Fidelis Care behavioral health Prior Auth Policy Update | OpenPayer
ModifiedFidelis CarePolicy N/A
Behavioral health authorization, utilization review, and coding guidance updates
This document describes Fidelis Care authorization, utilization review, and coding guidance updates related to COVID-19 and broader behavioral health and service-specific authorization rules affecting providers serving Fidelis Care members in New York State.
Policy Summary
PayerFidelis Care
PolicyBehavioral health authorization, utilization review, and coding guidance updates
Policy CodePolicy N/A
Change TypeMaterial coverage and authorization updates
Effective DateAug 1, 2021
Next Review DateN/A
Key ActionNotify Fidelis Care within 2 business days of OMH- or OASAS-licensed inpatient admissions and submit the required initial treatment documentation.
Effective 08/01/2021: Inpatient SUD services provided by OASAS-licensed, in-network NY facilities are not subject to authorization review and are not subject to concurrent utilization review for the first 28 days if the facility notifies Fidelis Care within two business days and provides specified documentation.
Effective 06/01/2021: Inpatient mental health treatment provided by OMH-licensed hospitals in New York State are not subject to authorization review, with notification to Fidelis Care within 2 business days required.
Effective 08/01/2021: Several outpatient substance use services (including outpatient visits, therapy, IOP, OTP) provided in-network and in-state do not require provider notification, authorization, or concurrent review.
Behavioral health outpatient services (psych testing CPT codes and ECT) require authorization and must be submitted on the Psychological/Neuropsychological testing request form.
Partial hospitalization, intensive outpatient, and inpatient mental health utilization review will be conducted only for members meeting NYS OMH Best Practice Manual clinical criteria (e.g., AOT status, high utilization thresholds).
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28 daysNo concurrent review period for in-network OASAS inpatient SUD admissions when notification provided
2 business daysFacility must notify Fidelis Care of inpatient SUD or OMH mental health admissions and initial treatment plan
First 7 daysNo authorization required for initial Mental Health Continuing Treatment / first PHP days
NY onlyExceptions limited to NYS OMH/OASAS-licensed in-network facilities
08/01/2021Policy effective date referenced
Coverage and Utilization Criteria
Inpatient Admission Authorization
All inpatient admissions require authorization and are reviewed for medical necessity.
Inpatient Admission Requirement: All inpatient admissions require an authorization and are reviewed for medical necessity
Emergency department stabilization does not require prior authorization; post-stabilization inpatient admissions do
Inpatient Substance Use Disorder (SUD) Authorization Exception
Inpatient SUD services provided by OASAS-licensed, in-network NY facilities:
Inpatient SUD in-network NY OASAS-licensed: Facility notifies Fidelis Care within two business days of admission and provides OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool; facility performs daily clinical review; no concurrent utilization review for the first 28 days28 days no concurrent review
Services may be subject to utilization review after day 28 or upon discharge; out-of-state, non-OASAS-licensed, or out-of-network facilities remain subject to authorization and concurrent review throughout admission
OMH-licensed Inpatient Mental Health Utilization Review Criteria
Inpatient mental health treatment provided by OMH-licensed hospitals in NY:
OMH licensed inpatient review triggers
Triggers: Current Assisted Outpatient Treatment (AOT) court order; AOT expired within 5 years; three (3) or more psychiatric inpatient hospitalizations in 12 months; four (4) or more psychiatric ED visits in 12 months; three (3) or more medical inpatient hospitalizations in 12 months; readmission to any mental health inpatient unit within 30 days of discharge; length of stay >30 days (concurrent review from day 31 onward)see above
Per NYS OMH Best Practice Manual
Partial Hospitalization and IOP Utilization Review Criteria
Partial hospitalization and Intensive Outpatient mental health services provided by OMH-licensed programs in NY will be reviewed only when clinical criteria are met:
Partial/IOP review triggers: Individuals with current AOT or AOT expired within 5 years; three (3) or more psychiatric inpatient hospitalizations in 12 months; four (4) or more psychiatric ED visits in 12 months; three (3) or more medical inpatient hospitalizations in 12 months; readmission within 30 days; length of stay >30 dayssee above
No prior authorization needed for first seven days of Partial Hospitalization; out-of-network facilities are subject to concurrent review throughout admission
ASD-related Services Authorization
Autism Spectrum Disorder (ASD) services:
ASD DME and ABA Authorization: Authorization required for DME speech-generation equipment and for Applied Behavioral Analysis (ABA); attestation of ASD diagnosis by a licensed physician or psychologist must accompany the request
Requests for members ages 18-20 have specific submission paths (email/fax/phone) as specified in the source text
CFTSS (Children & Family Treatment & Support Services)
CFTSS utilization management: 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
CFTSS services include CPST (H0036), FPSS/YPSS (H0038), PSR (H2017), and Crisis Intervention (H2001, S9484, S9485)
Age-based authorization matrix: Many OMH-designated services for children have specific age requirements and differing authorization needs: OMH SED clinic services, OMH outpatient, psychiatric and psychological services generally require no authorization for specified age groups; higher intensity services (Partial Hospitalization, ACT for ages 18-20, Continuing Treatment Day) require prior authorization and concurrent review; PROS requires concurrent review for ages 18-20
Requests for members under age 21 have specified submission routes (email/fax/phone)
Children's HCBS Authorization Criteria
Children's Home and Community Based Services (effective 10/1/19)
HCBS eligibility and initial authorization: HCBS-eligible members (identified by a Health Home or C-YES) require HCBS eligibility and a Plan of Care for initial authorization; initial authorization for services 1-6 is 96 units or 24 hours total of service within 60 days of HCBS provider notification; concurrent review is required for continued stayInitial auth: 96 units / 24 hours within 60 days
Respite services do not require prior authorization initially; concurrent review required after 7 consecutive days; Crisis Respite stays >72 hours trigger concurrent review
Diabetes Self-Management Training (DSMT)
Covered when ALL of the following are met
DSMT coverage: Members are allowed 10 hours/20 units in a continuous 6-month period; services must be provided by certified providers and are covered when billed with codes G0108 and G010910 hours/20 units
Authorization not required for these DSMT codes per source text
Asthma Self-Management Training (ASMT)
Covered when ALL of the following are met
ASMT coverage: Members with newly diagnosed asthma or asthma with medically complex conditions are allowed up to 10 hours of ASMT during a continuous 6-month period; medically stable members may receive up to 1 hour during a continuous 6-month period; services may be individual or group (max 8 patients)10 hours or 1 hour depending on stability
Authorization is not required for codes S9441, S9445, S9446, 98960-98962 when billed with diagnosis code J45x
Smoking Cessation Counseling
Covered when ALL of the following are met
Smoking Cessation Counseling: Smoking cessation counseling is reimbursed for up to 8 visits per calendar year using codes 99406 and 99407 and must be billed only with diagnosis codes F17.200 or F17.2018 visits/year
No authorization is required for Medicaid members per the source text
Facilities that are outside New York State, facilities that are not licensed, certified, or otherwise authorized by OASAS or OMH, and facilities that are outside of Fidelis Care’s provider network (out-of-network) are not eligible for the authorization and concurrent review exceptions described for in‑state, in‑network OASAS/OMH facilities. These facilities must request prior authorization and remain subject to concurrent review for the entire admission.
The policy lists specific therapeutic procedures and other services that are not covered for members with a diagnosis of Low Back Pain. Examples include therapeutic facet joint steroid injections in the lumbar and sacral regions, therapeutic steroid injections into intervertebral discs, and continuous or intermittent traction. Providers should not bill these services for members whose primary diagnosis is Low Back Pain as they will be non‑covered.
Therapeutic facet joint steroid injections performed in the lumbar and sacral regions (with or without CT fluoroscopic guidance) are explicitly listed as not covered when provided for members with a diagnosis of Low Back Pain. Submit prior authorization requests only when clinically indicated outside the Low Back Pain diagnosis; otherwise these procedures will be denied as non‑covered for that diagnosis.
Durable medical equipment and pharmaceutical treatments related to erectile dysfunction (examples: CPT/HCPCS codes 54360, 54400‑54402, 54405 and L7900) are specifically not covered for registered sex offenders. Providers should verify member eligibility and do not submit authorization requests for these items when the member is a registered sex offender.
Claims are non‑covered when billed with CPT code 20610 or 20611 in combination with the specified diagnosis code MI7.0. When these codes appear together on a claim, coverage will be denied; providers should ensure appropriate coding to avoid non‑covered billing.
The policy notes that CPT code 20610 is non‑covered when billed with certain diagnosis codes. While the full list of those diagnoses is in the source file, the document flags this pairings rule to prevent coverage for 20610 when billed with specified diagnosis codes; confirm diagnosis coding before submitting claims for procedures billed with 20610.
In addition to facet joint injections, the policy identifies an expanded set of therapeutic services that are not covered for Low Back Pain. This expanded list includes, but is not limited to, therapeutic injections of steroids into intervertebral discs, continuous or intermittent traction, and other pain management modalities enumerated under the Therapeutic Services section. These services will be denied when provided for the Low Back Pain diagnosis.
Some procedures and treatments described in the Therapeutic Services section require prior authorization (for example, topical oxygen requires authorization), while other listed procedures are explicitly not covered for Low Back Pain. Additionally, certain services (e.g., radiation therapy) require authorization through designated vendors (e.g., eviCore). Providers must follow the prior authorization requirements and the non‑coverage guidance when treating members with Low Back Pain.
Enteral formulas or disposable enteral items that require authorization
Cross-referenced J/Q/S HCPCS codes listed in appendixHCPCS
J1556
Listed cross-reference drug/HCPCS in appendix
J1557
Listed cross-reference drug/HCPCS in appendix
J1558
Listed cross-reference drug/HCPCS in appendix
J1559
Listed cross-reference drug/HCPCS in appendix
J1561
Listed cross-reference drug/HCPCS in appendix
J1562
Listed cross-reference drug/HCPCS in appendix
J7200
Listed cross-reference drug/HCPCS in appendix
J7201
Listed cross-reference drug/HCPCS in appendix
J7203
Listed cross-reference drug/HCPCS in appendix
J7204
Listed cross-reference drug/HCPCS in appendix
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CPT codes affecting coverageCPTNot Covered
CPT 20610
Procedure code referenced in non-coverage note
CPT 20611
Procedure code referenced in non-coverage note
Utilization triggers — OMH Best Practice thresholds
Psychiatric inpatient hospitalizations3 or more psychiatric inpatient hospitalizations in the prior 12 months
Psychiatric emergency visits4 or more psychiatric ED visits in the prior 12 months
ReadmissionReadmission to any mental health inpatient unit within 30 days of discharge
Provider Submission, Authorization, and Denial Risk
Prior Authorization
Prior Authorization Required
Prior authorization is required for the services and codes listed below. Providers must obtain authorization for all inpatient admissions, specified transplant codes, delegated orthopedic/spinal procedures, outpatient surgical procedures, many ancillary diagnostic and imaging services, select therapeutic procedures and devices, behavioral health programs listed under the Children’s BH carve-in and HCBS, and certain pharmacy, enteral, and specialty medications. Failure to obtain required authorizations (including for inpatient admissions, transplants, inpatient rehab, and delegated procedures) may result in claim denial.
All solid organ and bone marrow transplants require authorization at the time of transplant evaluation (examples: CPT ranges listed in source).
Orthopedic and spinal surgical procedures require authorization; select codes and devices delegated to TurningPoint Healthcare Solutions for review.
Outpatient surgeries listed in policy (e.g., blepharoplasty 15820-15823; bariatric 43770-43775; breast reconstruction 11920-11971,19300,19316-19396; many others) require prior authorization.
Outpatient therapy (PT/OT/ST) services after the initial evaluation require prior authorization through NIA (effective 10/1/2019); initial evaluations do not require authorization.
Definitions and Background
This policy aligns Fidelis Care’s utilization review and medical necessity processes with New York State OMH and OASAS guidance. For OMH‑licensed inpatient mental health treatment and OASAS‑licensed inpatient SUD services provided in New York State, the document establishes notification timelines and clinical review triggers: facilities must notify Fidelis Care within 2 business days of admission and may be exempt from prior authorization or concurrent review in defined initial periods (for example, up to 28 days for in‑network OASAS inpatient SUD admissions when the required notification and documentation are provided). Utilization review is applied based on NYS OMH Best Practice clinical criteria and may be triggered by high utilization patterns or specified clinical circumstances.
OASAS-licensed Inpatient SUD services — definition & scope
Scope — OASAS-licensed SUD inpatient servicesInpatient detoxification, inpatient rehabilitation, and inpatient residential treatment services provided by facilities in New York State that are licensed, certified, or otherwise authorized by OASAS and participating in the Fidelis provider network
Notification requirementFacility must notify Fidelis Care within 2 business days and provide required OASAS forms and LOCADTR tool documentation
Limitations — out-of-network/out-of-stateFacilities outside NYS or not OASAS-licensed or out-of-network remain subject to authorization and concurrent review
Level of care criteria for inpatient, partial hospitalization, and intensive outpatient services.
Admission triggers for OMH inpatient/partial/IOP: Current AOT; AOT expired within 5 years; 3+ psychiatric inpatient hospitalizations in 12 months; 4+ psychiatric ED visits in 12 months; 3+ medical inpatient hospitalizations in 12 months; readmission within 30 dayssee values above
Per NYS OMH Best Practice Manual
Continued stay concurrent review: Concurrent utilization review applies for members meeting the clinical triggers or for stays exceeding 30 days (concurrent review from day 31 onward)>30 days
Out-of-network facilities subject to concurrent review throughout admission
ABA Authorization: Authorization required from Behavioral Health for ABA; attestation of ASD diagnosis by a licensed physician or psychologist must accompany the request
Submission instructions provided for members ages 18-20
DME and ABA for ASD: DME speech-generation equipment and ABA require authorization and attestation of ASD diagnosis must be provided at time of request
Time Limits, Visit Counts, and Short-Term Exceptions
Mental Health Continuing Treatment (H2012) and Partial Hospitalization — first 7 days
No auth for initial periodMental Health Continuing Treatment (H2012) and the first 7 days of Partial Hospitalization do not require authorization
Partial Hospitalization post-7 daysAdditional days beyond the first 7 require prior authorization (relevant revenue/CPT/HCPCS codes noted in source)
OMH facility notificationOMH-licensed facilities must notify Fidelis Care within 2 business days as specified elsewhere in the policy
Inpatient SUD — concurrent review window
Concurrent review exemption periodNo concurrent utilization review for the first 28 days of an inpatient SUD admission when the facility notifies Fidelis Care within 2 business days
Notification method
Policy Summary
PayerFidelis Care
PolicyBehavioral health authorization, utilization review, and coding guidance updates
Policy CodePolicy N/A
Change TypeMaterial coverage and authorization updates
Effective DateAug 1, 2021
Next Review DateN/A
Key ActionNotify Fidelis Care within 2 business days of OMH- or OASAS-licensed inpatient admissions and submit the required initial treatment documentation.
Length of stay triggerLength of stay exceeding 30 days (concurrent review from day 31 onward)
Medical inpatient utilization3 or more medical inpatient hospitalizations in the prior 12 months
Inpatient SUD concurrent review window
Concurrent review exemption periodNo concurrent utilization review for the first 28 days of an inpatient SUD admission when facility notification requirements are met
Notification timeframeFacility must notify Fidelis Care within 2 business days of admission
Documentation requiredOASAS Appendix A Notification Form and OASAS LOCADTR Medical Necessity Tool (fax/email submission options provided)
HCBS initial authorization units/hours
Initial authorization units/hoursInitial authorization for HCBS services 1-6: 96 units or 24 hours total of service
Authorization windowInitial authorization applies within 60 days from notification received from HCBS provider
Required documentationHCBS eligibility and a Plan of Care (POC) are required for initial authorization
OB ultrasound frequency without prior auth
OB ultrasound allowance without prior authFirst 4 obstetric ultrasounds may be performed without authorization
Auth required for routine pregnancyFive or more ultrasounds for a normal pregnancy require authorization (diagnosis codes listed in source)
High-risk pregnanciesOB ultrasounds for high-risk pregnancies follow separate authorization criteria as listed
DSMT / ASMT session limits
DSMT maximumMembers are allowed 10 hours (20 units) of Diabetes Self-Management Training in a continuous 6-month period
ASMT — newly diagnosed/complexMembers with newly diagnosed or medically complex asthma may receive up to 10 hours of ASMT in a continuous 6-month period
ASMT — stable asthmaMedically stable asthma members may receive up to 1 hour of ASMT in a continuous 6-month period
Smoking cessation counselingSmoking cessation counseling reimbursed for up to 8 visits per calendar year (codes 99406/99407)
Radiology and radiation therapy services require authorization through eviCore Healthcare (full CPT list at eviCore).
Diagnostic testing (sleep studies including home sleep studies, genetic/BRCA testing except listed CPT exceptions, wireless capsule endoscopy, gastroenterology procedures in certain places of service) require prior authorization.
Therapeutic services such as phototherapy (CPT 96567, 96573-96574, 96900, 96910, 96912-96913, 96920-96922), hyperbaric oxygen, pain management injections, topical oxygen, ambulatory continuous glucose monitoring (95249), bronchial thermoplasty (31660,31661), radiofrequency ablation of uterine fibroids (58674) require authorization or are managed via vendor.
Behavioral health programs (Partial Hospitalization, ACT for ages 18-20, Continuing Treatment Day, PROS, inpatient psychiatric services for under-21 triggers) require prior authorization or concurrent review per Children’s BH carve-in guidance.
ADHC/ADHC-IAADHC: prior authorization required for any new patient and for the initial assessment (up to two visits); continuation reviewed for medical necessity.
HCBS services (Community Habilitation, Caregiver/Family Support, Habilitation Day, Community Self Advocacy, Prevocational, Supported Employment) — initial authorization requires HCBS eligibility and a plan of care and is limited (e.g., initial authorization of 96 units or 24 hours within 60 days); concurrent review required for continued services.
Enteral therapy items (HCPCS B4034–B4162) require authorization; criteria/benefit applicability described (tube-fed only, inborn metabolic disorders, children under 21 with medical formulas, certain adults with HIV/AIDS and weight/BMI criteria).
Oncology medications and supportive agents for members 18+ require prior authorization/review by New Century Health (NCH) before dispensing/administration; certain oncology or specialty products (radiopharmaceuticals, immune globulins, CAR-T, clinical trial meds, etc.) are reviewed directly by Fidelis Care.
Providers should submit authorizations and documentation via the channels specified for each program/vendor (Fidelis portal, NCH portal, vendor phone/fax numbers, or designated email addresses for children’s BH and HCBS requests).
Prior Authorization
Behavioral Health Programs Requiring Authorization
Behavioral health programs listed under the Children’s BH carve-in and HCBS programs require prior authorization or concurrent review as specified. Requests for members under age 21 (and ages 18–20 for some programs) have dedicated submission routes.
Partial Hospitalization Program: Prior authorization and concurrent review; Requirement Age = Under 21.
Assertive Community Treatment (ACT): Prior authorization and concurrent review; Requirement Age = 18–20.
Continuing Treatment Day: Prior authorization and concurrent review; Requirement Age = 18–20.
Personalized Recovery Oriented Services (PROS): Concurrent review (authorization rules vary by age group).
Inpatient Psychiatric Services for members under 21: Prior authorization and concurrent review per carve-in rules and NYS OMH criteria.
HCBS services 1–6 (e.g., Community Habilitation, Habilitation Day, Prevocational, Supported Employment): Initial authorization requires HCBS eligibility and a Plan of Care (POC); initial auth typically limited to 96 units or 24 hours within 60 days of notification; concurrent review required for continued services.
Short Term Crisis Respite: No authorization required for access; authorization required before stays exceeding 72 hours; concurrent review applies for longer stays.
Prior Authorization
Ancillary Services Requiring Authorization
Ancillary diagnostic, imaging, sleep, and therapy services require prior authorization or are managed by delegated vendors. Radiology and radiation therapy authorizations are handled through eviCore; outpatient therapy prior authorization is managed through National Imaging Associates (NIA).
Sleep studies (including home sleep studies) require prior authorization.
Genetic testing and BRCA testing require authorization except for CPTs 81220, 81329, 81336 (these are not required and have lifetime limits as noted).
Wireless capsule endoscopy and wireless motility capsule (91110–91112) require authorization unless performed in POS 11 or 24.
Selected gastroenterology procedures require authorization when performed in certain places of service if an office/ASC is available (e.g., 43235,43239,43248,45378,45380,45384,45385,46255,46260,46270).
Imaging services: OB ultrasound limits (first 4 without auth; five or more for normal pregnancy require auth); radiology services and radiation therapy require authorization via eviCore (links provided in policy).
Outpatient PT/OT/ST (after initial evaluation) require prior authorization through NIA; initial evaluations are exempt but all subsequent billed codes require authorization.
Billing Rule
Select Procedures, Phototherapy, and Not‑Covered Services
Select procedures, devices, phototherapy codes, and certain therapeutic services are either not covered for specified diagnoses or require authorization. Providers must follow the coding and non-coverage rules to avoid denials.
Some services are specifically not covered for members with a diagnosis of Low Back Pain: therapeutic facet joint steroid injections in the lumbar/sacral regions (with or without CT fluoroscopic guidance), therapeutic steroid injections into intervertebral discs, continuous or intermittent traction, and other listed low‑back therapies.
CPT 20610 (and 20611) is non‑covered when billed with certain diagnoses (policy notes CPT 20610/20611 non‑covered when billed with diagnosis MI7.0); providers should not bill these combinations.
All services reported with unlisted or temporary codes (including C‑codes) require authorization.
Ambulatory continuous glucose monitoring (95249), bronchial thermoplasty (31660, 31661), and radiofrequency ablation of uterine fibroids (58674) require prior authorization.
Prior Authorization
Pharmacy and Specialty Medication Prior Authorization
Pharmacy, enteral, and specialty medication authorizations are required per the policy. Oncology/supportive agents for adults 18+ are reviewed by New Century Health (NCH); many other injectable/specialty and enteral items are reviewed directly by Fidelis Care. Providers must use the designated submission channels and note exceptions.
Enteral therapy products (HCPCS B4034–B4162) require prior authorization; clinical criteria and beneficiary groups (tube-fed only, inborn metabolic disorders, children <21 with medical formulas, certain adults with HIV/AIDS and BMI/weight loss criteria) are specified in policy.
Oncology medications and supportive agents for members 18 and over require prior authorization/review by New Century Health (NCH). Providers should request PA via NCH’s web portal or by calling 1‑888‑999‑7713.
Certain categories of drugs are reviewed directly by Fidelis Care and should not be sent to NCH: radiopharmaceuticals; anti‑infectives; iron preparations; medications for clinical trials; medications not used for oncology indications; CAR T‑cell therapy; Cablivi; immune globulins; sickle cell disease therapies; pain medications; controlled substances; retrospective reviews.
Specific J‑codes / C‑codes / HCPCS drug items listed in the policy (examples and long list provided in source) require authorization prior to dispensing or administration.
Self‑administered medications are covered under the pharmacy benefit; authorization requests to the Fidelis Pharmacy Team can be submitted electronically via e‑fax to 1‑877‑533‑2405 as noted.
Authorization is not required for oncology indications for members under age 18 and is not required for ophthalmic indications (policy exceptions).
Prior Authorization
Vendor Managed Authorization
Some authorizations and administrative reviews are managed by delegated vendors. Vision and orthodontic authorizations for applicable populations must be requested through the delegated vendors. Use vendor contact points for submission.
Vision prior authorizations are handled by Davis Vision (1-800-601-3383).
Orthodontic services for Medicaid members under age 21 require authorization by DentaQuest (1-800-516-9615).
Radiology and radiation therapy authorizations are managed through eviCore Healthcare (link provided in policy).
Orthopedic/spinal procedure authorizations (and associated devices/HCPCS) may be delegated to TurningPoint Healthcare Solutions — providers should follow TurningPoint submission instructions for delegated CPT/HCPCS codes.
Documentation Required
ADHC and HCBS Authorization / Documentation
ADHC/ADHC‑IAADHC and HCBS initial authorization and documentation requirements: ADHC programs require prior authorization for new patients and for the initial assessment (up to two visits). HCBS initial authorizations require documentation of HCBS eligibility and a Plan of Care; concurrent review is required for continued services.
ADHC/ADHC‑IAADHC: Authorization required for any new patient and for the initial assessment (up to two visits). Members enrolled as of 8/1/13 remain in current care plan up to 90 days; continuation beyond that is reviewed for medical necessity.
HCBS initial authorization (services 1–6) requires documentation of HCBS eligibility and a Plan of Care; initial authorization timeframe examples: 96 units or 24 hours total within 60 days from notification; concurrent review required for continued services.
Respite Services: Planned Respite does not require prior authorization; Crisis Respite does not require access authorization but requires auth before stays exceeding 72 hours and concurrent review thereafter.
Denial Risk
Provider Action & Denial Risk Notes
Operational and submission notes, exceptions, and denial risks: follow policy submission routes, meet required documentation timelines (e.g., OMH Two‑Day Notification for inpatient mental health admissions), and be aware of denial triggers.
For OMH‑licensed inpatient mental health admissions: facility must notify Fidelis Care within 2 business days and submit the OMH Two‑Day Notification and Initial Treatment Plan form via fax (718‑896‑1784) or email (Mental_HealthAdmission@fideliscare.org).
Facilities must notify Fidelis Care of inpatient SUD admissions and provide the initial treatment plan within two business days (OASAS Appendix A / LOCADTR forms to fax/email or submit as directed).
Requests for services for members under age 21 (and ages 18–20 for some programs) can be submitted by email (e.g., chmmc@fideliscare.org, SM_Childrens_HCBS@fideliscare.org), fax ((347) 690‑7362), or by calling 1‑888‑FIDELIS and following Children’s Medicaid prompts.
Authorization is not required for oncology indications for members under 18 and not required for ophthalmic indications per policy notes.
Denial risk: failure to obtain required authorizations (inpatient admissions, transplants, inpatient rehab, delegated orthopedic/spinal procedures, and other listed services) may lead to denial of coverage or payment. Providers should follow delegated vendor requirements when applicable.
OMH-licensed Inpatient Mental Health Treatment — definition
Scope — OMH-licensed inpatient mental health treatmentInpatient mental health treatment for all ages provided by OMH-licensed hospitals in New York State
Notification and formFacility must notify Fidelis Care within 2 business days and submit the OMH Two-Day Notification and Initial Treatment Plan form
Utilization review applicationNot subject to routine authorization review; utilization review conducted only for members meeting NYS OMH Best Practice clinical triggers
HCBS (Home and Community Based Services) — definition
DefinitionHome and Community Based Services (HCBS) are a set of adult and children’s community-based services (e.g., Community Habilitation, Pre-vocational services, Supported Employment, Respite) requiring HCBS eligibility and a Plan of Care for authorization
Initial auth requirementHCBS eligibility and Plan of Care required for initial authorization; initial auth for services 1-6 is 96 units or 24 hours within 60 days of provider notification
Concurrent reviewConcurrent review is required for continued stay; respite services require concurrent review after specified durations
CFTSS — definition
DefinitionChildren and Family Treatment & Support Services (CFTSS) are a category of children’s community-based services (e.g., CPST H0036, FPSS H0038, PSR H2017, YPSS H0038, Crisis Intervention) for which utilization management requirements were discontinued effective 4/1/2020
Authorization stancePrior authorization was never required for CFTSS and concurrent review is no longer required
Service examplesIncludes CPST, FPSS/YPSS, PSR, and Crisis Intervention codes as listed in the policy
DSMT — definition
DefinitionDiabetes Self-Management Training (DSMT) is certified provider-delivered education for diabetes
Coverage limitMembers are allowed 10 hours (20 units) in a continuous 6-month period; services billed with codes G0108 and G0109 no longer require authorization
Provider requirementServices must be provided by certified providers to qualify for coverage
ASMT — definition
DefinitionAsthma Self-Management Training (ASMT) provides education for newly diagnosed or medically complex asthma patients and for stable patients with different hour limits
Coverage limitsUp to 10 hours during a continuous 6-month period for newly diagnosed/complex patients; stable asthma patients may receive up to 1 hour during a continuous 6-month period
Authorization exceptionsAuthorization is not required for codes S9441, S9445, S9446, 98960-98962 when billed with diagnosis J45x
ScopeRange describes enteral formulas and disposable items that require authorization
Authorization requirementProviders must request authorization for enteral therapy items described by codes in this range
Level of care criteria across multiple program types (inpatient, PHP, ACT, outpatient, HCBS).
Admission/authorization triggers for child behavioral services: OMH-designated SED clinic services, OMH outpatient, psychiatric and psychological services generally require no authorization for specified ages; higher intensity services (Partial Hospitalization, ACT ages 18-20, Continuing Treatment Day) require prior authorization and concurrent review; PROS requires concurrent review for ages 18-20
HCBS initial auth requirements and thresholds apply for eligible members (see HCBS criteria)
HCBS continued stay: HCBS services require concurrent review for continued stay; planned respite requires concurrent review after 7 consecutive days; crisis respite >72 hours triggers concurrent reviewInitial auth: 96 units / 24 hours
Requests for members under age 21 have specified submission routes
Outpatient - Counseling/Self-Management
Level of care criteria for outpatient counseling and self-management training.
Outpatient counseling/self-management limits: DSMT: up to 10 hours/20 units per continuous 6-month period; ASMT: up to 10 hours per continuous 6-month period for newly diagnosed/complex or 1 hour for stable patients; Smoking cessation: up to 8 visits per calendar year10 hours; 10 hours or 1 hour; 8 visits
Codes and billing requirements specified in source text; authorization not required for the listed DSMT/ASMT codes when billed as indicated
Submission instructions for ages 18-20 provided in source text
Community-based children & family behavioral services
CFTSS modalities include CPST (H0036), FPSS/YPSS (H0038), PSR (H2017) and Crisis Intervention (H2001, S9484, S9485); utilization management discontinued effective 4/1/2020
Prior authorization is not required for CFTSS
Self-management training and counseling
Education and counseling limits: DSMT: 10 hours/20 units per continuous 6-month period; ASMT: up to 10 hours per continuous 6-month for newly diagnosed/complex or 1 hour for stable patients; Smoking cessation counseling: reimbursed up to 8 visits per calendar year10 hours; 10 hours or 1 hour; 8 visits
Codes and billing criteria specified in source text; authorization not required for listed DSMT/ASMT/SCC codes when billed as indicated
Facility may fax or email OASAS Appendix A Notification Form and LOCADTR tool to the contacts provided in the policy
Post-exemption reviewServices may be subject to utilization review after day 28 or upon discharge
OB ultrasound (imaging) authorization frequency
OB ultrasound allowanceFirst 4 obstetric ultrasounds without authorization per pregnancy
Routine pregnancy thresholdFive or more ultrasounds for a normal pregnancy require authorization (diagnosis codes cited in source)
Radiology authorizationsOther radiology services require authorization through eviCore as specified
Initial HCBS authorizationInitial authorization for HCBS services (services 1-6): 96 units or 24 hours total within 60 days of HCBS provider notification
Concurrent review for continued stayConcurrent review is required for continued stay after initial authorization
Respite specificsPlanned Respite does not require prior authorization initially; concurrent review required after 7 consecutive days; Crisis Respite >72 hours triggers concurrent review
DSMT limitDSMT: 10 hours (20 units) in a continuous 6-month period
ASMT limitASMT: up to 10 hours per continuous 6-month period for newly diagnosed or medically complex patients; stable patients up to 1 hour per 6 months
Smoking cessation limitSmoking cessation counseling: up to 8 visits per calendar year (codes 99406/99407)