CurrentFidelis CarePolicy N/A

COVID-19 related authorization and behavioral health updates — Behavioral Health and Prior Authorization Guidance

Updates and operational guidance for authorizations, utilization review, and coverage changes related to COVID-19 and behavioral health services for Fidelis Care providers in New York State. Affects inpatient, outpatient, substance use disorder, and mental health services and associated authorization processes.

Policy Summary

PayerFidelis Care

PolicyBehavioral Health and Prior Authorization Guidance (coverage criteria)

Policy CodePolicy N/A

Change TypeOperational update / guidance

Effective DateJan 1, 2020

Next Review DateN/A

Key ActionNotify Fidelis Care within two business days of OMH- or OASAS-licensed inpatient admissions and submit required admission and treatment plan forms.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

No auth if in-state OMHOMH inpatient auth exception

First 28 daysInpatient SUD exception

Auth reqTMS

96116-96146Behavioral testing

40 visitsHome health max

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Coverage and Medical Necessity Criteria

OMH inpatient mental health: triggers for utilization review

Utilization review for inpatient mental health treatment provided by OMH-licensed hospitals in NYS is conducted only when ANY of the following triggers are present:

OMH utilization review triggers: 1) Individual is subject to a current Assisted Outpatient Treatment (AOT) court order; OR 2) Individual had an AOT court order that expired within the past five years; OR 3) High utilization as defined: three (3) or more psychiatric inpatient hospitalizations in the prior 12 months OR four (4) or more psychiatric emergency department visits in the prior 12 months OR three (3) or more medical inpatient hospitalizations in the prior 12 months; OR 4) Readmission to any mental health inpatient unit within thirty (30) days of discharge; OR 5) Length of stay exceeds 30 days (concurrent review from day 31 onwards).see thresholds

Applies to OMH‑licensed hospitals in NYS; facility must notify Fidelis within 2 business days and submit required OMH Two‑Day Notification/Initial Treatment Plan form.

Inpatient SUD: authorization and review conditions

Inpatient Substance Use Disorder (SUD) services provided by OASAS‑licensed, in‑network New York State facilities are not subject to authorization or concurrent review for the first 28 days provided ALL of the following are met:

Inpatient SUD initial period conditions: 1) Facility is licensed, certified or otherwise authorized by OASAS and participating in the Fidelis Care provider network; AND 2) Facility notifies Fidelis Care of the inpatient admission and initial treatment plan within two (2) business days using the OASAS Appendix A Notification Form and the LOCADTR tool (fax/email as specified); AND 3) Facility performs daily clinical review of the patient and periodically consults with Fidelis Care beginning on or just prior to day 14 to confirm medical necessity; AND 4) Prior to discharge, the facility provides a written discharge plan determined using the LOCADTR tool and indicates whether services in the discharge plan are secured or reasonably available.first 28 days

Out‑of‑state or out‑of‑network facilities remain subject to authorization and concurrent review throughout the admission; services may be subject to retrospective review.

PHP and IOP: utilization review triggers

Utilization review for Partial Hospitalization (PHP) and Intensive Outpatient (IOP) programs provided by OMH‑licensed programs in NYS will be conducted only when ANY of the following triggers are present:

PHP/IOP utilization review triggers: 1) Current Assisted Outpatient Treatment (AOT) court order; OR 2) AOT court order that expired within the past five years; OR 3) High utilization as defined: three (3) or more psychiatric inpatient hospitalizations in the prior 12 months OR four (4) or more psychiatric ED visits in the prior 12 months OR three (3) or more medical inpatient hospitalizations in the prior 12 months; OR 4) Readmission to any mental health inpatient unit within thirty (30) days of discharge; OR 5) Length of stay exceeds 30 days (concurrent review from day 31 onwards).see thresholds

Applies to OMH‑licensed PHP and IOP programs in NYS; out‑of‑network programs are subject to concurrent review throughout the admission.

Transcranial Magnetic Stimulation (TMS) medical necessity

TMS is covered when ALL of the following are met:

TMS coverage criteria: 1) Member is over 18 years old; AND 2) Treatment is administered using an FDA‑cleared device in accordance with FDA labeled indications; AND 3) Confirmed diagnosis of major depressive disorder (MDD); AND 4) Failure to respond to multiple trials of medication AND evidence‑based psychotherapy during the current episode of illness.age >18

Authorization is required for CPT codes 90867, 90868, and 90869.

Out-of-state or out-of-network inpatient Substance Use Disorder (SUD) and OMH-licensed inpatient mental health services remain subject to Fidelis Care prior authorization and concurrent utilization review throughout the admission. Facilities that are not in New York State, not OASAS/OMH licensed, or not in-network must request authorization and will have the admission reviewed on a concurrent basis. (Providers should refer to the facility notification and submission requirements described elsewhere in this policy.)

Certain services are explicitly identified as not covered for members with a primary diagnosis of Low Back Pain. Examples called out in the policy include: therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT/fluoroscopic guidance), therapeutic injections of steroids into intervertebral discs, and continuous or intermittent traction. These items are listed among other therapeutic and pain-management services in the Therapeutic Services section.

The Appendix I excerpt in this policy contains an enumerated list of HCPCS/CPT/J- and Q-codes that require prior authorization. The provided excerpt is a code list and does not include clinical inclusion or exclusion criteria within that appendix; providers must consult the appendix for the exact codes that require prior authorization.

The policy notes that prior authorization requirements listed in Appendix I do not apply when the listed J-/Q-/HCPCS codes are used for ophthalmic indications. In other words, authorization is not required for ophthalmic indications as stated in the Appendix I excerpt (Site of Care criteria section).

CPT code 20610 is listed as non-covered in specific circumstances: it is non-covered when billed in conjunction with hyaluronic acid products (e.g., J7318–J7332 variants referenced) and in the context of osteoarthritis when billed with the required concurrent codes as described. Providers should not expect coverage for 20610 under those billing combinations.

CPT code 96110 is designated in the policy as a non-covered service.

The policy lists additional specific services that are not covered when the member has a diagnosis of low back pain. Examples included are therapeutic facet joint steroid injections in the lumbar/sacral regions (with or without CT guidance), therapeutic injections into intervertebral discs, and continuous or intermittent traction. These items are called out under the Therapeutic Services section as excluded for low back pain.

Note: Appendix I as presented in this excerpt is primarily a code listing identifying specific HCPCS/CPT/J- and Q-codes that require prior authorization. Because this section is code-list focused, it does not include explicit clinical coverage inclusion/exclusion language within the appendix itself; clinical applicability must be determined by the broader policy criteria and individual authorization review processes.

Codes and Code Groups Requiring Prior Authorization or Special Handling

Other outpatient codes requiring prior authorizationCPTCovered

C1600	C1600 (as listed)
C1601	C1601 (as listed)
C1602	C1602 (as listed)
C1603	C1603 (as listed)
C1604	C1604 (as listed)
C1737	C1737 (as listed)
C7556	C7556 (as listed)
C7557	C7557 (as listed)
C7560	C7560 (as listed)
C9807	C9807 (as listed)

1–10 of 19

1/2

Behavioral health testing codesCPTCovered

96116	Neurobehavioral status exam (as listed)
96121	Assessment services (as listed)
96130	Psych testing (as listed)
96131	Psych testing (as listed)
96132	Neuropsych testing (as listed)
96133	Neuropsych testing (as listed)
96136	Psych testing (as listed)
96137	Psych testing (as listed)
96138	Psych testing (as listed)
96139	Psych testing (as listed)

1–10 of 11

1/2

Transcranial Magnetic Stimulation (TMS)CPTCovered

90867	TMS: initial/follow-up (as listed)
90868	TMS treatment (as listed)
90869	TMS additional codes (as listed)

Selected outpatient surgery codes (partial list)CPTCovered

15011	Skin surgery (as listed)
15012	Skin surgery (as listed)
11730	Debridement or nail removal (as listed)
43770	Bariatric surgery
43772	Bariatric surgery
43773	Bariatric surgery
43774	Bariatric surgery
15820	Blepharoplasty
15821	Blepharoplasty
15822	Blepharoplasty

1–10 of 14

1/2

Residential treatment codesmixedCovered

1001	Residential treatment (as listed)
1002	Residential treatment (as listed)
H0017	HCPCS residential service H0017 (as listed)
H0018	HCPCS residential service H0018 (as listed)
H0019	HCPCS residential service H0019 (as listed)
H2036	HCPCS residential service H2036 (as listed)

Outpatient services requiring PAmixedCovered

Sleep studies (home sleep studies)

Sleep studies, including home sleep studies

Genetic testing exemptions and limitsCPT

81220	CPT 81220 (genetic testing) — exempt from authorization; lifetime limit 1
81244	CPT 81244 — exempt from authorization
81329	CPT 81329 — exempt from authorization; combined lifetime limit with 81336 =1
81336	CPT 81336 — exempt from authorization; combined lifetime limit with 81329 =1
81420	81420 referenced in genetic testing list

Gastroenterology and selected proceduresCPTCovered

43235	Procedure requiring authorization in POS 19/22 when office-based/ASC available
43239	Procedure requiring authorization in POS 19/22 when office-based/ASC available
43248	Procedure requiring authorization in POS 19/22 when office-based/ASC available
45378	Procedure requiring authorization in POS 19/22 when office-based/ASC available
45380	Procedure requiring authorization in POS 19/22 when office-based/ASC available
45384	Procedure requiring authorization in POS 19/22 when office-based/ASC available
45385	Procedure requiring authorization in POS 19/22 when office-based/ASC available
46255	Procedure requiring authorization in POS 19/22 when office-based/ASC available
46260	Procedure requiring authorization in POS 19/22 when office-based/ASC available
46270	Procedure requiring authorization in POS 19/22 when office-based/ASC available

1–10 of 14

1/2

DME codes not requiring authorizationHCPCS

A4239	DME code not requiring authorization
A4287	DME code not requiring authorization
A4541	DME code not requiring authorization
A4554	DME code not requiring authorization
A4560	DME code not requiring authorization
A4670	DME code not requiring authorization
A4927	DME code not requiring authorization
A6530	DME code not requiring authorization
A6533	DME code not requiring authorization
A6590	DME code not requiring authorization

1–10 of 31

1/4

Speech therapy codes exempt from PACPT

92610	CPT 92610 — does not require authorization
92611	CPT 92611 — does not require authorization

Therapeutic services requiring PAmixedCovered

99183	Hyperbaric Oxygen Therapy
96567	Phototherapy
96573	Phototherapy
96574	Phototherapy
96900	Phototherapy
96910	Phototherapy
96912	Phototherapy
96913	Phototherapy
96920	Phototherapy
96921	Phototherapy

1–10 of 29

1/3

Chiropractic codes requiring PACPTCovered

98940	Chiropractic service requiring prior authorization
98941	Chiropractic service requiring prior authorization
98942	Chiropractic service requiring prior authorization
98943	Chiropractic service requiring prior authorization
rev 0940	Revenue code 0940 requiring prior authorization

Counseling service codesCPTCovered

G0108	Counseling services code — covered without authorization when billed by certified providers
G0109	Counseling services code — covered without authorization when billed by certified providers

Appendix I — HCPCS/Codes requiring PAHCPCSCovered

Appendix I list

Extensive list of C-, J-, G-, and other HCPCS codes (e.g., C9047, C9166, C9306, J0129, J0139, J0174, J0175, J0177-J0180, J0205-J0225, J0256-J0281, J0401-J0490, etc.) requiring prior authorization

Appendix I (start)HCPCS

J0220	ertranacogene dezaparvovec-
J0221	alglucosidase alfa (Lumizyme) / J0638 / canakinumab (Ilaris) / drlb (Hemgenix)
J0222	patisiran (Onpattro) / J0641 / levoleucovorin / J1412
J0223	givosiran (Givlaari) / J0642 / levoleucovorin (Khapzory) / rvox (Rocavian)
J0224	lumasiran / J0691 / lefamulin (Xenleta) / J1413 / delandistrogene
J0225	vutrisiran (Amvuttra) / J0699 / cefiderocol 10mg (Fetroja) / moxeparvovec-rokl (Elevidys)

Appendix I (continued)HCPCS

J0256	alpha 1-prot inhib NOS / J0706 / caffeine citrate inj / J1414 / fidanacogene elaparvovec-dzkt
J0257	alpha 1-prot inhib (Glassia) / J0717 / certolizumab pego (Cimzia) / (Beqvez)
J0270	alprostadil (Prostin VR) / J0725 / chorionic gonadotropin / J1426 / casimersen inj
J0275	alprostadil sup (Muse) / J0742 / imipenem, cilastatin / J1427 / viltolarsen (Viltepso)
J0281	aminocaproic acid inj / relebactam (Recarbrio) / J1428 / eteplirsen (Exondys 51)
J0401	aripiprazole ER inj (Abilify Maintena) / J0775 / collagenase clostrid histol / J1429 / golodirsen (Vyondys 53)
J0402	aripiprazole (Abilify asimtufii) / JO801 / corticotropin (Acthar gel) / J1438 / etanercept (Enbrel)
J0485	belatacept inj (Nulojix) / J0802 / corticotropin (ANI) / J1440 / fecal microbiota - live
J0490	belimumab (Benlysta) / J0841 / crotalidae F(ab')2 (equine) / (Rebyota)

Appendix I (additional examples)HCPCS

J0517	benralizumab (Fasenra) / J0879 / difelikefalin / J1447 / tbo-filgrastim (Granix)
J0565	bezlotoxumab (Zinplava) / J0887 / epoetin beta, ESRD (Mircera) / J1448 / trilaciclib inj
J1449	eflapegrastim-xnst inj / J1943 / aripiprazole lauroxil (Aristada) / J2998 / plasminogen, human-tvmh
J1453	fosaprepitant inj / J1944 / aripiprazole lauroxil (Aristada) / J2799 / risperidone (Uzedy)
J1454	fosnetupitant 235mg / J1950 / leuprolide acet (Lupron) / J3031 / fremanezumab-vfrm (Ajovy)
J1632	brexanolone (Zulresso)
J1745	infliximab (Remicade) / J2778 / ranibizumab (Lucentis) / J3401
J7186	VIIIVWF complex human (Alphanate) / J7322 / hyaluronan products / J7683
J7201	factor IX recombinant (Rixubis) / J7508 J7514 and related immunosuppressive agents
J9042	brentuximab (Adcetris) / J9258 / paclitaxel protein-bound / J9345 / retifanlimab-dlwr (Zynyz)

Selected J-codes (partial list shown in chunk 54)HCPCSCovered

J7209	listed in Appendix I requiring prior authorization
J7210	listed in Appendix I requiring prior authorization
J7211	listed in Appendix I requiring prior authorization

Chemotherapy/biologic J-codes (partial)HCPCSCovered

J9042	brentuximab (Adcetris) and related entries
J9046	bortezomib inj / carfilzomib entries
J9048	bortezomib inj (fresnius kabi) entries
J9049	bortezomib inj (Hospira) entries

Q-codes (biosimilars, injectables)HCPCSCovered

Q5124	ranibizumab-nuna (Byooviz) and related Q-code entries
Q5125	filgrastim-ayow (Releuko) and related Q-code entries
Q5132	adalimumab-afzb (Abrilada) and related biosimilar Q-code entries

High utilization triggers for utilization review

High-utilization triggers (utilization review)Three (3) or more psychiatric inpatient hospitalizations in the prior 12 months OR four (4) or more psychiatric ED visits in the prior 12 months OR three (3) or more medical inpatient hospitalizations in the prior 12 months.

Readmission triggerReadmission to any mental health inpatient unit within 30 days of discharge may trigger utilization review.

Prior Authorization, Notifications, and Documentation Requirements

Prior Authorization

Outpatient & DME Prior Authorization Required

Prior authorization is required for many outpatient procedures and DME items. Sleep studies (including home sleep studies) and other outpatient/DME services listed below must have PA prior to scheduling or claim submission.

Outpatient services that require PA include sleep studies (including home sleep studies).
Certain gastroenterology procedures require PA when performed in POS 19 or 22 if an office or ambulatory surgery center is available; these include 43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270 (PA not required in POS 11 or 24). Authorization is required for 43290 in any POS.
Durable medical equipment and supplies listed in the DME section require PA unless specifically exempted (see DME exemptions).

Prior Authorization

Genetic Testing and BRCA — Prior Authorization and Lifetime Limits

Genetic testing and BRCA testing require prior authorization except for specific CPT codes. Some CPTs have lifetime limits — providers must verify limits when requesting authorization.

Level of Care: Inpatient, PHP, IOP, Outpatient Counseling

Inpatient / Partial Hospitalization / IOP

Level of care review and utilization triggers for inpatient, partial hospitalization, and IOP services — covered when the listed admission/continued stay conditions apply:

Admission notification requirement for OMH/OASAS in‑state facilities: Facility must notify Fidelis within two business days of admission and submit required forms (OMH Two‑Day Notification and Initial Treatment Plan or OASAS Appendix A and LOCADTR).

If met, initial authorization/concurrent review may be waived per policy for specified timeframes.

Continued stay review triggers: Triggers include Assisted Outpatient Treatment (AOT) orders, high utilization (3+ psychiatric inpatient hospitalizations OR 4+ psychiatric ED visits OR 3+ medical inpatient hospitalizations in 12 months), readmission within 30 days, or length of stay >30 days (concurrent review from day 31 onward).

Facilities must perform daily clinical review and periodic consultation with Fidelis Care as described.

Discharge planning requirement:

Modality-Specific Requirements (TMS, ABA, PT/OT/ST)

TMS — Transcranial Magnetic Stimulation criteria

Transcranial Magnetic Stimulation (TMS) — medical necessity criteria:

TMS eligibility: Member is over 18 years old and treatment is delivered using an FDA‑cleared device for FDA‑labeled indications; there is a confirmed diagnosis of major depressive disorder (MDD); and the member has failed to respond to multiple medication trials and evidence‑based psychotherapy during the current episode.

Authorization required for CPT 90867‑90869.

Applied Behavior Analysis (ABA) and ASD-related DME

Applied Behavior Analysis (ABA) and related DME for Autism Spectrum Disorder — authorization requirements:

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

State‑expanded benefits include ABA and certain DME for members with ASD.

Applied Behavior Analysis (ABA) Coverage Criteria

ABA for Autism Spectrum Disorder

Applied Behavior Analysis (ABA) for Autism Spectrum Disorder — coverage prerequisites:

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

State expanded benefits include ABA and certain DME for ASD.

Visit and Unit Limits

Residential treatment codes referenced

Residential treatment CPT codesCPT codes 1001 and 1002 are referenced for residential treatment.

Residential HCPCS codesHCPCS codes H0017, H0018, H0019 and H2036 are referenced for residential services.

Visit limits notedNo explicit numeric visit limits for residential treatment are listed in the provided excerpt.

Rehabilitation (all therapies combined)

Rehabilitation visit limitRehabilitation services (all therapies combined) are limited to 60 visits per condition per plan year.

Applies across therapiesThe 60-visit limit applies to all therapy types combined (PT/OT/ST) per condition.

Background and Scope Notes

Background: New York State OMH-licensed inpatient mental health facilities and OASAS-licensed inpatient SUD programs have modified authorization and utilization review processes under this policy. In-network, in-state OMH and OASAS facilities generally do not require prior authorization for admissions when notification and required documentation are submitted within the specified timeframes; however, utilization review (including prior authorization or concurrent review) will be initiated when defined triggers occur (for OMH: current or recent AOT court orders, high utilization thresholds such as 3+ psychiatric inpatient hospitalizations or 4+ psychiatric ED visits in 12 months, readmission within 30 days, or length of stay beyond 30 days). Out-of-state or out-of-network facilities remain subject to authorization and concurrent review throughout the admission.

Definitions and Terminology

OMH licensed hospitals

OMH licensed hospitals (definition)OMH licensed hospitals: inpatient mental health treatment facilities licensed by the New York State Office of Mental Health (OMH).

Notification requirementFacilities must notify the insurer within 2 business days of admission (Fidelis Care Behavioral Health contact provided).

Context of applicabilityPolicy provisions for utilization review and authorization (including exceptions) apply to OMH-licensed hospitals in New York State.

OASAS licensed facilities

OASAS licensed facilities (definition)OASAS licensed facilities: inpatient detoxification, inpatient rehabilitation and inpatient residential treatment services licensed, certified or otherwise authorized by the New York State Office of Addiction Services and Supports (OASAS) and participating in Fidelis Care's provider network.

28-day initial period

Policy Summary

PayerFidelis Care

PolicyBehavioral Health and Prior Authorization Guidance (coverage criteria)

Policy CodePolicy N/A

Change TypeOperational update / guidance

Effective DateJan 1, 2020

Next Review DateN/A

Key ActionNotify Fidelis Care within two business days of OMH- or OASAS-licensed inpatient admissions and submit required admission and treatment plan forms.

SourceLink

On This Page

Length-of-stay trigger

Length of stay exceeding 30 days triggers concurrent review beginning on day 31.

Lifetime limits (genetic testing)

CPT 81220 lifetime limitCPT 81220 has a lifetime limit of 1.

CPT 81329 and 81336 combined lifetime limitCPT 81329 and CPT 81336 have a combined lifetime limit of 1.

Exempted CPTs notedCPTs 81220, 81244, 81329, 81336 and 81420 are listed in the genetic testing section regarding authorization/exemptions.

Home health benefit maximum

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

ScopeApplies to home health skilled services when medically necessary.

Related benefit noteHospice coverage (when medically necessary) is available up to 210 days (separate from home health visit maximum).

Prior authorization applicability

Appendix I applicabilityPrior authorization applies to the specific HCPCS J-codes and related entries enumerated in Appendix I; providers must request PA for items/drugs billed with those J-codes.

Provider actionProviders must consult Appendix I for exact codes requiring prior authorization and obtain PA before billing/administration.

Potential denial riskClaims for Appendix I J-codes may be denied if submitted without prior authorization.

Authorization is NOT required for CPT 81220, 81244, 81329, 81336 and 81420.
CPT 81220 has a lifetime limit of 1. CPTs 81329 and 81336 have a combined lifetime limit of 1.
Submit genetic testing authorization requests per the laboratory/testing request process; excluded tests and routing are described in the Genetics/Pharmacy/Enteral sections.

Prior Authorization

GI and Selected Procedures — Prior Authorization

Select gastroenterology and other outpatient procedures require prior authorization depending on place of service or universally for specific codes.

GI procedures that require PA in POS 19 and 22 (when office/ASC available): 43235, 43239, 43248, 45378, 45380, 45384, 45385, 46255, 46260, 46270.
43290 requires authorization in any place of service.
Other specified procedures requiring PA include penile prosthesis 54405 and codes 42975 and 97037.

Prior Authorization

DME Prior Authorization Requirements and Exemptions

DME prior authorization requirements include a list of HCPCS codes that do not require authorization and items that always require authorization. Special rules apply for certain codes like T2101 (donor breast milk).

DME codes that do NOT require PA include (partial list): A4239, A4287, A4541, A4554, A4560, A4670, A4927, A6530, A6533, A6590, A6540, A6591, A7021, A7046, A7049, E0130, E0655, L2210, L2630, L3100, L3221, L3702, L3762, L3809, L3915, L4350, L5991, L7360.
T2101 (Donor Breast Milk) requires authorization only when given in an outpatient setting.
Other DME items (compression garments, electric heat pads, protective helmets, surgical stockings, wigs, insulin pumps/infusion pumps, etc.) require authorization. New codes effective 4/1/24 (A4271, A4438, ...) do not require PA.

Prior Authorization

Therapy Initial Evaluation Exemptions and Delegated Authorization

Initial outpatient or facility-based therapy evaluations do not require prior authorization, but all subsequent therapy visits require authorization via the delegated vendor. Authorization timing and routing vary by setting.

Initial PT/OT/ST evaluations (designated initial evaluation CPT codes) do NOT require authorization.
All therapy services after the initial evaluation require authorization through Evolent (NIA) for outpatient/home therapy; submit authorization within 1 business day for outpatient, 2 business days for home health, or to Fidelis within 1 business day for inpatient settings.
Non-therapy providers (MD, DO, DPM, etc.) should request authorization for post-evaluation therapy services directly through Fidelis Care when appropriate.

Prior Authorization

Chiropractic Services — Prior Authorization

Chiropractic services billed with specified CPT/revenue codes require prior authorization.

Codes requiring authorization: 98940, 98941, 98942, 98943, revenue code 0940.

Prior Authorization

Vendor-Specific Authorizations

Certain vendor-specific services require authorization by the named vendor. Providers must route authorization requests to those vendors per the vendor instructions.

Orthodontic and major dental services: authorize via DentaQuest (1-800-516-9615).
Vision prior authorizations: Davis Vision (1-800-601-3383).
Evolent (NIA) handles delegated reviews for outpatient oncology medications and many radiology/radiation therapy services; see Evolent instructions for submission.

Prior Authorization

Enteral Therapy — Prior Authorization

Enteral nutrition products and disposables billed with HCPCS B4034–B4162 require prior authorization. Non-prescription enteral formulas for home use need a physician's written order stating medical necessity.

HCPCS B4034–B4162 require authorization for enteral formulas and disposable items.
Non-prescription enteral formulas for home use require a written order from a physician or licensed provider stating the formula is medically necessary for a disease-specific treatment regimen.
Authorization requests for enteral HCPCS codes should be submitted to the Pharmacy Team via e-fax per Pharmacy routing instructions.

Prior Authorization

Appendix I — Codes Requiring Prior Authorization

Appendix I lists numerous J-, Q-, and other HCPCS/CPT codes and product names that require prior authorization. Providers must consult Appendix I and obtain PA before billing these items or drugs.

Appendix I enumerates many J-, Q-, C-, G-, and specific product-level codes that require PA (partial list included in Appendix I).
Claims for items/drugs billed with HCPCS J-, Q-, C-, G- codes listed in Appendix I may be denied if prior authorization is not obtained.
Appendix I is maintained in the policy; providers must reference it for the full list and submission instructions.

Denial Risk

Codes Requiring Prior Authorization — Denial Risk

Prior authorization is required for any listed codes in Appendix I and other sections of this policy. Failure to obtain required prior authorization may result in claim denial or denial of coverage for admissions and services.

Claims submitted for J-, Q-, or other codes listed in Appendix I without prior authorization may be denied.
Providers should obtain PA before dispensing/administering oncology medications and supportive agents in outpatient settings per Evolent review requirements.
Maximum unit edits apply to all HCPCS codes regardless of authorization status; non-FDA HCPCS medications may be treated as exclusions.

Documentation Required

Facility Notification Requirements for Inpatient Admissions

Facilities must notify Fidelis Care within required timeframes for certain licensed inpatient admissions and submit required forms and initial treatment plans. Failure to notify timely may change concurrent review requirements.

OMH-licensed inpatient mental health hospitals: notify Fidelis Care within 2 business days of admission by calling 1-888-FIDELIS and/or faxing the OMH Two-Day Notification and Initial Treatment Plan form to 833-561-0094 (formerly 718-896-1784).
OASAS-licensed Inpatient SUD facilities: notify Fidelis Care of inpatient admission and initial treatment plan within 2 business days by fax to 833-663-1608 and submit OASAS Appendix A Notification Form and LOCADTR tool data as instructed.
All inpatient admissions require authorization (except emergency stabilization); facilities must notify Fidelis Care within two business days for OMH/OASAS exceptions and follow the facility-specific submission instructions.

Billing Rule

Pharmacy / Enteral Authorization Routing

Authorization requests for enteral and pharmacy-related HCPCS codes and oncology-related outpatient medications must be routed to the Pharmacy Team or delegated reviewer using the specified e-fax or vendor portal. See vendor-specific routing for oncology.

Submit authorization requests to the Pharmacy Team electronically via e-fax: 1-844-235-5090 for HCPCS enteral codes and other pharmacy/enteral authorizations.
Oncology-related outpatient medication requests (and supportive agents) require prior authorization and review by Evolent; submit via Evolent's web portal or call 1-888-999-7713.
Do not send requests excluded from Evolent review to Evolent; follow section B and Appendix I routing rules for oncology items.

Documentation Required

Voicemail and UM Communication Requirements

Utilization Management voicemail messages may contain detailed UM determination information only if the provider's voicemail is HIPAA-compliant and meets specified mailbox greeting requirements.

Voicemail greetings must identify the owner, organization, and state the mailbox is confidential and that PHI may be left.
If the mailbox meets HIPAA-compliance requirements, detailed UM messages may be left; otherwise a generic message requesting a callback will be left.
A second attempt to reach the provider directly will be made when notifying the provider of a UM determination, per Department of Health Reasonable Effort Policy.

Prior Authorization

Transcranial Magnetic Stimulation (TMS) — Eligibility and Authorization

Transcranial Magnetic Stimulation (TMS) is covered but requires authorization. Eligibility includes FDA-cleared device use, confirmed diagnosis of major depressive disorder, and failure to respond to multiple medication trials and evidence-based psychotherapy during the current episode.

Covered CPT codes: 90867, 90868, 90869 — authorization required.
Member must be over 18 and TMS must be administered using an FDA-cleared device consistent with labeled indications.
Eligibility requires failure to respond to multiple trials of medication and evidence-based psychotherapy during the current episode of illness; submit requests to Behavioral Health UM via email, fax (833-561-0098), or 1-888-FIDELIS extension 16072.

Prior to discharge, facilities must provide a written discharge plan determined using LOCADTR and indicate whether services in the discharge plan are secured or reasonably available.

Applies to OMH and OASAS inpatient programs as specified.

Outpatient Counseling

Outpatient counseling services coverage and limits:

Counseling services coverage: Counseling services billed with codes G0108 and G0109 are covered and do not require authorization when provided by certified providers; coverage is limited to 10 hours (20 units) in a continuous 12‑month period.

No authorization required for these services when delivered by certified providers; units limit applies per continuous 12‑month period.

PT/OT/ST — Physical, Occupational, Speech Therapy criteria

Physical, Occupational, and Speech Therapy (PT/OT/ST) authorization and visit limits:

Therapy services requiring prior authorization: Office or facility‑based initial evaluations for PT/OT/ST do not require authorization; however, all subsequent therapy services performed after the initial evaluation require prior authorization through Evolent (NIA) (submission timelines apply: within 1 business day for outpatient, 2 business days for home health, or to Fidelis within 1 business day for inpatient settings). CPT codes 92610 and 92611 do not require authorization. The rehabilitation and habilitation benefits are limited to 60 visits per condition per plan year (all therapies combined).

Failure to obtain required authorization for post‑evaluation therapy services may risk claim denial; see delegated authorization instructions.

Authorization contextAll outpatient therapy services after the initial evaluation require prior authorization through Evolent (NIA).

Habilitation (all therapies combined)

Habilitation visit limitHabilitation services (all therapies combined) are limited to 60 visits per condition per plan year.

Applies across therapiesThe 60-visit limit applies to all therapy types combined per condition (habilitation).

Authorization contextSubsequent habilitation services after initial evaluation require prior authorization per therapy rules.

Counseling services (G0108, G0109)

Counseling services unit limitCounseling services billed with G0108 and G0109 are covered up to 10 hours (20 units) in a continuous 12-month period.

Authorization statusThese counseling services no longer require authorization when provided by certified providers.

Provider requirementServices must be provided by certified providers to be covered under this allowance.

Inpatient SUD services at OASAS-licensed, in-network NYS facilities are not subject to authorization or concurrent review for the first 28 days if notification and documentation requirements are met.

Notification requirementFacility must notify Fidelis Care of the inpatient admission and initial treatment plan within two business days using OASAS Appendix A and LOCADTR.

Delegated review

Delegated review (definition)Certain prior authorizations (for radiology, therapy, and oncology medications/supportive agents) have been delegated to third parties such as Evolent (NIA) for review and approval.

Therapy delegationOutpatient PT/OT/ST authorizations (after initial evaluation) are to be requested through Evolent (NIA).

Oncology delegationOncology medications and supportive agents require prior authorization and review by Evolent before dispensing or administration in outpatient/ambulatory settings.

Appendix I

Appendix I (definition)Appendix I: a policy appendix that enumerates HCPCS/CPT/J- and Q-codes (with associated product names) that require prior authorization; providers must consult Appendix I for exact codes requiring PA.

ScopeAppendix I lists many specific J- and Q-codes and related entries that require prior authorization when billed.

Provider responsibilityProviders must request prior authorization for items/drugs billed with the HCPCS J-codes and related entries listed in Appendix I to avoid claim denial.