Fidelis Care Behavioral Health Prior Auth Policy

Coverage Criteria and Exemptions

OMH Inpatient Exemption (first 14 days)

OMH-licensed inpatient mental health treatment coverage and utilization review rules

OMH inpatient no auth conditions: OMH-licensed hospitals in New York State participating in Fidelis provider network are not subject to authorization review and Fidelis will not conduct concurrent utilization review for the first 14 days provided the facility: (i) notifies Fidelis Care of admission and the initial treatment plan within two business days using the OMH Two-Day Notification and Initial Treatment Plan form; (ii) performs daily clinical review of the patient; and (iii) participates in periodic consultation with Fidelis Care to ensure use of approved evidence-based clinical review criteria.

Notification via OMH two-day form required; applies to in-network OMH-licensed hospitals.

Inpatient SUD Exemption (first 28 days)

OASAS-licensed Inpatient SUD coverage and utilization review rules

Inpatient SUD no auth conditions: Inpatient SUD services provided by New York State OASAS-licensed, participating network facilities are not subject to authorization review and are not subject to concurrent utilization review during the first 28 days of the inpatient admission provided the facility: (i) notifies Fidelis Care of the inpatient admission and initial treatment plan within two business days (OASAS Appendix A Notification Form and LOCADTR may be submitted); (ii) performs daily clinical review of the patient; and (iii) periodically consults with Fidelis Care around day 14 to confirm medical necessity using the LOCADTR tool.

Facility may fax/email OASAS Appendix A and LOCADTR to designated fax; services may be subject to review after day 28 or retrospectively.

PH/IOP Utilization Review Triggers

Partial hospitalization and Intensive Outpatient utilization review triggers (per NYS OMH Best Practice Manual)

Triggers for utilization review: Members meeting ANY of the following: (1) current Assisted Outpatient Treatment (AOT) court order; (2) AOT expired within the past 5 years; (3) three (3) or more psychiatric inpatient hospitalizations in the prior 12 months; (4) four (4) or more psychiatric ED visits in the prior 12 months; (5) three (3) or more medical inpatient hospitalizations in the prior 12 months; (6) readmission to any mental health inpatient unit within 30 days of discharge; (7) length of stay >30 days (concurrent review from day 31 onward).

Applies to PH and IOP provided by OMH-licensed programs; admission and concurrent/continued stay review per NYS OMH Best Practice Manual.

TMS (90867-90869) Coverage Criteria

Transcranial Magnetic Stimulation (TMS) coverage criteria

TMS coverage criteria: Members >18 years may be eligible when TMS is administered using an FDA-cleared device for FDA-labeled indications, with a confirmed diagnosis of major depressive disorder (MDD), and failure to respond to multiple trials of medication and evidence-based psychotherapy during the current episode of illness.

Authorization is required for CPT codes 90867, 90868, and 90869; requests submitted to Behavioral Health as instructed.

ASD / ABA

Autism Spectrum Disorder (ASD) related coverage

ASD authorizations: Authorization is required for DME speech generation equipment; Applied Behavior Analysis (ABA) requires authorization from Behavioral Health; attestation of an ASD diagnosis by a licensed physician or psychologist must be provided at the time of request.

Behavioral Health handles ABA authorization requests.

Therapy coverage criteria

Covered when authorization and limits are observed:

Outpatient therapy authorization: All outpatient PT/OT/ST services after the initial evaluation require authorization through Evolent (NIA).

Initial office or facility-based evaluations do not require authorization, but subsequent billed therapy procedure codes do; CPTs 92610 and 92611 do not require authorization.

Therapy visit limits: Rehabilitation and habilitation benefits are limited to 60 visits per condition per plan year; the visit limit applies to all therapies combined.60 visits

Applies to PT/OT/ST combined.

Enteral and oncology drug coverage

Coverage requires documentation:

Enteral formula coverage: Non-prescription enteral formulas for home use require a written order from a physician or other licensed provider stating that the enteral formula is medically necessary and is used as a disease-specific therapeutic treatment for conditions that would cause malnutrition or chronic disability if untreated.

HCPCS codes B4034–B4162 describe enteral formulas/items that require authorization.

Oncology medications and supportive agents require prior authorization from Evolent before being dispensed at a pharmacy or administered in a physician's office, outpatient hospital, or ambulatory setting.

Some oncology requests are excluded from Evolent review; submit oncology PA requests per Evolent's Oncology Program instructions.

CPT code 96110 is explicitly listed in the policy as a non-covered service and should not be billed for coverage under this policy.

For members with a primary diagnosis of Low Back Pain, the policy specifies certain services that are not covered. These include therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT fluoroscopic guidance), continuous or intermittent traction, and therapeutic steroid injections into intervertebral discs.

The Appendix I listing notes that authorization is not required for ophthalmic indications; providers should refer to the appendix guidance when determining authorization needs for ophthalmic-related HCPCS/S-codes.

The policy references that many cosmetic procedures and certain combinations are non-covered or have special rules; for example, code 20610 is noted as non-covered when billed with specific hyaluronic acid J-codes. Providers should follow the outpatient surgery and exclusions guidance when submitting claims for cosmetic services.

The policy explicitly enumerates services that are not covered for Low Back Pain, repeating that excluded treatments include facet joint steroid injections in the lumbar/sacral regions, continuous or intermittent traction, and therapeutic steroid injections into intervertebral discs.

Relevant CPT / HCPCS / J-code Lists

Behavioral Health Testing CPTsCPTCovered

96116
96121
96130
96131
96132
96133
96136
96137
96138
96139

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TMS and relevant behavioral health codesCPT|HCPCSCovered

90867	TMS treatment
90868	TMS treatment
90869	TMS treatment
H0035	Partial hospitalization SUD revenue/HCPCS referenced

Partial hospitalization / IOP / ECT codesmixedCovered

90870	ECT outpatient
H2013	IOP HCPCS
S9480	IOP CPT-like code
905	Revenue code for IOP (as listed)
912	Revenue code for partial hospitalization/IOP (as listed)
944	Revenue code listed
945	Revenue code listed

Developmental pediatric testingCPT

96112	Developmental pediatric testing
96113	Developmental pediatric testing
96110	Non-covered service (not covered)

DME codes not requiring authorization (selected)HCPCS

A4670
A6533
A6590
A6540
A6591
A7021
A7046
A7049
E0130
E0135

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Therapeutic, scans, and procedure codes requiring authorization or notedCPTCovered

64530	Pain management/injection code (listed)
64553-64595	Pain management codes range
64600-64610	Pain management codes range
64618-64640	Pain management codes range
77089	TBS scan
77090	TBS scan
77091	TBS scan
77092	TBS scan
95249	Ambulatory continuous glucose monitoring
58674	Radiofrequency ablation of uterine fibroids

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Chiropractic codes requiring authorizationCPT|Revenue

98940
98941
98942
98943
0940	Revenue code

Counseling service codes (no authorization required)CPTCovered

G0108	Counseling service code (billing: GO108 in text appears as G0108)
G0109	Counseling service code (billing: GO109 in text appears as G0109)

Appendix I: assorted HCPCS/J codes requiring prior authorizationHCPCS|J-codes|C-codesCovered

C9047	caplacizumab-yhdp (Cablivi) and related mappings listed
J0129	abatacept (Orencia) and related mappings listed
J0139	adalimumab (Humira) and related mappings listed
J0174	lecanemab-irmb (Leqembi) and related mappings listed
J0401	aripiprazole ER inj (Abilify Maintena) and related mappings listed
J1632	brexanolone (Zulresso) and related mappings listed
J1559	immune glob (Hizentra) listed

Codes listed (partial)HCPCS

J1559

immune glob (Hizentra) / other mappings as listed

Codes listed (partial)HCPCS

J1572

IVIG (Flebogamma) / other mappings as listed

Codes listed (partial)HCPCS

J1745	infliximab (Remicade) / other mappings as listed
J1786	imiglucerase (Cerezyme) / other mappings as listed

Codes listed (partial)HCPCS

J1930	lanreotide (Somatuline) / other mappings as listed
J1943	aripiprazole lauroxil (Aristada Initio) / other mappings as listed

Codes listed (partial)HCPCS

J7190	factor VIII antihemophilic / other mappings as listed
J7200	factor IX recombinant / other mappings as listed

Codes listed (partial)HCPCS

J7210	factor VIII recomb (Afstyla) / other mappings as listed
J7309	aminolev acid top (Levulan) / other mappings as listed

Codes listed (partial)HCPCS

J7321	hyaluronan (Hyalgan, Supartz, Visco-3) / other mappings as listed
J7326	hyaluronan (Gel-One) / other mappings as listed

Codes listed (partial)HCPCS

J9119	cemiplimab-rwlc (Libtayo) / other mappings as listed
J9245	melphalan hydrochloride (Melphalan) / other mappings as listed

Codes listed (partial)HCPCS

J9210	listed mappings and product variants (see appendix)
J9216	listed mappings and product variants (see appendix)

Codes listed (partial)HCPCS

J9217	listed mappings and product variants (see appendix)
J9223	listed mappings and product variants (see appendix)

Codes Requiring Prior AuthorizationHCPCSCovered

J9210	listed mappings and product variants (see appendix)
J9216	listed mappings and product variants (see appendix)
J9217	listed mappings and product variants (see appendix)
J9223	listed mappings and product variants (see appendix)
J9225	listed mappings and product variants (see appendix)
J9226	listed mappings and product variants (see appendix)
J9227	listed mappings and product variants (see appendix)
J9228	listed mappings and product variants (see appendix)
J9229	listed mappings and product variants (see appendix)
J9245	listed mappings and product variants (see appendix)

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High utilization triggers — prior 12 months

High utilization — psychiatric inpatient>=3 psychiatric inpatient hospitalizations in prior 12 months

High utilization — psychiatric ED>=4 psychiatric emergency department visits in prior 12 months

High utilization — medical inpatient>=3 medical inpatient hospitalizations in prior 12 months

Authorization, Notification, and Documentation Requirements

Prior Authorization

DME and Selected HCPCS/J‑Codes Authorization Status

Durable medical equipment (DME) and selected HCPCS/J‑codes: Certain DME and HCPCS codes do not require prior authorization while many J-/Q-/C-/S-/Q999* codes in Appendix I do require prior authorization. See Appendix I for the comprehensive list and ensure prior authorization is obtained for listed J-/Q-/C-/S-/Q codes and associated products before dispensing or administration. Providers should submit supporting clinical documentation with PA requests for J‑code medications and be aware claims may be denied if PA is not obtained.

Examples of DME that do NOT require authorization: A4670, A6533, A6590, A6540, A6591, A7021, A7046, A7049, E0130, E0135, E0168, E0182, L3702, L3762, L3809, L3915, L4350, L5991, L7360, L7362, L7364, L7366, L8678, S8421, S8424, V5010, V5020, V2625, V2626, V5266.
T2101 (Donor Breast Milk) requires authorization only when given in an outpatient setting.
Appendix I contains the full list of HCPCS/J/Q codes and associated products that require prior authorization.

Prior Authorization

Therapy Prior Authorization (PT/OT/ST)

Outpatient therapy (PT/OT/ST) after the initial evaluation requires authorization through Evolent (NIA). Initial evaluation visits performed in office or facility do NOT require authorization, but all subsequent therapy services billed after the initial evaluation do.

Policy Background and References

Background: This policy incorporates New York State requirements for behavioral health services. It references NYS OMH and OASAS rules that affect inpatient coverage and utilization review — for example, OMH-licensed inpatient mental health admissions and OASAS-licensed inpatient substance use disorder (SUD) services have specific notification and short-term concurrent review exemptions when facilities submit the required two-business-day notifications and supporting forms. These state program requirements shape the policy's authorization and utilization-review processes for inpatient behavioral health services.

Key Definitions

OMH-licensed inpatient mental health treatment

DefinitionInpatient mental health treatment provided in New York State by hospitals licensed by the NYS Office of Mental Health (OMH)

Authorization exemption (first 14 days)OMH-licensed inpatient admissions are not subject to authorization review and Fidelis will not conduct concurrent utilization review for the first 14 days if the facility notifies Fidelis Care of admission and initial treatment plan within two business days using the OMH Two‑Day Notification and Initial Treatment Plan form

Facility responsibilitiesFacility must perform daily clinical review and participate in periodic consultation with Fidelis Care to ensure use of approved evidence‑based clinical review criteria

Inpatient SUD (OASAS-licensed) — definition and exemption note

DefinitionInpatient detoxification, inpatient rehabilitation and inpatient residential treatment services provided in New York State by facilities licensed, certified or otherwise authorized by OASAS

Level-of-Care Medical Necessity Criteria

Applied Behavior Analysis (ABA) Authorization Criteria

ABA authorization

ABA authorization: Authorization is required from Behavioral Health for Applied Behavior Analysis for members with ASD; an attestation of ASD diagnosis by a licensed physician or psychologist must be provided at time of request.

Behavioral Health processes ABA authorizations.

Specific Treatment Modality Criteria

TMS

TMS eligibility: Members over 18 with confirmed major depressive disorder who have failed multiple medication trials and evidence-based psychotherapy in the current episode, when treated with an FDA-cleared TMS device for labeled indications, may be authorized for TMS treatment.

Authorization required for CPTs 90867–90869; requests per Behavioral Health instructions.

ECT

ECT use: Outpatient ECT billed with CPT 90870 requires authorization per policy listing (relevant revenue and HCPCS codes referenced in ECT section).

Revenue codes and HCPCS (e.g., H0035 referenced for related services) are noted in the policy.

Rehabilitation

Benefit Maximums and Visit Limits

Home care skilled services visits (benefit maximum)

Home care skilled services maximum40 visits per plan year

Basis for approvalApprovals based on medical need for skilled services

Applies toHome health skilled nursing and therapy services provided in the home setting

Hospice care coverage maximum

Hospice coverage maximumUp to 210 days when medically necessary

Program requirementHospice care must be provided as part of a Hospice Care program certified pursuant to Article 40 of the N.Y. Public Health Law

OpenPayer

Behavioral Health: Authorization, Utilization Review, and Coverage Criteria

Coverage Criteria and Exemptions

Relevant CPT / HCPCS / J-code Lists

Authorization, Notification, and Documentation Requirements

Policy Background and References

Key Definitions

Level-of-Care Medical Necessity Criteria

Applied Behavior Analysis (ABA) Authorization Criteria

Specific Treatment Modality Criteria

Benefit Maximums and Visit Limits