CurrentFidelis CarePolicy N/A

COVID-19 Related Authorization and Behavioral Health Coverage (Authorization, Utilization Review, and Appendix I Coding)

Governs authorization, utilization review, and coding guidance for services during the COVID-19 period and related behavioral health coverage for Fidelis Care members in New York State, including inpatient, outpatient, SUD, OMH/OASAS licensed services, and selected procedures.

Policy Summary

PayerFidelis Care

PolicyCOVID-19 Related Authorization and Behavioral Health Coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for all non-emergent inpatient admissions and for specified outpatient procedures and Appendix I J-/HCPCS codes; follow OMH/OASAS notification requirements for applicable licensed facilities.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

28 daysOASAS SUD waiver period

14 daysOMH pediatric no concurrent review

RequiredInpatient authorization

90867-90869TMS CPTs

60Rehab visit limit

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40Home health visits

Coverage Criteria and Authorization Rules

OASAS Inpatient SUD — Waiver and conditions

OASAS-licensed inpatient substance use disorder (Inpatient SUD) services provided in New York State by licensed facilities are not subject to prior authorization and have defined notification and utilization review conditions.

ALL of the following

Inpatient detoxification, inpatient rehabilitation and inpatient residential treatment services provided by facilities licensed by OASAS in New York State are not subject to authorization review by Fidelis Care (effective 01/01/2020).
These services are not subject to concurrent utilization review during the first 28 days of the inpatient admission provided that the facility notifies Fidelis Care of the inpatient admission and the initial treatment plan within 2 business days of admission (facility may fax or email the OASAS Appendix A Notification Form and OASAS LOCADTR Medical Necessity Tool to fax 833-663-1608 or LOCADTR@fideliscare.org).
Facilities must perform daily clinical review of the patient; this does not require completion of the LOCADTR concurrent review module every day.
Facilities must periodically consult with Fidelis Care beginning on or just prior to day 14 of treatment to ensure use of the LOCADTR tool and medical necessity determination.
Inpatient SUD services may be subject to utilization review after day 28 from admission or upon discharge using the LOCADTR clinical review tool; prior to discharge the facility must provide the member and Fidelis Care with a written discharge plan determined using the LOCADTR tool and indicate whether services in the discharge plan are secured or reasonably available.
All Inpatient SUD services may be reviewed retrospectively to assess clinical necessity.
Facilities located outside New York State, or not licensed/certified by OASAS, or outside the Fidelis provider network must request authorization and their Inpatient SUD services remain subject to concurrent review throughout the admission.

OMH pediatric inpatient — Notification and review conditions

OMH-licensed inpatient mental health treatment for pediatric members has specific notification and concurrent review waiver conditions.

ALL of the following

Inpatient mental health treatment for members under age 18 provided by OMH-licensed hospitals in New York State and participating in the Fidelis network are not subject to authorization review (effective 01/01/2020).
Fidelis Care will not conduct concurrent utilization review during the first 14 days of inpatient admission provided the facility: (i) notifies Fidelis Care of the admission and initial treatment plan within 2 business days by completing the OMH Two-Day Notification and Initial Treatment Plan form and submitting by fax to 833-561-0094 or by email to MentalHealthAdmission@fideliscare.org; (ii) performs daily clinical review of the patient; and (iii) participates in periodic consultation with Fidelis Care to ensure use of evidence-based, peer-reviewed clinical review criteria approved by OMH appropriate to patient age to ensure medical necessity.
All inpatient mental health services provided by out-of-network facilities are subject to concurrent review throughout the admission.

COVERAGE CRITERIA — Utilization review triggers for OMH-licensed services (adult and child) per NYS OMH Best Practice Manual

Utilization review (admission and concurrent/continued stay) for OMH-licensed services (inpatient, partial hospitalization, intensive outpatient) for all ages is limited to members meeting NYS OMH Best Practice Manual clinical triggers. Fidelis Care requires notification timeframes and provides contact points for Behavioral Health inquiries.

ALL of the following

OMH-licensed inpatient mental health treatment for all ages provided by OMH-licensed hospitals in New York State are not subject to authorization review; facilities must notify the insurer within 2 business days of admission by calling 1-888-FIDELIS (1-888-343-3547), extension 16072 for Behavioral Health or by fax to 833-561-0094.
Utilization review will be conducted only for members who meet ONE or more of the following clinical criteria per NYS OMH Best Practice Manual:
- 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.

TMS coverage criteria

Transcranial Magnetic Stimulation (TMS) is covered with prior authorization for specified CPT codes and has eligibility criteria.

ALL of the following

TMS is a covered service but prior authorization is required for CPT codes 90867, 90868, and 90869.
Requests may be submitted by email to ghcmbh@fideliscare.org, fax to 833-561-0098, or by calling 1-888-FIDELIS and following the Behavioral Health prompts or dialing extension 16072.
Members age 18 and older may be eligible when TMS is administered using an FDA-cleared device per FDA-labeled indications and when additional criteria are met, including: a confirmed diagnosis of major depressive disorder (MDD) and failure to respond to multiple trials of medication and evidence-based psychotherapy during the current episode of illness.

Coverage Criteria and Authorization Requirements — Prior authorization is required for the following categories and codes unless otherwise noted or delegated

Prior authorization is required for multiple categories and specific codes across Durable Medical Equipment/Supplies, outpatient surgery, therapy services, therapeutic services, counseling limits, pharmacy HCPCS, and Appendix I codes. Certain codes and services are exempt from authorization per the listed rules.

ALL of the following

Durable Medical Equipment/Supplies: Some DME codes do not require authorization (examples: A4239, A4287, A4341, A4342, A4457, A4468, A4541, A4554, A4560, A4590, A4670, A4927, A6530, V2626, V5266). Effective 4/1/24 several codes (A4271, A4438, A4564, A4593, A4594, E0152, E0736) are new and do not require PA. Other DME and supplies (compression garments, electric heat/water bottle pads, protective helmets, surgical stockings, wigs, insulin pumps, etc.) require authorization.
Home Health Care approvals are based on medical need for skilled services; benefit maximum is 40 visits per plan year. Hospice coverage when medically necessary is available for up to 210 days with appropriate certification.
Outpatient surgery and selected procedural codes require prior authorization (examples include codes listed under Outpatient surgery section such as 20610 non-covered when billed with specified hyaluronic acid J-codes for knee osteoarthritis, abdominoplasty codes 15830–15879, facial cosmetic and rhinoplasty ranges 21120–21296, 30400–30520, and others). Certain outpatient orthopedic and spinal surgical procedures require authorization delegated to Evolent or TurningPoint as noted.

Code Lists and Coding Notes

Transplant CPTs requiring authorizationCPTCovered

32850-32856	Selected solid organ transplant related CPTs listed in transplant section
33930-33945	Selected cardiac transplant/related CPTs listed
38204-38215	Bone marrow / transplantation related CPTs listed
65710-65757	Ophthalmologic transplant codes range listed

Outpatient surgery CPT/HCPCS requiring authorizationmixedCovered

15820,15821,15822,15823	Blepharoplasty codes
43770,43772,43773,43774	Bariatric surgery codes
11920-11971,19300,19316-19342,19355,19370-19396	Breast reconstruction/mammoplasty codes
11730	Nail/fungal procedure requiring authorization with specific revenue codes
10040,11300-11313,11400-11471,11721	Selected dermatologic/skin surgery codes requiring authorization in ambulatory POS
A2025,A2030,11719,15769,15829,17340-17999,Q4354-Q4367	Codes requiring authorization for any place of service
10060,11100,17000,20600,20605	Codes requiring preauthorization when performed in freestanding ambulatory surgery centers (bill type 0831)

Behavioral health outpatient and testing codesmixedCovered

96137,96138,96139,96146	Psychological / neuropsychological testing — authorization required
96112,96113	Psychological testing — authorization required (96110 non-covered)
90870	Outpatient ECT — listed
Revenue 905,912; CPT 90899; S9480; HCPCS H2013	Intensive Outpatient Treatment revenue/CPT/HCPCS codes

Transcranial Magnetic Stimulation CPTsCPTCovered

90867	TMS initial treatment
90868	TMS subsequent treatment with stimulation
90869	TMS with management

Diagnostic and GI procedure codesCPTCovered

91110,91111	Wireless Capsule Endoscopy
91112,91113	Wireless Motility Capsule
43290,43235,43239,43248	Selected gastroenterology procedures requiring authorization depending on POS
45378,45380,45384,45385	Selected colon/upper GI procedure codes
46255,46260,46270	Selected gastroenterology procedure codes
54405	Penile prosthesis
42975,97037	Other procedures listed

Orthopedic/injection coding notesmixedNot Covered

20610	Arthrocentesis code — non-covered when billed with hyaluronic acid J-codes and knee OA diagnosis
J7318,J7320-J7329,J7331,J7332	Hyaluronic acid J-codes referenced with 20610

Outpatient Services Requiring AuthorizationmixedCovered

sleep studies

Sleep Studies, including Home Studies Sleep

Gastroenterology and Selected ProceduresCPTCovered

43290	Authorization required when performed in any place of service
43235	Requires authorization in POS 19 and 22 when office/ASC available
43239	Requires authorization in POS 19 and 22 when office/ASC available
43248	Requires authorization in POS 19 and 22 when office/ASC available
45378	Requires authorization in POS 19 and 22 when office/ASC available
45380	Requires authorization in POS 19 and 22 when office/ASC available
45384	Requires authorization in POS 19 and 22 when office/ASC available
45385	Requires authorization in POS 19 and 22 when office/ASC available
46255	Requires authorization in POS 19 and 22 when office/ASC available
46260	Requires authorization in POS 19 and 22 when office/ASC available

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DME Codes Not Requiring Authorization (partial list)HCPCS

A4239	DME code not requiring authorization (listed)
A4287	DME code not requiring authorization (listed)
A4341	DME code not requiring authorization (listed)
A4342	DME code not requiring authorization (listed)
A4457	DME code not requiring authorization (listed)
A4468	DME code not requiring authorization (listed)
A4541	DME code not requiring authorization (listed)
A4554	DME code not requiring authorization (listed)
A4560	DME code not requiring authorization (listed)
A4590	DME code not requiring authorization (listed)

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Therapeutic and Rehab Codes Requiring AuthorizationmixedCovered

S9472	Cardiac Rehab code (authorization required outpatient)
93797	Cardiac Rehab/monitoring (authorization required outpatient)
G0422	Cardiac Rehab code (authorization required outpatient)
G0423	Cardiac Rehab code (authorization required outpatient)
0943	Revenue code referenced for cardiac rehab
95249	Ambulatory continuous glucose monitoring
99183	Hyperbaric Oxygen Therapy

Counseling ServicesCPTCovered

G0108	Counseling service code (covered without authorization)
G0109	Counseling service code (covered without authorization)

Appendix I - Codes Requiring Prior Authorization (Drugs/Biologics/HCPCS)HCPCSCovered

Multiple C-, J-, G-, and other HCPCS codes

Appendix I: Extensive list of drug/biologic/HCPCS codes requiring prior authorization (examples include C9047, C9293, C9306, J0129, J0139, J0172, J0174, J0175, J0205, J0222, J0223, J0224, J0225, J1246, J1290, J1299, etc.)

Chiropractic Services Requiring AuthorizationCPTCovered

98940, 98941, 98942, 98943	Chiropractic service codes requiring authorization
0940	Chiropractic revenue code

Codes Requiring Prior Authorization (sample from start of Appendix I)HCPCS

J0222	patisiran (Onpattro) and other mappings as listed
J0223	givosiran (Givlaari) and associated notes (ESRD on Dialysis; J1096)
J0224	lumasiran and associated mappings
J0225	vutrisiran (Amvuttra) and associated notes (ESRD on Dialysis)
J0256	alpha 1-prot inhib NOS and related mappings

Continuation of Appendix I J-codesHCPCS

J1246	dinutuximab (Unituxin) and related mappings
J1290	ecallantide (Kalbitor) and related mappings
J1299	eculizumab inj (Soliris) and related mappings
J1302	sutimlimab-jome (Enjaymo) and related mappings
J1303	ravulizumab (Ultomiris)

Additional Appendix I J-codes in this segmentHCPCS

J3299	triamcinolone acetonide and assorted mappings
J3304	triamcin acet PF ER mic and related mappings
J3316	triptorelin ER (Triptodur)
J3355	urofollitropin (Bravelle) and related mappings
J3380	vedolizumab (Entyvio)
J3391	atidarsagene autotemcel
J3401	Vyjuvek / remestemcel-L-rknd (Ryoncil) and related mappings
J3490	unclassified drugs (multiple entries)
J7165	ESRD prothrombin complex and related mappings
J7171	Adamts13, recombinant-krhn and related mappings

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Selected J-codes listed (partial group)HCPCS

J8597	ramucirumab (Cyramza) and related entries as listed
J8600	melphalan (Alkeran) and related entries
J8611	methotrexate (Jylamvo) and related entries
J8612	methotrexate (Xatmep) and related entries
J8650	nabilone (Cesamet) and related entries
J8655	netupitant palonosetron and related entries

Additional J-codes (partial group)HCPCS

J8700	temozolomide (Temodar) and related entries
J8999	rx oral chemo and related entries
J9011	datopotamab deruxtecan-dlnk and related entries
J9021	asparaginase rec (Rylaze) and related entries
J9022	atezolizumab (Tecentriq) and related entries
J9023	avelumab (Bavencio) and related entries

Q- and miscellaneous codes listed (partial group)mixed

J9359	loncastuximab tesirine and related entries
J9380	teclistamab-cqyv (Tecvayli)
J9381	teplizumab mzwv (Tzield) and related entries
J9393	fulvestrant inj (teva) and related entries
J9999	misc chemo
Q0155	dronabinol oral (Syndros) and related entries
Q2042	tisagenlecleucel (Kymriah) and related entries
Q2054	lisocabtagene maraleucel and related entries
Q5100	trastuzumab- and bevacizumab- biosimilars and related Q-code group entries
Q5124	ranibizumab-nuna (Byooviz) filgrastim-ayow (Releuko) and related entries

inv-31: Inpatient SUD utilization review waiver — 28 days

Waiver periodInpatient SUD services are not subject to concurrent utilization review during the first 28 days of admission for in‑state OASAS‑licensed facilities when Fidelis Care is notified within two business days and daily clinical review is performed.

Notification requirementFacility must notify Fidelis Care of the inpatient admission and initial treatment plan within two (2) business days (OASAS Appendix A Notification Form or LOCADTR may be faxed/emailed).

Provider Requirements, Notifications, and Denial Risks

Denial Risk

Inpatient Authorization Required

All inpatient admissions require prior authorization except emergency services provided for stabilization. Fidelis Care does not require authorization for emergency room services or initial emergency stabilization, but post-stabilization inpatient admissions (non-emergent) must have authorization prior to or at the time of admission. Failure to obtain required inpatient authorization may result in claim denial or retrospective review.

Applies to all acute inpatient facility services and inpatient rehabilitation (acute, sub-acute, skilled nursing rehabilitation)
New fax for inpatient ER notifications: 833-663-1602

Prior Authorization

Outpatient and DME Services Require Prior Authorization

Prior authorization is required for the outpatient procedures, DME, and other services listed under the Outpatient and DME sections. Lack of authorization for these services may lead to denied claims or retrospective review.

Policy Background

The document summarizes temporary utilization review and authorization adaptations implemented during the COVID‑19 period and aligns those operational changes with New York State OMH and OASAS practices. For example, in‑state OASAS‑licensed inpatient SUD facilities are not subject to concurrent utilization review for the first 28 days provided timely notification and LOCADTR use, and OMH‑licensed pediatric inpatient admissions may be exempt from concurrent review for the first 14 days when the facility submits the OMH Two‑Day Notification and follows the specified clinical review procedures. These provisions reflect modified utilization management and authorization workflows adopted during the public health response and incorporated into the policy.

Defined Terms

inv-56: LOCADTR clinical review tool referenced for SUD admission notification and periodic clinical reviews

Tool nameLOCADTR clinical review tool is referenced for OASAS inpatient SUD admission notification, daily clinical review, periodic consultation, and for utilization review determinations.

Use timingFacilities are instructed to begin periodic consultation with Fidelis Care starting on or just prior to day 14 to ensure LOCADTR use and to apply LOCADTR for discharge planning and retrospective reviews.

Submission methodsOASAS Appendix A Notification Form and the LOCADTR Medical Necessity Tool may be faxed or emailed to Fidelis Care per the contact information provided.

inv-57: Two-Day Notification — OMH Two-Day Notification and Initial Treatment Plan form

FormOMH Two‑Day Notification and Initial Treatment Plan form must be completed and submitted to Fidelis Care by fax or email within two business days of admission for eligible pediatric OMH inpatient admissions.

Partial Hospitalization and IOP Criteria

Partial Hospitalization / Intensive Outpatient

Partial Hospitalization/IOP admission triggers: Admission and concurrent/continued‑stay utilization review for Partial Hospitalization and Intensive Outpatient Treatment (revenue codes 905/912, CPT 90899, S9480, HCPCS H2013) will be conducted only for members meeting OMH Best Practice triggers (AOT status/current or expired within 5 years; high utilization indicators as specified; readmission within 30 days; or length of stay exceeding 30 days with concurrent review starting on day 31).N/A

Applies to OMH‑licensed programs in NYS

Applied Behavior Analysis (ABA)

ABA authorization: Authorization is required from Behavioral Health for Applied Behavior Analysis (ABA); attestation of an Autism Spectrum Disorder (ASD) diagnosis by a licensed physician or psychologist must be provided at the time of request.N/A

DME speech generation equipment also requires authorization.

Special Treatment Modalities

TMS — treatment criteria

TMS modality criteria: TMS is covered for adults with MDD when administered using an FDA‑cleared device per labeled indications, with confirmed diagnosis of major depressive disorder, and failure to respond to multiple trials of medication and evidence‑based psychotherapy during the current episode; CPTs 90867–90869 require prior authorization.age >18

Requests submitted via Behavioral Health authorization channels.

ECT — treatment criteria

ECT modality note: Outpatient electroconvulsive therapy (ECT) is listed (CPT 90870); authorization requirements are addressed in the outpatient behavioral health services section and should be requested per provider instructions.N/A

Further ECT clinical criteria not provided in this fragment.

Visit Limits and Utilization Thresholds

inv-65: Intensive Outpatient Treatment (revenue/CPT/HCPCS listed) - utilization review applies per OMH triggers

Service codesIntensive Outpatient Treatment revenue/CPT/HCPCS codes include revenue 905 or 912, CPT 90899, S9480, and HCPCS H2013.

Utilization review triggersUtilization review for IOP applies only when members meet OMH Best Practice triggers (AOT status, high prior utilization, readmission within 30 days, or length of stay >30 days).

Submission guidanceAdmission and concurrent/continued stay reviews are conducted per OMH‑approved criteria for OMH‑licensed programs in New York State.

inv-66: Rehabilitation and Habilitation (combined therapy visit limits) — 60

Combined visit limitRehabilitation and habilitation therapy visit limit is 60 visits per condition per plan year (applies to all therapies combined).

Initial eval exemption

Policy Summary

PayerFidelis Care

PolicyCOVID-19 Related Authorization and Behavioral Health Coverage

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

SourceLink

On This Page

High utilization in the past year as evidenced by: 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.

Individuals who are readmitted to any mental health inpatient unit within 30 days of discharge from a mental health inpatient admission.

Individuals not meeting any of the above triggers whose length of stay exceeds 30 days (concurrent review from day 31 onwards).

The same OMH Best Practice Manual triggers apply for Utilization Review of Partial Hospitalization (all ages) and Intensive Outpatient programs (revenue codes 905 or 912; CPT 90899; S9480; HCPCS H2013).

Providers with questions are encouraged to call 1-888-FIDELIS (1-888-343-3547), extension 16072 for Behavioral Health; facilities should use the published OMH Best Practice Manual for details.

Therapy services: Effective 10/1/2021, outpatient PT/OT/ST services (all services after the initial evaluation) require prior authorization through Evolent (NIA); initial office/facility-based evaluations do not require authorization but subsequent billed procedure codes on the same date do require authorization. Home-based therapy authorization timelines differ (requests to Evolent within 2 business days for home). Visit limits: Rehabilitation and Habilitation benefits limited to 60 visits per condition per plan year (combined across therapy types).

Therapeutic Services: Certain services such as hyperbaric oxygen therapy, phototherapy, interventional pain management codes, prolotherapy, and others may require authorization. Specific services are not covered for members with a diagnosis of low back pain (e.g., therapeutic facet joint steroid injections in lumbar/sacral regions, continuous/intermittent traction, therapeutic injections of steroids into intervertebral discs). Cardiac and pulmonary rehabilitation in the outpatient setting require authorization.

Counseling Services: Members are allowed 10 hours/20 units in a continuous 12-month period provided by certified providers and do not require authorization when billed with codes G0108 and G0109.

Pharmacy/HCPCS: Appendix I lists HCPCS/C-codes requiring prior authorization; HCPCS codes for medications that are not FDA approved (e.g., certain J-codes) are considered benefit exclusions. S codes are benefit exclusions except for listed exceptions. Enteral therapy HCPCS B4034–B4162 require authorization. Authorization requests for Appendix I/Pharmacy should be submitted via e-fax to 1-844-235-5090.

Clinical review tool

Facilities must perform daily clinical review and periodically consult with Fidelis Care starting on or just prior to day 14 to ensure LOCADTR use for medical necessity determinations.

Post‑waiver reviewServices may be subject to utilization review after day 28 or upon discharge; discharge plans must be provided to the member and Fidelis Care using LOCADTR determinations.

inv-32: OMH pediatric concurrent review waiver — 14 days

Waiver periodOMH‑licensed inpatient mental health treatment for members under 18 is not subject to concurrent utilization review during the first 14 days when notification and other conditions are met.

Notification requirementFacility must notify Fidelis Care of admission and initial treatment plan within two business days using the OMH Two‑Day Notification and Initial Treatment Plan form (fax or email).

Facility responsibilitiesFacility must perform daily clinical review and participate in periodic consultation with Fidelis Care using OMH‑approved evidence‑based clinical review criteria.

ScopeApplies to OMH‑licensed hospitals in New York State participating in the Fidelis provider network; out‑of‑network facilities remain subject to concurrent review throughout the admission.

inv-33: Hospice days — up to 210 days

Maximum coverage periodWhen medically necessary, hospice care coverage is available for up to 210 days.

Certification requirementHospice care must be provided as part of a Hospice Care program certified pursuant to Article 40 of the N.Y. Public Health Law.

DocumentationCoverage determinations follow medical necessity criteria and certification per state law (documentation to support days covered).

inv-34: Rehabilitation visit limit — 60 visits per condition per plan year

Visit limitRehabilitation services are limited to 60 visits per condition per plan year (limit applies to all therapies combined).

Initial evaluationOffice or facility‑based PT/OT/ST initial evaluations do not require authorization, but subsequent billed procedure codes do require authorization prior to billing as specified.

Authorization routingAuthorization requests for outpatient therapy (other than initial eval) must be submitted to Evolent (NIA) within 1 business day for outpatient settings; home health within 2 business days; inpatient per Fidelis instructions.

inv-35: Habilitation visit limit — 60 visits per condition per plan year

Visit limitHabilitation services are limited to 60 visits per condition per plan year (limit applies to all therapies combined).

Authorization noteInitial evaluations do not require authorization, but ongoing habilitation therapy codes billed after the initial evaluation require prior authorization per therapy rules.

Submission timingAuthorization requests for non‑initial habilitation services must follow the same Evolent/Fidelis submission timeframes as rehabilitation services.

inv-36: Home health visits — 40 visits per plan year

Benefit maximumHome health skilled services benefit maximum is 40 visits per plan year.

Medical necessityHome care approvals are based on the medical need for skilled services; authorizations are required per clinical criteria.

Relation to DMEHome health visit approvals and DME/supplies follow separate authorization requirements described in the DME section.

Outpatient surgery codes (see policy list) such as blepharoplasty, bariatric surgery, breast reconstruction/mammoplasty, selected dermatology and ambulatory surgery center procedures
Durable Medical Equipment/Supplies: many DME items require authorization; some specific DME codes are listed as not requiring PA
Sleep studies (including home studies) require prior authorization

Prior Authorization

Cardiac and Pulmonary Rehabilitation Authorization

Cardiac and pulmonary rehabilitation services delivered in outpatient settings require prior authorization. Billing without prior authorization may result in denial.

Cardiac Rehab codes include S9472, 93797, G0422, G0423 and rev code 0943
Pulmonary rehabilitation services are included in the outpatient authorization requirement

Prior Authorization

Prior Authorization Required for Listed HCPCS/J Codes (Appendix I)

Prior authorization is required for the J-/HCPCS/Q codes and other codes listed in Appendix I. Providers must obtain authorization for these drugs and HCPCS-coded items prior to administration or billing. Claims for these codes may be denied or subject to retrospective review if authorization is not obtained.

Appendix I contains a large, non-exhaustive list of J- and Q-/HCPCS codes that require prior authorization (see Appendix I in this policy)
Maximum unit edits apply to HCPCS codes regardless of authorization status; some HCPCS codes for non–FDA-approved medications are benefit exclusions

Note

OMH Pediatric Notification Requirement (Two-Day Notification)

OMH-licensed inpatient pediatric mental health admissions (members under age 18) that meet the listed conditions are not subject to authorization review for the first 14 days, provided the facility notifies Fidelis Care of the admission and initial treatment plan within two business days. The facility must perform daily clinical review and participate in periodic consultation with Fidelis Care.

Submit OMH Two-Day Notification and Initial Treatment Plan form by fax to 833-561-0094 or by email to MentalHealthAdmission@fideliscare.org
If facility is out-of-network or outside NYS, standard authorization and concurrent review rules apply

Note

OASAS Inpatient SUD Notification Requirement

OASAS-licensed inpatient Substance Use Disorder (SUD) facilities in NYS are not subject to authorization review and are exempt from concurrent utilization review for the first 28 days if the facility notifies Fidelis Care of the admission and initial treatment plan within two business days. Facilities must perform daily clinical review and periodically consult with Fidelis Care.

Fax or email OASAS Appendix A Notification Form and LOCADTR tool to new fax 833-663-1608 or LOCADTR submission per Fidelis instructions
Facilities outside NYS or not OASAS-licensed must request authorization and are subject to concurrent review

Prior Authorization

Radiology Prior Authorization Delegation

Prior authorization for many radiology services has been delegated to Evolent (NIA). Providers should submit PA requests for delegated radiology CPT codes to Evolent. A full list of CPT codes requiring authorization for radiology is available via the delegated program link.

Cardiac ultrasounds are delegated to TurningPoint; other radiology codes delegated to Evolent (NIA) include specific imaging CPTs — check the delegated code list
When a CPT is delegated to Evolent (NIA), associated devices (HCPCS) will also be reviewed by Evolent (NIA)

Documentation Required

Documentation Required for Prior Authorization Requests

Authorization requests for drugs identified by J-codes listed in Appendix I must include supporting clinical documentation demonstrating medical necessity. Providers should submit requests to the appropriate Fidelis Care or Pharmacy team contact (see policy) and include required clinical rationale and records.

Submit oncology-related outpatient drug PA requests to Evolent per Section B; other Appendix I drug PAs submit to Fidelis Pharmacy Team via e-fax 1-844-235-5090
Include clinical history, diagnosis, prior therapies, and rationale supporting use of the requested medication

Note

Voicemail Requirements for Utilization Management Messages

Utilization Management voicemail messages to providers are permitted only if the provider voicemail is HIPAA-compliant. Mailbox greetings must identify the mailbox owner and organization and state that the mailbox is confidential and that PHI may be left. If voicemail is not HIPAA-compliant, only a generic message will be left and a callback requested.

If voicemail is HIPAA-compliant, a detailed UM message may be left; otherwise a generic message will be left and a second direct contact attempt will be made per Department of Health Reasonable Effort Policy

PurposeUsed to notify Fidelis Care of admission and initial treatment plan to qualify for the 14‑day concurrent review waiver for OMH‑licensed pediatric admissions.

Submission contactsNew fax: 833‑561‑0094 (formerly 718‑896‑1784) or email to MentalHealthAdmission@fideliscare.org per policy instructions.

inv-58: Hospice care — Hospice care must be provided as part of a certified Hospice Care program per NY law

Certification requirementHospice care must be provided as part of a Hospice Care program certified pursuant to Article 40 of the N.Y. Public Health Law.

Maximum daysWhen medically necessary, hospice coverage is available for up to 210 days.

ApplicabilityCoverage follows medical necessity and state certification requirements as described in the policy.

Counseling Services — treatment/counseling criteria

Counseling coverage: Counseling services billed with G0108 and G0109 are covered without prior authorization, must be provided by certified providers, and are limited to 10 hours (20 units) in a continuous 12‑month period.10 hours/20 units

No prior authorization required for these codes.

Office or facility‑based initial PT/OT/ST evaluations do not require authorization, but subsequent therapy procedure codes do.

Authorization routingNon‑therapy providers should request authorization for services after the initial evaluation directly through Fidelis; outpatient therapy authorizations go to Evolent (NIA) per timing rules.

inv-67: Home health skilled visits — 40

Home health skilled visits limitHome health skilled services benefit maximum is 40 visits per plan year.

Approval basisHome care approvals are based on medical need for skilled services; authorizations and timing follow the policy's home health and therapy guidance.

Related authorizationsFor home health therapy services, authorization submission timeframes differ (e.g., 2 business days for home health) and must be sent to the designated fax/destination.