CurrentFidelis CarePolicy N/A

COVID-19 UPDATE

Updates and routing guidance for prior authorization, concurrent review, delegated vendor responsibilities, and coverage limits across multiple service categories during the COVID-19 period (part 1 of 2). Covers inpatient admissions, behavioral health (OMH/OASAS), transplant, surgery categories, outpatient services, DME, therapy, imaging, pharmacy routing to New Century Health, and delegated vendors (TurningPoint, NIA).

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE

Policy CodePolicy N/A

Change TypeRouting/authorization update

Effective Date

Next Review Date

Key ActionObtain prior authorization for all inpatient admissions (except immediate ER stabilization) and for listed outpatient, surgical, DME, imaging, therapy, and pharmacy services; follow delegated vendor routing (TurningPoint, NIA, NCH).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this update.

28OASAS days without concurrent review

14OMH days without concurrent review

40Home health max visits/yr

210Hospice max days

~100+

HCPCS/J codes listed

Coverage Summary & Scope

This fragment (part 1 of 2) updates prior authorization routing and utilization review requirements during the COVID-19 period and across multiple service categories. It covers authorization rules for all inpatient admissions (emergency stabilization excepted), transplant evaluation timing, behavioral health (OMH/ OASAS) notification and limited concurrent review windows, numerous outpatient surgical and procedure code groups, diagnostic imaging, therapy, DME, and pharmacy routing for oncology agents. Providers must follow delegated vendor routing where specified: prior authorization for certain CPT/HCPCS codes is delegated to TurningPoint Healthcare Solutions, LLC (for specified surgical, ENT, orthopedic/spinal and cardiac procedure lists), National Imaging Associates (NIA) for radiology, outpatient therapy and radiation therapy, and New Century Health (NCH) for oncology medication and supportive agent prior authorizations. This document is one part of a two-part policy update and includes delegation notes for TurningPoint, NIA, and NCH. All cited vendor delegations and routing requirements are effective as stated in the source and must be followed when submitting authorization requests.

Note: delegated authorization responsibilities referenced include TurningPoint, NIA (National Imaging Associates), and NCH (New Century Health). This is part 1 of 2 of the policy fragment.

Thresholds

OASAS daysfirst 28 days (no authorization/concurrent review if notified within two business days)

OMH daysfirst 14 days (no concurrent review if facility notifies within two business days and meets requirements)

OB ultrasound threshold>= 5 ultrasounds for a normal pregnancy require authorization

Rehabilitation visit limit60 visits per condition per plan year (rehabilitation and habilitation)

Home health max visits40 visits per plan year

Hospice max daysUp to 210 days when medically necessary

Authorization & Medical Necessity Criteria

Inpatient admissions and emergency services

All inpatient admissions require authorization; emergency services for stabilization do not require prior authorization but post-stabilization and inpatient admissions after ER completion do.

ALL of the following

Emergency room services or any emergent service required to provide stabilization do NOT require authorization
Post-stabilization services and inpatient admissions after ER services are completed DO require authorization
All facility admissions are reviewed for medical necessity

All inpatient admissions require an authorization

Code Groups & Mappings

Transplant-related CPT codes (examples listed)CPTCovered

32850-32856	Thoracic procedure range (listed as transplant-related examples)
33930-33945	Cardiac procedure range
38204-38215	Bone marrow transplant codes
38230-38242	Stem cell/bone marrow harvesting/transplant codes
44133-44136	Colon/intestinal procedure codes
47133-47147	Hepatic procedure codes
48160	Pancreatic procedure example
48550-48556	Splenic procedure range
50300-50380	Urinary system procedures
50547	Kidney-related code

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Outpatient surgery codes requiring authorization (selected lists)CPT|HCPCSCovered

43770-43775	Bariatric surgery codes
S2083	Bariatric related HCPCS
15820-15823	Blepharoplasty
11920-11971	Breast reconstruction range
19300	Breast surgery/reduction/reconstruction
19316-19342	Breast reconstruction/revision range
19355	Breast reconstruction code
19370-19396	Breast related procedure range
11471	Skin surgery — requires auth if POS 24 (ambulatory surgery center)
11721	Nail/wart related removal — auth if POS 24

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Developmental / psychological testing codesCPTCovered

96116	Neuropsych testing — requires authorization
96121	Psych test administration — requires authorization
96130-96133	Psych testing/interpretation codes — require authorization
96136	Psych test interpretation — requires authorization
96112-96113	Developmental testing — require authorization
96110	Non-covered service

Residential treatment codesCPT|HCPCSCovered

1001	Residential treatment CPT (documented as '1001')
1002	Residential treatment CPT (documented as '1002')
H0017-H0019	HCPCS residential treatment codes
H2036	HCPCS residential/service code

Therapeutic and pain management codesCPT|HCPCS|RevenueCovered

99183	Hyperbaric oxygen therapy pre-procedure code — requires authorization
C1300	Hyperbaric related HCPCS — requires authorization
62320-62327	Epidural injection codes (pain management) — require authorization
63622,63688	Spinal implant codes — listed (63622/63688 do not require authorization from orthopedic specialties)
64400-64530,64553-64595,64600-64640	Nerve block/ablation ranges — require authorization
64582,64583,64628,64629	Other pain codes
58674	Radiofrequency ablation of uterine fibroids — requires authorization
31660,31661	Bronchial thermoplasty — requires authorization
61736,61737	Neurosurgical codes — listed
95249	Ambulatory continuous glucose monitoring

Chiropractic codes requiring authorizationCPT|RevenueCovered

98940-98943	Chiropractic manipulation codes — require authorization
0940	Revenue code for chiropractic services

Cardiac and Pulmonary Rehab codesCPT|HCPCS|RevenueCovered

S9472	Cardiac rehab HCPCS — requires authorization
93797	Cardiac stress testing related
93798	Cardiac testing related
G0422	Cardiac rehab outpatient code — requires authorization
G0423	Cardiac rehab group code — requires authorization
G0237-60239	Pulmonary rehab codes (range notation as listed)
S9473	Pulmonary rehab HCPCS
0943	Revenue code referenced for rehab

OB ultrasound diagnostic codes and pregnancy Dx codes referencedCPT|ICD-10Covered

OB ultrasounds	First 4 normal pregnancy ultrasounds no auth; >=5 require authorization
Z32.01	Encounter for pregnancy test and childbirth status — used in normal pregnancy dx list
High risk dx list (multiple ICD-10 codes)	Various ICD-10 codes listed for high-risk pregnancy that do NOT require authorization

TBS ScansCPTCovered

77089	Bone density — TBS scan
77090	Bone density — TBS scan
77091	Bone density — TBS scan
77092	Bone density — TBS scan

Wireless Capsule EndoscopyCPTCovered

91110	Wireless capsule endoscopy
91111	Wireless capsule endoscopy interpretation

Blood glucose monitors/testing supplies covered via pharmacy benefitHCPCS

A4253	Glucose test strip
49275	Listed (document shows 49275)
E0607	External insulin pump
E2100	Blood glucose monitor
E2101	Blood glucose monitor

HCPCS/J-code mappings listed in fragmentHCPCS

J3398	Listed repeatedly in mappings (context unclear)
J7629	Mapped in fragment (exact drug mapping unclear)
J7633	Mapped in fragment
J7634	budesonide comp con. / maps to J9198, gemcitabine (Infugem), Q2041, axicabtagene (Yescarta)
J7635	atropine inj.; maps to J9203, gemtuzumab (Mylotarg), Q2042, tisagenlecleucel (Kymriah)
J7636	atropine inh.; maps to J9204, mogamulizumab-kpkc, Q2043, sipuleucel-T (Provenge)
J7637	dexamethasone inh.; maps to Q2053, Brexucabtagene autoleucel
J7638	dexamethasone inh UD; maps to J9205
J7639	dornase alfa (Pulmozyme); maps to J9216, interferon gamma lb, Q2054, lisocabtagene maraleucel
J7641	flunisolide inh.; maps to J9210, emapalumab (Gamifant), Q2055, idecabtagene vicleucel

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What Providers Must Do

Prior Authorization

Authorization required for inpatient admissions and specified services

Obtain prior authorization for all inpatient admissions (emergency stabilization services do NOT require authorization; post-stabilization inpatient admissions do). Also obtain prior authorization for the many outpatient, surgical, DME, imaging, therapy, and pharmacy services listed in the policy. When services are delegated to third-party vendors, follow the vendor routing instructions (TurningPoint, NIA, NCH).

Documentation Required

OASAS Inpatient SUD notification and documentation

For in‑network OASAS‑licensed inpatient SUD admissions, the facility must notify Fidelis Care and submit the OASAS Appendix A Notification Form and the OASAS LOCADTR Medical Necessity Tool within two business days of admission, perform daily clinical review, and participate in periodic consultation (near day 14).

Form: OASAS Appendix A Notification Form

Background & Definitions

This update provides revised routing and authorization guidance during the COVID-19 period: all inpatient admissions require prior authorization while emergency room stabilization services do not, though post-stabilization inpatient admissions do require authorization and all facility admissions are reviewed for medical necessity. Transplants require authorization at the time of transplant evaluation. Effective dates and delegations are noted for vendor-managed review. Authorization delegations include TurningPoint Healthcare Solutions, LLC for many CPT codes across orthopedic, spinal, ENT and cardiac surgical procedures (and associated HCPCS devices), National Imaging Associates (NIA) for radiology services and outpatient therapy/radiation therapy (with effective dates noted), and New Century Health (NCH) for outpatient oncology medication and supportive agent prior authorizations. Many CPT and HCPCS code groups and specific codes (including extensive outpatient surgery lists, therapeutic and pain management ranges, developmental and neuropsych testing codes, DME and imaging codes, cardiac and pulmonary rehab, OB ultrasound thresholds, TBS scans, wireless capsule endoscopy, and numerous HCPCS/J-code mappings) require authorization or special handling per the lists in this fragment. Providers must route requests to the appropriate delegated vendor when a code is identified as delegated; excluded categories and submission channels for NCH and pharmacy routing are specified in the source.

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Definitions (as used in this fragment):

- OASAS: New York State Office of Addiction Services and Supports (facility licensing for substance use disorder treatment).

- OMH: New York State Office of Mental Health (state mental health facility licensing and best practice criteria).

- TurningPoint: TurningPoint Healthcare Solutions, LLC — delegated authorization vendor for specified CPT/HCPCS services (orthopedic/spinal, ENT, cardiac and other delegated procedure lists).

Revision History

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE

Policy CodePolicy N/A

Change TypeRouting/authorization update

Effective Date

Next Review Date

SourceLink

On This Page

Authorization required at time of transplant evaluation.

ALL of the following

32850-32856
33930-33945
38204-38215
38230-38242
44133-44136
47133-47147
48160
48550-48556
50300-50380
50547
65710-65757

Includes but not limited to listed CPT ranges and codes

OASAS Licensed Inpatient Substance Use Disorder (Inpatient SUD)

Effective 01/01/2020: in-network, in-state OASAS-licensed facilities are not subject to authorization review for first 28 days provided notification and initial treatment plan submission requirements are met.

Inpatient detoxification, inpatient rehabilitation and inpatient residential treatment services provided by NYS OASAS-licensed and Fidelis in-network facilities are NOT subject to authorization review

Notification via fax/email using OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool to 646-829-1421 or LOCADTR@fideliscare.org

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

Facilities must perform daily clinical review of the patient; periodic consultation with Fidelis Care around day 14 to ensure use of LOCADTR tool

Inpatient SUD services may be subject to utilization review after day 28 or upon discharge and may be reviewed retrospectively

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

Effective 06/01/2021: in-network OMH-licensed hospitals in NYS are not subject to authorization review if facility follows notification and review processes; utilization review limited to specific triggers.

OMH-licensed hospitals in NYS participating in Fidelis are NOT subject to authorization review if facility notifies insurer within 2 business days of admission (call or fax/email) and meets daily review and consultation requirementsfirst 14 days

Facility must submit 'Two-Day Notification and Initial Treatment Plan' form by fax (718-896-1784) or email to Mental_HealthAdmission@fideliscare.org

ANY of the following triggers

Individuals subject to a current Assisted Outpatient Treatment (AOT) court order, or had an AOT court order that expired within past 5 years
Three (3) or more psychiatric inpatient hospitalizations in the prior 12 months>=3 psych inpatient in 12 months
Four (4) or more psychiatric ED visits in the prior 12 months>=4 psych ED visits in 12 months
Three (3) or more medical inpatient hospitalizations in the prior 12 months>=3 medical inpatient in 12 months
Readmission to any mental health inpatient unit within thirty (30) days of dischargereadmission within 30 days
Length of stay exceeds 30 days (concurrent review from day 31 onwards)>30 days

Fidelis will not conduct concurrent utilization review the first 14 days of inpatient admissions provided facility: i) notifies Fidelis of admission and initial treatment plan within two business days, ii) performs daily clinical review, iii) participates in periodic consultation with Fidelisfirst 14 days

All inpatient mental health services provided by out-of-network facilities are subject to concurrent review throughout the admission

Delegation to TurningPoint Healthcare Solutions, LLC

Effective 9/20/2021 for DOS on/after 10/4/2021 for certain services; authorization delegated to TurningPoint for listed CPT codes and associated HCPCS devices.

Certain inpatient, outpatient, physician office, and in-home services for specified service categories are delegated to TurningPoint for authorization (effective dates noted)

If a CPT code is delegated to TurningPoint, associated devices (HCPCS codes) will also be reviewed by TurningPoint for medical necessity

Delegated categories explicitly include orthopedic & spinal surgical procedures, ENT surgical procedures, cardiac surgical procedures (see respective sections for code pointers)

Outpatient surgery categories requiring prior authorization

Lists of outpatient procedure categories and codes that require prior authorization (authorization may depend on place of service).

Bariatric surgery: 43770-43775, S2083 require prior authorization

Blepharoplasty: 15820-15823 require prior authorization

Breast reconstruction: 11920-11971, 19300, 19316-19342, 19355, 19370-19396 require prior authorization

ASC caveat: Some skin surgery treatments/repairs in office or POS 11 and 22 do NOT require authorization; but codes 11471, 11721 require authorization if performed as ambulatory surgery (POS 24)

ASC procedures: Specific codes (10060, 11100, 11900, 17000, 20600, 20605, 20610) should not be performed in freestanding ASCs; if performed in ASC billing with bill type 0831 they require authorization

CPT 20610 for hyaluronic acid joint injection noted as non-covered when billed with incomplete modifier/context

Always require auth: Only the following codes require authorization for any place of service: 11200-11201, 11719, 15769, 15829, 17340-17999

Ear procedures: Ear repair/ear piercing: 69300 and 69090 require authorization

Ophthalmologic/ENT: Specific ophthalmologic/ocular and ENT surgery codes listed (e.g., 66988, 67900-67911, 66989, 66991, 68841) require authorization

Reduction mammoplasty: 19300, 19318 require authorization

Vascular vein procedures/ablation/sclerotherapy: 36465-36466, 36468-36479, 36482-36483, 37718-37785, 37241-37244 require authorization

Facial cosmetic, septoplasty, rhinoplasty: 21120-21296, 30400-30520, 30620-30802, 30999, 31298, C9749, Q2028 require authorization

Gender reassignment surgery: 55970, 55980 require authorization

Speech processor implant: Speech Processor Implant Procedures: 69716, 69719, 69726, 69727 require authorization

Spinal surgery: Spinal Surgery: 20932-20934, 22867-22870, 62380 require authorization

Esophageal procedures: 43284, 43497 require authorization

Developmental Pediatric Testing

Authorization requirements for psychological/neuropsychological testing.

Psych testing: Psychological/Neuropsychological Testing: 96116, 96121, 96130-96133, 96136 require authorization; requests submitted on the Psychological/Neuropsychological testing request form

Developmental testing: Codes 96112, 96113 require authorization

Non-covered: CPT 96110 is a non-covered service

Partial Hospitalization / Intensive Outpatient / ECT

Utilization review only for members meeting OMH Best Practice triggers; out-of-network services subject to concurrent review.

Partial/IOP review triggers: Partial hospitalization and intensive outpatient mental health services for OMH licensed programs will have admission and concurrent/continued stay review only for members meeting OMH Best Practice Manual criteria (same trigger list as inpatient OMH section)

Out-of-network note: Out-of-network partial hospitalization and intensive outpatient services are subject to concurrent review throughout the admission

ECT and billing: Outpatient ECT code: 90870; Revenue codes: 912, 913, 944, 945; HCPCS H0035 referenced for partial hospitalization

Under21 submission: Requests for members under 21 can be submitted via email chmmc@fideliscare.org, fax (347) 690-7362 or by calling the Children's Medicaid line

Autism Spectrum Disorder (ASD)

Authorization requirements for ASD-related services and equipment.

DME speech generation: Authorization is required for DME speech generation equipment

ABA: Authorization is required from Behavioral Health for Applied Behavior Analysis (ABA)

Attestation of ASD diagnosis must be provided at time of request by a licensed physician or psychologist

Residential Treatment

Codes and HCPCS for residential treatment services.

Residential CPT: Residential treatment CPT codes: 1001 and 1002

Residential HCPCS: HCPCS codes: H0017-H0019, H2036

Outpatient and DME Services requiring prior authorization

Various diagnostic testing, genetic testing, GI procedures, capsule endoscopy, DME, supplies, home health and hospice rules.

Sleep studies, including home sleep studies require prior authorization

Genetic testing: Breast cancer testing (BRCA) and other genetic testing require authorization except CPT 81220, 81329, 81336 (these do not require authorization). CPT 81220 has lifetime limit of 1; CPTs 81329 and 81336 have combined limit of 1 per lifetime

Capsule endoscopy: Wireless Capsule Endoscopy: 91110, 91111 require authorization

GI POS rules: Gastroenterology procedures require authorization if performed in POS 19 and 22 when office-based or ASC available: 43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270

Orthotics are not covered

DME lists: Many specified DME codes do NOT require authorization (list provided); other DME codes require authorization

Supplies requiring authorization include electric heat/hot water pads, compression garments/stockings, surgical stockings, protective helmets, wigs, insulin pumps and infusion pumps

Glucose supplies: Codes for blood glucose monitors and testing supplies (A4253, 49275, E0607, E2100, E2101) are covered through the prescription drug benefit

Home health: Home Health Care approvals based on medical need for skilled services; benefit maximum 40 visits per plan year40 visits per plan year

Hospice Care coverage when medically necessary available for up to 210 days and must be provided as part of certified Hospice Care program per NY Public Health Law Article 40Up to 210 days

OB Ultrasounds

Authorization requirements based on count and pregnancy risk status.

First4: First 4 OB ultrasounds for a normal pregnancy can be performed without authorization<=4 ultrasounds

>=5: Five or more ultrasounds for a normal pregnancy require authorization>=5 ultrasounds

High risk: OB ultrasounds for high risk pregnancy (extensive dx code list) do NOT require authorization

Radiology and Imaging delegation to NIA

Delegation effective 9/20/2021 for DOS on/after 10/1/2021 to National Imaging Associates (NIA) for radiology services, and for outpatient therapy and radiation therapy.

Radiology delegation: Effective 9/20/2021 for DOS on/after 10/1/2021, authorization delegated to NIA for radiology servicesDOS on/after 10/1/2021

Excludes certain ultrasounds and cardiac ultrasounds delegated elsewhere

TBS scans: TBS Scans: 77089, 77090, 77091, 77092

Outpatient therapy timing: Effective 10/1/2021, Outpatient Therapy (PT/OT/ST) after initial evaluation requires authorization through NIA; CPT 92610 and 92611 do not require authorization

Office/facility initial PT/OT/ST evaluations do not require authorization; subsequent billed procedure codes on same date require authorization submission to NIA within 1 business day (outpatient) or 2 business days (home health). All home therapy treatments including evaluation require authorization

Radiation therapy services authorization delegated to NIA effective 10/1/2021DOS on/after 10/1/2021

Therapeutic services and exclusions

Therapeutic modalities requiring authorization and services not covered for low back pain.

Hyperbaric Oxygen Therapy: 99183 and C1300 require authorization

Pain management injection codes and ranges listed require prior authorization (62320-62327, 63622, 63688, 64400-64530, 64553-64595, 64600-64640, 64582, 64583, 64628, 64629)

63622 and 63688 do not require authorization when requested by orthopedic specialties

Not covered low back: Prolotherapy, therapeutic facet joint steroid injections in lumbar/sacral regions (with or without CT guidance), continuous/intermittent traction, and therapeutic injections into intervertebral discs are not covered for members with diagnosis of Low Back Pain

Cardiac/Pulmonary rehab: Cardiac and Pulmonary Rehabilitation in outpatient setting require authorization: Cardiac Rehab codes S9472, 93797, 93798, G0422, G0423, revenue code 0943; Pulmonary Rehab codes G0237-60239, 60424, S9473, revenue code 0943

Other therapies: Ambulatory continuous glucose monitoring: 95249; Radiofrequency Ablation of Uterine Fibroids: 58674; Bronchial Thermoplasty: 31660, 31661; Other listed neurosurgical codes: 61736, 61737

Chiropractic services

Chiropractic codes requiring prior authorization.

Chiropractic codes requiring prior authorization: 98940-98943 and revenue code 0940

Counseling Services

Coverage and authorization status for counseling services.

Counseling units: Members are allowed 10 hours / 20 units in a continuous 12 month period for counseling services provided by certified providers and these no longer require authorization10 hours / 20 units per 12 months

Services are covered when billed with codes G0108 and G0109

Diabetes self-management and education

Codes and coverage statements for DSMT and education.

DSMT: Diabetes Self-Management Training (DSMT) covered

Education and Training for patient self-management: 98960 referenced

Services provided by outside vendors

Authorization routing to external vendors.

Dental: Orthodontic and Major Dental services require authorization by DentaQuest (1-800-516-9615)

Vision prior authorizations handled by Davis Vision (1-800-601-3383)

Non-emergency ambulance transportation coverage criteria

Examples when non-emergency ambulance transport may be covered between facilities.

Examples: Transport from a non-participating hospital to a participating hospital; Transport to a hospital that provides a higher level of care not available at original hospital; Transport to a more cost-effective acute care facility

Emergency air/water ambulance reviewed for medical necessity

Pharmacy / New Century Health (NCH) requirements

Oncology medications and supportive agents require PA from New Century Health before dispensing or administration across lines of business (exclusions listed).

NCH PA: Oncology medications and supportive agents require prior authorization (PA) from New Century Health (NCH) before being dispensed at a pharmacy or administered in a physician's office, outpatient hospital, or ambulatory setting across Medicaid, Medicare, Essential Plan, QHP (excluding Child Health Plus)

Requests can be submitted via NCH web portal or by calling 1-888-999-7713, option 1

Excluded from NCH review and should NOT be sent to NCH: Antibiotics; Bone marrow/stem cell transplants, CAR-T; Cablivi; Controlled substances; Equipment requests; Genetic lab testing; Hemophilia drugs; Immune globulins; Inpatient drug requests; Iron preparations; Pain medications; Radiopharmaceuticals; Sickle cell diagnoses; Surgeries/surgical procedures

Pharmacy fax: Self-administered medications are covered under pharmacy benefit; other pharmacy codes requiring authorization should be submitted to Pharmacy Team via e-fax 1-877-533-2405

Exceptions: Outpatient oncology-related requests require authorization and review by New Century Health; authorization is not required for oncology indications for members less than 18; authorization is not required for ophthalmic indications

Authorization exceptions and requirements

Operational authorization rules and exceptions noted in document fragment:

Pediatric oncology: Authorization is not required for oncology indications for members less than 18

Ophthalmic: Authorization is not required for ophthalmic indications

Unlisted/Temporary codes: All services for 'Unlisted' or 'Temporary' Codes require authorization (such as C-codes)

Outpatient oncology-related requests require authorization and review by New Century Health

Tool/Contact: LOCADTR Medical Necessity Tool fax/email to 646-829-1421 or LOCADTR@fideliscare.org

Documentation Required

OMH inpatient 2-day notification and treatment plan

OMH‑licensed facilities must notify Fidelis Care within two business days of admission by completing and submitting the OMH 'Two‑Day Notification and Initial Treatment Plan' form, perform daily clinical review, and participate in periodic consultation to avoid concurrent review for the first 14 days.

Form: OMH 'Two‑Day Notification and Initial Treatment Plan' form
Submit by fax to 718-896-1784 or email to Mental_HealthAdmission@fideliscare.org

Prior Authorization

Use delegated vendor portals/contacts

Submit authorization requests to delegated vendors where specified. TurningPoint handles certain surgical and related CPT/HCPCS code categories (if a CPT is delegated to TurningPoint, associated HCPCS devices are reviewed by TurningPoint). National Imaging Associates (NIA) is delegated for radiology, outpatient therapy (and radiation therapy) per effective dates. New Century Health (NCH) handles oncology medication prior authorizations. Use each vendor's required submission channel and follow effective‑date routing rules noted in the policy.

TurningPoint: delegated CPT lists for orthopedic/spinal, ENT, cardiac and other surgical categories (see delegated lists)
NIA: delegated for radiology (effective 9/20/2021 for DOS on/after 10/1/2021) and outpatient therapy/radiation (effective dates in policy)
NCH: delegated for oncology medication PAs (see oncology section)

Prior Authorization

Submit outpatient therapy authorization timeliness

For outpatient therapy (PT/OT/ST) after the initial evaluation, submit authorization requests to NIA within the timeliness specified: within 1 business day for outpatient settings and within 2 business days for home health settings. Office/facility initial evaluations do not require authorization, but subsequent billed procedure codes (even if same date) do and must be submitted within these timeframes. All home therapy treatments, including evaluations, require authorization.

Outpatient submission timing: send to NIA within 1 business day for outpatient settings
Home health submission timing: send to NIA within 2 business days
Initial office/facility evaluations: do not require authorization (except subsequent billed services do)

Billing Rule

ASC billing and authorization

If the listed procedures (10060, 11100, 11900, 17000, 20600, 20605, 20610) are performed in a freestanding ambulatory surgery center billed with bill type 0831, an authorization is required.

Codes: 10060, 11100, 11900, 17000, 20600, 20605, 20610
Condition: Requires authorization when performed in freestanding ASC and billed with bill type 0831

Documentation Required

ASD attestation requirement

For requests for DME speech generation equipment and for Applied Behavior Analysis (ABA), provide an attestation of an ASD diagnosis at the time of the request. The attestation must be by a licensed physician or psychologist.

Attestation: Diagnosis of ASD must be provided at time of request by a licensed physician or psychologist
Services: DME speech generation equipment and ABA require authorization

Prior Authorization

Oncology medication PA routing

Route oncology medication and supportive agent prior authorization requests to New Century Health (NCH) via the NCH web portal or by calling 1-888-999-7713, option 1. Do NOT send excluded categories to NCH (e.g., antibiotics; bone marrow/stem cell transplants/CAR‑T; inpatient drug requests; equipment requests; genetic lab testing; immune globulins; radiopharmaceuticals; surgeries/surgical procedures; controlled substances; pain medications; hemophilia drugs; iron preparations; sickle cell diagnoses, etc.).

NCH submission: mynewcenturyhealth.com (web portal) or call 1-888-999-7713, option 1
Exclusions (do not send to NCH): Antibiotics; Bone marrow/stem cell transplants/CAR-T; Inpatient drug requests; Equipment requests; Genetic lab testing; Immune globulins; Radiopharmaceuticals; Surgeries/surgical procedures; Controlled substances; Pain medications; Hemophilia drugs; Iron preparations; Sickle cell diagnoses

Prior Authorization

Pharmacy team e-fax for other pharmacy authorizations

Submit pharmacy authorization requests (for pharmacy codes that require authorization and are not sent to NCH) electronically via e‑fax to the Fidelis Pharmacy Team at 1-877-533-2405.

e-fax: 1-877-533-2405

Denial Risk

Non-network facility services

Services provided by out‑of‑network or out‑of‑state facilities remain subject to authorization and concurrent review throughout the admission; failure to obtain required authorization may result in retrospective review and potential denial.

Prior Authorization

Authorization required for unlisted/temporary codes

All services reported with 'Unlisted' or 'Temporary' codes (such as C‑codes or other unlisted/temporary codes) require prior authorization; providers must obtain authorization for these codes.

Scope: All 'Unlisted' or 'Temporary' codes require authorization (e.g., C‑codes)

Prior Authorization

Outpatient oncology prior authorization

Outpatient oncology‑related requests require prior authorization and review by New Century Health (NCH); submit via the NCH web portal or by calling the NCH number.

NCH submission: mynewcenturyhealth.com or call 1-888-999-7713, option 1

- NIA: National Imaging Associates, Inc. — delegated authorization vendor for radiology services and for outpatient therapy and radiation therapy authorization effective as noted in the document.

- NCH: New Century Health — delegated prior authorization vendor for oncology medications and supportive agents (portal: mynewcenturyhealth.com; phone: 1-888-999-7713, option 1); excludes listed categories from NCH review.

- Unlisted or Temporary Codes: Codes not explicitly listed in the fragment (including C-codes and other temporary/unlisted HCPCS) — all services billed with unlisted or temporary codes require prior authorization per this policy fragment.