CurrentFidelis CarePolicy N/A

COVID-19 UPDATE

Provider guidance on prior authorization, utilization review, and coverage requirements across inpatient, outpatient, behavioral health, DME, home health, imaging, therapy, and specialty services for Fidelis Care Medicaid/CHP/HealthierLife lines; includes delegated authorization arrangements and service-specific rules and code lists. This is part 1 of 2 and covers services and procedural codes referenced in this section only.

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE

Policy CodePolicy N/A

Change TypeOperational guidance / consolidations

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for all inpatient admissions, transplant evaluations, and the outpatient and diagnostic procedures listed in the policy; follow delegated vendor processes where applicable (TurningPoint, NIA, DentaQuest, Davis Vision).

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes — brief records operational guidance and consolidations but has_material_change=false.

ManyCPT/HCPCS codes referenced

MultipleDelegated vendors

1-28Concurrent review/no-review windows (days)

8Max SCC visits per year

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Max ASMT hours (complex/new)

B4034-B4162Enteral therapy HCPCS range (CHP)

Coverage Summary & Scope

This policy provides COVID-19 operational guidance to providers and records multiple permanent policy changes and delegated arrangements affecting prior authorization and utilization review. It applies to Fidelis Care lines of business including Medicaid, Child Health Plus (CHP), and HealthierLife, and documents vendor delegations and procedural rules. This document is part 1 of 2 and covers operational guidance, permanent policy changes, delegations, and the services and CPT/HCPCS/ICD-10 codes referenced in this section only.

Authorization thresholds and limits

OASAS inpatient no-review windowFirst 28 days of admission (no concurrent utilization review if facility notifies Fidelis within 2 business days)

OMH inpatient no-review window (minors)First 14 days of admission (no concurrent review if facility notifies Fidelis within 2 business days and meets OMH form requirements)

OMH inpatient concurrent review triggerLength of stay exceeds 30 days (concurrent review from Day 31 onwards)

Partial hospitalization / OMH utilization triggersThree psychiatric inpatient admissions in prior 12 months OR Four psychiatric ED visits in prior 12 months OR Three medical inpatient admissions in prior 12 months

Intensive Outpatient initial no-auth windowFirst 7 days of service (additional days require authorization)

ASMT hours (complex/new)Up to 10 hours in a continuous six-month period for newly diagnosed or medically complex members

ASMT hours (stable)Up to 1 hour in a continuous six-month period for medically stable members

SCC visit limitUp to 8 visits per calendar year (sum of CPT 99406 and 99407)

Children's respite annual limitPlanned and Crisis Respite may not exceed 14 days (1,344 15-minute units) per year without medical necessity

Enteral therapy supplemental calories (adults with HIV/AIDS or related illness) Up to 1,000 calories per day

Prior Authorization and Utilization Review Criteria

Code Lists and Status Groups

Transplant CPT codes requiring authorizationCPTCovered

32850	Transplant related CPT
32851	Transplant related CPT
32852	Transplant related CPT
32853	Transplant related CPT
32854	Transplant related CPT
32855	Transplant related CPT
32856	Transplant related CPT
33930	Transplant related CPT
33931	Transplant related CPT
33932	Transplant related CPT

1–10 of 78

1/8

Outpatient surgery codes requiring authorizationCPTCovered

43770	Laparoscopic gastric bypass
43771	Bariatric surgery
43772	Bariatric surgery
43773	Bariatric surgery
43774	Bariatric surgery
43775	Bariatric surgery
15820	Blepharoplasty
15821	Blepharoplasty
15822	Blepharoplasty
15823	Blepharoplasty

1–10 of 34

1/4

Behavioral health test and therapy codes requiring authorizationCPTCovered

Behavioral health CPT/HCPCS/Rate codes - refer to behavioral health section

MLTC supply codes requiring authorizationHCPCSCovered

MLTC supply HCPCS codes requiring authorization - see MLTC policy

Therapeutic and other specialized procedure codesmixedCovered

Various specialized procedures (CPT/HCPCS) requiring authorization per policy

DXA and TBS codes (conditional)CPT

DXA and TBS codes conditional authorization

Therapy initial evaluation exceptionsCPT

Initial therapy evaluation codes not requiring authorization

Home health personal care and consumer direct HCPCS codesHCPCSCovered

Home health personal care and consumer directed HCPCS codes requiring authorization

OB ultrasound diagnosis codes exempt from authorizationICD-10

OB ultrasound diagnosis ICD-10 codes exempt from authorization

ASMT codesmixedCovered

ASMT (assessment) codes (HCPCS/CPT) covered and require authorization

Smoking Cessation Counseling CPT codesmixedCovered

Smoking cessation counseling CPT and related ICD-10 codes covered

Enteral therapy HCPCS range (covered_conditional)HCPCSCovered

Enteral therapy HCPCS codes - conditional coverage and authorization requirements

Oncology and other J-/C-codes referencedHCPCS

J- and C- HCPCS drug codes referenced for oncology and infusion services

S codesHCPCSNot Covered

S-codes are not covered

Non-covered when billed with CPT 20610/20611 or certain diagnosesmixedNot Covered

Specific HCPCS codes not covered when billed with CPT 20610/20611 or when certain ICD-10 diagnoses are present

What Providers Must Do

Prior Authorization

Obtain authorization for inpatient admissions and specified services

Obtain prior authorization for all inpatient admissions, transplant evaluations, and the outpatient and diagnostic procedures listed in the policy; follow delegated vendor processes where applicable (TurningPoint, NIA, DentaQuest, Davis Vision).

All inpatient admissions require authorization.
All solid organ and bone marrow/tissue transplants require authorization at time of transplant evaluation (includes listed CPT codes).
Follow delegated vendor processes where applicable (e.g., TurningPoint for certain outpatient procedures and cardiac surgeries; NIA for many radiology services; DentaQuest and Davis Vision for orthodontic/vision PAs).

Documentation Required

Notify Fidelis Care for certain OMH and OASAS admissions

Notify Fidelis Care within required timelines and submit the specified forms to the listed contacts to avoid concurrent review in the initial no-review windows for OMH and OASAS inpatient admissions.

Background and Rationale

This update consolidates numerous service-level prior authorization requirements and documents vendor delegations and pandemic-era operational guidance. It explains that many inpatient, outpatient, behavioral health, DME, home health, imaging, therapy, pharmacy, and specialty service authorization rules have been consolidated into a single operational guidance document; it also records multiple permanent policy changes and exceptions implemented during the pandemic (for example, OASAS inpatient SUD authorization and no concurrent review for the first 28 days when facilities notify Fidelis, and OMH inpatient mental health review exceptions and triggers). The policy notes that certain prior authorization responsibilities have been delegated to external vendors (for example, TurningPoint for ENT and cardiac procedures and National Imaging Associates (NIA) for many radiology and therapy authorizations) and that oncology medication prior authorization routing is delegated to New Century Health. It further documents behavioral health changes (such as removal of authorization for many outpatient behavioral health services and specific authorization rules for partial hospitalization, intensive outpatient treatment, ABA, and other programs) and references delegated prior authorization arrangements and service-specific permanent changes (including OASAS/OMH exceptions and delegated prior authorization arrangements).

Definitions and Abbreviations

Term	Definition
POS
Place of Service code
OMH
New York State Office of Mental Health
OASAS
New York State Office of Addiction Services and Supports
LOCADTR
Level of Care Determination and Tracking Record (LOCADTR) clinical review tool
SPOA
Single Point of Access
ASMT
Asthma Self-Management Training
SCC
Smoking Cessation Counseling
NCH
New Century Health (oncology PA vendor)
CHP
Child Health Plus
FFS
Fee for Service

Revision History

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE

Policy CodePolicy N/A

Change TypeOperational guidance / consolidations

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

OASAS inpatient SUD facilities: notify Fidelis Care within 2 business days of admission; fax or email OASAS Appendix A and LOCADTR to 646-829-1421 or LOCADTR@fideliscare.org to avoid concurrent review during the first 28 days.
OMH inpatient facilities (all ages): notify Fidelis Care within 2 business days by calling 1-888-FIDELIS ext 16072 or fax (718) 896-1784.
OMH inpatient for members under 18: submit OMH 'Two-Day Notification and Initial Treatment Plan' form by fax 718-896-1784 or email Mental_Health_Admission@fideliscare.org to avoid concurrent review during first 14 days.

Prior Authorization

Therapy authorization timing and vendor

Therapy prior authorization routing and timing: outpatient/home requests via NIA with specific business-day turnaround; inpatient requests to Fidelis; POS 31/32 fax instructions.

Route home & outpatient PT/OT/ST authorizations to National Imaging Associates (NIA).
NIA submission timelines: within 1 business day for outpatient setting; within 2 business days for home health setting.
Inpatient therapy authorization requests should be submitted to Fidelis within 1 business day.
For therapy in POS 31 & 32 (SNF/sub-acute rehab), fax prior authorization requests to 716-803-8307.

Billing Rule

OB ultrasound authorization rules

OB ultrasound authorization: the first four ultrasounds for pregnancy do not require authorization; five or more for a normal pregnancy require authorization; OB ultrasounds for high-risk pregnancy (listed ICD-10 codes) are exempt from authorization.

First 4 OB ultrasounds can be performed without an authorization.
Five or more ultrasounds for a normal pregnancy require authorization (normal pregnancy diagnosis codes listed).
High-risk pregnancy OB ultrasound diagnoses (ICD-10 codes O09.x, O36.80x series and others as listed) do not require authorization.

Documentation Required

Children's HCBS notification prior to initial appointment

For Children's Home and Community Based Services (C-YES) notify Fidelis Care prior to the member's initial appointment using the NYS Children's HCBS Authorization and Care Manager Notification Form; planned and crisis respite have annual unit limits and higher use requires medical necessity documentation and LPHA attestation.

Submit the NYS Children's HCBS Authorization and Care Manager Notification Form prior to rendering the service to prevent claims processing disruptions (email SM_Childrens_HCBS@fideliscare.org or fax 347-690-7362).
Planned and Crisis Respite services may not exceed 14 days (1,344 15-minute units) annually without medical necessity.
Respite beyond limits requires LPHA attestation and NYS DOH Children's HCBS Authorization and Care Manager Notification form; contact 1-888-FIDELIS or Children's Medicaid prompts for submission.

Prior Authorization

MLTC supply authorization

MLTC supplies listed require prior authorization; benefit limits and DME manual rules apply.

HCPCS supply codes requiring authorization for MLTC: A4335, A4554, T4521, T4522, T4523, T4524, T4529, T4530, T4533, T4535, T4537, T4539, T4540, T4543.
DME coverage and benefit limits are governed by the Medicaid DME Program Manual; benefits/limits apply as stated in the manual.
Supplies/disposables coverage differs for CHP — supplies not covered for CHP lines of business per the manual.

Prior Authorization

Enteral formula authorization for CHP

Enteral formulas and disposable items (HCPCS range) require prior authorization for Child Health Plus as of 2023-04-01; eligibility criteria and program effective date are specified.

HCPCS B4034-B4162 require authorization for Child Health Plus effective 2023-04-01.
Benefit applies to tube-fed individuals who can only obtain nutrition via tube, individuals with inborn metabolic disorders requiring specific formulas, and children under 21 requiring medical formulas for growth/development.
Adult eligibility criteria include specified BMI/weight-loss criteria or permanent structural limitation preventing chewing; up to 1,000 calories per day in specified cases.

Documentation Required

ASMT billing and diagnosis linkage

ASMT codes S9441, S9445, S9446 and education/training codes 98960-98962 do not require prior authorization when billed with an asthma diagnosis (J45x); ensure claims include the J45x diagnosis and no PA is required for these linked submissions.

ASMT codes covered without authorization when billed with J45x: S9441, S9445, S9446, 98960, 98961, 98962.
When billed with J45x diagnoses, no prior authorization is required for those code/diagnosis combinations.

Billing Rule

SCC billing constraints

Smoking cessation counseling CPTs must be billed only with specified nicotine dependence diagnoses and are reimbursed up to an annual limit.

CPT codes 99406 and 99407 must be billed ONLY with diagnosis codes F17.200, F17.201, F17.210, F17.211, F17.220, F17.221, F17.290, F17.291.
Reimbursement limited to up to 8 visits per calendar year (sum of 99406 and 99407).

Prior Authorization

Oncology medication prior authorization via New Century Health

Oncology medications and supportive agents require prior authorization via New Century Health; use the NCH web portal or phone; certain categories are excluded from NCH review; note transition of Medicaid/HARP pharmacy benefit to NYS FFS on 4/1/2023.

Submit oncology PA requests to New Century Health via web portal (https://um.newcenturyhealth.com) or phone 1-888-999-7713, option 1.
Do not send excluded categories to NCH (examples: antibiotics, inpatient drug requests, immune globulins, hemophilia drugs, certain equipment requests, radiopharmaceuticals, surgeries/surgical procedures, etc.).
Starting 4/1/2023, Medicaid/HARP pharmacy benefit transitions to NYS Fee for Service (FFS); oncology pharmacy benefit details are in NYRx Medicaid FFS Pharmacy Program.

Prior Authorization

Unlisted/Temporary codes require authorization

All services billed with unlisted or temporary codes (including many C-codes) require prior authorization; obtain PA before billing.

Unlisted and Temporary codes (including C-codes) require prior authorization.
Submit PA requests for services mapped to C-codes or other temporary codes as instructed in the policy.

Billing Rule

Orthodontic and vision vendor PA

Orthodontic services for members under 21 require prior authorization by DentaQuest; vision prior authorizations handled by Davis Vision — use the vendor contact numbers.

Orthodontic PA: DentaQuest at 1-800-516-9615 (members under age 21).
Vision PA: Davis Vision at 1-800-601-3383.
Follow vendor-specific submission/authorization processes as directed by DentaQuest and Davis Vision.