CurrentFidelis CarePolicy N/A

COVID-19 UPDATE

Lists services, settings, and specific CPT/HCPCS/revenue codes that require prior authorization or are exempted, plus procedural delegation to vendors (TurningPoint, NIA, New Century Health) and special rules for behavioral health, SUD, imaging, DME, therapy, and oncology-related pharmacy routing. Part 1 of 2; covers inpatient admission rules, delegated review programs, outpatient surgery, therapy, imaging, DME, behavioral health, and oncology-related pharmacy routing.

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNov 1, 2022

Next Review Date

Key ActionObtain prior authorization for all inpatient admissions (except emergent stabilization) and for the numerous listed outpatient, surgical, imaging, DME and therapy services per code lists and delegated vendors (TurningPoint, NIA, New Century Health).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes (has_material_change=false).

60Rehabilitation visit limit per condition/year

60Habilitation visit limit per condition/year

28 daysInpatient SUD concurrent review exemption (in-network, in-state)

14 daysOMH inpatient concurrent review exemption for <18

OB ultrasounds without authorization (normal pregnancy)

~60+J-codes referenced in this part

Coverage Summary & Scope

Fidelis Care's prior authorization and utilization review policy applies across inpatient and outpatient medical and surgical services, behavioral health (including OMH-licensed mental health and OASAS-licensed substance use disorder treatment), imaging and therapeutic services, durable medical equipment (DME), and pharmacy (including oncology drugs). All inpatient admissions require authorization except for emergent stabilization care; many outpatient procedures, testing, therapy visits and selected DME/drugs are subject to prior authorization per the specific CPT/HCPCS/revenue code lists in the policy.

The document delegates prior authorization review for specified procedure and drug categories to third-party vendors: TurningPoint Healthcare Solutions (selected surgical/ENT, cardiac, orthopedic/spine procedures and associated HCPCS devices), National Imaging Associates (NIA) for radiology, radiation therapy and outpatient PT/OT/ST authorization, and New Century Health (NCH) for oncology medications/supportive agents. It also lists DME codes that do not require authorization and directs providers to vendor portals/phone numbers for delegated reviews.

Special state-aligned exemptions apply: OASAS-licensed in-network inpatient SUD facilities in New York State are not subject to authorization or concurrent utilization review for the first 28 days of admission when the facility notifies Fidelis within 2 business days and uses the OASAS Appendix A/LOCADTR process; OMH-licensed inpatient mental health hospitals in New York State similarly are not subject to prior authorization generally, with OMH Best Practice Manual clinical triggers determining when utilization review is required, and members under 18 in OMH hospitals are exempt from concurrent review for the first 14 days provided the facility follows the two-day notification and daily review/consultation requirements.

Key thresholds and limits

Inpatient SUD exemption periodFirst 28 days from inpatient admission (no authorization or concurrent review if facility notifies Fidelis within 2 business days and submits OASAS Appendix A/LOCADTR)

OMH under-18 exemption periodFirst 14 days of inpatient admission (no authorization or concurrent review if OMH facility notifies Fidelis within 2 business days and meets daily review/consultation requirements)

Rehabilitation visit limit60 visits per condition per plan year (all therapies combined)

Habilitation visit limit60 visits per condition per plan year (all therapies combined)

OB ultrasound allowance without authFirst 4 ultrasounds for a normal pregnancy may be performed without authorization; 5 or more require authorization

Authorization / Medical Necessity Criteria (grouped)

Inpatient Admissions - General

All inpatient admissions require an authorization:

ALL of the following

Authorization not required for emergency room services or emergent services required to provide stabilization of an emergent condition
Authorization required for post-stabilization services and inpatient admissions after emergency room services are completed
All facility admissions are reviewed for medical necessity
All acute inpatient facility services require authorization (see Transplants and other sections for code lists)

Vendor Delegations, Pharmacy Routing & Provider Actions

Services Provided by Outside Vendors

Routing of authorizations to outside vendors for specified service categories:

Vendor routing

Dental/Orthodontic: Orthodontic and major dental services require authorization by DentaQuest (1-800-516-9615)
Vision prior authorizations by Davis Vision (1-800-601-3383)
Oncology meds via NCH: Oncology medications and supportive agents require prior authorization from New Century Health (NCH) before dispensing/administering in pharmacy, physician office, outpatient hospital, or ambulatory setting; requests via NCH web portal or 1-888-999-7713 option 1
Clinical trials may be sent to NCH for review

Codes & Code Groups

Inpatient/Transplant Codes (authorization required)CPTCovered

32850-32856	Transplant-related (listed as included)
33930-33945	Transplant-related (listed as included)
38204-38215	Transplant-related (listed as included)
38230-38242	Transplant-related (listed as included)
44133-44136	Transplant-related (listed as included)
47133-47147	Transplant-related (listed as included)
48160	Transplant-related (listed as included)
48550-48556	Transplant-related (listed as included)
50300-50380	Transplant-related (listed as included)
50547	Transplant-related (listed as included)

1–10 of 11

1/2

Outpatient Surgery Codes Requiring AuthorizationCPTCovered

15820-15823	Blepharoplasty
43770-43775	Bariatric surgery
11920-11971	Breast reconstruction (partial range)
19300	Breast surgery/reconstruction
19316-19342	Breast reconstruction
19355	Breast reconstruction
19370-19396	Breast reconstruction
10040	Skin surgery (authorization when POS 24)
11300-11313	Skin procedures (auth when POS24)
11400-11471	Skin procedures (auth when POS24)

1–10 of 49

1/5

Behavioral Health / Testing Codes (authorization required)CPT|HCPCS|RevenueCovered

96116	Neuropsych testing
96121	Neuropsych testing
96130	Psych testing
96131	Psych testing
96132	Neuropsych testing
96133	Neuropsych testing
96136	Health behavior assessment
96137	Health behavior assessment
96138	Health behavior intervention
96139	Health behavior intervention

1–10 of 24

1/3

Imaging / Therapy Codes (authorization required / delegated to NIA)CPT|HCPCSCovered

77089	TBS scan
77090	TBS scan
77091	TBS scan
77092	TBS scan
92610	Speech therapy code (no auth required)
92611	Speech therapy code (no auth required)
95249	Ambulatory continuous glucose monitoring (requires authorization)
S9472	Cardiac rehab code (authorization required)
93797	Cardiac rehab
93798	Cardiac rehab

1–10 of 15

1/2

DME - No Authorization Required (selected list)HCPCS

E0130	DME no auth required
E0135	DME no auth required
E0168	DME no auth required
E0182	DME no auth required
E0184	DME no auth required
E0235	DME no auth required
E0274	DME no auth required
E0305	DME no auth required
E0310	DME no auth required
E0424	DME no auth required

1–10 of 40

1/4

Oncology / Provider-Reviewed Drugs (NCH referral list - samples)HCPCS|J-code|C-code|G-codeCovered

C9054	lefamulin (Xenleta) listed
C9055	brexanolone listed
C9047	caplacizumab-yhdp (Cablivi) listed
C9063	eptinezumab-jjmr (Vyepti) listed
C9074	lumasiran (Oxlumo) listed
C9085	avalglucosidase alfa-ngpt inj listed
C9094	sutimlimab-jome listed
C9095	tebentafusp-tebn listed
J0129	abatacept (Orencia) referenced among J-code list
J0135	adalimumab (Humira) referenced among J-code list

1–10 of 12

1/2

Mapped HCPCS J-codes and associated items (extracted as present)HCPCS

J7181	multiple mapped entries (1 = recombinant (Tretten); 2 = J7318; 3 = hyaluronan (Durolane); 4 = J8499; 5 = oral non-chemo drug)
J7182	1 = factor VIII recombinant; 2 = J7320; 3 = hyaluronan (Genvisc); 4 = J8510; 5 = busulfan (Myleran)
J7183	1 = vWF human (Wilate); 2 = J7322; 3 = Visco-3; 4 = J8520; 5 = (blank)
J7185	multiple mapped entries including factor VIII recombinant; J7322; hyaluronan (Hymovis); J8521; capecitabine 500mg
J7186	1 = VIIINWF complex human (Alphanate referenced); 2 = J7324; 3 = hyaluronan (Orthovisc); 4 = J8562; 5 = fludarabine
J7187	1 = vWF complex (Humate-P) factor VIII recombinant; 2 = J7326; 3 = hyaluronan (Gel-One); 4-5 = (blank)
J8655	1 = netupitant palonosetron (Akynzeo 300/0); 2 = J9299; 3 = nivolumab (Opdivo); 4 = S0012; 5 = butorphanol nasal
J8700	1 = temozolomide (Temodar); 2 = J9302; 3 = ofatumumab (Arzerra); 4 = S0020; 5 = bupivacaine inj
J8999	1 = rX oral chemo; 2 = J9304; 3 = pemetrexed (Pemfexy); 4 = S0021; 5 = cefoperazone inj
J9015	1 = aldesleukin (Proleukin); 2 = J9307; 3 = pralatrexate (Folotyn); 4 = S0034; 5 = ofloxacin inj

1–10 of 50

1/5

Background & Definitions

Fidelis Care maintains a comprehensive prior authorization and utilization review program that requires authorization for all inpatient admissions (except emergent stabilization) and for many outpatient procedures, imaging, therapy, behavioral health testing/programs, selected DME and pharmacy items per the policy's code lists. The program delegates review responsibility for specified code sets to third-party vendors — TurningPoint, NIA, and New Century Health — and directs providers to submit requests to the delegated vendor or to Fidelis as specified. The policy also affirms alignment with NYS OMH and OASAS manuals by outlining state-specific notification, LOCADTR/Two-Day Notification requirements, and exemption periods for in-network, in-state facilities.

OASAS: New York State Office of Addiction Services and Supports — the state licensing/certification authority for substance use disorder (SUD) facilities; OASAS-licensed in-network inpatient SUD facilities in NY are exempt from authorization and concurrent utilization review for the first 28 days when the facility submits the OASAS Appendix A Notification Form and uses the LOCADTR medical necessity tool and notifies Fidelis within 2 business days.

OMH: New York State Office of Mental Health — the state licensing/certification authority for mental health hospitals/programs; OMH-licensed inpatient mental health treatment in NY is generally not subject to prior authorization per the OMH Best Practice Manual, but utilization review is conducted where specific clinical triggers are met; for members under age 18, OMH hospitals participating in network are exempt from concurrent review for the first 14 days when the facility submits the OMH Two-Day Notification and meets daily review/consult requirements.

LOCADTR: Level of Care and Duration of Treatment Record — the clinical necessity/utilization review tool referenced for OASAS inpatient SUD treatment reviews and discharge planning; facilities must use LOCADTR for the initial notification and for any concurrent review after the exemption period.

Revision History

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE

Policy CodePolicy N/A

Change TypeNo material change

Effective DateNov 1, 2022

Next Review Date

SourceLink

On This Page

Inpatient Rehabilitation Services (acute; sub-acute and skilled nursing rehabilitation) require prior authorization

Transplants

All solid organ and bone marrow transplants require authorization at time of transplant evaluation. Includes (but not limited to) the following CPT code ranges:

Transplant CPT codes

32850-32856
33930-33945
38204-38215
38230-38242
44133-44136
47133-47147
48160
48550-48556
50300-50380
50547
65710-65757

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Breast Cancer Surgery Centers

Members must receive mastectomy and lumpectomy procedures associated with breast cancer diagnosis at high-volume facilities per New York State policies.

Mastectomy and lumpectomy for breast cancer must be performed at high-volume facilities per NYS policies (links provided)

Delegated Authorization to TurningPoint Healthcare Solutions, LLC

Delegation of authorization to TurningPoint Healthcare Solutions, LLC for specified surgical categories and effective dates; route delegated CPT/HCPCS requests to TurningPoint.

Delegated categories

ENT delegation: ENT surgical procedures: effective 9/20/2021 for dates of service on or after 10/4/2021; authorization delegated to TurningPoint (see delegated CPT list)2021-10-04
Associated HCPCS reviewed by TurningPoint when CPT is delegated
Cardiac delegation: Cardiac surgical procedures: effective 9/20/2021 for dates of service on or after 10/4/2021; authorization delegated to TurningPoint (see delegated CPT list)2021-10-04
Associated HCPCS reviewed by TurningPoint when CPT is delegated
Orthopedic/spine delegation: Certain orthopedic and spinal surgical procedures delegated to TurningPoint; effective 10/1/2019 (delegation effective for dates on or after 12/23/2019)2019-12-23
If a CPT code is delegated to TurningPoint, associated HCPCS should be routed to TurningPoint
Routing instruction: If a CPT code is delegated to TurningPoint, requests for authorization should be directed to TurningPoint

Outpatient Surgery Prior Authorization - Selected Lists

Specific outpatient surgery CPT and HCPCS codes require authorization when performed in certain settings or always as listed; hyaluronic acid joint injection note included.

Outpatient surgery codes list

Blepharoplasty: 15820-15823 require authorization
Bariatric: 43770-43775 require authorization (S2083 no longer requires auth as of 8/1/22)
Breast reconstruction: 11920-11971, 19300, 19316-19342, 19355, 19370-19396 require authorization
Skin surgery POS24: When performed in POS 24 require authorization: 10040, 11300-11313, 11400-11471, 11721; codes requiring authorization in any POS: 11200-11201, 11719, 15769-15829, 17340-17999
Skin surgery ASC billtype: Codes 10060, 11100, 11900, 17000, 20600, 20605, 20610 performed in freestanding ASCs billing bill type 0831 require authorization; CPT 20610 (hyaluronic acid joint injection) noted as non-covered in some contexts
Hyaluronic acid joint injection non-coverage noted
Ear procedures: 69300 and 69090 require authorization
Other listed codes: Codes 66989, 66991, 68841; abdominoplasty 15830-15839,15847,15876-15879; reduction mammoplasty 19300,19318; 30999,31298,C9749,Q2028; vascular 36465-36466,36468-36479,36482-36483,37718-37785,37241-37244; esophageal 43284,43497; spinal 20932-20934,22867-22870,62380; speech processor implants 69716,69719,69726,69727 require authorization
If CPT appears on TurningPoint delegated list, request should be directed to TurningPoint

Behavioral Health Outpatient Services - Testing and Authorization

Authorization required for specified psychological, neuropsychological, developmental testing and related behavioral services; partial hospitalization and intensive outpatient codes and OMH utilization triggers apply.

Testing and behavioral codes

Psychological/Neuropsych testing: Codes 96116,96121,96130,96131,96132,96133,96136,96137,96138,96139,96146 require authorization; submit requests via Psychological/Neuropsychological testing request form
Developmental pediatric testing: Codes 96112 and 96113 require authorization; 96110 is non-covered
Partial hospitalization revenue codes 912,913,944,945 and HCPCS H0035 require authorization; utilization review triggers follow OMH Best Practice Manual
Outpatient ECT: 90870 requires authorization
Intensive outpatient: Revenue code 905 or 912, CPT 90899, S9480, HCPCS H2013 require authorization; utilization review triggers per OMH Best Practice Manual

Therapeutic Services and Coverage Limits

Authorization or non-coverage statements for various therapeutic services and limits:

Therapeutic services

Phototherapy codes listed (96567, 96573-96574, 96900, 96910, 96912, 96913, 96920-96922) in authorization context
Pain management codes including injections and TENS (20526,20550-20553,21073,27096,62263-62264,62273,62280-62282,62290,64583,64628,64629) require authorization
Hyperbaric oxygen: Hyperbaric Oxygen Therapy (99183 and C1300) require authorization for requests from orthopedic specialties
Low back pain non-covered: Services not covered for members with diagnosis of Low Back Pain: prolotherapy; therapeutic injections of steroids into intervertebral discs; therapeutic facet joint steroid injections in lumbar and sacral regions; continuous or intermittent traction
Cardiac/pulmonary rehab: Cardiac rehab codes (S9472,93797,93798,G0422,G0423,rev 0943) and pulmonary rehab codes (G0237-G0239, G0424, S9473, rev 0943) require authorization
Ambulatory CGM: Ambulatory continuous glucose monitoring code 95249 requires authorization

Chiropractic Services

Authorization requirement for chiropractic services:

Chiropractic CPT codes 98940-98943 and revenue code 0940 require authorization

Counseling Services

Coverage limit and authorization status for counseling services:

Members are allowed 10 hours/20 units in a continuous 12-month period for counseling services which must be provided by certified providers and no longer require authorization10 hours / 20 units per 12 months

Services covered when billed with codes G0108 and G0109

Prior Authorization

Authorization required for inpatient admissions and specific services

Obtain prior authorization for all inpatient admissions and for many listed outpatient, surgical, imaging, DME and therapy services. Refer to the code lists in the policy (including transplant and outpatient surgery lists). Delegated review programs (TurningPoint, NIA, New Century Health) handle authorization for many CPT and related HCPCS devices—if a CPT is delegated, associated HCPCS device codes are also reviewed by that vendor.

Inpatient admissions and acute inpatient facility services require authorization.
Transplant procedures listed (e.g., 32850-32856; 33930-33945; 38204-38215; 38230-38242; 44133-44136; 47133-47147; 48160; 48550-48556; 50300-50380; 50547; 65710-65757) require authorization at transplant evaluation.
Outpatient surgery, imaging, DME and therapy codes listed in the policy require authorization as specified.
Third‑party vendors (TurningPoint, NIA, New Century Health) are delegated for many code groups; follow vendor routing when codes are delegated.

Prior Authorization

Delegated authorization routing

If a CPT code is delegated to TurningPoint, NIA or New Century Health, submit the prior authorization request to the delegated vendor per the policy. When CPT review is delegated, associated HCPCS device codes tied to that CPT are also reviewed by the delegated vendor—include those HCPCS codes with the submission when applicable.

TurningPoint: ENT, cardiac, orthopedic/spine and other listed surgical CPTs—associated HCPCS devices are reviewed by TurningPoint when CPT is delegated.
NIA: radiology and outpatient therapy services are delegated to NIA for authorization per effective dates.
New Century Health (NCH): oncology medication and supportive agents routed to NCH via web portal or phone.
When a CPT is on a delegated vendor list, direct the auth request to that vendor and include associated HCPCS device codes if applicable.

Prior Authorization

Oncology medication PA via New Century Health

Oncology medications and supportive agents require prior authorization via New Century Health (NCH). Submit requests through NCH's web portal or call 1‑888‑999‑7713, option 1. Do NOT send requests excluded from NCH review (see exclusions list); those excluded categories should be routed per the policy.

Submit oncology drug PA requests to New Century Health (my.newcenturyhealth.com or 1‑888‑999‑7713, option 1).
Excluded from NCH review (do not send to NCH): antibiotics; bone marrow/stem cell transplants/CAR‑T; Cablivi; controlled substances; equipment (infusion pumps); genetic lab testing; hemophilia drugs; immune globulins; inpatient drug requests; iron preparations; pain medications; radiopharmaceuticals; surgeries/surgical procedures; sickle cell diagnoses; etc.
Clinical trials may be sent to NCH for review per the policy.

Documentation Required

Notification and forms for OASAS SUD and OMH mental health admissions

For in‑network OASAS inpatient SUD and OMH inpatient mental health admissions, notify Fidelis Care within two (2) business days and submit the required forms. Use OASAS Appendix A Notification Form and the LOCADTR tool (fax/email) for OASAS SUD; use the OMH Two‑Day Notification form for OMH admissions and submit by fax or email. These notifications support the concurrent‑review exemption periods.

OASAS SUD (in‑state, in‑network): notify within 2 business days and fax/email OASAS Appendix A Notification Form and LOCADTR (LOCADTR @fideliscare.org or fax 646‑829‑1421).
OMH inpatient mental health: notify Fidelis within 2 business days using the OMH Two‑Day Notification form (fax 718‑896‑1784 or email MentalHealthAdmission_fideliscare@).
LOCADTR must be used for SUD utilization review and discharge planning as described.
Failure to notify as required may subject admissions to authorization and concurrent review.

Billing Rule

Therapy authorization timing and routing

Therapy authorization requests must follow the timing and routing rules. Initial office/facility‑based PT/OT/ST evaluations do not require authorization, but any other billed therapy procedure codes (even on the same date) do require authorization. Submit outpatient therapy auths to NIA within one (1) business day (outpatient) or two (2) business days (home health). For therapy in inpatient POS 31/32, prior authorization requests must be sent to 716‑803‑8307. Non‑therapy providers should route auths through Fidelis for post‑evaluation services.

Initial PT/OT/ST evaluations (office/facility) do not require authorization; other codes billed the same date require authorization.
Outpatient setting authorization requests to NIA within 1 business day; home health setting within 2 business days.
Inpatient therapy (POS 31 & 32) prior auths: send to 716‑803‑8307.
CPT 92610 and 92611 (speech codes) do not require authorization.

Documentation Required

ASD attestation requirement

An attestation of an ASD diagnosis must be provided at the time of request by a licensed physician or psychologist for authorizations related to Applied Behavior Analysis (ABA) and speech‑generation DME. Authorization is required for DME speech generation equipment and ABA services are authorized via Behavioral Health.

Attestation must be signed by a licensed physician or psychologist and submitted with the authorization request.
Authorization required for DME speech generation equipment and for ABA; submit to Behavioral Health as specified.

Denial Risk

Out of network services

Out‑of‑network benefits are generally not available; however, authorization may be provided for medically necessary services not available in‑network. Failure to obtain required authorization for such services may result in claim denial or other adverse payment outcomes.

There are no routine out‑of‑network benefits; exceptions: authorization may be granted when medically necessary services are not available in‑network.
Providers should obtain required prior authorization to avoid denials when out‑of‑network care is needed.

Note

Check NCH drug review list on website

Providers must consult the payer website for the authoritative, up‑to‑date list of drugs that require New Century Health (NCH) review prior to authorization. The policy repeatedly directs providers to the website for the definitive NCH drug list and mappings of J/C/C codes.

Check the Fidelis/NCH web page (New Century Health Oncology Program QHP EP (2022) on fideliscare.org) for the current list of drugs requiring NCH review.
The document’s drug/J‑code mappings are illustrative—use the website as the authoritative source.

Prior Authorization

Oncology outpatient prior authorization reference

Outpatient oncology‑related requests require prior authorization and review by New Century Health per Section B of the policy. Providers must consult Section B for details and route outpatient oncology authorization requests to NCH as instructed.

See Section B for outpatient oncology prior authorization rules and routing to New Century Health.
Route outpatient oncology medication and supportive agent requests to NCH via the web portal or 1‑888‑999‑7713, option 1.

Documentation Required

Ophthalmic indication authorization exception

Authorization is not required for ophthalmic indications per the policy statement; providers may bill ophthalmic uses without prior authorization as indicated.

Policy explicitly states: authorization is not required for ophthalmic indications.
Confirm any related coding or vendor routing if a code is otherwise delegated, but ophthalmic indications are excepted from auth requirement.