ModifiedFidelis CarePolicy N/A

Behavioral health and utilization authorization rules

Defines prior authorization, notification, and utilization review requirements for inpatient, outpatient, and behavioral health services for Fidelis Care members in New York State, including special rules for OMH and OASAS licensed facilities and selected procedures.

Policy Summary

PayerFidelis Care

PolicyBehavioral health and utilization authorization rules

Policy CodePolicy N/A

Change TypeMaterial updates to authorization and exemption rules

Effective DateN/A

Next Review DateN/A

Key ActionNotify Fidelis Care within two business days for OMH/OASAS inpatient admissions and submit the mandated notification form.

SourceLink

POLICY UPDATE CHANGES

OASAS licensed in-state inpatient SUD services are not subject to prior authorization and are exempt from concurrent review for the first 28 days if notification and initial treatment plan are provided within two business days.

OMH licensed inpatient mental health treatment in NYS is not subject to prior authorization; concurrent review exemptions apply with specified notification and review conditions.

Outpatient behavioral health authorizations removed for most services; specified services (testing, ECT, PHP, IOP beyond initial days, ABA policy note) still require authorization or have special rules.

No prior authorization needed for first seven days of Intensive Outpatient Treatment; additional days require authorization.

Applied Behavioral Analysis (ABA) is not covered by Fidelis Care for NYS Managed Medicaid as of 8/1/2021 (covered by Medicaid FFS).

Prior authorization no longer required for Personalized Recovery Oriented Services (PROS) effective February 1, 2022.

Children and Family Treatment & Support Services (CFTSS) utilization management requirements have been discontinued effective 4/1/2020.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

28 daysOASAS SUD exemption

14 daysOMH under-18 exemption

7 daysIOP initial days

2/1/2022PROS authorization removed

4/1/2020CFTSS UM discontinued

8/1/2021ABA coverage moved

Coverage & Utilization Review Criteria

OMH inpatient review triggers

Utilization review will be conducted only for members who meet ANY of the following clinical triggers:

OMH utilization review triggers: Individuals subject to a current Assisted Outpatient Treatment (AOT) court order; Individuals who had an AOT court order that expired within the past five years; Individuals with high utilization defined as: (1) Three or more psychiatric inpatient hospitalizations in the prior 12 months OR (2) Four or more psychiatric ED visits in the prior 12 months OR (3) Three or more medical inpatient hospitalizations in the prior 12 months; Individuals readmitted to any mental health inpatient unit within 30 days of discharge; Individuals not meeting the above triggers whose length of stay exceeds 30 days (concurrent review from Day 31 onwards)

Per NYS OMH Best Practice Manual

Partial Hospitalization / Intensive Outpatient review triggers

Utilization review (admission and concurrent/continued stay) will be conducted only for members who meet ANY of the following triggers:

PHP/IOP utilization review triggers: Individuals subject to a current Assisted Outpatient Treatment (AOT) court order; Individuals who had an AOT order that expired within the past five years; Individuals with high utilization in the prior 12 months as defined by OMH triggers (three or more psychiatric inpatient hospitalizations OR four or more psychiatric ED visits OR three or more medical inpatient hospitalizations); Individuals readmitted within 30 days of a prior mental health inpatient discharge; Length of stay exceeds 30 days (concurrent review from Day 31 onwards)

Applies to OMH licensed programs in NYS

OASAS inpatient SUD coverage rules

Coverage stance for in-state, in-network OASAS licensed inpatient SUD services:

OASAS inpatient SUD authorization exemption: In-state, in-network OASAS licensed inpatient detoxification, rehabilitation and residential treatment are not subject to prior authorization and are exempt from concurrent utilization review for the first 28 days provided the facility notifies Fidelis Care of the admission and initial treatment plan within two business days and performs daily clinical review with periodic consultation starting on or just prior to day 1428 days

Services may be subject to utilization review after day 28 or upon discharge; out-of-state or out-of-network facilities remain subject to prior authorization and concurrent review

Intensive Outpatient - Utilization Review Criteria

Utilization review for intensive outpatient mental health treatment will be conducted only for members who meet the following clinical criteria:

NYS OMH triggers

High utilization: (1) Three or more psychiatric inpatient hospitalizations in the prior 12 months OR (2) Four or more psychiatric ED visits in the prior 12 months OR (3) Three or more medical inpatient hospitalizations in the prior 12 months3/4/3

Applied Behavioral Analysis (ABA)

Applied Behavioral Analysis coverage differs by program:

NYS Managed Medicaid: ABA benefit is covered by NYS Medicaid Fee-For-Service as of 8/1/2021 and is not covered by Fidelis Care for NYS Managed Medicaid2021-08-01

Providers should bill Medicaid FFS per state guidance

Child Health Plus ABA: Member under age 21 with DSM-5 diagnosis of autism spectrum disorder and/or Rett Syndrome; referral by a NYS licensed physician or qualified practitioner; prior authorization required from Behavioral Health using the Fidelis ABA authorization formage<21

Use Fidelis ABA Treatment Report form available on Fidelis Care website

PROS and CORE

Personalized Recovery Oriented Services (PROS) and CORE Services:

PROS prior authorization is not required effective February 1, 2022; prior to this date authorization was required2022-02-01

CORE Services are available if eligible and do not require prior authorization; Service Initiation Form must be submitted within 3 business days of first service visit

Eligibility determined through adult HealthierLife plan and LPHA Recommendation Form required

CFTSS

Children and Family Treatment & Support Services (CFTSS):

CFTSS coverage: Utilization management requirements discontinued effective 4/1/2020; listed CFTSS modalities do not require prior authorization or concurrent review2020-04-01

Includes OLP, CPST, PSR, FPSS, YPSS, Crisis Intervention

Children's HCBS

Children's Home and Community Based Services (age ≤20):

Children's HCBS initiation: Services available to members age 20 and younger who are HCBS-eligible; effective 12/01/2021 providers must submit Section 1 of the NYS DOH Children's HCBS Authorization and Care Manager Notification form prior to the member's initial appointment2021-12-01

Submit via specified Fidelis Care email/fax/phone to avoid claims processing disruptions

Selected coverage criteria

Covered when specific conditions are met for Medicaid Managed Care enrollees transitioning from LTHHCP or meeting clinical thresholds for enteral therapy:

LTHHCP transition benefits: Medical Social Services (S9127) and Home Delivered Meals (S5170) are covered with an authorization for Medicaid Managed Care enrollees who transitioned from the Medicaid Fee-for-Service Long Term Home Health Care Program and were receiving these services at the time of transition

Authorization required

ADHC/AADHC authorization: Authorization required for any new ADHC/AADHC patient and for the initial assessment (up to two visits). Members enrolled as of 8/1/13 may remain in current care plan up to 90 days; continuation beyond 90 days reviewed for medical necessity

Enteral therapy eligibility: Enteral therapy HCPCS B4034-B4162 requires authorization and applies to: tube-fed individuals who can only obtain nutrition via tube; individuals with inborn metabolic disorders requiring specific formulas; children under 21 needing medical formulas for growth/development; adults with HIV/AIDS or other conditions meeting BMI and documented unintentional weight loss thresholds or requiring total nutritional support where tube placement is contraindicated

Behavioral training coverage

Behavioral and self-management trainings covered with stated limits:

DSMT: Diabetes Self-Management Training: members allowed 10 hours/20 units in a continuous 6-month period; services provided by certified providers and billed with G0108/G0109; authorization not required10 hours/20 units per 6 months

ASMT: Asthma Self-Management Training: authorized codes S9441, S9445, S9446, 98960-98962 when billed with diagnosis J45x; newly diagnosed or medically complex members allowed up to 10 hours in a continuous 6-month period; medically stable members up to 1 hour per continuous 6-month period; authorization not required10 hours or 1 hour per 6 months depending on status

Smoking Cessation Counseling: Smoking cessation counseling reimbursed for up to 8 visits per calendar year using codes 99406 and 99407 and billed only with specified F17 ICD-10 codes; authorization not required8 visits per calendar year

As of 8/1/2021, the Applied Behavioral Analysis (ABA) benefit for New York State Managed Medicaid is the responsibility of Medicaid Fee‑For‑Service (FFS) and is not covered by Fidelis Care. Providers should bill ABA services to NYS Medicaid FFS per state guidance.

For members in New York State Managed Medicaid, ABA is covered by Medicaid Fee‑For‑Service effective 8/1/2021 and therefore is not covered by Fidelis Care. Providers and contractors must follow NYS FFS billing and authorization procedures for ABA services beginning on that date.

DME, procedural services, and pharmaceutical treatments for erectile dysfunction are specifically listed and are not covered for registered sex offenders. The codes called out include procedural CPT codes and the prosthesis HCPCS code (see coding table for the full code list).

Coverage for erectile dysfunction interventions excludes registered sex offenders; therefore related durable medical equipment, procedures, and medications for erectile dysfunction are not covered when the member is a registered sex offender. Refer to the coding section for the enumerated CPT/HCPCS codes.

Pharmacy supplies may be limited by plan; specifically, certain pharmacy supplies are not covered for Child Health Plus (CHP) in accordance with the member's CHP benefit plan. Providers should confirm CHP pharmacy benefit limitations before submitting claims.

The policy identifies a set of J‑codes (including J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332, J7333) that are non‑covered when billed in combination with specified CPT codes or diagnoses. See the coding and exclusions sections for the exact combinations and billing guidance.

CPT code 20610 is identified as non‑covered when billed with certain M17.* diagnosis codes (the policy lists M17.0, M17.10‑M17.12, M17.2, M17.20‑M17.32, M17.4, M17.5, M17.9). Providers should not bill 20610 with these listed diagnoses; such claim combinations may be denied.

The policy lists specific therapeutic services that are not covered for members with a diagnosis of Low Back Pain. These include prolotherapy; therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT guidance); therapeutic steroid injections into intervertebral discs; and continuous or intermittent traction. Providers should not submit authorization requests for these treatments for members whose primary diagnosis is Low Back Pain.

Certain medication and drug requests require direct review by Fidelis Care rather than delegation to New Century Health. Examples include CAR T‑cell therapy, immune globulins, radiopharmaceuticals, controlled substances, retrospective reviews, inpatient drug requests, and medications used in clinical trials. The policy notes these items must be submitted directly to Fidelis Care for review and are not automatically processed via delegated pathways.

The document reiterates that the listed J‑codes (for example, J7318, J7320–J7329, J7331–J7333) are not covered when billed with CPT 20610 or 20611 or when billed with the enumerated M17.* diagnosis codes. This exclusion appears both in the exclusions and in the not‑medically‑necessary sections and should be followed when adjudicating claims.

Codes and Billing Identifiers

Transplant-related CPT ranges listed for authorizationCPT

32850-32856
33930-33945
38204-38215
38230-38242
44133-44136
47133-47147
48160
48550-48556
50300-50380
50547

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Outpatient surgery codes requiring prior authorization (selected)CPT

43770-43775	Bariatric surgery
S2083	Bariatric related
15820-15823	Blepharoplasty
11920-11971	Breast reconstruction
19300	Breast-related
19316-19342
19355
19370-19396
10040	Skin surgery (authorization if POS 24)
11300-11313	Skin surgery (authorization if POS 24)

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Additional outpatient surgery/other procedure codesCPT

21120-21296	Facial cosmetic, septoplasty, rhinoplasty
30400-30450
30465-30520
30620-30802
30999
31298
C9749
Q2028
36465-36466	Vascular/vein procedures
36468-36479

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Behavioral health outpatient codesCPT|HCPCS|RevenueCovered

96116	Psychological testing
96121	Psychological testing
96130-96133	Neuropsychological testing
96136-96139
96146
96112	Developmental pediatric testing
96113	Developmental pediatric testing
96110	Non-covered service
90870	Outpatient ECT
H0035	Partial hospitalization HCPCS

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Intensive Outpatient Codesmixed

905	Revenue code (Intensive Outpatient)
906	Revenue code (Intensive Outpatient)
912	Revenue code (Intensive Outpatient)
90899	CPT (Intensive Outpatient)
S9480	CPT/HCPCS (Intensive Outpatient)
H2013	HCPCS (Intensive Outpatient)

PROS/CORE/ACT/Related Behavioral Health CodesHCPCS

H2012	Mental Health Continuing Day Treatment
H0040	Assertive Community Treatment (ACT)
H2017	Psychosocial Rehabilitation (CORE)
H0036	Community Psychiatric Support and Treatment (CPST)
H0038	Peer Supports / Empowerment Services
H2014	Family Support and Training
A0160	Provider Travel Supplement

Adult behavioral health-HCBS CodesHCPCS

T2017	Habilitation and Residential Support Services
T2015	Pre-Vocational Services
T2019	Transitional Employment
H2023	Supported Employment
H2025	Supported Employment
T2013	Education Support Services
A0160	Provider Travel Supplement

Children and Family Treatment & Support Services (CFTSS) CodesmixedCovered

90791	OLP - Other Licensed Practitioner (assessment)
H0004	OLP - Behavioral health counseling
H2011	OLP - Clinic-based services
90882	OLP - Group psychotherapy (hypnosis)
H0036	CPST
H2017	PSR
H0038	FPSS / YPSS
H2001	Crisis Intervention
S9484	Crisis Intervention
S9485	Crisis Intervention

Erectile Dysfunction DME and procedural codesmixed

54360	Erectile Dysfunction procedural code
54400	Erectile Dysfunction procedural code
54401	Erectile Dysfunction procedural code
54402	Erectile Dysfunction procedural code
54405	Erectile Dysfunction procedural code
54408	Erectile Dysfunction procedural code
54410	Erectile Dysfunction procedural code
54411	Erectile Dysfunction procedural code
54416	Erectile Dysfunction procedural code
54417	Erectile Dysfunction procedural code

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DME/Services for Erectile Dysfunction (not covered for registered sex offenders)CPT|HCPCS

54360
54400-54402
54405
54408
54410
54411
54416
54417
55870
L7900

Diabetes Self-Management Training covered codesCPTCovered

G0108	Diabetes self-management training individual session
G0109	Diabetes self-management training group session

Asthma Self-Management Training covered codesCPTCovered

S9441
S9445
S9446
98960-98962

Smoking Cessation Counseling covered CPT codesCPTCovered

99406	Smoking and tobacco use cessation counseling intermediate
99407	Smoking and tobacco use cessation counseling intensive

Allowed smoking cessation diagnosis codesICD-10

F17.200	Nicotine dependence, unspecified, uncomplicated
F17.201
F17.210
F17.211
F17.220
F17.221
F17.290
F17.291

Enteral therapy HCPCS codes requiring authorizationHCPCSCovered

B4034-B4162

Enteral formulas and disposable enteral items requiring authorization

Listed C/G/J HCPCS and crosswalk entries (oncology/infusible/specialty drugs)HCPCS

C9054	Drug/biologic crosswalk entries listed
C9055
C9063
C9074
C9085
C9086
C9399	Unclassified drugs/biologics
G0516
G0517
G0518

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Enumerated J-codes and mappingsHCPCS

J3110	romosozumab (Evenity) mapping entries
J3121	testosterone enanthate / other mappings
J3145	testosterone undecanoate / other mappings
J3241	teprotumumab / other mappings
J3245	tildrakizumab (Ilumya) / other mappings
J3262	tocilizumab (Actemra) / other mappings
J3285	treprostinil (Remodulin) / other mappings
J3304	triamcinolone related mappings
J3315	triptorelin pamoate (Trelstar) / mappings
J3316	triptorelin ER (Triptodur) / mappings

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OASAS concurrent review exemption — 28 days

OASAS concurrent review exemption period28 days (Inpatient SUD services exempt from concurrent utilization review for the first 28 days if facility notifies Fidelis Care of admission and initial treatment plan within 2 business days and follows LOCADTR review/consultation requirements)

Notification requirementFacility must notify Fidelis Care within two business days and may fax/email the OASAS Appendix A Notification Form and LOCADTR to 646-829-1421 or LOCADTR@fideliscare.org

Clinical review requirement

What Providers Must Do / Authorization Workflow

Prior Authorization

CORE and HCBS authorization stance

Effective February 1, 2022, CORE Services do not require prior authorization. Adult behavioral health Home and Community Based Services (HCBS) do require prior authorization after the intake period. HCBS prior authorization requests must be submitted to Fidelis Care by e-mail (QHCMHARPBH@FidelisCare.org) or fax (347-868-6427) for approval. CORE Services require submission of the Service Initiation Form to Fidelis Care by e-mail (QHCMHARPBH@FidelisCare.org) or fax (347-868-6427) within 3 business days of the first service visit.

CORE Services (no PA effective 2/1/2022): H2017, H0036, H0038, H2014, A0160. Submit Service Initiation Form within 3 business days.
Adult behavioral health-HCBS: intake period (3 visits or 14 days) does NOT require PA; PA required after intake. Submit PA to QHCMHARPBH@FidelisCare.org or fax 347-868-6427.

Prior Authorization

Children's HCBS notification / prior authorization workflow

Children's Home and Community Based Services (Children's HCBS) effective 12/01/2021 require providers to notify Fidelis Care of the identified service requested prior to the member's initial appointment. Providers must submit Section 1 of the NYS DOH Children's HCBS Authorization and Care Manager Notification form before initiating services to prevent claim disruptions. Submissions may be sent by e-mail to SM_Childrens_HCBS@fideliscare.org, fax to (347) 690-7362, or by calling 1-888-FIDELIS and following the prompts for Children's Medicaid. C-YES and Health Home providers must also submit the Plan of Care.

Policy Background & Scope

This policy defines utilization management and authorization rules for behavioral health services in New York State, aligning Fidelis Care processes with NYS OMH and OASAS licensing and Best Practice manuals. It establishes notification and concurrent review exemptions for licensed in‑state facilities (for example, OMH inpatient concurrent review exemption of 14 days for members under 18 and OASAS inpatient SUD exemption of 28 days when notification and required forms are submitted), specifies OMH/OASAS clinical triggers for utilization review, and clarifies prior authorization and documentation requirements for selected outpatient behavioral health services.

Key Terms and Tools

LOCADTR clinical review tool

LOCADTR toolLOCADTR clinical review tool is used for SUD inpatient medical necessity assessment and for concurrent review notifications after exemption periods

Submission methodsFacilities may fax/email OASAS Appendix A and LOCADTR to 646-829-1421 or LOCADTR@fideliscare.org

Use timingLOCADTR-based consultation with Fidelis Care should begin on or just prior to day 14 of inpatient SUD treatment

Assisted Outpatient Treatment (AOT) — court order trigger

AOT court order as triggerIndividuals subject to a current Assisted Outpatient Treatment (AOT) court order are included as triggers for utilization review per NYS OMH Best Practice Manual

Recent AOT history

Level of Care — Inpatient, PHP, IOP, Outpatient

Applied Behavioral Analysis Coverage Rules

ABA coverage note

Note on coverage location and payer responsibility for ABA services:

ABA coverage transfer note: As of 8/1/2021, Applied Behavioral Analysis for NYS Managed Medicaid is covered by NYS Medicaid Fee-For-Service and not by Fidelis Care2021-08-01

Providers should bill FFS per state guidance

ABA eligibility and coverage

ABA coverage depends on membership type:

Child Health Plus ABA eligibility: Member under age 21 with DSM-5 diagnosis of autism spectrum disorder and/or Rett Syndrome; referred by a NYS licensed physician or qualified practitioner; prior authorization required from Behavioral Health using Fidelis ABA formage<21

Modalities: ECT, PHP, IOP, CFTSS, Self-management

ECT

Outpatient ECT: Authorization is required for outpatient electroconvulsive therapy (CPT 90870)

PHP/IOP

Partial Hospitalization: Authorization required per listed rate/revenue/HCPCS codes; utilization review applies only for members meeting OMH triggers

Requests for members under 21 have specific contact methods

Intensive Outpatient: No prior authorization needed for the first seven days; additional days require authorization and utilization review per NYS OMH criteria (revenue codes 905, 906, 912; CPT 90899; S9480; HCPCS H2013)7 days

Visit and Service Day Limits

Intensive Outpatient Treatment (authorization-free initial period)

IOP initial days without authorization7 (first seven service days of Intensive Outpatient Treatment are provided without prior authorization)

Provider actionAdditional IOP days beyond the initial 7 require authorization and utilization review per NYS OMH criteria

Relevant codesRevenue 905/906/912; CPT 90899; S9480; HCPCS H2013

Intensive Outpatient Treatment — First 7 service days without authorization

First 7 IOP service daysFirst 7 service days of Intensive Outpatient Treatment do not require authorization

After 7 daysSubsequent IOP service days require prior authorization

Policy Changes & Effective Dates

See the policy header 'Change List' and update summary for a concise record of material changes, including the transfer of ABA coverage for NYS Managed Medicaid to Medicaid Fee‑For‑Service effective 8/1/2021, removal of certain authorizations for licensed OMH/OASAS programs, and the list of services requiring direct Fidelis review (e.g., CAR T‑cell therapy, immune globulins, inpatient drug requests). Refer to the document changes component for full details and effective dates.

Policy Summary

PayerFidelis Care

PolicyBehavioral health and utilization authorization rules

Policy CodePolicy N/A

Change TypeMaterial updates to authorization and exemption rules

Effective DateN/A

Next Review DateN/A

Key ActionNotify Fidelis Care within two business days for OMH/OASAS inpatient admissions and submit the mandated notification form.

SourceLink

On This Page

BMI and weight loss thresholds specified

See enteral therapy criteria for BMI <18.5 or BMI <22 with >=5% unintentional weight loss in prior 6 months

Facility must perform daily clinical review and periodically consult with Fidelis Care starting on or just prior to day 14

Scope after exemptionServices may be subject to utilization review after day 28 or upon discharge using the LOCADTR clinical review tool

OMH under-18 concurrent review exemption — 14 days

OMH under-18 concurrent review exemption period14 days (Fidelis Care will not conduct concurrent utilization review during first 14 days for OMH-licensed inpatient admissions for members under 18 provided facility submits OMH Two-Day Notification and Initial Treatment Plan within 2 business days)

Notification submissionComplete OMH 'Two-Day Notification and Initial Treatment Plan' form and submit by fax to 718-896-1784 or email to Mental_Health_Admission@fideliscare.org

Facility obligationsPerform daily clinical review and participate in periodic consultation with Fidelis Care to ensure use of approved OMH clinical review criteria

IOP initial authorization-free period — 7 days

IOP initial authorization-free period7 days (No prior authorization needed for first seven days of Intensive Outpatient Treatment)

Codes referencedRevenue codes 905, 906, 912; CPT 90899; S9480; HCPCS H2013

After initial periodAdditional service days beyond the first seven require prior authorization and utilization review per NYS OMH criteria

Intensive outpatient high utilization threshold

High utilization definition for IOPThree (3) psychiatric inpatient hospitalizations OR Four (4) psychiatric ED visits OR Three (3) medical inpatient hospitalizations in the prior 12 months

Source of criteriaDefined per NYS OMH Best Practice Manual and applied to Intensive Outpatient, Partial Hospitalization, and Inpatient OMH-licensed services

ApplicationMembers meeting any high-utilization trigger are subject to utilization review for IOP admissions/continued stay

Intensive outpatient concurrent review threshold — >30 days

Concurrent review trigger by length of stayConcurrent utilization review is triggered when length of stay exceeds 30 days (concurrent review from Day 31 onwards)

Applies toIntensive Outpatient admissions (and OMH inpatient/PH when length of stay >30 days) per NYS OMH Best Practice Manual

Out-of-network ruleOut-of-network IOP and inpatient services remain subject to concurrent review throughout the admission

BMI threshold for supplemental enteral nutrition

BMI criteria (severe underweight)BMI under 18.5 — eligible for supplemental enteral nutrition (up to 1,000 calories/day) when compliant with medical/nutritional plan

BMI plus weight loss criterionBMI under 22 with documented unintentional weight loss of ≥5% within prior 6 months — eligible for supplemental enteral nutrition (up to 1,000 calories/day)

Other enteral indicationsAlso applies for tube-fed individuals who can only obtain nutrition via tube, inborn metabolic disorders requiring specific formulas, children under 21 for growth/development needs, or total nutritional support when tube placement contraindicated

Continuous six-month period limits — DSMT and ASMT

DSMT limit (6-month period)10 hours (20 units) in a continuous six-month period

ASMT limits (6-month period)Up to 10 hours for newly diagnosed or medically complex members; up to 1 hour for medically stable members during a continuous six-month period

AuthorizationThese self-management training services do not require authorization when billed with specified codes

Diagnosis list (partial)

Sample diagnosis codes (partial list)M17.0; M17.10–M17.12; M17.2; M17.20–M17.32; M17.4; M17.5; M17 (partial listing as noted)

ContextThese diagnoses are cited in the document in relation to non-coverage rules when billed with specific J-codes or CPT 20610/20611

Reference noteSee policy non-coverage note for full diagnosis enumeration and applicable billing restrictions

Services requiring pre-notification include Community Habilitation, Day Habilitation, Caregiver/Family Support and Services, Community Self Advocacy Training and Support, Prevocational Services (age 14+), Supported Employment (age 14+), Respite Services, Palliative Care, Environmental/Vehicle Modifications, Adaptive and Assistive Equipment.
Submit Section 1 of NYS DOH Children's HCBS Authorization and Care Manager Notification form to SM_Childrens_HCBS@fideliscare.org or fax 347-690-7362 prior to rendering service.

Documentation Required

ABA documentation requirement

Applied Behavior Analysis (ABA) prior authorization for Child Health Plus is required. ABA authorization requests must include the Fidelis Care Applied-Behavioral-Analysis Treatment Report form available on the Fidelis Care website.

ABA eligibility: under age 21 with DSM-5 diagnosis of Autism Spectrum Disorder and/or Rett Syndrome; referral by NYS-licensed provider (physician, psychologist, NP, PA as specified).
Submit ABA authorization via the Applied-Behavioral-Analysis Treatment Report form: https://www.fideliscare.org/Portals/0/Providers/FormsApplications/Applied-Behavioral-AnalysisTreatment-Report.pdf

Prior Authorization

Fidelis direct review list and oncology-related prior authorization

Certain medication and therapy requests are routed to New Century Health (NCH) for prior authorization; however, specific oncology and related categories are reviewed directly by Fidelis Care and must not be sent to NCH. Submit oncology medication PA requests for members 18+ via NCH's portal or phone for Medicaid Managed Care, Essential Plan, and Qualified Health Plan (excluding Child Health Plus).

Oncology PA (NCH) applies to members 18+ in MMC, EP, QHP (excludes CHP). Request at my.newcenturyhealth.com or 1-888-999-7713 option 1.
Do NOT send the following to NCH — send to Fidelis Care pharmacy team instead or follow Fidelis direction: CAR T-cell therapy; Cablivi; Immune Globulins; Sickle Cell Disease therapy; Pain Medications; Controlled Substances; Retrospective reviews; Radiopharmaceuticals; Anti-infectives; Iron Preparations; Medications for Clinical Trials; Inpatient drug requests; Medications not being used for an oncology or oncology-related indication.

Prior Authorization

Oncology-related prior authorization

Oncology-related outpatient medication requests for members 18 and over in Medicaid Managed Care, Essential Plan, and Qualified Health Plan (excluding Child Health Plus) must be submitted to New Century Health for prior authorization. For the list of drugs requiring NCH review, providers should check Fidelis Care's Pharmacy Services webpage. Certain oncology-related services and codes remain subject to additional authorization rules.

Submit oncology/supportive agent PA to NCH at my.newcenturyhealth.com or call 1-888-999-7713, option 1.
Refer to Fidelis Care Provider Pharmacy Services page for the current NCH drug list: https://www.fideliscare.org/Provider/Provider-Resources/Pharmacy-Services

Step Therapy

CFTSS step therapy

Children and Family Treatment & Support Services (CFTSS) have no step therapy requirements and utilization management requirements have been discontinued; prior authorization was never required for these services.

CFTSS services include OLP (90791, H0004, H2011, 90882), CPST (H0036), PSR (H2017), FPSS/YPSS (H0038), Crisis Intervention (H2001, S9484, S9485).
Concurrent review is no longer required for CFTSS; contact 1-888-FIDELIS for questions.

Denial Risk

Non-coverage triggers

All services billed with 'Unlisted' or 'Temporary' codes (such as C-codes) require prior authorization. Additionally, certain J-codes are non-covered under specific billing combinations and may trigger non-coverage when billed with particular CPT codes or diagnoses.

Unlisted/Temporary codes require authorization (e.g., C-codes).
Non-coverage example: J7318, J7320-J7329, J7331-J7333 are non-covered when billed with CPT code 20610 or 20611 or when billed with diagnoses in the M17.* series (e.g., M17.0, M17.10-M17.32, M17.4, M17.5, M17.9).

Note

Not specified / no action

(No additional provider-action content specified in these source chunks.)

Individuals whose AOT order expired within the past five years are also included in utilization review triggers

Applies to levels of careAOT-related triggers apply to OMH inpatient, partial hospitalization, and intensive outpatient utilization review criteria

High utilization triggers

High utilization definitionThree (3)+ psychiatric inpatient hospitalizations in prior 12 months OR Four (4)+ psychiatric ED visits in prior 12 months OR Three (3)+ medical inpatient hospitalizations in prior 12 months

Applies toUsed as a utilization review trigger for OMH inpatient, partial hospitalization, and intensive outpatient services

Concurrent review implicationMembers meeting high-utilization triggers are subject to utilization review for admission and continued stay

Assisted Outpatient Treatment (AOT) — inclusion criteria

AOT inclusion windowIndividuals subject to a current AOT court order or whose AOT expired within the past five years are included in utilization criteria

Policy sourcePer NYS OMH Best Practice Manual as reflected in Fidelis Care criteria for OMH-licensed programs

Implication for reviewTriggers admission/concurrent review consideration across OMH levels of care

Enteral Therapy (HCPCS B4034-B4162)

Enteral Therapy HCPCS rangeHCPCS B4034–B4162 (enteral formulas and disposable items require authorization)

Authorization requirementEnteral therapy codes B4034–B4162 require prior authorization for eligible beneficiaries

Related eligibilityApplies to tube-fed individuals, certain metabolic disorders, children under 21 for growth/development, and adults meeting BMI/weight-loss criteria

Use Fidelis ABA Treatment Report form

NYS Managed Medicaid ABA: ABA benefit covered by Medicaid Fee-For-Service as of 8/1/2021 and therefore not covered by Fidelis Care for managed Medicaid2021-08-01

Out-of-network IOP subject to concurrent review throughout admission

CFTSS

CFTSS modalities: Includes OLP, CPST, PSR, FPSS, YPSS, Crisis Intervention; utilization management requirements discontinued effective 4/1/2020; no prior authorization or concurrent review required2020-04-01

Providers may contact Fidelis Care with questions

Self-management training / Smoking cessation counseling

DSMT/ASMT/SCC: Coverage and visit/time limits as specified: DSMT 10 hours/20 units per continuous 6-month period; ASMT up to 10 hours (new/complex) or up to 1 hour (stable) per continuous 6-month period; Smoking cessation counseling reimbursed up to 8 visits per calendar year with codes 99406/99407 and specified F17 diagnosis codesSee individual entries

Authorization not required

Concurrent review triggersIOP subject to OMH utilization review triggers (AOT, high utilization, readmission, >30 days length of stay)

Mental Health Continuing Day Treatment (H2012) — First 7 days

H2012 initial authorization-free periodMental Health Continuing Day Treatment (H2012): first 7 service days do not require authorization

After initial periodAdditional H2012 service days require prior authorization

Submission contactsRequests for members ages 18–20 may be made via chmmc@fideliscare.org, fax (347) 690-7362, or 1-888-FIDELIS

Diabetes Self-Management Training — 10 hours / 20 units

DSMT limit10 hours (20 units) during a continuous six-month period

Billing codesG0108 (individual) and G0109 (group)

AuthorizationThese services no longer require authorization when billed with specified codes

Asthma Self-Management Training — time limits

ASMT time limitsUp to 10 hours during a continuous six-month period for newly diagnosed or medically complex members; up to 1 hour for medically stable members

Billing codesS9441, S9445, S9446, 98960–98962 when billed with diagnosis J45x

Session formatMay be provided individually or in groups (max 8 patients); authorization not required when billed with specified codes

Smoking Cessation Counseling — 8 visits

Smoking Cessation Counseling limitUp to 8 visits per calendar year (using codes 99406 and 99407) billed only with specified F17 ICD-10 codes

AuthorizationNo authorization required for smoking cessation counseling as specified

Allowed diagnosis codesF17.200, F17.201, F17.210, F17.211, F17.220, F17.221, F17.290, F17.291