ModifiedFidelis CarePolicy N/A

Behavioral health authorization and utilization review updates (OMH/OASAS) — COVID-19 related

Updates to Fidelis Care authorization, utilization review, and coding guidance affecting inpatient, outpatient, behavioral health, substance use, and related services in New York State; intended for providers and facility billing/authorization staff.

Policy Summary

PayerFidelis Care

PolicyBehavioral health authorization and utilization review updates (OMH/OASAS) — COVID-19 related

Policy CodePolicy N/A

Change TypeAuthorization & utilization review exemptions and process updates

Effective DateJan 1, 2020

Next Review Date

Key ActionFacilities must notify Fidelis Care within two business days and submit required OMH/OASAS forms to qualify for authorization exemptions.

SourceLink

POLICY UPDATE CHANGES

OMH licensed inpatient mental health treatment in NYS is not subject to authorization review by Fidelis Care effective 06/01/2021, with notification and limited concurrent review conditions.

OASAS licensed inpatient SUD facilities in-network in NYS are not subject to prior authorization or concurrent review for the first 28 days effective 01/01/2020 when notification and reporting requirements are met.

Inpatient mental health treatment for members under age 18 provided by OMH licensed hospitals in-network is not subject to authorization review with 14-day concurrent review protections when specific notification and process conditions are met.

Behavioral health outpatient services (psych testing, ECT, partial hospitalization, IOP) have specified authorization and utilization review criteria per OMH guidance.

28 daysInpatient SUD concurrent review exempt period (in-network, NYS OASAS licensed)

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14 daysOMH-licensed pediatric inpatient concurrent review exempt period

01/01/2020Effective date for OASAS inpatient SUD change

06/01/2021Effective date for OMH inpatient mental health authorization change

1-888-FIDELIS ext 16072Behavioral Health contact

Coverage & Level-of-Care Criteria

OMH inpatient mental health utilization review criteria

Utilization review for OMH licensed inpatient mental health treatment will be conducted only when members meet ANY of the following per NYS OMH Best Practice Manual:

OMH inpatient utilization review triggers: 1) Individuals subject to a current Assisted Outpatient Treatment (AOT) court order; 2) Individuals who had an AOT court order that expired within the past five years; 3) High utilization defined by EITHER (a) three or more psychiatric inpatient hospitalizations in the prior 12 months OR (b) four or more psychiatric ED visits in the prior 12 months OR (c) three or more medical inpatient hospitalizations in 12 months; 4) Individuals readmitted to any mental health inpatient unit within 30 days of discharge; 5) Individuals not meeting the above whose length of stay exceeds 30 days (concurrent review begins on day 31).see text

Per NYS OMH Best Practice Manual

OASAS inpatient SUD exemption

Inpatient SUD (OASAS licensed, in-network NYS facilities) authorization/concurrent review exemptions apply when ALL of the following are met:

OASAS inpatient SUD exemption conditions: 1) Facility is OASAS licensed, certified or otherwise authorized in NYS and participating in Fidelis Care provider network; 2) Facility notifies Fidelis Care of the inpatient admission and the initial treatment plan within two (2) business days using OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool (fax/email submission); 3) Facility performs daily clinical review of the patient and periodically consults with Fidelis Care starting on or just prior to day 14 to ensure LOCADTR use; 4) Exemption from prior authorization and concurrent utilization review applies for the first twenty-eight (28) days of the inpatient admission; services may be subject to utilization review after day 28 or upon discharge.28 days

Effective 01/01/2020

Pediatric OMH inpatient exemption/process

For OMH-licensed inpatient mental health treatment for members under 18 in-network, prior authorization is not required when ALL conditions are met:

Pediatric OMH inpatient notification conditions: 1) Facility notifies Fidelis Care of admission and initial treatment plan within two business days by completing the OMH 'Two-Day Notification and Initial Treatment Plan' form and submitting to Fidelis Care by fax or email; 2) Facility performs daily clinical review of the patient; 3) Facility participates in periodic consultation with Fidelis Care to ensure use of evidence-based, peer-reviewed clinical review criteria appropriate to the patient's age; 4) No concurrent utilization review during the first fourteen (14) days of admission when the above conditions are met.14 days

Applies to OMH-licensed in-network pediatric admissions; effective date referenced

Partial hospitalization and IOP review criteria

Partial hospitalization and Intensive Outpatient (IOP) mental health utilization review will be conducted only for members who meet ANY of the OMH clinical triggers:

Partial hospital/IOP utilization review triggers: 1) Individuals subject to a current Assisted Outpatient Treatment (AOT) court order; 2) Individuals who had an AOT court order that expired within the past five years; 3) High utilization defined by EITHER (a) three or more psychiatric inpatient hospitalizations in the prior 12 months OR (b) four or more psychiatric ED visits in the prior 12 months OR (c) three or more medical inpatient hospitalizations in 12 months; 4) Individuals readmitted to any mental health inpatient unit within 30 days of discharge; 5) Individuals not meeting the above whose length of stay exceeds 30 days (concurrent review begins on day 31).see text

Per NYS OMH Best Practice Manual

Rehabilitation and Habilitation limits

Therapy visit limits and authorization conditions

Rehabilitation benefit: Benefit limited to 60 visits per condition per plan year; the visit limit applies to all therapies combined.60 visits

See therapy authorization timing for PA submission windows

Habilitation benefit: Benefit limited to 60 visits per condition per plan year; the visit limit applies to all therapies combined.60 visits

Home Health and Hospice

Home health and hospice coverage notes

Home Health Care: Home care approvals are based on medical need for skilled services; benefit maximum is 40 visits per plan year.40 visits

Home health approvals require demonstration of skilled needs

Hospice Care: Hospice care must be provided as part of a NY certified Hospice Care program; when medically necessary, coverage is available for up to 210 days.210 days

Program certified pursuant to Article 40 of NY Public Health Law

Effective January 1, 2020, Fidelis Care no longer requires provider notification, prior authorization, or concurrent authorization review for in-network, in-state outpatient substance use disorder (SUD) services when delivered in New York State. This exemption applies to outpatient office visits, therapy visits, counseling visits, intensive outpatient programs (IOP), outpatient clinic visits for SUD, outpatient rehabilitation treatment, and opioid treatment programs provided by in-network, in-state facilities. Out-of-state or out-of-network providers remain subject to authorization requirements. Providers with questions may contact Fidelis Care Behavioral Health at 1-888-FIDELIS, ext. 16072.

The policy identifies a set of services and procedures that are not covered for members with a diagnosis of Low Back Pain. Examples listed include prolotherapy; therapeutic injections of steroids into intervertebral discs; therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT fluoroscopic image guidance); continuous or intermittent traction; and specified interventional pain management codes (e.g., 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688 and HCPCS C1778, C1787, C1883, C1897). These services should not be billed as covered for members whose primary condition is Low Back Pain.

Appendix I lists multiple HCPCS/J/S codes that require prior authorization; however, the document expressly states that authorization is not required for ophthalmic indications for the listed codes. When ophthalmic use is the clinical indication, prior authorization is not required per the Appendix I note.

As noted in Appendix I, the list of HCPCS/J/S codes requiring prior authorization includes an explicit exception: authorization is not required for ophthalmic indications. This exception applies where the billed code in Appendix I is being used for an ophthalmic clinical indication.

The policy specifies that, for any place of service, CPT code 20610 is non-covered when used for intra-articular injection of hyaluronic acid for the treatment of osteoarthritis of the knee. Providers should not submit authorization requests for 20610 for this indication because it is listed as a non-covered service.

CPT code 96110 (and the policy note indicating it is non-covered) is designated as a non-covered service for behavioral health testing per this policy. Requests for psychological/neuropsychological testing should use the listed authorized codes and the required testing request form; 96110 should not be submitted for coverage.

The policy explicitly lists multiple interventional pain management procedures as not covered for Low Back Pain. The document examples include specified CPT/HCPCS codes (for example, 63650, 63655, 63661–63664, 63685, 63688 and HCPCS C1778, C1787, C1883, C1897) and procedural categories such as prolotherapy, therapeutic injections of steroids into intervertebral discs, therapeutic facet joint steroid injections in the lumbar/sacral regions, and continuous or intermittent traction. These items are considered not medically necessary for members with a primary diagnosis of Low Back Pain and should not be authorized or billed as covered services in that context.

Codes and Coding Rules

Transplant CPT codes requiring authorization at evaluationCPTCovered

32850	listed transplant code
32851	listed transplant code
32852	listed transplant code
32853	listed transplant code
32854	listed transplant code
32855	listed transplant code
32856	listed transplant code
33930	listed transplant code
33931	listed transplant code
33932	listed transplant code

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1/19

Behavioral health testing and ECTCPTCovered

96116	Neuropsych testing/assessment code
96121	Neuropsych testing/assessment code
96130	Psych testing code
96131	Psych testing code
96132	Psych testing code
96133	Psych testing code
96136	Psych testing code
96137	Psych testing code
96138	Psych testing code
96139	Psych testing code

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Residential treatment CPTsCPT

1001	Residential treatment CPT
1002	Residential treatment CPT

Residential treatment HCPCSHCPCS

H0017	HCPCS residential/behavioral health code
H0018	HCPCS residential/behavioral health code
H0019	HCPCS residential/behavioral health code
H2036	HCPCS residential/behavioral health code

TBS scan CPT codesCPT

77089	TBS scan
77090	TBS scan
77091	TBS scan
77092	TBS scan

DME codes (no PA required / listed)HCPCS

A4341	listed as new DME code not requiring PA
44342	listed as new DME code not requiring PA
A4560	listed as new DME code not requiring PA
A6590	listed as new DME code not requiring PA
A6591	listed as new DME code not requiring PA
A7049	listed as new DME code not requiring PA
E0677	listed as new DME code not requiring PA
E0711	listed as new DME code not requiring PA
K1035	listed as new DME code not requiring PA
L8678	listed as new DME code not requiring PA

1–10 of 15

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Therapy codes exempted from PACPT

92610	speech/language/hearing procedure — does not require authorization
92611	speech/language/hearing procedure — does not require authorization

Cardiac Rehabilitation Codes (authorization required)mixedCovered

S9472	Cardiac rehabilitation code
93797	Cardiac rehab/monitoring
93798	Cardiac rehab/monitoring
G0422	Cardiac rehab session
G0423	Cardiac rehab session
0943	Revenue code listed for cardiac rehab

Chiropractic Codes (PA required)CPT|RevenueCovered

98940	Chiropractic manipulation
98941	Chiropractic manipulation
98942	Chiropractic manipulation
98943	Chiropractic manipulation
0940	Revenue code associated with chiropractic services

Interventional pain management / Not covered for Low Back PainCPT|HCPCSNot Covered

63622	neurosurgical/pain management code — note: does not require authorization for requests from orthopedic specialties
63650	Interventional pain management codes (listed as not covered for low back pain)
63655	Interventional pain management codes
63661	Interventional pain management codes
63662	Interventional pain management codes
63663	Interventional pain management codes
63664	Interventional pain management codes
63685	Interventional pain management codes
63688	Interventional pain management codes
C1778	Interventional pain management HCPCS

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Appendix I: Codes Requiring Prior AuthorizationHCPCSCovered

Multiple J- and C-codes listed in Appendix I

Extensive list of J-/C-/other HCPCS codes requiring prior authorization (examples include J0222, J0401, J0490, J0585, J0638, etc.)

Miscellaneous imaging and procedure codesCPT|HCPCS

95249	Ambulatory continuous glucose monitoring
61736	Other listed neurosurgical code
61737	Other listed neurosurgical code
77089	TBS scan
77090	TBS scan
77091	TBS scan
77092	TBS scan

Codes listed in Appendix I (partial)HCPCS

J0879	palifermin (Kepivance) (as listed)
J0887	multiple entries (see appendix: epoetin beta, immune glob, paliperidone pal ER noted)
J0888	multiple entries (epoetin beta non-ESRD, immune glob powder, Sustenna noted)
J0896	luspatercept-aamt (Reblozyl) and others (Trinza noted)
J0897	denosumab (Prolia, Xgeva) (and related entries)

Expanded HCPCS/J/Q/S codes listed (partial, many grouped entries)mixed

J2502	pasireotide LA (and related entries)
J2503	pegaptanib (Macugen)
J2506	pegfilgrastim (Neulasta)
J2507	pegloticase (Krystexxa)
J2760	phentolamine inj
J2777	faricimab-svoa (Vabysmo)
J2778	ranibizumab (Lucentis)
J2779	ranibizumab implant
J2781	pegcetacoplan inj (Syfovre)
J2783	reslizumab (Cinqair)

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Codes listed in Appendix IHCPCSCovered

Q5128	Listed associated items (e.g., tamoxifen citrate oral; Stimufend; S0122; menotropins; S0189; testosterone pellet (Testopel))
Q5129	Listed associated items (e.g., bevacizumab-adcd inj; S0126; follitropin beta; S0194; prenatal vitamins 30 days)
Q5130	Listed associated items (e.g., pegfilgrastim-pbbk inj (Fylnetra); S0137; ganirelix acetate inj; didanosine oral; S4991; nicotine patches; non-legend smoking cessation gum)
Q5131	Listed associated items (e.g., adalimumab-aacf (Idacio); S0139; finasteride oral; minoxidil oral; prescription generic drug)
Q5132	Listed associated items (e.g., adalimumab-afzb (Abrilada); S0140; saquinavir oral; S5001; prescription brand name drug)

Additional S-codesHCPCSCovered

S0012	butorphanol nasal; S0142; colistimethate inh; S9430; pharmacy compounding
S0017	aminocaproic acid inj; S0145; peg interferon alfa-2A; dispensing services
S0020	bupivicaine inj; S0148; pegylated interferon alfa-2B

OB ultrasound count for authorization — inv-30: first 4 no authorization; 5+ require authorization

OB ultrasound authorization thresholdFirst 4 OB ultrasounds for a normal pregnancy may be performed without authorization; five or more ultrasounds for a normal pregnancy require prior authorization

OB ultrasound count (duplicate) — inv-31

OB ultrasound allowance (duplicate)First 4 OB ultrasounds for a normal pregnancy may be performed without authorization; five or more ultrasounds require authorization

Provider Notifications, Submission & Authorization Actions

Prior Authorization

Outpatient ECT and Testing Prior Authorization

Outpatient electroconvulsive therapy (ECT) and psychological/neuropsychological testing require prior authorization. Outpatient ECT (CPT 90870) requires authorization. Psychological/Neuropsychological testing (examples: 96116, 96121, 96130-96139, 96146 and related codes) require authorization and all testing requests must be submitted on the Psychological/Neuropsychological Testing Request Form. Note: CPT 96110 is a non-covered service.

Outpatient ECT: CPT 90870 — prior authorization required
Psychological/Neuropsychological testing: submit on testing request form — authorization required
CPT 96110 — not covered

Prior Authorization

DME Prior Authorization Rules

Durable medical equipment (DME) and certain supplies require prior authorization; however, a subset of DME codes are exempt from PA. Effective 4/1/23 the following codes do not require authorization: A4341, A4342, A4560, A6590, A6591, A7049, E0677, E0711, K1035, L8678. Additional DME codes that do not require authorization include: A4287, A4457, L4350, V2626, V5266. Other DME and supplies (e.g., compression garments/gradient stockings, electric heat/hot water pads, protective helmets, surgical stockings, wigs, insulin pumps and insulin infusion pumps) require authorization. Providers should verify PA requirements per code prior to ordering.

Background & Scope

Background: This policy update summarizes authorization and utilization review changes implemented during the COVID-19 period and aligns Fidelis Care processes with New York State behavioral health agency guidance (OMH and OASAS). Key COVID-19–era operational changes include removal of authorization requirements for many in-network outpatient SUD services effective 01/01/2020, special notification and exemption rules for OASAS inpatient SUD admissions (exemption for the first 28 days when LOCADTR/Appendix A notification is submitted within two business days), and revised OMH inpatient mental health review practices (OMH-licensed inpatient admissions are not subject to routine authorization review except when clinical triggers are met, with pediatric OMH in-network admissions exempt from concurrent review for the first 14 days when notification and process conditions are met; OMH inpatient change effective 06/01/2021). These adjustments reflect both public health operational needs and NYS agency directives and are intended to reduce administrative burden while preserving necessary utilization oversight.

Definitions & Abbreviations

LOCADTR — inv-66: Level of Care Utilization System / LOCADTR medical necessity tool for SUD inpatient treatment

LOCADTR purposeLevel of Care Utilization System (LOCADTR) medical necessity tool used for SUD inpatient treatment clinical review and discharge planning

LOCADTR submission requirementOASAS inpatient facilities must submit the LOCADTR tool to Fidelis Care within two business days of admission to qualify for the 28‑day exemption

LOCADTR use during stayFacilities must perform daily clinical review and periodically consult with Fidelis Care starting on or just prior to day 14 to ensure LOCADTR use

AOT — inv-67: Assisted Outpatient Treatment court order (OMH trigger)

AOT definition and roleAssisted Outpatient Treatment (AOT) court order — individuals currently subject to, or with an AOT order expired within the past five years, trigger utilization review for OMH inpatient services

Level-of-Care Criteria

Inpatient (OMH licensed; OASAS licensed SUD)

Level-of-care criteria and utilization review triggers for inpatient behavioral health settings (OMH-licensed mental health and OASAS-licensed SUD):

Inpatient level-of-care triggers: Admission to OMH-licensed inpatient mental health or OASAS-licensed inpatient SUD facilities requires facility notification within two business days; utilization review for OMH inpatient applies only when OMH triggers are met (AOT current or within 5 years, high utilization, 30-day readmission, or length of stay >30 days); OASAS inpatient SUD facilities meeting notification and LOCADTR submission requirements qualify for a 28-day concurrent review exemption.See individual criteria

Per OMH and OASAS guidance

Partial Hospitalization / Intensive Outpatient

Criteria used to determine admission and continued stay for Partial Hospitalization and Intensive Outpatient services are based on OMH clinical triggers:

Partial Hospitalization / IOP level-of-care criteria:

Treatment Modalities & Service Criteria

Partial Hospitalization (Mental Health)

Partial hospitalization authorization is tied to OMH-specified revenue/HCPCS codes and the OMH utilization review triggers:

Partial Hospitalization (Mental Health): Services billed to revenue codes 912, 913, 944, 945 or HCPCS H0035 will be subject to utilization review for admission and continued stay only when OMH clinical triggers are met (AOT, high utilization, 30-day readmission, or length of stay >30 days).see text

Per OMH Best Practice Manual

ECT and Psychological/Neuropsychological Testing

Authorization is required for ECT and specified psychological/neuropsychological testing codes:

ECT and Psychological/Neuropsychological Testing: Outpatient ECT (CPT 90870) requires authorization. Psychological and neuropsychological testing CPT codes listed in the policy require authorization and requests must be submitted using the Psychological/Neuropsychological testing request form; CPT 96110 is a non-covered service.

Applied Behavior Analysis (ABA) & ASD Criteria

ABA and ASD criteria

Applied Behavior Analysis (ABA) and related ASD authorizations:

ABA authorization requirements: 1) Authorization is required from Behavioral Health for Applied Behavior Analysis; 2) Attestation of an ASD diagnosis must be provided at time of request by a licensed physician or psychologist; 3) Authorization is required for DME speech generation equipment associated with ASD services.

Per ASD policy section

Visit Limits & Benefit Maximums

Home health skilled visits (benefit maximum) — inv-78

Home health skilled visits maximumHome health skilled visit approvals are based on medical need; benefit maximum is 40 visits per plan year

Skilled services requirementHome care approvals require demonstration of medical need for skilled services

Hospice care coverage maximum (days) — inv-79

Hospice coverage maximumWhen medically necessary, hospice care coverage is available for up to 210 days as part of a certified NY Hospice Care program

Certification requirementHospice care must be provided as part of a program certified pursuant to Article 40 of the NY Public Health Law

Counseling services (G0108, G0109) — inv-80: allowed counseling services in 12-month period (10 hours / 20 units)

Policy Summary

PayerFidelis Care

PolicyBehavioral health authorization and utilization review updates (OMH/OASAS) — COVID-19 related

Policy CodePolicy N/A

Change TypeAuthorization & utilization review exemptions and process updates

Effective DateJan 1, 2020

Next Review Date

Key ActionFacilities must notify Fidelis Care within two business days and submit required OMH/OASAS forms to qualify for authorization exemptions.

SourceLink

On This Page

Therapy authorization timing — inv-32: outpatient/home health/inpatient timing rules

Outpatient therapy authorization timingAuthorization requests for outpatient PT/OT/ST (after initial evaluation) must be sent to NIA within 1 business day

Home health therapy authorization timingAuthorization requests for therapy provided in the home must be sent within 2 business days to NIA

Inpatient therapy authorization timingAuthorization requests for therapy provided in inpatient settings must be sent to Fidelis within 1 business day

List of DME codes not requiring PA: A4341, A4342, A4560, A6590, A6591, A7049, E0677, E0711, K1035, L8678, A4287, A4457, L4350, V2626, V5266
Examples of DME/supplies requiring PA: compression garments/stockings; electric heat/hot water pads; protective helmets; surgical stockings; wigs; insulin pumps and infusion pumps

Prior Authorization

Outpatient Therapy Prior Authorization

Outpatient therapy (physical, occupational, speech) requires authorization for services delivered after the initial evaluation. Initial evaluation CPT codes performed in office/facility do not require authorization. Authorization for subsequent therapy services must be obtained through National Imaging Associates (NIA). CPT codes 92610 and 92611 do not require authorization. For home health therapy settings, submit authorization within 2 business days; for outpatient settings submit to NIA within 1 business day when applicable. Visit limits apply (rehabilitation and habilitation: 60 visits per condition per plan year combined).

Initial evaluations (office/facility) — no authorization required
All other therapy services after initial evaluation — authorization required through NIA
CPT 92610 and 92611 — no authorization required
Timing: outpatient requests to NIA within 1 business day; home health within 2 business days (per policy guidance)
Visit limits: Rehabilitation and Habilitation — 60 visits per condition per plan year (combined)

Prior Authorization

Cardiac Rehabilitation Prior Authorization

Outpatient cardiac and pulmonary rehabilitation services require prior authorization when delivered in an outpatient setting. Cardiac rehabilitation relevant codes include S9472, 93797, 93798, G0422, G0423 and revenue code 0943. Obtain authorization prior to delivering outpatient rehab services.

Cardiac rehab codes: S9472, 93797, 93798, G0422, G0423, rev code 0943
Pulmonary rehab codes require authorization as indicated in the policy

Prior Authorization

Chiropractic Prior Authorization

Chiropractic services require prior authorization for listed codes. The following chiropractic CPT/HCPCS codes require PA: 98940, 98941, 98942, 98943 and revenue code 0940. Submit authorization requests before providing services to avoid claim denials.

Chiropractic codes requiring PA: 98940, 98941, 98942, 98943
Revenue code: 0940

Prior Authorization

Pharmacy / Infused Medication Prior Authorization

Pharmacy-covered infused and medical benefit medications (HCPCS J‑codes and Appendix I enumerated codes) require prior authorization. Oncology medications and supportive agents require prior authorization and review by Evolent (formerly New Century Health) before dispensing or administration. Submit pharmacy/medical benefit PA requests via the Pharmacy Team e-fax: 1-844-235-5090, or follow the oncology submission pathways described below. Appendix I lists J-/HCPCS-/S-codes requiring PA; ophthalmic indications are exempt from PA for specified codes.

Submit general pharmacy/HCPCS PA requests via e-fax: 1-844-235-5090
Oncology medications/supportive agents: prior auth required through Evolent (NCH); portal or 1-888-999-7713
Appendix I enumerates J-/HCPCS-/S-codes that require PA; ophthalmic indications are excluded where noted

Note

Triggers for Utilization Review

Utilization review (prior authorization and concurrent review) may be triggered by multiple circumstances including: all inpatient admissions (except emergency stabilization), readmissions, extended lengths of stay, high utilization patterns, and specific program rules (OMH/OASAS exceptions). Examples: inpatient admissions are reviewed for medical necessity; OMH-licensed inpatient mental health admissions may be exempt from review when notification requirements are met, but certain triggers (AOT orders, multiple prior hospitalizations/ED visits, readmission within 30 days, stays >30 days) will prompt utilization review.

All inpatient admissions require authorization (emergency stabilization exception applies)
Triggers for UM review include: Assisted Outpatient Treatment (AOT) status, ≥3 psychiatric inpatient admissions in 12 months, ≥4 psychiatric ED visits in 12 months, ≥3 medical inpatient admissions in 12 months, readmission within 30 days, and length of stay >30 days
OMH/OASAS licensed program exceptions require timely facility notification and initial treatment plan submission to avoid concurrent review during specified initial days

Prior Authorization

Imaging Prior Authorization

Imaging and radiology prior authorization has been delegated to National Imaging Associates (NIA). Providers must obtain authorization for radiology services per the NIA program. Note exceptions: the first four OB ultrasounds in a normal pregnancy do not require authorization; certain fetal echocardiograms/cardiac ultrasounds and specified OB ultrasound indications are exempt. A full list of CPT codes requiring authorization is maintained by NIA.

Radiology prior authorization delegated to NIA
First four OB ultrasounds for a normal pregnancy — no authorization required
Five or more ultrasounds for a normal pregnancy — authorization required
Refer to NIA for the full list of CPT codes requiring authorization

Denial Risk

Therapeutic / Interventional Services — Coverage and PA Alerts

Certain therapeutic and interventional procedures are not covered for low back pain and/or require prior authorization. Examples of interventional pain management codes that are not covered for members with a diagnosis of low back pain include: 63650, 63655, 63661, 63662, 63663, 63664, 63685, 63688 and associated device HCPCS (C1778, C1787, C1883, C1897). Other not-covered services include prolotherapy, therapeutic intradiscal steroid injections, continuous or intermittent traction, and specified facet joint injections in the lumbar/sacral regions. Providers should confirm coverage and prior authorization requirements before performing these services.

Interventional pain management codes not covered for low back pain: 63650, 63655, 63661-63664, 63685, 63688
Associated HCPCS device codes: C1778, C1787, C1883, C1897
Examples of not-covered procedures: prolotherapy; intradiscal steroid injections; continuous/intermittent traction; lumbar/sacral facet joint steroid injections

Denial Risk

Claims Submitted Without Prior Authorization — Denial Risk

Claims submitted for services billed without an approved prior authorization may be denied or result in provider/member financial responsibility. Failure to obtain required authorization for listed codes (including those in Appendix I, delegated vendor lists, and program-specific code sets) can lead to claim denial.

Claims for services requiring PA but billed without authorization are at risk for denial
Appendix I and delegated vendor lists identify many codes that require PA — verify before providing services

Prior Authorization

Prior Authorization Required for Listed Codes (Appendix I)

Prior authorization is required for the codes enumerated in Appendix I (HCPCS / J‑codes / S‑codes and others). Appendix I provides an extensive, non-exhaustive list of HCPCS/J/S codes that require PA; some entries note multiple related code mappings. Authorization is not required for ophthalmic indications where specifically exempted. Providers should consult Appendix I and program-specific guidance (NIA, Evolent, TurningPoint) when determining PA requirements.

Appendix I lists HCPCS/J/S codes requiring PA (numerous entries)
Ophthalmic indications are exempt from PA where noted in Appendix I

Documentation Required

OMH Two-Day Notification

OMH Two-Day Notification and Initial Treatment Plan: For OMH‑licensed inpatient mental health facilities participating in Fidelis' network, providers must notify Fidelis Care within two business days of admission and submit the OMH Two-Day Notification and Initial Treatment Plan form by fax to 833-561-0094 (formerly 718-896-1784) or by email to the designated Mental Health Admissions inbox. Compliance with the Two-Day notification and submission requirements avoids concurrent review for the initial defined period; facilities must also perform daily clinical review and participate in periodic consultation with Fidelis Care.

Submit OMH Two-Day Notification & Initial Treatment Plan within 2 business days
Fax: 833-561-0094 (formerly 718-896-1784) or email to Mental Health Admission@fideliscare.org
Facility obligations: daily clinical review and periodic consultation with Fidelis Care

Step Therapy

Oncology Submission Instructions and Review / Step Logic

Oncology submission instructions and review/step logic: Outpatient oncology medications and supportive agents require prior authorization through Evolent (formerly New Century Health). Submit oncology-related requests via the New Century Health/Evolent web portal or by phone at 1-888-999-7713 (follow prompts). Oncology requests routed to Evolent are reviewed per program clinical pathways and step therapy rules where applicable. Do not send oncology-related requests to the general Appendix I e-fax; follow the Evolent pathway. Clinical trials and complex oncology cases may be routed to Evolent for review.

Oncology PA & review via Evolent (New Century Health) — portal or 1-888-999-7713
Evolent implements oncology-specific clinical review, step logic and step therapy where applicable
Do not submit oncology medication requests to Appendix I e-fax — use the oncology pathway

Prior Authorization

Appendix I Enumerates HCPCS / J‑codes Requiring Prior Authorization

Appendix I enumerates numerous HCPCS/J-codes and related S-codes that require prior authorization; the list is maintained and updated in the policy Appendices. Some entries include multiple code mappings and proprietary code cross-references. Providers must consult Appendix I for the most current list when determining PA requirements for specific drugs or HCPCS-coded services.

Appendix I contains extensive listings of codes (J-, HCPCS-, S-) requiring PA
Entries may include mapped or related codes — review Appendix I for details and updates

Documentation Required

Voicemail HIPAA Compliance for UM Messages

Utilization Management voicemail HIPAA compliance: UM staff may leave detailed UM messages only if the provider's voicemail is HIPAA-compliant. The mailbox greeting must identify the owner, the organization, and state that the mailbox is confidential and PHI may be left. If the voicemail is not HIPAA-compliant, UM will leave a generic message requesting a callback. UM will make a second direct attempt to reach the provider as required by Department of Health Reasonable Effort Policy.

Voicemail greeting must identify owner, organization, and state mailbox is confidential and can receive PHI
Non‑HIPAA-compliant voicemail — UM leaves generic message requesting call back
UM will make a second attempt to contact provider per DOH Reasonable Effort Policy

AOT as review trigger

AOT status is one of the clinical criteria per NYS OMH Best Practice Manual that will prompt utilization review for OMH inpatient mental health treatment

NIA — inv-68: National Imaging Associates (radiology authorization vendor)

NIA roleNational Imaging Associates (NIA) has been delegated prior authorization responsibility for radiology services and outpatient therapy authorizations

NIA processing noteProviders must send outpatient and home‑based therapy authorization requests to NIA within specified timeframes (see therapy timing)

Evolent (formerly New Century Health / NCH) — inv-69: oncology prior authorization manager

Evolent roleEvolent (formerly New Century Health / NCH) manages prior authorization review for oncology medications and supportive agents

Oncology submission methodsOncology PA requests can be submitted via New Century Health web portal or by calling 1-888-999-7713; clinical trials may be sent to Evolent for review

Codes Requiring Prior Authorization — inv-70: Appendix I reference

Appendix I referenceAppendix I lists HCPCS/J/Q/S and related codes that require prior authorization (see Appendix I for full code list)

Ophthalmic exceptionAuthorization is not required for ophthalmic indications where noted in Appendix I

Admission or continued stay review applies when individuals meet OMH triggers: current or recent (within 5 years) AOT order; high utilization (3+ psych inpatient hospitalizations OR 4+ psych ED visits OR 3+ medical inpatient hospitalizations in prior 12 months); readmission within 30 days; or length of stay exceeding 30 days (concurrent review from day 31).

Revenue codes 912, 913, 944, 945 and HCPCS H0035 referenced for partial hospitalization

Outpatient Counseling

Outpatient counseling level-of-care criteria and limits

Outpatient Counseling criteria: Counseling services are covered when billed with codes G0108 and G0109; services must be provided by certified providers and do not require prior authorization. Benefit limit is 10 hours (20 units) in a continuous 12-month period.10 hours / 20 units

Per policy section VI Counseling Services

Per Behavioral Health Outpatient services section

Counseling

Counseling service coverage and operational notes:

Counseling services billed with G0108 and G0109 are covered when provided by certified providers; they do not require prior authorization and are limited to 10 hours (20 units) in a continuous 12-month period.10 hours / 20 units

Providers should follow billing guidance and limits in policy

Counseling services limitMembers are allowed 10 hours (20 units) of counseling services in a continuous 12‑month period when billed with codes G0108 or G0109

Provider requirementThese counseling services must be provided by certified providers and no longer require authorization