Fidelis Care behavioral health Prior Auth update | OpenPayer
ModifiedFidelis CarePolicy N/A
Behavioral health utilization management and authorization policy
Defines Fidelis Care authorization, notification, and utilization review requirements for inpatient, outpatient, and community behavioral health and substance use services in New York State; applies to Fidelis Care providers and facilities serving affected members.
Policy Summary
PayerFidelis Care
PolicyBehavioral health utilization management and authorization policy
Policy CodePolicy N/A
Change TypeMultiple material updates
Effective DateN/A
Next Review DateN/A
Key ActionOMH- and OASAS-licensed facilities must notify Fidelis Care within 2 business days and submit required forms to avoid delays and enable appropriate utilization review exemptions.
OMH-licensed inpatient mental health treatment in NYS is not subject to prior authorization effective 06/01/2021, with notification requirements.
Inpatient SUD services at OASAS-licensed, in-network NYS facilities are not subject to authorization or concurrent review for the first 28 days effective 01/01/2020, with notification and LOCADTR reporting requirements.
Certain outpatient substance use services in-network/in-state do not require provider notification, authorization, or concurrent review effective 01/01/2020.
Partial hospitalization and intensive outpatient services in OMH-licensed programs will only undergo utilization review when specified high-utilization triggers are met; first 7 days of PHP for under-21 members do not require authorization.
Authorization removed from most outpatient behavioral health services; exceptions such as psychological testing codes and outpatient ECT still require authorization.
Certain community and HCBS behavioral health services have defined authorization rules or are not subject to authorization (e.g., PROS, CORE services, CFTSS).
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28 daysno concurrent utilization review for in-network OASAS inpatient SUD admissions
14 daysno concurrent utilization review for OMH-licensed inpatient mental health admissions for under-18 when notification and forms submitted
7 daysfirst days of partial hospitalization/mental health continuing treatment do not require authorization (varies by program/age)
06/01/2021OMH inpatient authorization change date
07/01/2022Outpatient SUD authorization rule update
S9430S9430 pharmacy compounding non-covered in specific billing contexts
Coverage Criteria and Authorization Rules
OMH inpatient utilization review triggers
OMH-licensed inpatient mental health treatment in NYS — utilization review conducted only when specified triggers are met
Triggers for utilization review: Individuals meeting ANY of the following: Three (3) or more psychiatric inpatient hospitalizations in the prior 12 months; Four (4) or more psychiatric emergency department (ED) visits in the prior 12 months; Three (3) or more medical inpatient hospitalizations in the prior 12 months; Subject to a current Assisted Outpatient Treatment (AOT) court order or had an AOT order that expired within the past five years; Readmission to any mental health inpatient unit within 30 days of discharge; Length of stay exceeds 30 days (concurrent review from day 31 onwards).see text
OMH-licensed inpatient admissions in-network are not subject to prior authorization but the facility must notify Fidelis Care within 2 business days of admission; only cases meeting these triggers will undergo utilization review per NYS OMH Best Practice Manual.
Partial Hospitalization UR triggers
Partial hospitalization (PHP) utilization review criteria for OMH-licensed programs
PHP UR triggers: Individuals meeting ANY of the following: Current Assisted Outpatient Treatment (AOT) court order or AOT expired within the past five years; Three (3) or more psychiatric inpatient hospitalizations in the prior 12 months; Four (4) or more psychiatric ED visits in the prior 12 months; Three (3) or more medical inpatient hospitalizations in the prior 12 months; Readmission to any mental health inpatient unit within 30 days of discharge; Length of stay exceeds 30 days (concurrent review from day 31 onwards).see text
Partial hospitalization services provided by out-of-network facilities remain subject to concurrent review throughout the admission; first seven days for members under 21 do not require authorization.
Intensive Outpatient UR triggers
Intensive outpatient (IOP) utilization review criteria for OMH-licensed programs
IOP UR triggers: Individuals meeting ANY of the following: Current Assisted Outpatient Treatment (AOT) court order or AOT expired within the past five years; Three (3) or more psychiatric inpatient hospitalizations in the prior 12 months; Four (4) or more psychiatric ED visits in the prior 12 months; Three (3) or more medical inpatient hospitalizations in the prior 12 months; Readmission to any mental health inpatient unit within 30 days of discharge; Length of stay exceeds 30 days (concurrent review from Day 31 onwards).see text
Out-of-network IOPs are subject to concurrent review throughout the admission.
OASAS inpatient SUD authorization and UR
Inpatient Substance Use Disorder (SUD) services at in-network OASAS-licensed NYS facilities
Inpatient SUD authorization rules: (1) In-network, OASAS-licensed facilities are not subject to authorization or concurrent utilization review for the first twenty-eight (28) days of the inpatient admission provided the facility notifies Fidelis Care of the admission and submits the initial treatment plan/LOCADTR within two (2) business days; (2) Facilities must perform daily clinical review of the patient and periodically consult with Fidelis Care (starting on or about the 14th day) to ensure LOCADTR use; utilization review may occur after day 28 or upon discharge using the LOCADTR tool.28 days
Out-of-state, unlicensed, or out-of-network facilities remain required to request authorization and are subject to concurrent review throughout admission.
PROS / CORE / HCBS authorization policy
Community HCBS / PROS / CORE services
PROS and CORE authorization status: Personalized Recovery Oriented Services (PROS) and CORE services do not require prior authorization effective as specified (PROS effective 02/01/2022; CORE services available and do not require authorization); Service Initiation or eligibility documentation (e.g., Service Initiation Form for CORE) must be submitted within required timeframes (for CORE, within 3 business days of first service visit).
Eligibility and enrollment requirements apply for HCBS, PROS, and CORE services; prior authorization may be required after intake periods for certain HCBS offerings.
CFTSS coverage stance
Children and Family Treatment and Support Services (CFTSS)
CFTSS utilization management: Utilization management requirements for CFTSS were discontinued effective 04/01/2020; prior authorization was never required and concurrent review is no longer required.
Providers may contact Fidelis Care for questions regarding CFTSS.
CFTSS (Children and Family Treatment & Support Services)
Children and Family Treatment & Support Services (CFTSS) coverage stance
CFTSS UM removal: Effective 04/01/2020, utilization management requirements for Children and Family Treatment and Support Services (CFTSS) were discontinued; prior authorization was never required and concurrent review is no longer required.
Providers may contact Fidelis Care with questions.
Children's HCBS
Children's Home and Community Based Services (HCBS) availability and notification
HCBS availability and notification: Additional HCBS services are available to members age 20 and younger if determined HCBS-eligible; effective 12/01/2021, providers must notify Fidelis Care of the identified service requested prior to the member's initial appointment (with exceptions, e.g., notification for Respite Services removed effective 06/01/2022).
Providers must submit the Plan of Care and required documentation (C-YES and Health Home providers) prior to rendering services to prevent claims processing disruptions.
CLHRS / OLHRS
Core Limited Health Related Services (CLHRS) and Other Limited Health Related Services (OLHRS)
CLHRS coverage: Certain CLHRS services (for example: nursing services, Skill Building Licensed Behavioral Health Practitioner [LBHP], clinical consultation/supervision, treatment planning and discharge planning) will be covered on a per diem basis and Fidelis Care will not conduct utilization review for these services.
Effective dates noted for coverage of 29-I facility services; OLHRS delivered by 29-I facilities also have no utilization review.
Home Health Care
Home Health Care coverage and authorization
Home Health Care authorization: Home care approvals are based on the medical need for skilled services; personal care services, Personal Emergency Response System (PERS), Consumer Directed Personal Assistance Services (CDPAS), and other home health services require authorization.
Codes and billing units were updated effective 04/01/2018 for some services.
Counseling Services
Counseling services coverage
Counseling allowance: Members are allowed 10 hours (20 units) in a continuous six-month period for counseling services provided by certified providers; these services no longer require authorization and are covered when billed with codes G0108 and G0109.10 hours / 20 units per 6 months
ASMT and Smoking Cessation
Self-management and cessation programs
ASMT coverage: Asthma self-management training (ASMT) is allowed, including for pregnant women; authorization is not required for codes S9441, S9445, S9446 and 98960-98962 when billed with appropriate diagnosis codes (J4Sx). Medically stable members may receive up to one (1) hour of ASMT during a continuous six-month period; group sessions limited to no more than eight patients.1 hour per 6 months
Smoking cessation coverage: Smoking cessation counseling is reimbursed for up to eight (8) visits per calendar year using the sum of codes 99406 and 99407 and must be billed with diagnosis codes F7.200 or F17.201 for Medicaid members; no authorization is required for Medicaid members when billing criteria are met.Up to 8 visits per year
Billing must include designated diagnosis codes; no authorization required for Medicaid members.
Psychological/neuropsychological testing requests must be submitted on the designated testing request form for authorization. Authorization is required for codes 96112 and 96113. Note: 96110 is a non‑covered service.
Durable medical equipment, procedures, and pharmaceutical treatments for erectile dysfunction are specifically excluded for registered sex offenders. Examples include CPT codes 54360, 54400–54402, 54405, 54408, 54410, 54411, 54416, 54417, 55870 and HCPCS L7900.
Certain requests are excluded from New Century Health (NCH) review and must not be submitted to NCH. These exclusions include: Antibiotics; Bone marrow, stem cell transplants, and CAR‑T cell therapy; Cablivi; controlled substances; equipment requests; genetic laboratory testing and laboratory services; hemophilia drugs; immune globulins; inpatient drug requests; pain medications; iron preparations; radiopharmaceuticals; surgeries/surgical procedures; and sickle cell diagnoses. Authorization requests for enteral therapy items should instead be submitted to the Pharmacy Team via the e‑fax number provided in the enteral therapy section.
For enteral therapy and certain prescription S‑codes, product‑specific authorization distinctions apply. Authorization is not required for ophthalmic indications. Note that authorization requirements may vary by member product (for example, CHP vs NYM vs HARP) as described in the product‑specific notes.
The pharmacy compounding and dispensing service S9430 is non‑covered when billed in certain contexts. Specifically, S9430 is non‑covered when billed with CPT codes 20610 or 20611, and it is non‑covered when billed with specified diagnoses per the note in the compounding section. Providers should review related exclusions before billing S9430 alongside these CPT codes or diagnosis codes.
Inpatient admissions require prior authorization and all facility admissions are reviewed for medical necessity. Services billed at an inpatient level without appropriate prior authorization or admissions determined not to be medically necessary upon review may be denied. Elective surgical procedures completed within 24 hours are not approved at an inpatient level of care and should be billed as outpatient when performed within the Fidelis Care network.
Although authorization is no longer required for most podiatry services, certain podiatric procedures remain not covered for members with a diagnosis of Low Back Pain. Examples of non‑covered services include therapeutic facet joint steroid injections in the lumbar and sacral regions without CT/fluoroscopic guidance, continuous or intermittent traction, and therapeutic injections of steroids into intervertebral discs.
Pharmacy compounding and dispensing services billed under S9430 are non‑covered in specified billing contexts. In particular, S9430 is non‑covered when billed with CPT codes 20610 or 20611 and when submitted with the listed diagnosis codes referenced in the compounding note. Providers must follow the policy exclusions and not submit these combinations for authorization.
Code Lists and Key Coding Rules
Transplant CPT codes requiring authorization at evaluationCPTCovered
Community Psychiatric Support and Treatment (CPST)
H2014
Family Support and Training
Behavioral and counseling CPT/HCPCS codes referencedmixedCovered
S9441
Asthma self-management training
S9445
Asthma self-management training
S9446
Asthma self-management training
98960
ASMT related code
98961
ASMT related code
98962
ASMT related code
99406
Smoking cessation counseling
99407
Smoking cessation counseling
G0108
Counseling services
G0109
Counseling services
Home health HCPCS codes (examples from change notes)HCPCS
S5130U1
Home health Level I (new HCPCS code as of 04/01/2018)
G0162
Nursing Supervision
Imaging codesCPTCovered
77080
DXA scan
77081
DXA scan
77089
TBS scan
77090
TBS scan
77091
TBS scan
77092
TBS scan
Erectile dysfunction codes (not covered for registered sex offenders)mixed
54360
Erectile dysfunction procedure
54400
Erectile dysfunction procedure
54401
Erectile dysfunction procedure
54402
Erectile dysfunction procedure
54405
Erectile dysfunction procedure
54408
Erectile dysfunction procedure
54410
Erectile dysfunction procedure
54411
Erectile dysfunction procedure
54416
Erectile dysfunction procedure
54417
Erectile dysfunction procedure
1–10 of 12
1/2
Smoking Cessation Counseling CodesCPTCovered
99406
Smoking and tobacco use cessation counseling visit, intermediate
99407
Smoking and tobacco use cessation counseling visit, intensive
Required Diagnosis Codes for SCC Billing (as written)ICD-10
F7.200
Documented as billing DX code (as written in document)
F17.201
Documented as billing DX code (as written in document)
Enteral Therapy HCPCS Range Requiring AuthorizationHCPCSCovered
B4034-B4162
HCPCS codes for enteral formulas/disposable items requiring authorization
Specific drug/biologic HCPCS/Codes listed for authorization mappingmixed
multiple C9/J/G/J0.. etc.
Long list of specific C- and J- codes and mapping to drugs/biologics as listed in the document (e.g., C9054=lefamulin/Xenleta mapping, many J-codes and product names).
inflximab-dyyb (Inflectra) referenced with product/member notes
S0187
tamoxifen citrate oral
S0189
testosterone pellet (Testopel)
S4991
nicotine patches, non-legend
S4990
nicotine patches, legend
S0197
prenatal vitamins 30 days
S0194
vitamin suppl 100 caps
Prescription S-codesHCPCS
S5000
prescription generic drug
S5001
prescription brand name drug
S4995
smoking cessation gum
Compounding and CPT interactionsHCPCS | CPTNot Covered
S9430
pharmacy compounding and dispensing services
CPT 20610
CPT code listed as creating non-coverage when billed with S9430
CPT 20611
CPT code listed as creating non-coverage when billed with S9430
High-utilization triggers for utilization review
High-utilization triggers (examples)Three (3) or more psychiatric inpatient hospitalizations in the prior 12 months; Four (4) or more psychiatric ED visits in the prior 12 months; Three (3) or more medical inpatient hospitalizations in the prior 12 months; Readmission to any mental health inpatient unit within 30 days of discharge; Current or recent (expired within 5 years) Assisted Outpatient Treatment (AOT) court order; Length of stay exceeds 30 days (concurrent review from day 31).
Applies toOMH-licensed inpatient, Partial Hospitalization (PHP), and Intensive Outpatient (IOP) programs in NYS when listed triggers are met.
Provider Responsibilities, Notifications, and Authorization Steps
Prior Authorization
Outpatient surgery/procedure authorization
Certain outpatient surgical and procedural services require prior authorization. Providers must request authorization before performing the service; lack of required authorization may result in denial or claim payment issues. Some code sets and selected procedure groups have authorization delegated to TurningPoint Healthcare Solutions — when a CPT code is on the TurningPoint delegated list, associated devices (HCPCS) will also be reviewed by TurningPoint. Examples of service groups that require authorization include bariatric surgery, blepharoplasty, breast reconstruction, skin surgery codes listed as requiring authorization, eyelid/ocular surgery, abdominoplasty/lipectomy/panniculectomy, facial cosmetic procedures (including septoplasty/rhinoplasty), reduction mammoplasty, vascular procedures, speech processor implant procedures, gender reassignment surgery, spinal surgery, certain orthopedic and spinal outpatient procedures, esophageal procedures, and cardiac surgical procedures (delegated to TurningPoint for certain settings).
Bariatric surgery: 43770-43775, S2083
Blepharoplasty: 15820-15823
Breast reconstruction: 11920-11971, 19300, 19316-19342, 19355, 19370-19396
Skin surgery: codes 10040, 11300-11313, 11400-11471, 11721 (require authorization if ambulatory surgery POS 24); other skin surgery codes listed continue to require authorization
LOCADTR definitionLevel of Care and Drug and Alcohol Treatment Referral (LOCADTR) medical necessity tool used for OASAS inpatient SUD concurrent review and discharge planning.
Use timingFacilities must submit LOCADTR results and initial treatment plan to Fidelis Care within two (2) business days of admission for in-network OASAS inpatient SUD services.
Review windowIn-network OASAS inpatient SUD admissions are not subject to concurrent utilization review for the first 28 days provided notification and LOCADTR submission occur; UR may occur after day 28 or upon discharge using LOCADTR.
OMH Two-Day Notification and Initial Treatment Plan form
Form nameOMH Two-Day Notification and Initial Treatment Plan form (OMH-developed form).
Submission timing
Level-of-Care Criteria for Behavioral Health Services
Admission UR triggers: See OMH/PHP/IOP high-utilization triggers: Assisted Outpatient Treatment (AOT) status; Three (3) or more psychiatric inpatient hospitalizations in the prior 12 months; Four (4) or more psychiatric ED visits in the prior 12 months; Three (3) or more medical inpatient hospitalizations in prior 12 months; Readmission within 30 days; Length of stay >30 days (concurrent review from day 31).see text
OMH inpatient admissions in-network are not prior-authorized but facilities must notify Fidelis Care within 2 business days; partial hospitalization first 7 days for members under 21 do not require authorization.
Community-based behavioral health services (CFTSS/PSR/CPST/Peer Supports)
Community-based behavioral health services — program categories and CFTSS status
Psychological/neuropsychological testing requests must use the designated testing request form; 96112 and 96113 also require authorization (96110 is non-covered).
PHP / IOP
Partial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP) criteria
PHP/IOP clinical triggers: Utilization review for PHP and IOP in OMH-licensed programs applies when members meet high-utilization triggers: AOT status (current or within 5 years); Three (3) or more psychiatric inpatient hospitalizations in prior 12 months; Four (4) or more psychiatric ED visits in prior 12 months; Three (3) or more medical inpatient hospitalizations in prior 12 months; Readmission within 30 days; Length of stay >30 days (concurrent review from day 31).see text
Visit Limits and Short-term Authorization Exceptions
Mental Health Continuing Treatment (H2012)
H2012 initial daysMental Health Continuing Treatment (H2012): the first 7 service days do not require authorization; additional service days require authorization.
Applies toApplies to Mental Health Continuing Treatment services as specified for member populations (Child Health Plus context noted).
Provider actionRequests beyond the initial 7 days require prior authorization submission to Behavioral Health per policy procedures.
Partial hospitalization for members under 21
Partial hospitalization (under 21)Partial hospitalization for members under 21: the first 7 service days do not require authorization; additional days require authorization.
Codes referenced
Background and Policy Scope
This policy reflects utilization management and authorization updates that align with New York State regulatory guidance for OMH and OASAS‑licensed facilities. Effective changes include: OMH‑licensed inpatient mental health treatment in‑state (effective 06/01/2021) is exempt from prior authorization when provided by OMH‑licensed facilities but requires timely notification and submission of the OMH Two‑Day Notification and Initial Treatment Plan; in‑network OASAS‑licensed inpatient SUD admissions are not subject to authorization or concurrent utilization review for the first 28 days provided required notifications and LOCADTR reporting occur within the specified timeframe. Facilities are required to notify Fidelis Care within two business days and submit the prescribed forms; daily clinical review and periodic consultation with Fidelis Care are also required per the OMH/OASAS guidance.
Policy Summary
PayerFidelis Care
PolicyBehavioral health utilization management and authorization policy
Policy CodePolicy N/A
Change TypeMultiple material updates
Effective DateN/A
Next Review DateN/A
Key ActionOMH- and OASAS-licensed facilities must notify Fidelis Care within 2 business days and submit required forms to avoid delays and enable appropriate utilization review exemptions.
Concurrent review timingConcurrent review applies when length of stay exceeds 30 days (review from day 31 onwards) or when any high-utilization trigger is present.
DXA scan frequency
DXA frequencyOne DXA (CPT 77080 or 77081) every two years for: women age >65; men age ≥70; women age 51–64 and men age 51–69 when accompanied by specified diagnosis codes (e.g., Z13.820 or codes on attached list).
Other ages/diagnosesRequests for 77080/77081 outside the specified age/diagnosis groups require prior authorization.
Related imaging codesTrabecular Bone Score (TBS) scans use CPT 77089–77092 (listed separately).
Counseling services limit
Counseling allowanceMembers are allowed 10 hours (20 units) in a continuous 6-month period for counseling services billed with codes G0108 and G0109.
Provider requirementServices must be provided by certified providers.
AuthorizationThese counseling services no longer require authorization.
Asthma self-management training limit
ASMT limitAsthma self-management training: up to 1 hour during a continuous six-month period for medically stable members.
Authorized codesAuthorization is not required for codes S9441, S9445, S9446, 98960–98962 when billed with diagnosis codes J4Sx.
Group sessionsGroup ASMT sessions limited to no more than eight patients.
Smoking cessation visits
Maximum visitsSmoking cessation counseling reimbursed for up to 8 visits per calendar year using the sum of CPT codes 99406 and 99407.
Billing diagnosisMust be billed only with diagnosis codes F7.200 or F17.201 (as written); for Medicaid members no authorization is required if criteria met.
Code combinationTotal visits are the sum of 99406 and 99407 across the calendar year.
Certain outpatient orthopedic and spinal procedures require prior authorization (effective dates and TurningPoint delegation apply)
Prior Authorization
Outpatient and DME prior authorization
Specific outpatient and durable medical equipment (DME) services require prior authorization. Sleep studies (including home sleep studies) and selected DME and enteral therapy items require prior authorization. Submit authorization requests per the instructions in this policy to avoid delays.
Sleep studies, including Home Sleep Studies, require prior authorization
DME items and selected outpatient services not listed as exempt require prior authorization per benefit
Pharmacy supplies do not require authorization; oncology medications and supportive agents require prior authorization via New Century Health (see Oncology block)
Prior Authorization
Therapy and radiology prior authorization
Outpatient therapy (PT, OT, ST) and many radiology services require prior authorization through delegated vendors. Effective dates apply: National Imaging Associates (NIA) manages authorization for radiology services (effective 10/1/2021 for many radiology codes) and for outpatient therapy services (effective 10/1/2021 for therapy after the initial evaluation). For therapy, the initial evaluation does not require authorization but all subsequent therapy services performed by a therapy provider require authorization through NIA. Non-therapy providers should request authorizations through Fidelis Care.
Radiology: Authorization delegated to National Imaging Associates (NIA) for many radiology services (effective 10/1/2021); cardiac ultrasounds delegated to TurningPoint
Outpatient Therapy (PT/OT/ST): All services after the initial evaluation require authorization through NIA; CPT 92610 and 92611 do not require authorization
Initial office/facility therapy evaluations do not require authorization, but any other billed therapy codes on the same date do require authorization
Home therapy treatments, including evaluations, require authorization (different timing for submission: outpatient setting within 1 business day; home health within 2 business days)
Prior Authorization
Authorization required for listed HCPCS/J/Q/S codes
Authorization is required for listed enteral therapy HCPCS and associated J/Q/S codes. Enteral formulas and disposables (B4034-B4162) require authorization for tube-fed individuals and selected clinical situations. Some J/Q/S drug/product codes and certain Q-codes/biosimilars have product-specific authorization distinctions (e.g., Q5103 infliximab-dyyb). Submit enteral and related authorization requests to the Pharmacy Team or follow the NCH submission instructions where applicable. Certain enteral-related requests and code groups are excluded from New Century Health review and should not be sent to NCH.
Associated J/Q/S codes listed in policy require authorization; some products/biosimilars have distinct authorization rules (e.g., Q5103 infliximab-dyyb and other Q-codes)
Submit authorization requests to Pharmacy Team via e-fax 1-877-533-2405 or follow vendor-specific submission portals for oncology (NCH) when applicable
Excluded request types (do not send to NCH): antibiotics, bone marrow/stem cell/CAR-T, controlled substances, equipment requests, certain lab testing, inpatient drug requests, radiopharmaceuticals, surgeries/procedures, and specified diagnoses
Documentation Required
HCBS notification / Plan of Care
Children's Home and Community Based Services (Children's HCBS) for members age 20 and younger who are determined HCBS-eligible require notification to Fidelis Care prior to the member's initial appointment (effective dates noted in policy). C-YES and Health Home providers must submit the Plan of Care and required documentation to Fidelis Care to receive authorization/confirmation. Failure to submit required notification prior to services may disrupt claims processing.
Services include Community Habilitation, Habilitation Day, Caregiver/Family Support, Prevocational Services (age 14+), Community Self Advocacy Training, Supported Employment (age 14+), Palliative Care, Environmental & Vehicle Modifications, Adaptive/Assistive Equipment, and others listed in policy
Submit notification prior to rendering service to: SM_Childrens_HCBS@fideliscare.org, fax (347) 690-7362, or call 1-888-FIDELIS and follow Children’s Medicaid prompts
Providers must submit Plan of Care to comply with workflow; determination will be communicated verbally and in writing
Documentation Required
OMH notification and documentation
Providers of OMH-licensed inpatient mental health services must notify Fidelis Care within two business days of admission using the OMH Two-Day Notification and Initial Treatment Plan form (fax 718-896-1784 or email to Mental Health Admission @fideliscare.org). Facilities must perform daily clinical review, participate in periodic consultation with Fidelis Care, and use the evidence-based clinical review criteria approved by OMH. Out-of-network inpatient mental health services are subject to concurrent review throughout the admission.
Complete and submit OMH Two-Day Notification and Initial Treatment Plan form by fax or email within two business days
Timely participation in daily clinical review and periodic consultation with Fidelis Care is required
Questions: call Fidelis Care Behavioral Health during regular business hours at 1-888-FIDELIS, extension 16072
Documentation Required
OASAS notification and documentation
OASAS-licensed inpatient substance use disorder (SUD) facilities must notify Fidelis Care within two business days of admission and may fax/email the OASAS Appendix A Notification Form and LOCADTR reporting per instructions. For in-state, in-network outpatient SUD services certain notifications/authorizations are not required, but out-of-state or out-of-network facilities must request authorization and remain subject to concurrent review. Facilities must provide a written discharge plan prior to member discharge as determined by LOCADTR.
Fax/email OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool to 646-829-1421 or submit as instructed
Facilities must notify within two business days, perform daily clinical review, and consult with Fidelis Care no later than about day 14 of treatment
Out-of-state or non-OASAS licensed facilities must request authorization and remain subject to concurrent review throughout admission
Documentation Required
LTHHCP transition documentation
For Medicaid enrollees transitioned from the Medicaid Fee-for-Service Long Term Home Health Care Program (LTHHCP), coverage of Medical Social Services (S9127) and Home Delivered Meals (S5170) requires authorization and documentation supporting the authorization must be provided.
Medical Social Services (S9127) and Home Delivered Meals (S5170) require authorization for transitioned LTHHCP members
Providers must submit documentation supporting the need for continued services at the time of transition into Medicaid Managed Care
Prior Authorization
Product-specific authorization distinctions
Product-specific authorization distinctions apply for certain medications, biosimilars, and supply codes. Authorization requirements may vary by product line and by member product (e.g., CHP, NYM, HARP). Some codes require authorization for CHP members but not for NYM or HARP members, while other codes require authorization for NYM/HARP but not CHP. Verify product-specific rules before submitting requests.
Example: Q5103 infliximab-dyyb (Inflectra) has product-specific notes in the policy
Some S-codes and prescription supply codes have member-product specific authorization requirements (see policy for details)
When in doubt, follow the submission instructions and vendor delegation notes (NCH, TurningPoint, NIA, Pharmacy Team) for the specific product
OMH-licensed facilities must submit the Two-Day Notification and Initial Treatment Plan to Fidelis Care within two (2) business days of admission by fax (718-896-1784) or email to the designated Mental Health Admissions address.
Facility obligationsFacilities must perform daily clinical review and participate in periodic consultation with Fidelis Care to ensure use of evidence-based clinical review criteria.
Community psychosocial, peer, and family support services include Psychosocial Rehabilitation (H2017), Community Psychiatric Support and Treatment (H0036), Peer Supports (H0038), and Family Support and Training (H2014). Utilization management for CFTSS was discontinued effective 04/01/2020 and prior authorization was never required.
Providers may contact Fidelis Care with questions about CFTSS or CORE services.
First seven service days for certain programs (e.g., PHP for members under 21) do not require authorization; out-of-network programs remain subject to concurrent review throughout admission.
Community psychosocial/peer/family support services
Community psychosocial, peer, and family support services (CORE/CFTSS/PSR/CPST)
Community psychosocial modalities: Covered community services include Psychosocial Rehabilitation (H2017), Community Psychiatric Support and Treatment (H0036), Peer Supports (H0038), and Family Support and Training (H2014). CFTSS utilization management has been discontinued effective 04/01/2020.
CORE services do not require prior authorization; Service Initiation Forms must be submitted within required timeframes for CORE enrollment.
Smoking Cessation Counseling (SCC)
Smoking cessation counseling (SCC) criteria and billing limits
SCC billing and limits: Smoking cessation counseling reimbursed up to eight (8) visits per calendar year using the sum of codes 99406 and 99407; must be billed with diagnosis codes F7.200 or F17.201 for Medicaid members. No authorization is required for Medicaid members when billing criteria are met.Up to 8 visits per year
These codes are summed for reimbursement; ensure required diagnosis codes are present for Medicaid billing.
ABA
Applied Behavioral Analysis (ABA) coverage for NYS plans
ABA coverage note: For New York State Medicaid Managed Care, ABA benefit was moved to NYS Medicaid Fee-For-Service effective 08/01/2021 and is not covered by Fidelis Care for Medicaid members; Child Health Plus members under age 21 with autism spectrum disorder or Rett Syndrome may be eligible for ABA and require referral and prior authorization from Behavioral Health using the ABA authorization request form.
Referral must be from specified licensed clinicians (e.g., NYS licensed physicians, psychologists, nurse practitioners, physician assistants).
Revenue codes 905, 906, or 912; CPT 90899; S9480; HCPCS H2013 are listed in the PHP section.
Out-of-network noteAll partial hospitalization services provided by out-of-network facilities are subject to concurrent review throughout the admission.
Counseling services (G0108, G0109)
Counseling thresholdCounseling services (G0108, G0109): 10 hours / 20 units per continuous 6-month period.
AuthorizationThese counseling services no longer require authorization when billed with G0108 or G0109.
Provider requirementServices must be provided by certified providers.
Smoking cessation counseling (99406 + 99407)
SCC visitsSmoking cessation counseling (CPT 99406 + 99407): reimbursed up to 8 visits per calendar year (sum of the two codes).
AuthorizationNo authorization is required for Medicaid members when billed with the specified diagnosis codes and criteria are met.
Billing diagnosisMust be billed only with diagnosis codes F7.200 or F17.201 as written in the document.
Smoking cessation counseling (sum of 99406 and 99407)
Maximum visits (sum)Smoking cessation counseling: maximum of 8 visits per calendar year when summing CPT codes 99406 and 99407.
Eligible codes99406 and 99407 are the codes summed for the annual visit limit.
Medicaid billing noteFor Medicaid members, billing must meet listed diagnosis criteria and no authorization is required.