ModifiedFidelis CarePolicy N/A

Authorization and coverage rules for inpatient and outpatient behavioral health and related services

Defines Fidelis Care authorization requirements, carve-ins for behavioral health services into MAP plans (effective Jan 2023), and lists selected CPT/HCPCS codes and service categories requiring prior authorization or exempt from authorization. Affects providers and facilities in Fidelis Care's network in New York State.

Policy Summary

PayerFidelis Care

PolicyAuthorization and coverage rules for inpatient and outpatient behavioral health and related services

Policy CodePolicy N/A

Change TypeMaterial updates (carve-in changesconcurrent review exemptionstesting PA clarifications)

Effective DateN/A

Next Review DateN/A

Key ActionNotify Fidelis Care within two business days of OMH- or OASAS-licensed inpatient admissions and submit required initial treatment plans/LOCADTR entries to qualify for the concurrent review exemption periods.

SourceLink

POLICY UPDATE CHANGES

Effective 01/01/2020, certain OMH-licensed inpatient mental health treatment for members under 18 in-network are not subject to authorization review for the first 14 days when notification and initial treatment plan requirements are met.

Effective 01/01/2020, OASAS-licensed inpatient SUD facilities in New York State in-network are not subject to authorization review and concurrent review during the first 28 days if LOCADTR notification and reporting requirements are met.

Effective 1/1/2023, additional Behavioral Health services are carved into the MAP Plan benefit package.

Authorization requirement removed from most outpatient behavioral health services except specified CPT codes for psychological/neuropsychological testing.

14 daysOMH inpatient concurrent exemption

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Coverage Criteria and Exemptions

Medical Nutrition Therapy (MNT) and Diabetes Self-Management Training (DSMT)

Medical nutrition therapy (MNT) and Diabetes Self-Management Training (DSMT) coverage and authorization rules.

ALL of the following

Medical Nutrition Therapy (MNT) by a licensed nutrition provider is covered for members with a diagnosis of diabetes.
Provider must be a licensed nutritional provider.
Eight visits per year are covered without prior authorization when billed with codes 97802, 97803, G0270, or G0271.
No authorization required for up to eight visits per year.
Diabetes Self-Management Training (DSMT) is covered when provided by certified providers and billed with codes G0108 and G0109.
Members are allowed 10 hours (20 units) in a continuous 2-month period; authorization is not required.

Prior Authorization Required for Listed Injectables

Prior authorization requirements for listed injectable medications (non-oncology) administered in outpatient, physician office, ambulatory, or other settings.

ALL of the following

The injectable codes listed as non-oncology that require authorization must have prior authorization submitted to the Pharmacy Team.
Authorization requests should be submitted electronically via e-fax to the Pharmacy Team at 1-844-235-5090 (as of 10/1/2023).
Former fax: 1-877-882-5892.
Oncology-related injectables require prior authorization via Evolent (New Century Health) for participating providers; non-participating providers should submit oncology-related authorization requests to WellCare By Fidelis Care as directed (fax 1-844-235-5090).
Refer to the New Century Health / Evolent program for the oncology drug list and submission portal.
Self-administered medications are covered under the pharmacy benefit and follow pharmacy benefit prior authorization rules, not the physician-administered injectable process.

CPT/HCPCS Code Lists and Coding Notes

Transplant CPT Codes (partial list)CPTCovered

32850	listed transplant-related CPT (document lists many codes)
38204	listed transplant-related CPT
44133	listed transplant-related CPT

Outpatient surgery CPT Codes requiring authorization (examples)CPTCovered

15820-15823	Blepharoplasty codes
43770-43774,43888	Bariatric surgery codes
11920-11971,19300,19316-19342,19355,19370-19396	Breast reconstruction codes
20610	Joint injection — non-covered for hyaluronic acid
11308-11312	Skin surgery / dermatology codes (examples)

Behavioral health testing and treatment codesmixed

96110	Psychological testing — non-covered
96112	Psych testing — authorization required
96113	Psych testing — authorization required
96116,96121,96130-96133,96136-96139,96146	Psychological/Neuropsychological testing — authorization required
90870	Outpatient ECT

Imaging codes requiring authorization / notedCPT

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

Endoscopy/related CPT codes with PA notesCPT

43235	Esophagogastroduodenoscopy (example listed requiring authorization in POS 19/22)
43239	EGD with dilation (example)
43248	EGD with biopsy (example)
45378	Colonoscopy (example listed)
45380	Colonoscopy (example listed)
45384	Colonoscopy (example listed)
45385	Colonoscopy (example listed)
46255	Hemorrhoid/rectal procedure (example listed)
46260	Anorectal procedure (example listed)
46270	Anorectal procedure (example listed)

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DME codes exempt from authorization (examples)HCPCS

L1902	DME code listed as not requiring authorization
L2112	DME code listed as not requiring authorization

Therapeutic and pain management codes (examples)CPT

96567	Phototherapy (listed)
20526	Needle/injection (pain management codes listed)
62263	Pain management/spinal injection codes (listed)
95249	Ambulatory continuous glucose monitoring

Medical Nutrition Therapy codesCPT|HCPCSCovered

97802	Medical Nutrition Therapy initial assessment
97803	Medical Nutrition Therapy re-assessment/follow-up
G0270	MNT group session
G0271	MNT individual session

Diabetes Self-Management Training (DSMT)HCPCSCovered

G0108	Diabetes Self-Management Training individual
G0109	Diabetes Self-Management Training group

Injectable HCPCS/Codes requiring authorization (partial list)mixedCovered

C9047	listed subentries (e.g., caplacizumab-yhdp (Cablivi) etc.)
C9048	listed subentries
C9050	listed subentries
C9051	listed subentries
C9063	listed subentries (e.g., eptinezumab-jjmr (Vyepti))
C9142	listed subentries (e.g., bevacizumab-maly (Alymsys))
C9145	listed subentries
C9146	listed subentries
C9147	listed subentries
C9149	listed subentries (e.g., teplizumab-mzwv (Tzield))

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Medicare J-codes and related entriesCPT

J7294	listed in Medicare drug/J-code mapping
J7295	listed in Medicare drug/J-code mapping
J9048	listed in Medicare drug/J-code mapping
J9049	listed in Medicare drug/J-code mapping
J9051	listed in Medicare drug/J-code mapping
J9056	listed in Medicare drug/J-code mapping
J7296	listed in Medicare drug/J-code mapping
J7520	listed in Medicare drug/J-code mapping
J7525	listed in Medicare drug/J-code mapping
J7527	listed in Medicare drug/J-code mapping

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Concurrent review exemption periods — OMH & OASAS

OMH inpatient mental health (<18)No concurrent utilization review for the first 14 days when facility notifies Fidelis Care of admission and initial treatment plan within two business days using the OMH Two‑Day Notification and Initial Treatment Plan, performs daily clinical review, and participates in periodic consultation.

OASAS inpatient SUD (in‑state, in‑network)No concurrent utilization review for the first 28 days when facility notifies Fidelis Care of admission and initial treatment plan within two business days using the LOCADTR medical necessity tool and meets LOCADTR reporting/consultation requirements.

Applies only to in‑network NYS licensed facilitiesFacilities outside New York State, not OASAS/OMH licensed, or out‑of‑network must request authorization and remain subject to concurrent review throughout admission.

Provider Submission, Authorization, and Denial Risk

Prior Authorization

Prior Authorization Required for Listed Outpatient and DME Services

Prior authorization is required for the outpatient and DME services enumerated in Section IV (e.g., sleep studies, select diagnostic testing including certain genetic tests, wireless capsule and motility studies, select gastroenterology and esophageal procedures, penile prosthesis, and others). Providers should obtain authorization before performing or billing these services to avoid denial of payment.

See Section IV for full list of outpatient and DME services requiring authorization (includes imaging, endoscopy, sleep studies, selected genetic testing, wireless capsule/endoscopy, gastroenterology procedures, penile prosthesis 54405, and others).
Authorization is required for 43290 in any place of service and for certain procedures when performed in POS 19 and 22 if an office or ambulatory surgery center is available (see Section IV).

Prior Authorization

Authorization Required for Unlisted / Temporary Codes

All services billed with an “Unlisted” or “Temporary” code (including C‑codes and other unlisted/temporary HCPCS/CPT codes) require prior authorization. Failure to obtain authorization for unlisted or temporary codes may result in claim denial.

Background and Scope

Behavioral health services encompass inpatient, residential, partial hospitalization and outpatient treatment modalities that are regulated in New York State by OMH and OASAS. The policy reflects OMH and OASAS operational requirements that affect authorization and utilization review: for OMH‑licensed inpatient mental health treatment of members under age 18, facilities that are in‑network and that notify Fidelis Care within two business days using the OMH Two‑Day Notification and Initial Treatment Plan process, perform daily clinical review, and participate in periodic consultation are not subject to concurrent authorization review for the first 14 days. Similarly, OASAS‑licensed in‑state, in‑network inpatient SUD facilities that notify Fidelis Care within two business days using the LOCADTR tool and meet LOCADTR documentation and discharge planning requirements are not subject to authorization or concurrent review for the first 28 days. Providers should follow the notification, LOCADTR, and documentation workflows described in the policy to qualify for these exemption periods.

Key Definitions

LOCADTR definition and use for OASAS inpatient SUD admissions

LOCADTR definitionLOCADTR is the OASAS medical necessity tool used by inpatient SUD facilities to notify Fidelis Care of admissions and to support ongoing medical necessity determinations.

Use for admissionsFacilities must notify Fidelis Care of the inpatient admission and initial treatment plan within two business days using the LOCADTR tool to qualify for the 28‑day concurrent review exemption.

Ongoing reporting and dischargeFacilities must use LOCADTR for periodic consultation/ongoing review and provide a LOCADTR‑determined written discharge plan prior to discharge; services may be reviewed retrospectively.

OMH two-day notification and initial treatment plan requirement

OMH Two‑Day NotificationOMH‑licensed inpatient mental health facilities must notify Fidelis Care of admission and the initial treatment plan within two business days using the OMH 'Two‑Day Notification and Initial Treatment Plan' email to MentalHealthAdmission@fideliscare.org.

Level of Care and Setting Criteria

Treatment Modalities and Service Types

ECT and IOP — treatment modality criteria (1 top-level node)

ECT and IOP billing and authorization: Outpatient ECT (CPT 90870) and associated revenue/HCPCS codes (revenue 912, 913, 944, 945; HCPCS H0035) and Intensive Outpatient program billing codes (CPT 90899, S9480, HCPCS H2013) are listed and require authorization as specified elsewhere in the policy.

Providers must follow the authorization instructions for these modalities.

Detox and SUD treatment settings — criteria for detox/SUD settings (1 top-level node)

Detox and SUD treatment settings criteria: Coverage and authorization vary by setting and payer; medically managed and supervised detox services and related SUD treatment settings have differing coverage status for hospital versus freestanding facilities and by MAP Medicaid before/after Jan 2023 and MAP Medicare. Providers should consult the carve‑in crosswalk and OASAS/OMH regulations for setting‑specific requirements.

LOCADTR documentation and two‑day notification requirements apply for in‑network OASAS facilities to qualify for the 28‑day exemption.

Visit Limits and Quantity Rules

Coverage changes under MAP carve‑in for OMH/OASAS services

MAP carve‑in changes (Jan 1, 2023)Multiple OMH/OASAS behavioral health services were carved into the MAP Plan benefit package beginning 1/1/2023; coverage status varies by service and setting (hospital vs freestanding).

Examples of affected servicesPartial Hospitalization, PROS, Crisis Residence, Medically Managed/Medically Supervised Detox, Inpatient Rehabilitation, Residential, Outpatient Clinic and other SUD services show changed coverage/ carve‑in status in the policy crosswalk.

MAP Medicare distinctionsMAP Medicare commonly lists many freestanding behavioral health settings as Not Covered even after the Medicaid carve‑in changes; review the crosswalk for payer‑specific status.

Medical Nutrition Therapy visits without authorization

MNT visits (repeat)Eight (8) Medical Nutrition Therapy visits per year are covered without prior authorization when billed with 97802/97803 or G0270/G0271.

Policy Summary

PayerFidelis Care

PolicyAuthorization and coverage rules for inpatient and outpatient behavioral health and related services

Policy CodePolicy N/A

Change TypeMaterial updates (carve-in changesconcurrent review exemptionstesting PA clarifications)

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

Documentation Required

OMH Notification and Documentation

For OMH‑licensed inpatient mental health treatment for members under age 18, the facility must notify Fidelis Care of both the admission and the initial treatment plan within two business days of admission using the OMH two‑day notification process. The facility must perform daily clinical review and participate in periodic consultation with Fidelis Care; services may be reviewed retrospectively for medical necessity.

Notification: complete the OMH ‘‘Two‑Day Notification and Initial Treatment Plan’ email to MentalHealthAdmission@fideliscare.org within two business days of admission.
OMH‑licensed pediatric inpatient admissions are not subject to authorization or concurrent review for the first 14 days if notification and other conditions are met; inpatient services for members 18 and older continue to require prior authorization and concurrent review.

Documentation Required

OASAS LOCADTR Documentation and Notification

For OASAS‑licensed inpatient Substance Use Disorder (SUD) treatment in New York State that is in‑network and OASAS‑licensed, facilities are not subject to authorization review and are not subject to concurrent utilization review during the first 28 days provided the facility: notifies Fidelis Care of the inpatient admission and initial treatment plan within two business days via LOCADTR, uses the LOCADTR medical necessity tool, and participates in periodic consultation. Facilities must provide a LOCADTR‑based discharge plan prior to member discharge.

Submit LOCADTR notifications to the Fidelis LOCADTR fax (new fax number) at 833‑663‑1608 (formerly 646‑829‑1421) or via LOCADTR portal per Fidelis instructions.
Out‑of‑state or out‑of‑network facilities and non‑OASAS‑licensed facilities must still request authorization and are subject to concurrent review throughout the admission.
Facilities must use the LOCADTR concurrent review module and consult with Fidelis Care by day 14 of treatment; services may be subject to review after day 28 or retrospectively.

Prior Authorization

Therapy Prior Authorization Submission Timing and Fax

Prior authorization rules and timing for outpatient therapy (PT, OT, ST) and home therapy: initial evaluations performed in office or facility do not require authorization, but all subsequent therapy services require prior authorization through NIA. Authorization requests must be submitted within specified timeframes and to the correct fax number.

All therapy services after the initial evaluation require prior authorization through NIA; the initial evaluation CPTs for PT/OT/ST are exempt from authorization but other CPTs billed on the same date still require authorization.
Timing: send authorization requests to NIA within 1 business day for outpatient (office/facility) services and within 2 business days for home health therapy services. For therapy services provided in inpatient settings (POS 31 & 32), follow inpatient authorization timing to Fidelis Care.
Submission fax: prior authorization requests for therapy are to be sent to 833‑663‑1611 (formerly 716‑803‑8307). Non‑therapy providers (MD, DO, DPM, etc.) should request authorizations for all services after the initial evaluation directly through Fidelis Care.

Prior Authorization

Pharmacy Injectable Authorization Routing

Authorization routing for injectable medications: oncology medications/supportive agents for participating providers require prior authorization via Evolent (New Century Health). Non‑oncology injectable codes (both participating and non‑participating providers) require authorization submitted to Fidelis Care Pharmacy Team via the designated e‑fax.

Oncology medications and supportive agents for participating providers: request PA via Evolent (New Century Health) portal at my.newcenturyhealth.com or call 1‑888‑999‑7713 for program review.
Non‑oncology injectable codes: submit authorization requests electronically via e‑fax to the Fidelis Pharmacy Team at 1‑844‑235‑5090 (effective 10/01/2023; formerly 1‑877‑882‑5892).
For oncology requests by non‑participating providers, submit authorization requests to the Wellcare by Fidelis Care review fax at 1‑844‑235‑5090 (effective 10/01/2023).

Infusion / injectable behavioral health medication criteria (1 top-level node)

Infusion/injectable behavioral health medication authorization: Specific behavioral‑health‑related injectable medications (for example, brexanolone/Zulresso and other listed J/C/HCPCS codes) are included in the policy list of injectables requiring prior authorization; these require PA submission through the Pharmacy Team process described in the policy.

See the injectable HCPCS/J‑code lists and Medicare J‑code mappings in the policy for code‑level details.