CurrentFidelis CarePolicy N/A

Behavioral health authorization and utilization review rules

Defines authorization, utilization review, and coverage procedures for behavioral health and related inpatient/outpatient services for Fidelis Care members (New York State), including special rules for OMH/OASAS licensed facilities and select programs.

Policy Summary

PayerFidelis Care

PolicyBehavioral health authorization and utilization review rules

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionAll inpatient admissions require prior authorization and facility admissions are reviewed for medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7 daysPartial hospitalization no-auth period

28 daysInpatient SUD concurrent-review exemption

Effective 06/01/2021OMH inpatient prior-auth stance

10 hrsCounseling allowance (6 mo)

10 hrsASMT max (6 mo)

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Coverage Criteria and Special Rules

OMH inpatient utilization review criteria

OMH licensed inpatient mental health treatment — utilization review conducted only for members meeting ANY of the following triggers per NYS OMH Best Practice Manual

OMH inpatient utilization review triggers: Individuals with high utilization of inpatient or emergency department (ED) services in the past year; Individuals subject to a current Assisted Outpatient Treatment (AOT) court order or who had an AOT order that 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; Readmission to any mental health inpatient unit within 30 days of discharge; Individuals whose length of stay exceeds 30 days (concurrent review from Day 31 onwards)see node text

Based on NYS OMH Best Practice Manual

Inpatient SUD authorization and review rules

OASAS licensed inpatient SUD services — initial concurrent review exemption

Inpatient SUD initial requirements: Facility must be OASAS licensed and in-network; facility must notify Fidelis Care of the inpatient admission and provide the initial treatment plan within two (2) business days (may fax/email OASAS Appendix A Notification Form and LOCADTR tool); facility performs daily clinical review and consults periodically with Fidelis Care around treatment day 1428 days exemption from Fidelis concurrent utilization review if conditions met

After 28 days services may be subject to utilization review

Partial Hospitalization coverage criteria

Partial Hospitalization (MH/SUD)

Partial hospitalization authorization: No authorization required for the first seven (7) days of partial hospitalization; additional service days require authorization7 days

Revenue/CPT/HCPCS codes identified (e.g., revenue codes 905, 906, 912; CPT 90899; S9480; HCPCS H2013)

ABA coverage/authorization

Applied Behavioral Analysis (ABA) for Child Health Plus

ABA coverage conditions: Member under age 21 with DSM-5 diagnosis of autism spectrum disorder or Rett Syndrome; referral by a qualifying NYS licensed provider; prior authorization required from Behavioral Health for ABA under Child Health Plusage <21

Benefit for NYS Managed Medicaid moved to Medicaid Fee‑For‑Service as of 8/1/2021 (not covered by Fidelis for that program)

IOP/PHP utilization review criteria

Intensive outpatient and IOP/Partial hospitalization in OMH-licensed programs

IOP/PHP utilization review triggers: Utilization review (admission and continued stay) applies only for members who meet the same high‑utilization/AOT/readmission/length‑of‑stay triggers used for OMH inpatient (e.g., >=3 psychiatric inpatient hospitalizations in 12 months; >=4 psychiatric ED visits in 12 months; readmission within 30 days; length of stay >30 days)see text

Out‑of‑network facilities are subject to concurrent review throughout the admission

Selected coverage criteria and administrative rules

Covered services and administrative rules contained in this excerpt

CORE Services availability: Community Oriented Recovery and Empowerment (CORE) Services are available when eligible through enrollment in the adult HealthierLife plan with a supporting LPHA Recommendation Form; Service Initiation Form must be submitted to Fidelis Care by e-mail (QHCMHARPBH@FidelisCare.org) or fax (347-868-6427) within 3 business days of the first service visit

Services do not require authorization but do require timely notification

CFTSS utilization management: Effective 4/1/2020, utilization management requirements for Children and Family Treatment & 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 notification: Certain Children's Home and Community Based Services require notification to Fidelis Care prior to the member's initial appointment; providers must submit the Authorization and Care Manager Notification form to SM_Childrens_HCBS@fideliscare.org, fax (347) 690-7362, or call 1-888-FIDELIS to avoid claim processing disruptions; C-YES and Health Home providers must submit the Plan of Care

ASMT — covered with limits

Asthma Self-Management Training (ASMT) coverage rules

ASMT eligibility: Members (including pregnant women) with newly diagnosed asthma or asthma with a medically complex condition (exacerbation, poor control, complication) are eligible for up to ten (10) hours of ASMT during a continuous six‑month period; medically stable members may receive up to one (1) hour during a continuous six‑month period

ASMT may be provided individually or in group sessions (group size ≤ 8); codes S9441, S9445, S9446, 98960‑98962 require no authorization when billed with J45x

SCC — covered with limits

Smoking Cessation Counseling (SCC) coverage rules

SCC eligibility: Smoking cessation counseling reimbursed for up to eight (8) visits per calendar year using the sum of CPT codes 99406 and 99407 and must be billed only with diagnosis codes F17.200 or F17.2018 visits/year

No authorization required for Medicaid members

Enteral Therapy — covered with clinical criteria

Enteral Therapy coverage criteria (selected criteria extracted)

Enteral therapy benefit criteria: Coverage applies when one of the following is met: (1) tube‑fed individuals who can only obtain nutrition through a tube; (2) individuals with inborn metabolic disorders requiring specific formulas; (3) children under 21 who require medical formulas for growth/development; (4) adults with HIV/AIDS or related illness who are oral‑fed and require supplemental nutrition with documented compliance, BMI <22 and unintentional weight loss ≥5% within prior 6 months (up to 1,000 cal/day); (5) adults requiring supplemental nutrition with BMI <18.5 (up to 1,000 cal/day); (6) individuals requiring total nutritional support who cannot chew and placement of a feeding tube is contraindicatedsee node text

Enteral HCPCS codes B4034‑B4162 require prior authorization

Authorization and age-based rules

Authorization rules and coverage exceptions in this extract

Oncology authorization by age and program: Outpatient oncology‑related requests require authorization and review by New Century Health for members 18 and over in Medicaid Managed Care, Essential Plan, and Qualified Health Plan (excluding Child Health Plus); oncology indications for members under 18 do not require authorization; authorization is required for Child Health Plus members and not required for NYM or HARP membersage >= 18

PA via New Century Health portal or phone; CHP exception noted

Non-covered combinations

Non‑coverage pairing rules

Non-covered code/diagnosis combinations: Specific J‑codes listed (see policy) are non‑covered when billed with CPT codes 20610 or 20611 or with diagnosis MI7.0N/A

See document for exact J‑code list

For New York State Managed Medicaid, the Applied Behavioral Analysis (ABA) benefit is administered through Medicaid Fee‑For‑Service effective 8/1/2021 and therefore is not covered by Fidelis Care for NYS Managed Medicaid. For Child Health Plus members under age 21 ABA requires prior authorization from Behavioral Health when the member meets diagnostic and referral criteria (DSM‑5 diagnosis of autism spectrum disorder or Rett Syndrome and referral by a qualifying NYS‑licensed provider).

DME, procedures, and pharmaceutical treatments for erectile dysfunction are expressly excluded for members who are registered sex offenders. Examples of non‑covered codes/items include penile prosthesis and related procedures (e.g., 54360, 54400‑54402, 54405, 54408, 54410, 54411, 54416‑54417, 55870, HCPCS L7900).

Pharmacy‑related supplies associated with enteral therapy do not require prior authorization; however, supplies are not covered for Child Health Plus (CHP) members and coverage should be confirmed against the member's benefit plan. Enteral formulas and disposable items (HCPCS range B4034‑B4162) do require authorization when the enteral therapy benefit criteria are met.

A set of specific J‑codes (including J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332, J7333) are designated as non‑covered when billed with CPT codes 20610 or 20611 or when billed with the diagnosis code MI7.0. Providers should avoid billing these combinations to prevent denied claims.

CPT code 96110 is specified in the policy as a non‑covered service and should not be billed for outpatient behavioral health testing services under this plan.

For members with a diagnosis of Low Back Pain, certain therapeutic interventions are not covered. These exclusions 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 procedures.

Certain medication classes and specific scenarios require prior authorization or specialized review. Oncology medications and supportive agents for members age 18 and over in specified lines of business require prior authorization and routing to New Century Health; select agents (e.g., CAR T‑cell therapies, immune globulins, radiopharmaceuticals, and other specialty or controlled therapies) also require authorization. Authorization requests for pharmacy‑administered drugs should be submitted to the Pharmacy Team via e‑fax at 1‑877‑533‑2405 when indicated.

No summary content was extracted for this item.

Codes, Groups, and Coding Rules

Provider Notifications, Authorizations, and Submission Rules

Prior Authorization

Applied Behavioral Analysis (ABA) Prior Authorization

Authorization is required for Applied Behavioral Analysis (ABA) services when provided by out-of-network or out-of-state providers. Note: New York State Medicaid Fee‑for‑Service began covering ABA effective 08/01/2021; Fidelis Care does not manage that benefit for NYS Managed Medicaid. Verify payer responsibility before submitting a prior authorization request.

ABA benefit moved to NYS Medicaid FFS as of 08/01/2021 — Fidelis Care does not cover ABA for NYS Managed Medicaid.
Out-of-network or out-of-state ABA providers must request prior authorization through the appropriate payer.

Prior Authorization

Partial Hospitalization Prior Authorization

Partial Hospitalization (mental health and/or substance use) requires authorization beyond the initial service period outlined below. Utilization review (admission and concurrent/continued stay) is conducted for OMH‑licensed programs using NYS OMH Best Practice criteria.

No authorization needed for the first seven days of partial hospitalization services; additional days require prior authorization.

Background and Scope

New York State OMH‑licensed inpatient mental health facilities are subject to special notification and utilization review rules. OMH facilities must notify the plan within 2 business days of admission using the OMH Two‑Day Notification and Initial Treatment Plan form. OMH‑licensed inpatient mental health treatment is exempt from prior authorization for admissions meeting OMH criteria (effective 06/01/2021), and concurrent utilization review is conducted only when patients meet specified high‑utilization or other review triggers (for example, multiple recent hospitalizations, readmission within 30 days, or length of stay exceeding 30 days).

Key Definitions

OMH licensed hospital definition

DefinitionOMH licensed hospital: a hospital licensed by the New York State Office of Mental Health providing inpatient mental health treatment in New York State

Notification requirementFacility must notify Fidelis Care within 2 business days of admission (call 1-888-FIDELIS extension 16072 or fax (718) 896-1784)

Prior authorization stanceInpatient mental health treatment provided by OMH licensed hospitals is not subject to prior authorization review except when members meet specified utilization review triggers

OASAS licensed facility definition

DefinitionOASAS licensed facility: an inpatient substance use disorder facility licensed, certified or otherwise authorized by the NYS Office of Addiction Services and Supports

Notification requirement

Level-of-Care Specific Criteria

ABA (Child Health Plus) criteria

Child Health Plus ABA: Member under 21 with DSM‑5 diagnosis of autism spectrum disorder or Rett Syndrome; referral by NYS licensed provider; prior authorization required from Behavioral Healthage <21

NYS Managed Medicaid ABA benefit moved to Medicaid Fee‑For‑Service as of 8/1/2021

Specific Treatment Modalities and Criteria

ECT, IOP, PHP

ECT/IOP/PHP triggers: Utilization review based on high‑utilization triggers and readmission/length‑of‑stay criteria (e.g., >=3 psych inpatient hospitalizations in 12 months; >=4 psych ED visits in 12 months; readmission within 30 days; length of stay >30 days)see text

Out‑of‑network facilities subject to concurrent review throughout admission

CPST / PSR / Peer Support

CPST/PSR/Peer Supports: CPST (H0036), PSR (H2017), and Peer Support services (H0038) are listed as CORE and CFTSS services; prior authorization was never required for CFTSS and concurrent review is no longer required; CORE requires Service Initiation Form submission within 3 business days but not authorization

Providers may contact Fidelis Care for questions

Service Frequency and Visit Limits

Partial Hospitalization (no authorization required for first 7 days)

Initial no-auth periodPartial Hospitalization: no authorization required for the first 7 days of service

Codes referencedRevenue codes 905, 906, 912; CPT 90899; S9480; HCPCS H2013

After initial periodAdditional service days beyond day 7 require authorization and concurrent review triggers apply

Counseling services (codes G0108, G0109) — 10 hours / 20 units in 6-month period

Service codesCounseling services billed with G0108 and G0109

Limit10 hours (20 units) in a continuous 6-month period

Policy Summary

PayerFidelis Care

PolicyBehavioral health authorization and utilization review rules

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionAll inpatient admissions require prior authorization and facility admissions are reviewed for medical necessity.

SourceLink

On This Page

Notification should be submitted prior to rendering service

Counseling services coverage: Members are allowed 10 hours / 20 units of counseling in a continuous six‑month period; these services must be provided by certified providers and do not require authorization when billed with codes G0108 and G010910 hours / 20 units per 6 months

Asthma self‑management training coverage: Members with newly diagnosed or medically complex asthma may receive up to 10 hours of ASMT in a continuous six‑month period; medically stable members may receive up to 1 hour in six months; authorization is not required for codes S9441, S9445, S9446, 98960‑98962 when billed with diagnosis codes J45x<=10 hours for new/complex; <=1 hour for stable

Group sessions limited to no more than eight patients

Smoking cessation counseling coverage: Smoking cessation counseling reimbursed up to 8 visits per calendar year using codes 99406 and 99407 and must be billed only with diagnosis codes F17.200 or F17.201; no authorization is required for Medicaid members<=8 visits/year

Revenue codes: 905, 906, or 912; CPT 90899, S9480; HCPCS H2013.

Concurrent review triggers include high utilization (multiple inpatient/ED visits), Assisted Outpatient Treatment (AOT) status, readmission within 30 days, or length of stay >30 days.

Prior Authorization

Prior Authorization Requirements (selected services)

Selected outpatient, imaging, diagnostic, therapy, DME, and other services require prior authorization. Follow delegated review instructions where specified (e.g., TurningPoint, NIA, New Century Health). Submit requests to the appropriate reviewer to avoid denials or processing delays.

Outpatient & DME examples: sleep studies (including home sleep studies) require authorization.
Diagnostic/genetic testing: select genetic tests and BRCA-related testing require authorization (exceptions: CPT 81220, 81329, 81336 may be exempt as noted).
Imaging: certain ultrasounds beyond routine allowances and many radiology services may require authorization; radiology delegated to NIA for dates on/after 10/01/2021.
Outpatient therapy (PT/OT/ST) after the initial evaluation requires authorization via NIA; all home therapy treatments (including evaluations) require authorization.
Long Term Home Health Care Services (certain ADHC/ADHCIAADHC new patients, initial assessment visits) require authorization.

Prior Authorization

Enteral Therapy Prior Authorization and Documentation

Enteral therapy (HCPCS B4034–B4162) requires prior authorization and clinical documentation that demonstrates medical necessity based on diagnosis, nutritional needs, BMI/weight loss criteria, growth/development needs for children, or inability to obtain nutrition orally.

HCPCS range: B4034–B4162 require authorization for formulas and disposables.
Typical clinical indications: tube‑feeding dependency; inborn errors of metabolism needing specialized formulas; children <21 requiring medical formulas for growth/development; adults with HIV/AIDS meeting BMI/weight loss thresholds.
Pharmacy supplies for enteral therapy may be excluded from authorization depending on plan (e.g., CHP exclusions).

Prior Authorization

Authorization Requirement for Oncology‑Related Requests

Oncology-related medications and supportive agents for members age 18 and over require prior authorization via New Century Health (NCH) before dispensing or administration in pharmacy, physician office, outpatient hospital, or ambulatory settings for applicable lines of business. Some oncology requests and specific drug categories remain under Fidelis Care review — submit to the correct pathway.

NCH portal: mynewcenturyhealth.com or call 1‑888‑999‑7713 for PA requests (applies to Medicaid Managed Care, Essential Plan, Qualified Health Plan; excludes Child Health Plus for oncology PA requirement).
Do not send requests meant for Fidelis Care to NCH; certain categories (e.g., CAR T‑cell, immune globulins, radiopharmaceuticals, medications for clinical trials, retrospective reviews, non‑oncology indications) are reviewed directly by Fidelis Care/Pharmacy Team.
Authorization is not required for oncology indications for members <18; CHP members require authorization.
Pharmacy PA fax (electronic fax) for non‑NCH meds: 1‑877‑533‑2405.

Prior Authorization

Procedure‑Specific Authorization (delegations)

Certain procedure groups have authorization delegated to third‑party reviewers (e.g., TurningPoint, NIA). Providers must submit authorization requests to the delegated vendor when codes are listed on that vendor's delegated list. Associated devices (HCPCS) are reviewed with the delegated CPT code.

TurningPoint handles authorization for many outpatient, inpatient, office, and in‑home procedures (see TurningPoint delegated CPT list). If a CPT is delegated, associated HCPCS device codes are also reviewed by TurningPoint.
National Imaging Associates (NIA) reviews many radiology and outpatient therapy authorizations for dates on/after their delegation effective dates.
When in doubt, check the payer's delegated‑codes lists and submit to the vendor named for that code to prevent misrouting.

Denial Risk

Failure to Submit Required Notifications — Risk of Delay or Denial

Failure to submit required notifications or authorization/notification forms may lead to claim processing delays, denials, or retrospective review. Submit the specified forms within the stated timeframes to avoid disruptions in coverage or billing.

Children's HCBS: submit Authorization and Care Manager Notification form prior to initiating services to SM_Childrens_HCBS@fideliscare.org, fax (347) 690‑7362, or call 1‑888‑Fidelis and follow Children’s Medicaid prompts.
Inpatient SUD: facilities must notify Fidelis Care of an inpatient SUD admission and initial treatment plan within 2 business days (fax/email options provided) to avoid concurrent review exceptions; facilities outside NYS/network must request authorization.
CORE Services: Service Initiation Form must be submitted within 3 business days of the first service visit to QHCMHARPBH@FidelisCare.org or fax 347‑868‑6427.

Documentation Required

OMH Admission Notification Requirements

OMH‑licensed inpatient mental health admissions require submission of the OMH Two‑Day Notification and Initial Treatment Plan to Fidelis Care (fax 718‑896‑1784 or email MentalHealthAdmission@fideliscare.org). OMH programs are subject to utilization review and daily clinical review procedures and must participate in periodic consultation with Fidelis Care.

Two‑Day Notification form must be submitted within two days of admission.
Out‑of‑network OMH facilities remain subject to concurrent review throughout the admission.
Questions: contact Fidelis Care Behavioral Health at 1‑888‑FIDELIS during business hours.

Documentation Required

CORE Service Initiation Documentation and Submission

For CORE (Community Oriented Recovery and Empowerment) services, the Service Initiation Form must be submitted within 3 business days of the first service visit. CORE services do not require authorization when enrolled and eligible through the adult HealthierLife plan, but timely submission of the initiation documentation is required.

Submit Service Initiation Form to QHCMHARPBH@FidelisCare.org or fax 347‑868‑6427 within 3 business days of first service.
CORE availability contingent on enrollment in the adult HealthierLife plan and LPHA Recommendation Form completion.

Documentation Required

Outpatient and Home Therapy Authorization & Documentation

Outpatient and home therapy documentation must demonstrate medical necessity; after the initial evaluation, ongoing therapy visits (PT/OT/ST) require prior authorization. For outpatient settings, if non‑evaluation codes are billed on the same date as an initial evaluation, authorization must be requested within 1 business day (outpatient) or 2 business days (home health).

Initial evaluation CPTs for PT/OT/ST do not require prior authorization, but all subsequent billed procedure codes do.
All home therapy treatments, including evaluations, require prior authorization.
Non‑therapy providers should request authorizations for therapy services (beyond initial evaluation) directly through Fidelis Care when not covered by delegated vendor.

Billing Rule

Behavioral Service Billing and Documentation (Testing, ASMT, SCC)

Behavioral health billing/documentation rules: Psychological/neuropsychological testing and certain behavioral services require authorization and specific request forms; asthma self‑management training and smoking cessation counseling have distinct authorization and billing rules.

Psychological/Neuropsychological testing: authorization removed for most outpatient behavioral health services, but codes 96116, 96121, 96130–96133, 96136–96139, and 96146 continue to require authorization. Requests must use the Psychological/Neuropsychological testing request form; 96110 is non‑covered.
ASMT (Asthma Self‑Management Training): authorization not required when billed with J45x for S9441, S9445, S9446, 98960–98962. Members may receive up to 10 hours (newly diagnosed/complex) or 1 hour (medically stable) within specified periods.
Smoking Cessation Counseling (SCC): no authorization required; billing limited to up to 8 visits per calendar year using 99406/99407 with smoking diagnosis code F17.200/F17.201.

Facility must notify Fidelis Care within 2 business days of admission and provide the initial treatment plan (may fax/email OASAS Appendix A and LOCADTR tool)

Concurrent review exemptionInpatient SUD services provided by in-network OASAS-licensed facilities are exempt from concurrent utilization review for the first 28 days if notification and initial plan are submitted within 2 business days

CORE / HCBS / CFTSS definitions

CORE ServicesCommunity Oriented Recovery and Empowerment (CORE) Services available via adult HealthierLife enrollment with LPHA Recommendation; Service Initiation Form must be submitted within 3 business days of first visit

HCBS categoriesIncludes Pre-Vocational (T2015), Transitional Employment (T2019), Education Support (T2013), Supported Employment (H2023/H2025), and Provider Travel Supplement (A0160)

CFTSSChildren and Family Treatment & Support Services (CFTSS) include CPST (H0036), PSR (H2017), FPSS/YPSS (H0038) and do not require prior authorization; utilization management discontinued effective 4/1/2020

ASMT definition

TermASMT: Asthma Self-Management Training — structured education for members with newly diagnosed asthma or medically complex asthma, delivered individually or in groups (group size <= 8)

Covered codesCodes include S9441, S9445, S9446, 98960-98962; authorization not required when billed with J45x

LimitsUp to 10 hours during a continuous six-month period for newly diagnosed/medically complex cases; up to 1 hour for medically stable members

OASAS licensed facility definition

TermSCC: Smoking Cessation Counseling — behavioral counseling using CPT codes 99406 and 99407 billed with tobacco use disorder diagnosis codes F17.200 or F17.201

Coverage limitReimbursed up to 8 visits per calendar year (sum of 99406 and 99407)

AuthorizationNo authorization required for Medicaid members per document

ASMT / SCC delivery and limits: ASMT may be provided individually or in groups (max group size 8); newly diagnosed or medically complex asthma: up to 10 hours per continuous six‑month period; medically stable asthma: up to 1 hour per six months. SCC reimbursed up to 8 visits per calendar year (codes 99406+99407) billed with F17.200 or F17.201. Authorization not required for ASMT codes when billed with J45x and no authorization required for Medicaid members for SCC10 hours / 1 hour / 8 visits

Billing must use specified diagnosis codes

Provider requirementServices must be provided by certified providers; authorization no longer required

ASMT — hours limits by clinical status

ASMT hours for new/complex casesUp to 10 hours during a continuous six-month period for newly diagnosed or medically complex asthma members

ASMT hours for stable casesUp to 1 hour during a continuous six-month period for medically stable asthma members

DeliveryMay be provided individually or in group sessions of no more than eight patients; codes S9441/S9445/S9446/98960-98962 and billing rules apply

Smoking Cessation Counseling visit limit

Service codesCPT codes 99406 and 99407

LimitUp to 8 visits per calendar year (sum of 99406 + 99407)

Billing diagnosisMust be billed only with diagnosis codes F17.200 or F17.201

ASMT for newly diagnosed or medically complex asthma members — 10 hours

ASMT for newly diagnosed/complex asthma10 hours during a continuous six-month period

EligibilityMembers with newly diagnosed asthma or asthma with medical complexity (exacerbation, poor control, complication)

Delivery constraintsGroup sessions limited to no more than eight patients; no authorization required for specified codes when billed with J45x

ASMT for medically stable asthma members — 1 hour

ASMT for medically stable members1 hour during a continuous six-month period

ApplicabilityFor members whose asthma is medically stable

Coding noteAuthorization not required for S9441/S9445/S9446/98960-98962 when billed with J45x

Smoking cessation counseling (99406+99407) — 8 visits

Codes99406 and 99407

LimitMaximum of 8 visits per calendar year when billed with F17.200 or F17.201

AuthorizationNo authorization required for Medicaid members