Fidelis Care prior auth rules for behavioral health

Coverage Criteria and Clinical Utilization Rules

OMH inpatient MH utilization review criteria

Utilization review for OMH-licensed inpatient mental health treatment in NYS will be conducted only when specified triggers are present:

OMH inpatient utilization review triggers: Individuals meeting ANY of the following: current Assisted Outpatient Treatment (AOT) court order; AOT court order expired within 5 years; high utilization as defined below; readmission to any mental health inpatient unit within 30 days of discharge; or length of stay > 30 days

Applies to OMH-licensed hospitals in New York State

High utilization: Either: 3 or more psychiatric inpatient hospitalizations in the prior 12 months; OR 4 or more psychiatric emergency department visits in the prior 12 months; OR 3 or more medical inpatient hospitalizations in the prior 12 months

Inpatient SUD authorization exception criteria

Inpatient SUD provided by NYS OASAS-licensed, in-network facilities are not subject to prior authorization or concurrent review for the first 28 days provided notification conditions are met:

Inpatient SUD initial period: Facility is OASAS‑licensed, located in New York State, and participating in Fidelis Care's provider network AND notifies Fidelis Care of the inpatient admission and initial treatment plan within 2 business days (using OASAS Appendix A Notification Form and LOCADTR tool) AND performs daily clinical review of the patient AND periodically consults with Fidelis Care beginning on or just prior to treatment day 1428 days

Concurrent review may apply after 28 days or for out-of-network or out-of-state facilities

Partial Hospitalization / IOP criteria

Partial hospitalization and intensive outpatient mental health utilization review in OMH-licensed programs will be conducted only for members meeting specific triggers:

PH/IOP utilization review triggers: Members meeting ANY of the following: current AOT court order; AOT court order expired within 5 years; high utilization as defined (3+ psychiatric inpatient hospitalizations OR 4+ psychiatric ED visits OR 3+ medical inpatient hospitalizations in the prior 12 months); readmission within 30 days of a mental health inpatient discharge; or length of stay > 30 days

Applies to OMH-licensed programs in New York State; out‑of‑network facilities are subject to concurrent review throughout

Behavioral outpatient testing and ECT

Behavioral health outpatient services and testing require authorization for specified codes and testing forms:

Behavioral outpatient testing auth: Authorization required for listed psychological/neuropsychological testing codes and for outpatient ECT (CPT 90870); all testing requests should be submitted on the Psychological/Neuropsychological testing request form

CPT 96110 is a non‑covered service

ASD services authorization

Autism Spectrum Disorder services:

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

Authorization for ABA is obtained from Behavioral Health

Therapy: initial evaluation and visit limits

Coverage and limits apply as follows for therapy services:

Therapy authorization and limits: Office or facility-based PT/OT/ST initial evaluations do not require authorization; all other therapy procedure codes require authorization. Outpatient therapy after the initial evaluation requires prior authorization through National Imaging Associates (NIA). Rehabilitation and habilitation benefits are limited to 60 visits per condition per plan year.60 visits per condition per plan year

If other billed procedure codes are performed on same date as the initial evaluation, an authorization request must be submitted within the specified business day timeframe

Home Health and Hospice

Home health and hospice coverage rules:

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

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

OMH-licensed inpatient mental health treatment provided by OMH-licensed hospitals in New York State that participate in Fidelis Care’s provider network are generally not subject to authorization review when notification and other conditions are met. To qualify for this exception the facility must notify Fidelis Care within 2 business days of admission (call 1-888-FIDELIS extension 16072 or submit the OMH Two-Day Notification and Initial Treatment Plan form to the new fax 833-561-0094 or by email). Utilization review (prior authorization and concurrent review) will be conducted only when specified clinical triggers are present (for example, current or recently expired AOT orders, defined high-utilization patterns, readmission within 30 days, or stays >30 days); otherwise concurrent review is waived for the initial 14-day period when the notification and daily clinical review conditions are met.

Inpatient substance use disorder (SUD) services delivered by New York State OASAS-licensed facilities that are in-network are not subject to prior authorization or concurrent utilization review for the first 28 days of the admission provided the facility: (1) notifies Fidelis Care of the admission and initial treatment plan within 2 business days (via the OASAS Appendix A Notification Form and LOCADTR tool to fax 833-663-1608 or LOCADTR fideliscare org); (2) performs daily clinical review; and (3) participates in periodic consultation beginning near treatment day 14. Facilities outside NYS, not OASAS-licensed, or out-of-network remain subject to authorization and concurrent review throughout the admission.

The policy identifies specific therapeutic services that are not covered for members with a diagnosis of Low Back Pain. Examples include lumbar/sacral therapeutic facet joint steroid injections (with or without CT fluoroscopic guidance), continuous or intermittent traction, and therapeutic intradiscal steroid injections. These services are excluded from coverage when rendered for the listed low back pain diagnoses and should not be submitted for authorization in those clinical scenarios.

Most HCPCS S codes are treated as benefit exclusions. Exceptions to this exclusion list include S0013, S0190, S0191, and S9435. The policy further instructs that oral medication S codes should be billed under the prescription benefit rather than as HCPCS S codes. Providers should follow the stated routing for pharmacy authorization requests and treat excluded S codes per the prescription benefit rules.

Requests for products listed in Appendix I generally require prior authorization; however, the Appendix explicitly states that authorization is not required for ophthalmic indications when those products are being used for eye-related diagnoses. Providers should document the ophthalmic indication when submitting claims for such products.

CPT code 20610 (joint injection of hyaluronic acid for treatment of osteoarthritis of the knee) is listed in the policy as non-covered for any place of service. Providers should not submit authorization requests for hyaluronic acid injections under CPT 20610 for knee osteoarthritis, as payment will not be provided for that indication.

CPT code 96110 is identified in the behavioral health section as a non-covered service. Psychological/neuropsychological testing requests for covered testing and ECT (for example, 90870 and the listed 96xxx testing codes) must be submitted on the specified testing request form; do not submit 96110 for coverage.

In addition to the previously cited exclusions for therapeutic facet procedures and intradiscal injections, the policy lists several other services that are not covered for Low Back Pain diagnoses. These include continuous or intermittent traction and other non-specified therapeutic injections or modalities when billed for the excluded low back pain indications. Providers should reference the policy’s therapeutic services section before seeking authorization for these services in patients with Low Back Pain.

Codes and Code Groups Requiring Authorization or Not Covered

Transplant CPT Codes requiring authorizationCPTCovered

32850	Thoracic/lung transplant procedure codes
32851	Lung transplant procedure
32852	Lung transplant procedure
32853	Lung transplant procedure
32854	Lung transplant procedure
32855	Lung transplant procedure
32856	Lung transplant procedure
33930	Heart transplant; orthotopic
33931	Heart transplant additional codes
33932	Heart transplant

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Outpatient surgery CPT codes requiring authorization (selected)CPTCovered

15820	Blepharoplasty
15821	Blepharoplasty
15822	Blepharoplasty
15823	Blepharoplasty
11309	Skin surgery
11310	Skin surgery
11311	Skin surgery
11312	Skin surgery
11313	Skin surgery
11400	Skin excision

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Residential treatment codesmixedCovered

1001	Residential treatment CPT code 1001
1002	Residential treatment CPT code 1002
H0017	HCPCS residential treatment
H0018	HCPCS residential treatment
H0019	HCPCS residential treatment
H2036	HCPCS residential treatment

Diagnostic and Procedure codes requiring authorizationmixedCovered

91110	Wireless capsule endoscopy
91111	Wireless capsule endoscopy
91112	Wireless motility capsule
91113	Wireless motility capsule
43235	Esophagogastroduodenoscopy (EGD)
43239	EGD with procedure
43248	EGD with dilation
45378	Colonoscopy with biopsy
45380	Colonoscopy with removal
45384	Colonoscopy complex

1–10 of 21

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DME codes (PA-exempt and PA-required)HCPCS

A4341	DME item — PA-exempt (effective 4/1/23)
A4342	DME item — PA-exempt
A4560	DME item — PA-exempt
A6590	DME item — PA-exempt
A6591	DME item — PA-exempt
A7049	DME item — PA-exempt
E0677	DME item — PA-exempt
E0711	DME item — PA-exempt
K1035	DME item — PA-exempt
L8678	DME item — PA-exempt

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Imaging codes delegated to NIA / requiring prior authorizationmixedCovered

77089	TBS scan - bone density (77089-77092)
77090	TBS scan
77091	TBS scan
77092	TBS scan
Various imaging CPTs	Full list of radiology and advanced imaging prior auth codes delegated to National Imaging Associates (NIA) — see NIA delegated list

DME codes not requiring prior authorization (selected)HCPCSCovered

A4287	DME - does not require PA
A4457	DME - does not require PA
L4350	DME - does not require PA
V2626	DME - does not require PA
V5266	DME - does not require PA
A4341	DME - PA-exempt (new effective 4/1/23)
A4342	DME - PA-exempt
A4560	DME - PA-exempt
A6590	DME - PA-exempt
A6591	DME - PA-exempt

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Cardiac and Pulmonary Rehab and Monitoring codesmixedCovered

S9472	Cardiac rehab
93797	Cardiac monitoring
93798	Cardiac monitoring
G0422	Cardiac rehab per day
G0423	Cardiac rehab per session
Rev code 0943	Revenue code for cardiac rehab
95249	Ambulatory continuous glucose monitoring

Chiropractic procedure codes requiring prior authorizationCPTCovered

98940	Chiropractic manipulative treatment
98941	Chiropractic manipulative treatment
98942	Chiropractic manipulative treatment
98943	Chiropractic manipulative treatment
Rev code 0940	Revenue code associated with chiropractic services

Counseling codes not requiring authorizationCPTCovered

G0108	Counseling services - covered without auth
G0109	Counseling services - covered without auth

Select J-codes from Appendix I requiring prior authorization (sample)HCPCSCovered

J0135	Bevacizumab or related biologic per Appendix
J0172	Oncology/supportive care biologic
J0174	Monoclonal antibody biologic
J0218	Enzyme replacement therapies
J0219	Enzyme replacement therapies
J0221	Enzyme replacement therapies
J0270	Intra-urethral/prostaglandin agents
J0591	Deoxycholic acid (Kybella)

Additional sample Appendix I codes requiring prior authorizationHCPCSCovered

Q2041	CAR-T related Q-code (Yescarta)
Q2042	CAR-T related Q-code (Kymriah)
Q2054	Cell therapy Q-code
Q2055	Cell therapy Q-code
Q2056	Cell therapy Q-code

Q-code mappings requiring prior authorization (selected)Q-codeCovered

Q0516	Pharmacy supplying fee mapping and biologic mapping
Q0517	Pharmacy supplying fee mapping
Q0518	Pharmacy supplying fee mapping
Q0519	Pharmacy supplying fee mapping

What Providers Must Do / Authorization and Notification Actions

Prior Authorization

Prior Authorization Required for Inpatient Admissions and Many Procedures

All inpatient admissions require prior authorization. Failure to obtain required inpatient authorization or other required prior authorizations may result in denial or delayed payment. Providers must obtain authorization prior to elective admissions and for many specified procedures and services; emergency room stabilization services do not require prior auth but post-stabilization inpatient admissions do.

All acute inpatient facility services require authorization
Inpatient rehabilitation (acute, sub-acute, skilled nursing rehabilitation) requires prior authorization
Transplants require authorization at time of transplant evaluation (see code list)

Prior Authorization

DME Codes and Authorization Requirements

Certain DME/medical supply HCPCS codes do not require prior authorization (effective 4/1/23 for listed codes). Other DME, orthotics, and many supplies do require prior authorization. Compression garments/gradient stockings, electric heat/water bottle pads, protective helmets, surgical stockings, wigs, insulin pumps and infusion pumps, and other DME/supplies require authorization prior to coverage. Providers should verify current list of exempt DME codes before submitting requests.

Policy Background and Scope

This update clarifies utilization review and authorization practices implemented during the COVID-19 period and aligns Fidelis Care’s handling of behavioral health and SUD inpatient care with New York State guidance. Specifically, OMH-licensed inpatient mental health treatment in NYS that participates in the Fidelis network has modified concurrent review procedures (initial 14-day waiver with required notification and daily clinical review) and OASAS-licensed, in-network inpatient SUD has a similar 28-day concurrent review waiver when the facility satisfies the notification and clinical review requirements. These adjustments aim to reduce administrative burden while preserving clinical oversight through required facility notifications, daily clinical review, and periodic consultation; out-of-state, out-of-network, or non-licensed facilities remain subject to standard prior authorization and concurrent review processes.

Definitions and Delegation Notes

OMH / OASAS licensed facilities — definition and scope

DefinitionFacilities licensed by New York State OMH (mental health) or OASAS (substance use disorder) that participate in Fidelis Care's provider network.

OMH inpatient ruleOMH‑licensed inpatient mental health hospitals in NYS that participate in Fidelis' network are not subject to authorization review when they notify Fidelis and meet the conditions outlined (notification within 2 business days, daily clinical review, periodic consultation).

OASAS inpatient ruleIn‑state OASAS‑licensed, in‑network facilities providing inpatient SUD are not subject to prior authorization or concurrent review for the first 28 days if they notify Fidelis within 2 business days and follow LOCADTR/notification procedures.

Delegated prior authorization — categories and vendors

Delegated categoriesCertain service categories are delegated to third‑party reviewers: radiology/imaging prior authorization is delegated to National Imaging Associates (NIA); oncology medication review is delegated to Evolent (formerly New Century Health).

Level of Care: Inpatient, Partial Hospitalization, IOP, and Counseling

Inpatient, Partial Hospitalization, Intensive Outpatient

Top-level criteria used to determine appropriate behavioral health level of care (inpatient, partial hospitalization, intensive outpatient):

Admission triggers for higher level of care: Member meets ANY of: current Assisted Outpatient Treatment (AOT) court order; AOT expired within 5 years; 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 > 30 days

Applies to OMH‑licensed programs in New York State

Concurrent review waiver periods: Concurrent review is waived during the initial specified period for applicable licensed facilities (e.g., OMH inpatient under‑18 or program‑specific rules and the OASAS 28‑day SUD period) provided the facility notifies Fidelis and submits required forms and performs daily clinical review; concurrent review may commence after these periods or if triggers are met14 or 28 days where specified

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

Treatment Modalities and Modality-Specific Criteria

Partial Hospitalization

Partial hospitalization specific utilization review criteria and codes:

Partial Hospitalization authorization: Partial hospitalization requires utilization review only for members meeting OMH triggers; relevant billing includes revenue codes 912, 913, 944, 945 and HCPCS H0035

All partial hospitalization services provided by out‑of‑network facilities are subject to concurrent review throughout the admission

Intensive Outpatient Program (IOP)

Intensive outpatient program (IOP) specific utilization review criteria and codes:

IOP authorization: Intensive outpatient requires utilization review only for members meeting OMH triggers; relevant billing includes revenue code 905 or 912, CPT 90899, S9480, and HCPCS H2013

All intensive outpatient services provided by out‑of‑network facilities are subject to concurrent review throughout the admission

Applied Behavior Analysis (ABA) Authorization Criteria

ABA authorization

Authorization criteria for Applied Behavior Analysis (ABA) for ASD:

ABA authorization: Authorization required for Applied Behavior Analysis; request must include attestation of Autism Spectrum Disorder diagnosis by a licensed physician or psychologist at time of request

Authorization obtained through Behavioral Health

Benefit Visit Limits and Periods

Home care skilled visits (benefit maximum)

Benefit maximumHome care skilled visits: benefit maximum is 40 visits per plan year.

Medical necessity basisHome care approvals are based on medical need for skilled services.

Submission timingAuthorization requirements and timing for home health requests are described in the therapy/authorization routing sections of the policy.

Hospice care coverage maximum

Coverage maximumHospice care coverage is available up to 210 days when medically necessary and provided as part of a certified Hospice Care program per NY Public Health Law.

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

Authorization and Utilization Review for Behavioral Health, Substance Use, Inpatient and Selected Services