Authorization and Utilization Requirements for Inpatient, Outpatient, and Behavioral Health Services
Governance of prior authorization, utilization review, and notification requirements for a range of medical, surgical, and behavioral health services for Fidelis Care members (New York State focused), including special rules for OMH and OASAS licensed programs and select outpatient procedures.
Effective 01/01/2022: SUD services provided by OASAS-licensed in-network NY facilities are not subject to prior authorization and not subject to concurrent utilization review for the first 28 days if timely notification and initial treatment plan are provided.
Effective 06/01/2021: Inpatient mental health treatment at OMH-licensed NY hospitals is not subject to prior authorization; utilization review is limited to members meeting specified high-utilization or other triggers.
Effective 01/01/2020: Inpatient mental health treatment for members under 18 at OMH-licensed, in-network NY hospitals are not subject to prior authorization and are not subject to concurrent review during the first 14 days if notification and initial treatment plan are provided.
Effective January 1, 2020: Fidelis Care does not require notification, prior authorization, or concurrent review for certain in-network, in-state outpatient substance use services including outpatient visits, IOP, OTPs, and outpatient rehabilitation.
Effective 9/20/2021 (DOS on/after 10/4/2021): Prior authorization for specific ENT and cardiac surgical procedures has been delegated to TurningPoint Healthcare Solutions, LLC.
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