This authorization grid summarizes Fidelis Care prior authorization and utilization review requirements and identifies delegated reviewers and program exceptions. It requires authorization for all inpatient admissions (except emergency stabilization) and for transplant evaluations, many inpatient and outpatient procedures, imaging, therapy beyond initial evaluation, DME, and numerous HCPCS/C/J pharmacy codes listed in Appendix I.
Key delegated prior authorization vendors: TurningPoint Healthcare Solutions, LLC (delegated for ENT and cardiac surgical procedures and associated devices), National Imaging Associates (NIA) (delegated for radiology and radiation therapy services and outpatient therapy authorization management), and Evolent / New Century Health (NCH) (delegated for oncology medications and supportive agents). Requests for Appendix I pharmacy/HCPCS codes must be submitted to the Pharmacy Team (efax 1-844-235-5090) and oncology drug requests to NCH per the grid.
State-licensed behavioral health exceptions: In-network, in‑state OASAS‑licensed inpatient SUD facilities are not subject to prior authorization and are exempt from concurrent utilization review for the first 28 days provided the facility notifies Fidelis Care within 2 business days and follows LOCADTR/Appendix A notification processes. In‑state OMH‑licensed inpatient mental health hospitals are not subject to authorization review; utilization review is conducted only for members meeting OMH triggers (including AOT within 5 years or high utilization thresholds) and pediatric OMH inpatient admissions are exempt from concurrent review for the first 14 days if the facility notifies Fidelis within 2 business days and follows the Two‑Day Notification process.
Appendix I lists numerous HCPCS, C, J, Q and S codes and mappings that require prior authorization (partial list shown in the document); oncology and supportive agents are routed to NCH/Evolent and other listed codes must be submitted to the Pharmacy Team via efax. The grid notes that some DME codes (for example A4341, A4342, V5266) do not require PA effective as indicated, and that maximum unit edits apply to all HCPCS codes.
This file is part 1 of a multi‑part authorization grid and contains high‑level program rules, delegations, behavioral health exceptions, and Appendix I references; additional parts contain the extensive HCPCS/J‑code mappings, code lists and detailed thresholds referenced here.