CurrentFidelis CarePolicy N/A

COVID-19_UPDATE_Authorization_Coding_Guidelines

Fidelis Care provider notice describing prior authorization, delegation, and coverage rules for inpatient, outpatient, behavioral health, imaging, therapy, DME, pharmacy and other services during the COVID-19 update. This part (1 of 2) lists services that require authorization, delegated reviewers, specific CPT/HCPCS/revenue codes, and special rules for state-licensed behavioral health/SUD facilities.

Policy Summary

PayerFidelis Care

PolicyCOVID-19_UPDATE_Authorization_Coding_Guidelines

Policy CodePolicy N/A

Change TypeAdministrative consolidation

Effective Date

Next Review Date

Key ActionObtain prior authorization for all inpatient admissions (post-stabilization and planned admissions); emergency stabilization services do not require prior authorization.

SourceLink

>=1Delegated review vendors referenced (NIA, TurningPoint, New Century Health)

60Rehab/habilitation visit limit

4OB ultrasounds without auth (normal pregnancy)

28OASAS inpatient SUD no-concurrent-review days

14OMH under-18 no-concurrent-review days

S-codesBenefit exclusions category

Policy overview and scope

This administrative update consolidates COVID-19–era authorization and coding guidance and clarifies delegation of prior authorization to third-party vendors including National Imaging Associates (NIA), TurningPoint Healthcare Solutions, and New Century Health (NCH).

It lists state-specific rules that exempt in-state, in-network OMH-licensed mental health hospitals (all ages and a pediatric 0–17 rule) and OASAS-licensed inpatient SUD facilities from prior authorization when notification and conditions are met, and it surfaces utilization-review triggers and thresholds (OMH concurrent review from Day 31 for long stays, pediatric OMH no-concurrent-review for the first 14 days, OASAS no-concurrent-review for the first 28 days).

The document includes numerous CPT/HCPCS/revenue codes and code groups requiring authorization (e.g., transplant codes such as 32850–32856, 33930–33945, 38204–38242), outpatient surgery groups (selected CPT ranges), therapy/rehab codes, chiropractic codes, behavioral health partial hospitalization/intensive outpatient codes, J- and Q-code drug mappings, and lists of DME orthotics that are not covered and DME codes that do not require authorization.

It also notes special coverage/limits and rules: rehabilitation/habilitation visit limits of 60 visits per condition per plan year, home health maximum 40 visits per plan year, hospice coverage up to 210 days, OB ultrasound rule (first 4 ultrasounds for a normal pregnancy without authorization; 5 or more require authorization), and certain non-coverage items (S-codes are benefit exclusions).

Scope summary: Part 1 of 2 describes prior authorization requirements, delegated reviewers, specific CPT/HCPCS/revenue codes, state-licensed behavioral health/SUD exceptions and notification instructions, and other coverage and billing rules relevant to inpatient, outpatient, imaging, therapy, DME and pharmacy services.

Key thresholds & operational highlights

Rehab / Habilitation visit limit60 visits per condition per plan year (applies to all therapies combined)

OB ultrasounds without prior auth (normal pregnancy)First 4 ultrasounds do not require authorization; 5 or more require authorization

OASAS Inpatient SUD no-concurrent-review periodNo concurrent utilization review during first 28 days if facility notifies Fidelis within 2 business days and uses LOCADTR processes

OMH under-18 no-concurrent-review periodNo concurrent utilization review during first 14 days if facility notifies Fidelis within 2 business days and meets OMH conditions

Home health visit maximumBenefit maximum 40 visits per plan year

Hospice coverage maximumCoverage available up to 210 days when medically necessary (NY Public Health Law Article 40 certified program)

Transplant authorization requirement

Authorization and utilization review criteria

Inpatient admissions and emergent services

All inpatient admissions require an authorization except emergent stabilization services.

All inpatient admissions require authorization.

Emergency room services and emergent services required for stabilization do NOT require authorization; post-stabilization services and inpatient admissions after ER services do require authorization.

All facility admissions are reviewed for medical necessity.

Inpatient Rehabilitation Services

Prior authorization required for acute, sub-acute and skilled nursing rehabilitation.

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

Code groups and mappings

Transplant-related CPT codes (authorization required)CPTCovered

32850
32851
32852
32853
32854
32855
32856
33930
33931
33932

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Transplant-related CPT codes (authorization required) - additional included rangesCPTCovered

44133-44136
47133-47147
48160
48550-48556
50300-50380
50547
65710-65757

Outpatient surgery CPT codes requiring prior authorization (selected groups listed)CPTCovered

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

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Outpatient surgery notesCPTCovered

11200	Requires authorization for any place of service
11201	Requires authorization for any place of service
11719	Requires authorization for any place of service
15769-15829	Requires authorization for any place of service
17340-17999	Requires authorization for any place of service

Outpatient surgery facial/orthopedic/spinal examplesCPTCovered

21120-21296	Facial/cosmetic procedures
30465-30520	Facial/nasal procedures
30620-30802	Facial/nasal procedures
30999	Unlisted facial procedures
31298	Facial procedure example
20932-20934	Orthopedic procedures
22867-22870	Spinal surgery
62380	Spinal injection/related

TurningPoint delegated outpatient codesCPTCovered

(see TurningPoint grid)

Certain ENT, Cardiac, orthopedic and spinal CPTs delegated to TurningPoint per policy

ENT/Eye/Facial/Spinal/Orthopedic specific CPT codes (selected)CPTCovered

65760-65775	Eyelid & ocular surgery codes
66987-66991	Ocular surgery codes
67900-67911	Ocular/eyelid codes
65710-65757	Additional eyelid/ocular codes listed
21120-21296	Facial cosmetic procedures
30465-30520	Facial/nasal procedures
30620-30802	Facial/nasal procedures
30999	Unlisted facial procedures
31298	Endoscopic nasal procedure example
20932-20934	Orthopedic specific codes

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Therapy and rehabilitation CPT/HCPCS codes (authorization rules)mixedCovered

92610	Speech/voice evaluation — does not require prior authorization per policy
92611	Speech/voice procedure — does not require prior authorization per policy
S9472	Cardiac rehab related HCPCS
93797	Cardiac rehab service
93798	Cardiac rehab service
G0422	Cardiac rehab service
G0423	Cardiac rehab service
G0237-G0239	Pulmonary rehab group codes
G0424	Pulmonary rehab
S9473	Pulmonary rehab HCPCS

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Therapy visit limits and routingmixedCovered

(rehab limits)

Rehabilitation and Habilitation limited to 60 visits per condition per plan year; outpatient PT/OT/ST after initial evaluation require prior authorization through NIA (effective 10/1/2021).

Chiropractic codes (authorization required)CPTCovered

98940	Chiropractic manipulative treatment
98941	Chiropractic manipulative treatment
98942	Chiropractic manipulative treatment
98943	Chiropractic manipulative treatment

Partial Hospitalization / Intensive Outpatient codes (behavioral health)Revenue|HCPCS|CPTCovered

Revenue: 912	Partial hospitalization revenue code
Revenue: 913	Partial hospitalization revenue code
Revenue: 944	Partial hospitalization revenue code
Revenue: 945	Partial hospitalization revenue code
HCPCS: H0035	Partial hospitalization HCPCS
Revenue: 905	Intensive outpatient revenue code example
CPT: 90899	Intensive outpatient / other behavioral health evaluation code
S9480	Intensive outpatient HCPCS/S code
HCPCS: H2013	Intensive outpatient HCPCS

DME codes not covered (orthotics list)HCPCSNot Covered

E0130	Orthotic — not covered
E0135	Orthotic — not covered
E0168	Orthotic — not covered
E0182	Orthotic — not covered
E0184	Orthotic — not covered
E0235	Orthotic — not covered
E0274	Orthotic — not covered
E0305	Orthotic — not covered
E0310	Orthotic — not covered
E0424	Orthotic — not covered

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DME codes that do not require authorizationHCPCS

L3762	DME not requiring authorization
L7360	DME not requiring authorization
L7362	DME not requiring authorization
L7364	DME not requiring authorization
L7366	DME not requiring authorization
S8421	DME not requiring authorization
S8424	DME not requiring authorization
V5266	DME not requiring authorization

OB ultrasound diagnosis codes (examples provided)ICD-10

Z32.01	Pregnancy ultrasound related
Z33.1	Pregnancy state
Z34.00-Z34.03	Encounter for supervision of normal pregnancy
Z34.80-Z34.83	Encounter for supervision of normal pregnancy
Z34.9-Z34.93	Encounter for supervision of pregnancy
O09.00-O09.03	High risk pregnancy — no authorization required for OB ultrasounds
O09.1-O09.13	High risk pregnancy — no authorization required for OB ultrasounds
O36.80X0-O36.80X5	Fetal monitoring/complication codes — high risk examples
O36.80X9	Fetal complication code example

OB ultrasound authorization noteICD-10

(policy_note)

First 4 OB ultrasounds for a normal pregnancy do not require authorization; five or more ultrasounds for a normal pregnancy require authorization; OB ultrasounds for listed high-risk pregnancy codes do not require authorization.

J-codes and related mappings (benefit applies to)HCPCSCovered

J2779	mapped equivalents listed (ranibizumab implant / hyaluronan mappings referenced)
J2783	mapped equivalents listed
J2786	mapped equivalents listed
J2787	mapped equivalents listed
J2793	mapped equivalents listed
J2794	mapped equivalents listed
J2796	mapped equivalents listed
J2798	mapped equivalents listed
J2840	mapped equivalents listed
J7320	hyaluronan and related products referenced

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J-code pharmacy notemixedCovered

(pharmacy_mappings)

Many mappings and matched equivalents are provided in the pharmacy section; refer to the Pharmacy/NCH grids for full mappings.

Q-codes and related mappingsHCPCSCovered

Q2041	cell therapy mapping / referenced for CAR-T
Q2042	tisagenlecleucel (Kymriah) mapping
Q2043	histrelin implant mapping
Q2054	histrelin implant (Supprelin LA) mapping
Q2056	inotuzumab mapping / referenced multiple times
Q4074	nelarabine mapping
Q5103	pemetrexed inj (Hospira) mapping
Q5110	mapping for tebentafusp-tebn
Q5113	pemetrexed inj (Hospira) mapping
Q5115	pemetrexed inj (Accord) mapping

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S-codes (Benefit exclusions)HCPCSNot Covered

S0012	butorphanol nasal and related mappings; S codes are benefit exclusions
S0017	butorphanol nasal mapping
S0020	bupivicaine inj mapping; nicotine patches listed
S0021	cefoperazone inj mapping
S0034	ofloxacin inj mapping
S0040	ticarcillin inj mapping
S0074	cefotetan inj mapping
S0078	fosphenytoin inj mapping
S0080	bevacizumab-bvzr related S-code mapping
S0081	rituximab-pvvr related S-code mapping

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What providers must do

Prior Authorization

Authorization required for inpatient admissions

Obtain prior authorization for all inpatient admissions (post-stabilization and planned admissions); emergency stabilization services do not require prior authorization.

Prior Authorization

Transplant authorization

Request authorization at time of transplant evaluation for all solid organ and bone marrow/tissue transplants; include listed transplant CPT codes when submitting.

Definitions and operational notes

Operational notes: the consolidation is intended to align COVID-19-era authorization and coding guidance into a single administrative notice and to document delegations of prior authorization to third-party vendors — radiology and imaging to NIA, selected ENT/cardiac/orthopedic surgical code review to TurningPoint, and outpatient oncology medications/supportive agents to New Century Health (NCH).

State-specific exceptions and operational steps: in-state OMH-licensed hospitals and OASAS-licensed inpatient SUD facilities are generally not subject to prior authorization when they notify Fidelis Care within 2 business days using the prescribed forms/contacts; those facilities must follow the specified LOCADTR/Two-Day Notification procedures and comply with periodic clinical consultation requirements.

This notice is Part 1 of 2 and lists services and codes that require authorization or are delegated. It reiterates that many outpatient surgical and therapeutic procedures require prior authorization and that delegations mean associated devices (HCPCS) follow the CPT delegation.

Prescription routing and exclusions: S-codes are benefit exclusions (oral medications billed with S-codes should be processed through the prescription benefit). The pharmacy section directs outpatient oncology and many J-/Q-code drug requests to NCH, while listing categories excluded from NCH review.

Unlisted and temporary code rule: All services billed with 'Unlisted' or 'Temporary' codes require authorization (for example, C-codes), and the document calls out that providers must submit authorization requests to the delegated vendor or Fidelis as specified for the service type.

Definitions (brief)

Document revisions

source_document_summaryLatest

Source document: consolidated COVID-19 update — no dated revisions provided in brief; document summarizes authorization and coding guidelines, delegations to NIA/TurningPoint/New Century Health, state-specific OMH and OASAS rules, code lists, and coverage/authorization rules. Document-level has_material_change flag: false; status: CURRENT.

Policy Summary

PayerFidelis Care

PolicyCOVID-19_UPDATE_Authorization_Coding_Guidelines

Policy CodePolicy N/A

Change TypeAdministrative consolidation

Effective Date

Next Review Date

Key ActionObtain prior authorization for all inpatient admissions (post-stabilization and planned admissions); emergency stabilization services do not require prior authorization.

SourceLink

On This Page

Authorization required at time of transplant evaluation for all solid organ and bone marrow/tissue transplants (specified CPT list)

Delegated prior authorization vendors referencedNational Imaging Associates (NIA), TurningPoint Healthcare Solutions, New Century Health (NCH)

Medical rehabilitation can be completed at an acute or sub-acute level of care.

Transplants

Authorization required at time of transplant evaluation for all solid organ and bone marrow/tissue transplants.

All solid organ and bone marrow / tissue transplants require authorization at the time of the transplant evaluation.

Includes but not limited to: CPT/HCPCS codes include 32850, 32851, 32852, 32853, 32854, 32855, 32856, 33930-33945, 38204-38215, 38230-38242, and additional transplant-related CPTs listed in the transplant code group.

Reference full CPT/HCPCS transplant list provided in source.

Breast Cancer Surgery Centers

Facility volume requirement for mastectomy/lumpectomy associated with breast cancer diagnosis.

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

Link to NYS policy provided in source.

OASAS Licensed Inpatient Substance Use Disorder Treatment (In-state, in-network)

Effective 01/01/2020: in-network, in-state OASAS licensed facilities are not subject to prior authorization and have limited concurrent review for first 28 days with notification requirements and LOCADTR processes.

Inpatient SUD (detox, inpatient rehab, inpatient residential) provided by NYS OASAS licensed and participating facilities are not subject to prior authorization review by Fidelis Care.

Not subject to concurrent utilization review during first 28 days provided facility notifies Fidelis Care of admission and initial treatment plan within 2 business days.28 days

Facility may fax/email OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool to 646-829-1421 or LOCADTR@fideliscare.org.

Facility must perform daily clinical review (not required to perform LOCADTR every day) and periodically consult with Fidelis Care starting on/just prior to day 14 to ensure LOCADTR use.Day 14

Services may be subject to utilization review after day 28 or upon discharge using LOCADTR; prior to discharge the facility must provide written discharge plan indicating whether discharge services are secured or reasonably available.

All services may be reviewed retrospectively for clinical necessity.

OASAS Inpatient SUD (out-of-state, out-of-network, non-OASAS)

Authorization and concurrent review requirements for facilities not in-state/in-network/OASAS-licensed.

Facilities outside New York State, not OASAS licensed/certified/authorized, or outside the Fidelis Care network must request prior authorization for Inpatient SUD services.

All Inpatient SUD services provided by such facilities are subject to concurrent review throughout the admission.

Providers may contact Fidelis Care Behavioral Health with questions.

Elective Surgical Procedures

Authorization rules for elective surgeries and inpatient vs outpatient level of care.

Many surgical/medical procedures completed within 24 hours will not be approved at an inpatient level of care; the same services billed as outpatient within the Fidelis network do not require authorization.24 hours

Examples include laparoscopic procedures and thyroid surgery if completed within 24 hours from onset of surgery.

Refer to the provided list of inpatient-only procedures for specifics.

Orthopedic and Spinal Surgical Procedures

Prior authorization required and some delegation to TurningPoint.

Orthopedic and spinal surgical procedures performed inpatient or outpatient require prior authorization for dates of service.

For list of codes requiring prior authorization see source; TurningPoint reviews associated devices when CPT is delegated.

If a CPT code is delegated to TurningPoint, associated HCPCS device codes will also be reviewed by TurningPoint.

OMH Licensed Inpatient Mental Health Treatment (all ages) - NYS in-network

Effective 06/01/2021: OMH licensed hospitals in NYS are not subject to prior authorization, with notification requirements and specified clinical triggers for utilization review.

Inpatient mental health treatment provided by OMH licensed hospitals in NYS are not subject to prior authorization review by Fidelis Care.

Facility must notify insurer within 2 business days of admission by calling 1-888-FIDELIS ext.16072 or fax (718)-896-1784.

Utilization Review will be conducted only for members meeting any of the following clinical criteria

High utilization in past year: 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 prior 12 months.

OMH Licensed Inpatient Mental Health Treatment (under 18) - NYS in-network

Effective 01/01/2020: under-18 OMH licensed hospitals in-network are not subject to prior authorization and not subject to concurrent review for first 14 days if notification and other conditions met.

Inpatient mental health treatment for members under age 18 provided by OMH licensed hospitals in NYS and participating in Fidelis network are not subject to prior authorization review by Fidelis Care.

Notification and review conditions: Fidelis Care will not conduct concurrent utilization review during the first 14 days provided the facility: (i) notifies Fidelis Care of admission and the initial treatment plan within 2 business days using the OMH Two-Day Notification and Initial Treatment Plan form submitted by fax or email; (ii) performs daily clinical review; and (iii) participates in periodic consultation with Fidelis Care to ensure use of evidence-based OMH-approved criteria.14 days

Submit form by fax 718-896-1784 or email Mental_Health_Admission@fideliscare.org.

Out-of-network inpatient mental health services are subject to concurrent review throughout the admission.

ENT and Cardiac Surgical Procedures delegation to TurningPoint

Prior authorization delegated to TurningPoint Healthcare Solutions, LLC for specified settings and codes.

ENT surgical procedures (inpatient, outpatient, physician office) — prior authorization delegated to TurningPoint; if CPT delegated to TurningPoint, associated HCPCS devices will also be reviewed by TurningPoint.

For list of codes see source.

Cardiac surgical procedures (inpatient, outpatient, physician office) — prior authorization delegated to TurningPoint; associated devices reviewed if CPT delegated.

For list of codes see source.

Outpatient surgery (codes requiring prior authorization)

List of outpatient surgery categories and CPT codes requiring prior authorization; some items note place-of-service exceptions and delegated review.

A. Bariatric surgery: Bariatric surgery CPTs 43770-43775 require prior authorization (note S2083 no longer requires authorization as of 2022-08-01).

B. Blepharoplasty: Blepharoplasty CPTs 15820-15823 require prior authorization.

C. Breast reconstruction: Breast reconstruction CPTs 11920-11971, 19300, 19316-19342, 19355, 19370-19396 require prior authorization.

D. Skin surgery and dermatological procedures: Many skin surgery treatments and repairs in POS 11/22 do NOT require authorization. Codes 10040, 11300-11313, 11400-11471, 11721 require authorization when performed as ambulatory surgery (POS 24). Codes 11200, 11201, 11719, 15769-15829, 17340-17999 require authorization in any place of service.

E. Selected codes ASC billing exception: Services coded 10060, 11100, 11900, 17000, 20600, 20605, 20610 should not be performed in freestanding ASCs; if performed in freestanding ASC billing with bill type 0831 they require authorization. CPT 20610 for hyaluronic acid joint injection is non-covered with specified osteoarthritis diagnosis codes.

List of OA diagnosis codes provided in source.

F. Ear repair: Ear repair and ear piercing CPTs 69300 and 69090 require prior authorization.

G. Eyelid & ocular surgery: Eyelid & ocular surgery CPTs 65760-65775, 66987-66991, 67900-67911 and others listed require prior authorization.

H. Abdominoplasty etc.: Abdominoplasty, lipectomy, panniculectomy CPTs 15830-15839, 15847, 15876-15879 require prior authorization.

I. Reduction mammoplasty: Reduction mammoplasty CPTs 19300 and 19318 require prior authorization.

J. Facial cosmetic: Facial cosmetic, septoplasty, rhinoplasty CPTs 21120-21296, 30465-30520, 30620-30802, 30999, 31298, C9749, Q2028 require prior authorization; CPTs on TurningPoint delegated list should be requested through TurningPoint.

K. Vascular procedures: Vascular procedures (vein stripping/ligation/ablation/sclerotherapy) CPTs listed (36465-36483, 37241-37244, 37718-37785) require prior authorization.

L. Spinal Surgery: Spinal surgery CPTs 20932-20934, 22867-22870, 62380 require prior authorization.

M. Speech Processor Implants: Speech processor implant CPTs 69716, 69719, 69726, 69727 require prior authorization.

N. Esophageal procedures: Esophageal procedures CPTs 43284, 43497 require prior authorization.

O. Orthopedic/Spinal delegated to TurningPoint: Certain outpatient orthopedic and spinal surgical procedures require prior authorization which has been delegated to TurningPoint.

Ambulatory and specialty services — testing, behavioral health partial hospitalization/intensive outpatient, ASD, residential

Authorization and utilization review rules for testing and behavioral health programs.

Psychological/Neuropsychological testing: Testing CPTs 96116, 96121, 96130-96133, 96136-96139, 96146 require authorization and requests should be submitted on the Psychological/Neuropsychological testing request form.

Developmental Pediatric Testing: CPTs 96112 and 96113 require authorization; CPT 96110 is non-covered.

Outpatient ECT CPT 90870 requires authorization.

Partial Hospitalization: Partial hospitalization revenue codes 912, 913, 944, 945 and HCPCS H0035 — utilization review (admission and concurrent/continued stay) for OMH licensed programs in NYS conducted only for members meeting NYS OMH Best Practice Manual clinical criteria; out-of-network partial hospitalization subject to concurrent review throughout admission.

Triggers mirror OMH inpatient triggers (AOT, high utilization, readmission, LOS>30 days).

Intensive Outpatient Treatment: Intensive outpatient revenue code 905 or 912, CPT 90899, S9480, HCPCS H2013 — utilization review similar to partial hospitalization with same NYS OMH triggers; out-of-network services subject to concurrent review.

ASD: Authorization is required for DME speech generation equipment and for Applied Behavior Analysis (authorization from Behavioral Health). Attestation of ASD diagnosis by a licensed physician or psychologist must be provided at time of request.

Residential Treatment: Residential treatment CPTs 1001 and 1002; HCPCS H0017-H0019, H2036 listed for residential services.

Outpatient and DME Services requiring prior authorization

Diagnostic testing, DME, home health, hospice and imaging authorization rules and limits.

Diagnostic testing: Sleep studies (including home), BRCA and genetic testing require authorization with exceptions: CPTs 81220, 81329, 81336, 81420 do NOT require authorization; CPT 81220 limit 1 lifetime; CPTs 81329 and 81336 combined limit 1 per lifetime. Wireless capsule endoscopy (91110-91111) and motility capsules (91112-91113) require authorization. Certain GI procedures require authorization when performed in POS 19 or 22 if office/ASC available; CPT 43290 requires authorization in any POS. Penile prosthesis 54405 requires authorization.

DME/Supplies: Orthotics are not covered (many E/L/L codes listed). DME codes that do NOT require authorization include L3762, L7360, L7362, L7364, L7366, S8421, S8424, V5266. Other DME codes require authorization. Supplies requiring authorization include compression garments, electric heat pads, surgical stockings, protective helmets, wigs, insulin pumps and infusion pumps.

Full code lists provided in source.

Home Health/Hospice: Home health approvals based on medical need for skilled services with benefit maximum 40 visits per plan year. Hospice care must be part of a NY Public Health Law Article 40 certified program; coverage up to 210 days when medically necessary.Home Health max 40 visits; Hospice up to 210 days

Imaging - OB ultrasound rules: First 4 OB ultrasounds for a normal pregnancy can be performed without authorization; five or more ultrasounds for a normal pregnancy require authorization (example ICD-10 codes listed). OB ultrasounds for high-risk pregnancy diagnosis codes do NOT require authorization.First 4 ultrasounds without auth; 5+ require auth

Prior authorization for radiology delegated to National Imaging Associates, Inc. (NIA). TBS scans 77089-77092 require authorization.

Outpatient Therapy (PT/OT/ST)

Effective 10/01/2021: all services after initial evaluation require prior authorization through NIA (with some exceptions).

Outpatient PT/OT/ST: All outpatient PT, OT, ST services performed by a therapy provider after the initial evaluation require prior authorization through NIA. CPTs 92610 and 92611 do not require prior authorization.

Initial evaluations in office or facility do not require prior authorization, but other billed codes even on same date require authorization prior to billing.

Submission timing: Submit authorizations to NIA within 1 business day for outpatient setting or 2 business days for home health; inpatient settings submit to Fidelis within 1 business day. For therapy in POS 31 & 32 (SNF/Sub-Acute), prior auth requests to 716-803-8307.

Non-therapy providers should request prior authorization for post-evaluation services directly through Fidelis Care.

Visit limits: Rehabilitation benefit limited to 60 visits per condition per plan year (applies to all therapies combined). Habilitation benefit limited to 60 visits per condition per plan year (applies to all therapies combined).60 visits per condition per plan year

Podiatry Services

Authorization no longer required for podiatric services generally; individual services listed on grid may still require authorization.

Authorization is no longer required for podiatric services overall; authorization requirements will apply to individual services indicated on the prior-authorization grid and rendered by podiatrists.

Therapeutic Services

List of therapeutic procedure codes requiring authorization and specific exclusions for low back pain.

Phototherapy/HBOT: Phototherapy CPTs 96567, 96573-96574, 96900, 96910, 96912-96913, 96920-96922 require authorization. Hyperbaric Oxygen Therapy CPT 99183 and C1300 require authorization.

Pain management codes (20526, 20550-20553, 21073, 27096, 62263-62282, 62290, 62320-62327, 63622, 63688, 64400-64530, 64553-64595, 64600-64640, 64582-64583, 64628-64629) require authorization. Note: 63622 and 63688 do NOT require authorization for requests from orthopedic specialties.

Not covered for Low Back Pain: Prolotherapy; therapeutic facet joint steroid injections in lumbar/sacral regions; therapeutic injections of steroids into intervertebral discs; continuous or intermittent traction are not covered for members with diagnosis of Low Back Pain.

Cardiac/Pulmonary Rehab & Radiation: Cardiac and pulmonary rehabilitation require authorization in outpatient setting (cardiac: S9472, 93797, 93798, G0422, G0423; pulmonary: G0237-G0239, G0424, S9473). Radiation therapy prior authorization delegated to NIA.

Other therapeutic codes: Ambulatory continuous glucose monitoring 95249, radiofrequency ablation of uterine fibroids 58674, bronchial thermoplasty 31660/31661, and other listed codes (e.g., 61736, 61737, vision therapy 92066, 95919) require authorization.

Chiropractic Services

Certain chiropractic CPT codes require prior authorization.

Chiropractic CPTs 98940, 98941, 98942, 98943 and revenue code 0940 require prior authorization.

Diabetes Self-Management Training (DSMT)

Coverage and authorization status for DSMT.

Members are allowed 10 hours/20 units in a continuous 12-month period for Diabetes Self-Management Training (DSMT). Services must be provided by certified providers and no longer require authorization. Bill with codes G0108 and G0109.10 hours / 20 units per 12-month period

Services provided by outside vendors

Prior authorization vendors and non-emergency transport coverage rules.

Dental & Vision: Orthodontic and Major Dental services require prior authorization by DentaQuest (1-800-516-9615). Vision prior authorizations by Davis Vision (1-800-601-3383).

Non-emergency transport: Non-emergency ambulance transportation by a licensed provider may be covered between facilities when transport is from a non-participating to participating hospital; to a hospital providing higher level of care not available at origin; to a more cost-effective acute care facility; or from an acute facility to a sub-acute setting.

Pharmacy

Formulary and prior authorization programs/delegations for oncology and specialty medications.

Formulary updates: Monthly formulary updates available on Fidelis website pharmacy page.

Enteral therapy HCPCS codes B4034-B4162 require authorization. Enteral therapy benefit applies to therapeutic formulas for metabolic disorders and certain non-prescription enteral formulas with a written order stating medical necessity.B4034-B4162

New Century Health delegation: Oncology medications and supportive agents require prior authorization from New Century Health (NCH) before dispensing or administration in pharmacy or outpatient/physician/ambulatory settings for all ages. Requests via NCH web portal or 1-888-999-7713 option 1. Clinical trials may be sent to NCH.

Requests excluded from NCH review: Requests excluded from NCH (do not send to NCH) include antibiotics; bone marrow/stem cell transplants/CAR-T; Cablivi; controlled substances; equipment requests (infusion pumps); genetic lab testing; hemophilia drugs; immune globulins; inpatient drug requests; iron preparations; pain medications; radiopharmaceuticals; surgeries/surgical procedures; sickle cell diagnoses.

General Billing Notes / Requirements

Operational notes and requirements included in this part:

S-code exclusions: S codes are benefit exclusions; oral medications billed with S codes should be processed through the prescription benefit.

Unlisted/Temporary codes: All services for 'Unlisted' or 'Temporary' Codes require authorization (such as C-codes).

Oncology routing: Outpatient oncology-related requests require prior authorization and review by New Century Health.

Certain request types are excluded from NCH review as noted in the pharmacy section.

Documentation Required

OASAS inpatient notification

For in-state in-network OASAS-licensed inpatient SUD, notify Fidelis Care of the admission and initial treatment plan within 2 business days by fax or email and use the OASAS Appendix A and LOCADTR tool as required.

Fax: 646-829-1421
Email: LOCADTR@fideliscare.org
Use OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool

Prior Authorization

OMH inpatient notification

For OMH licensed inpatient mental health admissions, notify Fidelis Care within 2 business days to avoid prior authorization and meet review conditions.

Call: 1-888-FIDELIS (1-888-343-3547), ext. 16072
Fax: (718) 896-1784
Email (pediatric admissions): Mental_Health_Admission@fideliscare.org (use OMH Two-Day Notification and Initial Treatment Plan form)

Prior Authorization

Therapy authorization via NIA

For outpatient PT/OT/ST services after the initial evaluation, submit prior authorization to National Imaging Associates (NIA) within the required timelines; inpatient and SNF/Sub-Acute exceptions apply and visit limits apply.

Submit to NIA within 1 business day for outpatient setting or within 2 business days for home health setting
For inpatient settings submit to Fidelis within 1 business day
For POS 31/32 (SNF/Sub-Acute Rehab) prior auth requests to 716-803-8307
Initial evaluations in office/facility do not require prior authorization (other billed therapy codes on same date do)
Rehabilitation and habilitation benefit limited to 60 visits per condition per plan year (all therapies combined)

Prior Authorization

Oncology medication authorization via New Century Health

Submit outpatient oncology medication and supportive agent prior authorization requests to New Century Health (NCH) before dispensing or administration; use NCH web portal or phone and do not send excluded request types to NCH.

NCH web portal: https://um.newcenturyhealth.com/Account/Logon/frm_LogOn
Phone: 1-888-999-7713, option 1
Do NOT send the excluded request types (e.g., antibiotics; bone marrow/stem cell transplants/CAR-T; inpatient drug requests; equipment requests like infusion pumps; certain radiopharmaceuticals; etc.) to NCH

Billing Rule

Freestanding ASC billing for specified codes

If services coded 10060, 11100, 11900, 17000, 20600, 20605, or 20610 are performed in a freestanding ambulatory surgery center billing with bill type 0831, authorization is required; CPT 20610 billed with specified osteoarthritis diagnosis codes is non-covered.

CPT list: 10060, 11100, 11900, 17000, 20600, 20605, 20610
Note: CPT 20610 for hyaluronic acid joint injection is non-covered when billed with OA diagnosis codes M17.0, M17.10-M17.12, M17.2, M17.20-M17.32, M17.4, M17.5, M17.9

Documentation Required

ASD attestation

Attestation of the ASD diagnosis must be provided at the time of the authorization request by a licensed physician or psychologist for ASD-related services (e.g., authorization for DME speech generation equipment and ABA).

Prior Authorization

DME and enteral authorization

Obtain authorization for DME and enteral therapy items as specified; enteral therapy HCPCS codes B4034-B4162 require authorization and enteral formulas require a written order stating medical necessity.

HCPCS: B4034-B4162
Non-prescription enteral formulas require a written order stating the enteral formula is medically necessary

Prior Authorization

Imaging authorization via NIA

Submit radiology and imaging prior authorization requests to National Imaging Associates (NIA) where radiology services have been delegated.

Prior Authorization

TurningPoint delegated authorizations

For CPT codes delegated to TurningPoint (ENT, Cardiac, and certain orthopedic/spinal procedures), submit prior authorization requests to TurningPoint; associated HCPCS device codes will also be reviewed by TurningPoint when the CPT is delegated.

Prior Authorization

Authorization for Unlisted/Temporary Codes

All services for 'Unlisted' or 'Temporary' Codes (such as C-codes) require authorization prior to billing.

Prior Authorization

Oncology Prior Authorization Routing

Outpatient oncology-related requests require prior authorization and review by New Century Health (NCH) per the oncology program routing rules.

Billing Rule

S-code Benefit Exclusions

S codes are benefit exclusions and should be processed through the prescription benefit for oral medications.

POS (Place of Service) examples11 = office; 22 = outpatient hospital; 24 = ambulatory surgery center; 19 = off‑campus outpatient hospital site

LOCADTRLevel of Care and Drug and Alcohol Treatment Referral (LOCADTR) Medical Necessity Tool used for SUD utilization review per OASAS requirements

S codes (benefit exclusions)S codes are benefit exclusions; oral medications billed with S codes should be processed through the prescription benefit