all therapies combined).

Appendix I contains codes requiring prior authorization; submit Appendix I PAs to Pharmacy Team via e-fax 1-844-235-5090.

Prior Authorization

Use delegated vendors/portals and PA requirement for listed J/S/Q codes

Use delegated vendors and submission portals for vendor‑managed services and for listed drug/product codes requiring PA. For pharmacy/administered oncology medications use New Century Health (Evolent/NCH) portal or phone; for Appendix I pharmacy/HCPCS items submit via pharmacy e-fax.

Pharmacy e-fax for Appendix I items: 1-844-235-5090.
New Century Health (Evolent/NCH) oncology portal: https://um.newcenturyhealth.com/Account/Logon and phone 1-888-999-7713 (option 1).
DentaQuest 1-800-516-9615; Davis Vision 1-800-601-3383.

10/01/2021operational_change

Effective 10/01/2021: Outpatient PT/OT/ST services after the initial evaluation require prior authorization via Evolent (NIA).

01/01/2024delegation_change

Effective 01/01/2024: Musculoskeletal Management Program (orthopedic & spinal procedures) delegated to Evolent (NIA); associated HCPCS devices reviewed by Evolent when CPTs delegated.

04/01/2024code_changeLatest

Effective 04/01/2024: DME code A4271 added to list of HCPCS codes that do NOT require prior authorization.