Fidelis Care behavioral health Prior Auth Policy Update

Coverage and Medical Necessity Criteria

inv-01: Inpatient admission authorization

Covered when ALL of the following are met

Inpatient admissions: All inpatient admissions require authorization; emergency services for stabilization do not require authorization but post-stabilization and inpatient admission do

Facility admissions are reviewed for medical necessity

inv-02: Inpatient SUD (OASAS) coverage criteria

OASAS-licensed inpatient SUD coverage rules

In-network in-state OASAS facilities: Inpatient detoxification, inpatient rehabilitation and inpatient residential treatment provided by OASAS-licensed, in-network NYS facilities are not subject to prior authorization and are exempt from concurrent review for the first 28 days provided facility notifies Fidelis Care within two business days using Appendix A and LOCADTR28 days

Facilities must perform daily concurrent review, consult with Fidelis Care prior to the 14th day, and provide a written discharge plan prior to discharge

inv-03: OMH inpatient mental health

OMH-licensed inpatient mental health coverage rules

OMH inpatient authorization exemptions and triggers: Inpatient mental health treatment at OMH-licensed NYS hospitals are not subject to authorization review; facilities must notify Fidelis Care within 2 business days. Utilization review will be conducted only for members meeting specific high-utilization triggers or readmission within 30 days; for members under 18 in-network OMH hospitals are exempt from authorization and concurrent review for first 14 days if notification and OMH two-day form requirements are met14 days for <18 exemptions; concurrent review from day 31 onward for other stays

Triggers include >=3 psychiatric inpatient admissions in 12 months, >=4 psychiatric ED visits, >=3 medical inpatient hospitalizations, or readmission within 30 days

inv-04: Partial Hospitalization and IOP criteria

Partial Hospitalization and Intensive Outpatient (IOP) utilization review criteria

PH/IOP utilization review triggers: Utilization review (admission and continued stay) for partial hospitalization and intensive outpatient mental health programs will be conducted only for members meeting high-utilization triggers per NYS OMH Best Practice Manual (>=3 psych inpatient hospitalizations in 12 months; >=4 psych ED visits in 12 months; >=3 medical inpatient hospitalizations in 12 months; readmission within 30 days). Concurrent review applies if length of stay exceeds 30 days30 days concurrent review threshold

Out-of-network facilities remain subject to concurrent review throughout admission

inv-05: Behavioral health testing and ABA

Behavioral health outpatient testing and ABA

Psychological/neuropsych testing and ABA: Authorization required for specified psychological and neuropsychological testing CPT codes listed (96116, 96121, 96130-96133, 96136-96139, 96146, 96112, 96113) and for outpatient ECT (90870); 96110 is non-covered. ABA requires prior authorization from Behavioral Health for eligible members (Child Health Plus members under 21 require referral and prior authorization)

Testing requests should be submitted on the Psychological/Neuropsychological testing request form; ABA authorization request form available on Fidelis Care provider forms site

inv-06: CFTSS — No Utilization Management

CFTSS utilization management stance

CFTSS UM discontinuation: Effective 4/1/2020, utilization management requirements for Children and Family Treatment and Support Services (CFTSS) are discontinued; prior authorization was never required and concurrent review is no longer required

Providers may contact Fidelis Care with questions

inv-07: Children's HCBS — Enrollment and Notification

Children's HCBS enrollment and notification criteria

Eligibility and notification: Children's Home and Community Based Services are available to members age 20 and younger if determined HCBS-eligible by a Health Home or C-YES. Effective 12/01/2021, providers must notify Fidelis Care of the identified service prior to the member's initial appointmentage <=20

Providers must submit the Plan of Care to Fidelis Care before rendering services to prevent claims processing disruptions

inv-08: Counseling Services

Counseling services coverage

Counseling allowance: Members are allowed 10 hours (20 units) in a continuous 6-month period; services must be provided by certified providers and no longer require authorization10 hours per 6 months

Covered when billed with codes G0108, G0109

inv-09: Asthma Self-Management Training (ASMT)

Asthma Self-Management Training coverage

ASMT coverage by clinical status: Members with newly diagnosed asthma or asthma with medically complex conditions may receive up to 10 hours of ASMT in a continuous 6-month period; medically stable members may receive up to 1 hour in a continuous 6-month period10 hours (complex) or 1 hour (stable) per 6 months

Authorization is not required for S9441, S9445, S9446, 98960-98962 when billed with J45x

inv-10: VI Counseling Services

VI Counseling Services covered

VI Counseling coverage: VI counseling services are covered when billed with codes G0108 or G0109; members are allowed 10 hours (20 units) in a continuous 6-month period and these services do not require authorization10 hours per 6 months

Services must be provided by certified providers

inv-11: Asthma Self-Management Training

Asthma Self-Management Training (ASMT) coverage

ASMT eligibility: Members with newly diagnosed asthma or asthma with medically complex conditions are allowed up to 10 hours of ASMT during a continuous six-month period; medically stable members may receive up to 1 hour during a continuous six-month period

Services may be individual or group (max 8); authorization not required when billed with S9441, S9445, S9446, or 98960-98962 with diagnosis codes J45x

inv-12: Smoking Cessation Counseling

Smoking Cessation Counseling (SCC) coverage

SCC coverage: Smoking cessation counseling reimbursed for up to 8 visits per calendar year using codes 99406 and 99407 and must be billed with tobacco use diagnosis codes (e.g., F17.200, F17.201). For Medicaid members, no authorization is required8 visits/year

inv-13: Enteral Therapy and Pharmacy Authorization Criteria

Enteral therapy and specialty pharmacy items requiring authorization

Enteral therapy PA criteria: Enteral therapy HCPCS codes B4034-B4162 require authorization. Benefit applies to patients who require supplemental nutrition with documented compliance with a medical/nutritional plan and meet BMI thresholds (<18.5 or <22 with 5% unintentional weight loss in 6 months) or who require total nutritional support due to structural limitationsBMI <18.5 or BMI <22 with >=5% unintentional weight loss in 6 months

Pharmacy supplies do not require authorization; oncology/supportive agents for members 18+ require PA via New Century Health where indicated

inv-14: Authorization required

Covered when submitted with authorization for the mapped product/code

Authorization requirement: Items billed under HCPCS B4034-B4162 that are mapped to specific J- or Q-codes listed in the policy require prior authorization

Providers must include the specific mapped J- or Q-code and product name when requesting authorization

The policy lists specific coded exclusions and coverage notes relevant to behavioral health and outpatient surgical coding. 96110 is explicitly identified as a non-covered service in the psychological/neuropsychological testing section. Additionally, CPT 20610 is noted as non-covered when billed in specific ambulatory surgery center contexts or billed with certain diagnosis codes; providers should confirm billing combinations when using this code in ambulatory settings.

For members with a diagnosis of Low Back Pain, the therapeutic services section enumerates specific services that are not covered. These include therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT fluoroscopic guidance), continuous or intermittent traction, therapeutic injections of steroids into intervertebral discs, and other listed pain management/therapeutic procedures. Providers should not request authorization for these excluded services for Low Back Pain diagnoses.

Enteral therapy and related pharmacy items billed under HCPCS codes B4034-B4162 require prior authorization; however, routine pharmacy supplies do not require authorization. The policy also notes that supplies are not covered under Child Health Plus (CHP) and providers should refer to the member’s benefit plan for coverage details. When requesting authorization for enteral/specialty items, include the mapped J-/Q-code and product name as specified.

The excerpt provided contains no explicit additional exclusions beyond those already listed in the document snippet. No further Not Medically Necessary (NMN) conditions are specified in this portion of the policy.

The policy identifies several authorization exceptions and line-of-business distinctions. Authorization is not required for oncology indications for members under age 18. Authorization is required for Child Health Plus (CHP) members for certain items, while it is not required for NYM or HARP members in some cases. The document also lists ophthalmic indications as not requiring authorization. Providers should follow the specified submission pathways (e.g., New Century Health for certain oncology medications for members 18+) where applicable.

A series of J73xx entries (e.g., J7318–J7333 as listed) are noted in the policy as non-covered when billed in combination with CPT 20610 or 20611 or with certain specified diagnoses. The source text for some of these combinations is partially garbled; therefore providers should verify claim coding combinations and consult the payer for adjudication guidance when billing these codes together.

Elective surgical or medical procedures that are completed within 24 hours are generally not approved for inpatient level of care and should be billed as outpatient. The policy clarifies that services completed within a 24-hour period will not meet inpatient admission criteria and require appropriate outpatient authorization or prior-notification workflows.

The therapeutic services section reiterates services that are not covered specifically for Low Back Pain diagnoses. In addition to facet joint steroid injections and traction, the list includes various pain management injection procedures and other therapeutic interventions referenced under the therapeutic services heading; providers should review diagnosis-driven coverage guidance before submitting requests for these services.

Coverage criteria details are contained elsewhere in this policy document (see the Coverage Criteria and Authorization sections). This block is a placeholder for the full set of coverage criteria and logic that govern prior authorization and medical necessity determinations.

The provided excerpt does not specify discrete conditions or clinical scenarios labeled as Not Medically Necessary (NMN). This block serves as a placeholder where NMN criteria would be listed when present in the full policy.

Codes, Triggers, and Coding Rules

Transplant codes requiring authorization at time of transplant evaluationCPTCovered

32850-32856	Transplant-related codes (document list)
33930-33945	Transplant-related codes (document list)
38204-38215	Transplant-related codes (document list)
38230-38242	Transplant-related codes (document list)
44133-44136	Transplant-related codes (document list)
47133-47147	Transplant-related codes (document list)
48160	Transplant-related codes (document list)
48550-48556	Transplant-related codes (document list)
50300-50380	Transplant-related codes (document list)
50547	Transplant-related code

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Outpatient surgery codes requiring prior authorization (partial list)CPTCovered

43770-43775	Bariatric surgery
S2083	Bariatric surgery
15820-15823	Blepharoplasty
11920-11971	Breast reconstruction
19300	Breast reconstruction / reduction / related
19316-19342	Breast reconstruction related codes
19355	Breast reconstruction
19370-19396	Breast reconstruction
11200-11201	Skin procedure codes (authorization continues)
11719	Nail procedure code

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Behavioral health and community services codesmixed

96116	Psych testing (requires auth)
96121	Psych 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 testing (requires auth)
96137	Psych testing (requires auth)
96138	Psych testing (requires auth)
96139	Psych testing (requires auth)

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PROSHCPCS

H2018	Personalized Recovery Oriented Services (PROS)
H2019	Personalized Recovery Oriented Services (PROS)

Adult HCBS / Rehabilitation and Support CodesHCPCS

H0040	Assertive Community Treatment (ACT)
H2012K	Intensive Psychiatric Rehabilitation Treatment (IPRT)
H2017	Psychosocial Rehabilitation
T2017	Habilitation and Residential Support Services
H0036	Community Psychiatric Support and Treatment (CPST)
H0038	Empowerment Services / Peer Supports (FPSS/YPSS)
H0045	Short Term Crisis Respite / Intensive Crisis Respite
H2014	Family Support and Training
T2015	Pre-Vocational Services
T2019	Transitional Employment

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CFTSS and ASMT related codesmixed

90791	Other Licensed Practitioner evaluation
H0004	Brief Intervention
H2011	Other behavioral health service code listed under OLP
90882	Pharmacologic management
S9441	Asthma self-management training, individual
S9445	Asthma self-management training, group
S9446	Asthma self-management training, other
98960	Education and training for patient self-management
98961	Education and training
98962	Education and training

DME supply codes with authorization notesHCPCS

A4335	DME supply code (authorization required for MLTC)
A4554	DME supply code (authorization required for MLTC)
T4521	DME supply codes
T4522	DME supply codes
T4523	DME supply codes
T4524	DME supply codes
T4529	DME supply codes
T4530	DME supply codes
T4533	DME supply codes
T4535	DME supply codes

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Therapeutic and procedure codes (authorization notes)CPT

95249	Ambulatory continuous glucose monitoring
20526	Injection procedure
20550	Trigger point injection
20551	Trigger point injection
20552	Injection procedure
20553	Injection procedure
63622	Spinal neurosurgery code (no auth for ortho requests)
63688	Spinal neurosurgery code (no auth for ortho requests)
58674	Radiofrequency ablation of uterine fibroids
31660	Bronchial thermoplasty

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Imaging and diagnostic codesCPT

91110	Wireless Capsule Endoscopy
91111	Wireless Capsule Endoscopy
91112	Wireless Motility Capsule
77080	DXA scan
77081	DXA scan

LTHHCP transition service codesHCPCS

S9127	Medical Social Services (LTHHCP transition)
S5170	Home Delivered Meals

Covered counseling CPT/HCPCSHCPCSCovered

G0108	VI counseling services (covered when billed with G0108)
G0109	VI counseling services (covered when billed with G0109)

Asthma self-management training codesCPT | HCPCSCovered

S9441	Asthma education and training, individual
S9445	Asthma education, group
S9446	Asthma education, other
98960	Education and training for patient self-management; individual
98961	Education and training for patient self-management; group
98962	Education and training for patient self-management; home visit

Smoking cessation counseling codes and diagnosisCPT | ICD-10Covered

99406	Smoking and tobacco use cessation counseling visit; intermediate
99407	Smoking and tobacco use cessation counseling visit; intensive
F17.200	Nicotine dependence, unspecified, uncomplicated (example billing DX referenced)
F17.201	Nicotine dependence, unspecified, in remission (example billing DX referenced)

Enteral therapy HCPCS requiring authorizationHCPCSCovered

B4034-B4162

Enteral formulas and disposable items

List of many J-/C-/G- codes and mapped biologic/drug names (partial)mixed

C9054	Unclassified/clinic-specific crosswalk codes (document lists subentries mapping to J-codes and drug names)
G0516	Insertion of implant / listed mappings
G0517	Removal of implant / listed mappings
J0223	Drug-specific J-code mapped in listing

HCPCS/J/Q codes mapped in documentmixed

B4034-B4162	Enteral Therapy HCPCS code range
J7208	mapped entries listed under HCPCS (see document)
J7209	mapped entries listed under HCPCS (see document)
J7210	mapped entries listed under HCPCS (see document)
J7211	mapped entries listed under HCPCS (see document)
J7212	mapped entries listed under HCPCS (see document)
J7308	mapped entries listed under HCPCS (see document)
J7309	mapped entries listed under HCPCS (see document)
J7311	mapped entries listed under HCPCS (see document)
J7312	mapped entries listed under HCPCS (see document)

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Enteral and specialty HCPCS/J/S/Q codes listedmixed

B4034-B4162	Enteral formulas or disposable items requiring authorization
J7639	Multiple mappings to specific drugs (dornase alfa Pulmozyme; J9229; inotuzumab ozogamicin (Besponsa); Q9991; trastuzumab (Herceptin) and others) as listed
Q9992	Mapped items including buprenorphine ER (Sublocade) and others listed
S0013	Esketamine nasal spray (listed)
S0104	Zidovudine oral and related mappings
S0106	Bupropion SR and related mappings

CPT codes affecting coverageCPT

20610	CPT - trigger for non-coverage with certain J73xx codes
20611	CPT - trigger for non-coverage with certain J73xx codes

High-utilization triggers for utilization review

High-utilization triggersExamples: >=3 psychiatric inpatient hospitalizations in 12 months; >=4 psychiatric ED visits in 12 months; >=3 medical inpatient hospitalizations in 12 months; readmission to any mental health inpatient unit within 30 days

Concurrent review thresholdConcurrent review applies for stays exceeding 30 days (concurrent review from day 31 onwards)

ApplicabilityTriggers apply to inpatient, partial hospitalization, and intensive outpatient mental health programs per NYS OMH Best Practice Manual

Provider Responsibilities, Notifications, and Authorization Workflow

Prior Authorization

Surgical Prior Authorization (delegations noted)

Numerous surgical and outpatient procedures require prior authorization. Delegated authorizations: TurningPoint Healthcare Solutions, LLC is delegated for many ENT, certain orthopedic/spinal, cardiac, and select surgical/procedure CPT codes (see TurningPoint delegated lists). National Imaging Associates, Inc. (NIA) is delegated for many radiology services and outpatient therapy authorization workflow (see NIA delegated lists). When a CPT/HCPCS code is delegated, submit the authorization request to the delegated vendor per their workflow and timelines; associated device HCPCS billed with a delegated CPT will also be reviewed by that vendor.

TurningPoint delegated for ENT, select orthopedic/spinal, cardiac, and other surgical CPT lists (effective dates noted in policy).
NIA delegated for radiology services (effective 9/20/2021 for dates of service on/after 10/1/2021) and for outpatient PT/OT/ST authorizations (effective 10/1/2021).
When delegated, follow the delegated vendor's authorization submission process and timelines; authorizations issued by delegates satisfy Fidelis requirements.

Prior Authorization

Prior Authorization Required for Select Outpatient, Imaging, and Therapy Services

Policy Background and Scope

This document describes Fidelis Care’s authorization and utilization review processes across levels of care, including inpatient, outpatient, and behavioral health services. All inpatient admissions require authorization and are reviewed for medical necessity. OMH‑licensed inpatient mental health and in‑network OASAS inpatient SUD facilities have specific notification and concurrent‑review exemptions (e.g., OMH pediatric admissions exempt for the first 14 days if notification requirements are met; OASAS inpatient SUD admissions exempt from concurrent review for the first 28 days with timely notification). The policy also details prior authorization requirements for behavioral health testing, enteral therapy (HCPCS B4034–B4162), and many specialty pharmacy/HCPCS/J/Q codes, and describes delegated authorization workflows for certain outpatient surgery, imaging, and therapy services.

Defined Terms and Tools

LOCADTR medical necessity tool (SUD)

LOCADTR toolLOCADTR medical necessity tool is referenced for inpatient SUD clinical review and discharge planning

Use in documentationFacilities may fax or email the OASAS Appendix A Notification Form and OASAS LOCADTR tool to Fidelis Care as part of notification

Role in utilization reviewLOCADTR guides daily concurrent review and determines medical necessity for continued inpatient SUD treatment

OMH notification form for pediatric admissions

OMH Two‑Day Notification formOMH Two‑Day Notification and Initial Treatment Plan form is required for pediatric OMH inpatient mental health admissions to Fidelis Care within 2 business days

Submission methodsForm may be submitted by fax to 718‑896‑1784 or by email to Mental_HealthAdmission@fideliscare.org

Admission and Level-of-Care Rules

inv-85: Inpatient, Partial Hospitalization, Intensive Outpatient

Criteria grouping for levels of care

Admission triggers for OMH/PH/IOP: High-utilization triggers (e.g., >=3 psychiatric inpatient hospitalizations in 12 months; >=4 psychiatric ED visits in 12 months; >=3 medical inpatient hospitalizations in 12 months) or readmission within 30 days may trigger utilization review for inpatient, partial hospitalization, and intensive outpatient programs

Concurrent review applies for stays exceeding 30 days

inv-86: HCBS / CFTSS / PROS / ACT

Level-of-care criteria for community services

HCBS/CFTSS/PROS/ACT guidance: CFTSS utilization management requirements have been discontinued; HCBS services (including PROS and ACT) have eligibility and notification rules for members up to age 20 and certain programs require enrollment/Plan of Care submission as specifiedage <=20 for Children’s HCBS notification requirement

Specific Treatment Modalities and Requirements

inv-88: ECT

ECT coverage/requirements

Outpatient ECT: Outpatient electroconvulsive therapy (ECT) (CPT 90870) requires authorization

inv-89: ABA

ABA coverage rules

ABA eligibility and authorization: Applied Behavioral Analysis (ABA) requires prior authorization from Behavioral Health for applicable members. Child Health Plus members under age 21 may be eligible if diagnosed with autism spectrum disorder or Rett Syndrome and referred by approved NYS licensed clinicians

ABA authorization request form available on Fidelis Care provider forms site

inv-90: CFTSS / PSR / CPST / Peer Supports

Community and rehabilitative modalities

Applied Behavioral Analysis (ABA) Criteria

inv-87: Applied Behavioral Analysis (ABA) criteria

Applied Behavioral Analysis (ABA) coverage rules (partial)

ABA eligibility (Child Health Plus): Members under age 21 with diagnosis of autism spectrum disorder or Rett Syndrome per DSM-5 and referral by approved NYS licensed clinicians may be eligible; prior authorization from Behavioral Health is required

Authorization request form available on Fidelis Care provider forms site

Service Frequency and Visit Limits

Mental Health Continuing Treatment (H2012)

H2012 initial periodMental Health Continuing Treatment (H2012) — first 7 service days do not require authorization

Post‑initial authorizationAdditional service days beyond the initial 7 require authorization

ApplicabilityApplies to H2012 continuing treatment services per policy

Counseling services (G0108, G0109)

Counseling services limitCounseling services (G0108, G0109) allowance: 10 hours (20 units) in a continuous 6‑month period

Provider requirementServices must be provided by certified providers and no longer require authorization

Policy Revision History

2021-11-02coding update

Sublocade (buprenorphine ER) 100 mg mapping and related HCPCS/J-code mappings listed for enteral/specialty code crosswalks

2021-10-01delegation update

Authorization delegation to National Imaging Associates (NIA) for radiology services and outpatient therapy authorizations effective for dates of service on or after 2021-10-01; TurningPoint delegations effective 2021-10-04 noted for certain surgical services

2021-06-01policy scope change

OpenPayer

Authorization and Utilization Review — Behavioral Health and Related Services