CurrentFidelis CarePolicy N/A

COVID-19 UPDATE

Updates to Fidelis Care authorization, utilization review, and coverage handling across inpatient, outpatient, behavioral health, DME, home health, imaging, therapy, pharmacy and specialized programs (OMH/ OASAS/HCBS/ACT/ABA/etc.), including delegated reviewers and place-of-service specifics. Part 1 of 2 — contains policy statements, code lists and operational requirements referenced to links and delegated entities.

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE

Policy CodePolicy N/A

Change TypeOperational/coverage updates

Effective Date

Next Review Date

Key ActionObtain authorization for all inpatient admissions (except emergent stabilization) and for specified services per the policy and follow delegated vendor workflows where applicable.

SourceLink

POLICY UPDATE CHANGES

Pharmacy benefits for Fidelis Medicaid Managed Care and HARP members transitioned to NYRx (Medicaid FFS) effective April 1, 2023.

Oncology medications and supportive agents require PA from Evolent (formerly New Century Health) for Medicaid Managed Care and HARP (excludes CHP).

Enteral therapy HCPCS codes B4034-B4162 require authorization and Child Health Plus applicability is noted.

S codes are benefit exclusions except specified exceptions; prescription benefit for oral S codes will transfer to FFS on 4/1/2023.

MultipleService lines impacted

DelegatedDelegated prior authorization vendors

Coverage Summary & Scope

Scope: This update summarizes operational COVID-19-related guidance and broad changes to Fidelis Care authorization, utilization review, and coverage policies across service lines including Medicaid, Child Health Plus (CHP), HealthierLife (HARP) and MLTC. It highlights alignment with NYS OMH/OASAS guidance, delegated prior authorization to third-party reviewers (TurningPoint, Evolent/NIA/New Century Health), and the transition of Medicaid/HARP pharmacy benefits to NYRx (NYS Medicaid FFS) effective April 1, 2023.

Background: The policy consolidates COVID-19 operational notices with routine authorization and utilization-review rules for inpatient, outpatient, behavioral health, DME, home health, imaging, therapy and specialty pharmacy — noting delegated reviewers, vendor submission workflows, and external lists/forms referenced for authorization and notification.

Authorization & Medical Necessity Criteria (by service line)

Inpatient Admissions and Facility Reviews

All inpatient admissions require authorization except emergency stabilization; all facility admissions reviewed for medical necessity.

ALL of the following

Emergency room services or emergent services required to provide stabilization do not require authorization.
Post-stabilization services and inpatient admissions after ER services are completed require authorization.
New fax number for Inpatient ER: 833-663-1602 (formerly 347-868-6411).
All facility admissions are reviewed for medical necessity.

Inpatient Rehabilitation Services

Acute, sub-acute and skilled nursing rehabilitation require prior authorization.

Prior authorization required for inpatient rehabilitation services (acute, sub-acute, skilled nursing rehabilitation).

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

Transplants

All solid organ and bone marrow transplants require authorization at time of transplant evaluation. Listed CPT codes are examples.

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

Includes (but not limited to) listed CPT codes in code group (see Appendix): e.g., 32850-32856, 33930-33945, 38204-38242, 44133-44136, 47133-47147, 48160, 48550-48556, 50300-50380, 50547, 65710-65757.

Outpatient Surgery Prior Authorization List

Most outpatient behavioral health services no longer require authorization; specific testing, developmental testing, ABA, partial/IOP/PROS rules and limits remain.

citations":["30","31"],"intro":"Selected diagnostic, endoscopic, genetic, sleep, capsule endoscopy, and other outpatient procedures require authorization; place-of-service caveats apply.","nodes":["{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Sleep studies (including home sleep studies) require prior authorization.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Diagnostic testing and genetic testing require authorization (note: CPT 81220,81329,81336,81420 do NOT require authorization; CPT 81220 has lifetime limit 1; 81329/81336 combined limit 1).\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Gastroenterology procedures require authorization; wireless capsule endoscopy (91110,91111) and wireless motility capsule (91112,91113) require authorization.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Certain procedures require authorization if performed in POS 19 or 22 when office/ASC available: 43235,43239,43248,45378,45380,45384,45385,46255,46260,46270.\",\"threshold\":\"POS 19/22\",\"note\":\"Authorization required for 43290 in any place of service.\",\"children\":[]}"],"ref":"b1_9","title":"Outpatient and DME Services Requiring Prior Authorization"},{"citations":["31"],"intro":"DME coverage follows Medicaid DME Program Manual; certain supplies transitioned to NYRx on 4/1/23 and some MLTC supply codes require authorization.","nodes":["{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"DME coverage per Medicaid DME Program Manual; specific supplies list referenced via link.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Effective 4/1/23, specific DME supplies billed by physicians with POS 12 or 14 for Medicaid/HARP transitioned to NYRx FFS; list available via provided codes PDF.\",\"threshold\":\"4/1/2023\",\"note\":\"\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"For MLTC members, the following supply codes require authorization: A4335, A4554, T4521, T4522, T4523, T4524, T4529, T4530, T4533, T4535, T4537, T4539, T4540, T4543.\",\"threshold\":\"\",\"note\":\"Benefit limits per Medicaid DME Program Manual apply.\",\"children\":[]}"],"ref":"b1_10","title":"Durable Medical Equipment (DME)"},{"citations":["32","33"],"intro":"Home care approvals based on medical need; personal care, PERS, CDPAS, and nursing assessment require authorization and specific HCPCS codes/units.","nodes":["{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"All home health personal care services for Medicaid and MLTC require authorization and use specified HCPCS codes.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Personal Emergency Response System (PERS) requires authorization.\",\"threshold\":\"\",\"note\":\"PERS is a Medicaid and MLTC benefit.\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Consumer Directed Personal Assistance Services (CDPAS) require authorization.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Nursing assessment (HCPCS T1001) billed per visit; levels and service units are outlined in policy.\",\"threshold\":\"\",\"note\":\"Includes PRI & intense cases, service billing units per visit or per 15 minutes as applicable.\",\"children\":[]}"]","ref":"b1_11","title":"Home Health Care"},{"citations":["34","35"],"intro":"Many imaging services require authorization (delegated to NIA); OB ultrasound and DXA frequency/diagnosis rules specified.

Codes: Authorization, Delegation, and Non-Covered Lists

Transplant CPT codes (listed)CPTCovered

32850	Thoracic transplant procedure
32851	Thoracic transplant procedure
32852	Thoracic transplant procedure
32853	Thoracic transplant procedure
32854	Thoracic transplant procedure
32855	Thoracic transplant procedure
32856	Thoracic transplant procedure
33930	Heart transplant
33931	Heart transplant
33932	Cardiac transplant

1–10 of 83

1/9

Outpatient surgery codes requiring authorization (selected)CPTCovered

15820	Blepharoplasty, lower lid
15821	Blepharoplasty, lower lid with extensive herniated fat pad
15822	Blepharoplasty, upper lid
15823	Blepharoplasty, upper lid with extensive herniated fat pad
43770	Laparoscopic gastric bypass
43771	Revision of bariatric procedure
43772	Laparoscopic adjustable gastric band
43773	Removal of gastric band
43774	Bariatric surgery code
43775	Bariatric surgery code

1–10 of 18

1/2

ENT/Cardiac/Delegated Surgery lists (delegated reviewers)mixed

TurningPoint Delegation	ENT and Cardiac prior authorization delegated to TurningPoint Healthcare Solutions, LLC — see delegated code lists and device reviews
Evolent Delegation	Orthopedic/spinal code delegation to Evolent (NIA) — device HCPCS reviewed by Evolent when CPT delegated

Behavioral health testing and service codesCPTCovered

OMH/Behavioral

Behavioral health inpatient notifications and codes per OMH guidance — notification and not subject to prior auth for in-network OMH licensed facilities under specified conditions

DXA and TBS scansCPTCovered

77080	Dual-energy X-ray absorptiometry (DXA)
76977	Trabecular bone score (TBS) adjunct to DXA

Wireless capsule and motilityCPTCovered

91110	Wireless capsule endoscopy
91111	Wireless capsule endoscopy interpretation

Pain management and related codesCPTCovered

20550	Injection(s); single tendon sheath, or ligament
20551	Injection(s); single tendon sheath

Bronchial thermoplasty and other high-tech proceduresCPTCovered

31675

Bronchial thermoplasty

Ambulatory continuous glucose monitoringHCPCSCovered

A4234	Ambulatory continuous glucose monitor sensor
A4235	Ambulatory continuous glucose monitor transmitter

MLTC DME supply codes requiring authorizationHCPCSCovered

E1399

Durable medical equipment, miscellaneous

Home health and personal care HCPCS codes (selected)HCPCSCovered

G0151	Services of home health aide
G0156	Services related to home care supervision

Enteral therapy HCPCSHCPCSCovered

B4164	Enteral formula, modular, per 100 calories
B4163	Enteral formula

HCPCS/CPT/Drug HCPCS codes listed as requiring prior authorization (Appendix I long list)HCPCSCovered

J0172	Injection, abatacept, 1 mg
J0174	Injection, anakinra, 1 mg
J0179	Injection, belimumab, 1 mg
J0180	Injection, benralizumab, 1 mg
J0205	Injection, bevacizumab, 1 mg
J0207	Injection, bleomycin sulfate, 1 unit
J0208	Injection, bortezomib, 1 mg
J0215	Injection, bosutinib, 1 mg
J0217	Injection, brentuximab vedotin, 1 mg
J0218	Injection, brivanib, 1 mg

1–10 of 152

1/16

Items excluded from New Century Health (do not send to NCH)mixedNot Covered

Excluded Items

Certain items and procedures are excluded from review by New Century Health — do not send to NCH per internal guidance

S codes handling notesHCPCS

S-codes

S codes require special handling; follow payer-specific guidance

HCPCS codes considered benefit exclusions (non-FDA approved meds)HCPCSNot Covered

Non-FDA Meds

Selected HCPCS codes representing non-FDA-approved medications are benefit exclusions

Maximum unit edits statementmixed

Maximum Unit Edits

Maximum unit edits apply as stated in the provider billing guidelines

What Providers Must Do (Prior Auth, Documentation, Billing Rules)

Prior Authorization

Authorize inpatient admissions and specified services

Obtain prior authorization for all inpatient admissions (post‑stabilization) and for the specified service lines listed in the policy (inpatient rehabilitation, transplants, outpatient surgery, imaging, DME, home health, etc.). Emergency room services or emergent stabilization do not require authorization. Follow the CPT/HCPCS code lists referenced in the policy when submitting requests.

Inpatient rehabilitation (acute, sub‑acute, skilled nursing rehab) — authorization required
All solid organ and bone marrow transplants — see transplant CPT list
Outpatient surgery codes and site‑of‑service specific lists — see outpatient surgery sections and code lists
Imaging and DME/home health lines — see delegated/vendor code lists and DME MLTC codes

Background & Definitions

This background explains key policy drivers: COVID-19 operational updates and guidance (see agency COVID-19 link), New York State OMH and OASAS policy implementations that change prior authorization and utilization review requirements (e.g., OMH/ OASAS inpatient notification and concurrent review exemptions), delegation of prior authorization to external reviewers (TurningPoint for ENT/cardiac and Evolent/NIA/New Century Health for oncology, radiology, orthopedics and therapy), and the pharmacy benefit transition to NYRx effective 4/1/2023.

Operational notes and external references: The document references multiple external code lists, vendor code grids and forms — for example OMH two-day notification and LOCADTR forms for inpatient mental health and OASAS Appendix A/LOCADTR notifications for inpatient SUD, delegated reviewers’ CPT/HCPCS lists (TurningPoint and Evolent/NIA), the Medicaid DME Program Manual and NYRx Medicaid Pharmacy List of Reimbursable drugs and Appendix I drug/HCPCS authorization grids — providers should follow the specified links, forms and vendor submission workflows when seeking authorizations or notifications.

Term	Definition
OMH	New York State Office of Mental Health
OASAS	New York State Office of Addiction Services and Supports
NIA	Evolent/NIA delegated prior authorization reviewer (Evolent referenced as NIA for delegated radiology, therapy and other reviews)
TurningPoint	TurningPoint Healthcare Solutions, delegated prior authorization reviewer for ENT and cardiac surgical procedures (associated devices HCPCS also reviewed by TurningPoint)
NYRx	NYS Medicaid Fee-for-Service (FFS) Pharmacy Program to which Fidelis Medicaid and HARP pharmacy benefits transition effective April 1, 2023 (physician-administered drugs listed on Medicaid Pharmacy List of Reimbursable available through NYRx)
NCH/Evolent	External vendor used for oncology prior authorization review (New Century Health, now referenced as Evolent); oncology medications and supportive agents require PA from Evolent (formerly New Century Health) before dispensing or administration for Medicaid Managed Care and HARP (excludes CHP)

Exclusions & Non-Covered Items

Coverage stance: Mixed — the policy retains prior authorization requirements for many services and drug/HCPCS codes while removing or exempting authorization for some behavioral health and OMH/OASAS inpatient services under specified conditions, and delegating many authorization functions to third-party reviewers.

Items excluded from New Century Health (do not send to NCH): the policy lists specific categories that should NOT be routed to NCH, including Antibiotics, Bone marrow / stem cell transplants / CAR-T, Cablivi, Controlled substances, Equipment requests, Genetic lab testing and laboratory services, Hemophilia drugs, Immune globulins, Inpatient drug requests, Iron preparations, Pain medications, Radiopharmaceuticals, Surgeries / surgical procedures, and Sickle cell diagnoses.

Policy Updates

April 1, 2023clarifiedLatest

Pharmacy benefits for Fidelis Medicaid Managed Care and HARP members transitioned to NYRx (Medicaid FFS) effective April 1, 2023 — physician‑administered drugs listed on the Medicaid Pharmacy List of Reimbursable are available through NYRx and oncology pharmacy requests routing notes.

revisedLatest

Oncology medications and supportive agents require prior authorization (PA) from Evolent (formerly New Century Health) for Medicaid Managed Care and HARP (excludes Child Health Plus); requests may be submitted via phone (1-888-999-7713, option 1) or website.

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE

Policy CodePolicy N/A

Change TypeOperational/coverage updates

Effective Date

Next Review Date

Key ActionObtain authorization for all inpatient admissions (except emergent stabilization) and for specified services per the policy and follow delegated vendor workflows where applicable.

SourceLink

On This Page

nodes":["{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Radiology prior authorization delegated to Evolent (NIA) for many services; cardiac ultrasounds delegated to TurningPoint.\",\"threshold\":\"\",\"note\":\"Full CPT lists via links.\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"OB ultrasound rules: first 4 OB ultrasounds can be performed without authorization; five or more for a normal pregnancy require authorization; OB ultrasounds for high-risk pregnancies do not require authorization.\",\"threshold\":\"4 vs >=5\",\"note\":\"Normal pregnancy dx codes example: Z32.01 etc.; high-risk dx codes listed in policy.\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"DXA/TBS\",\"text\":\"DXA scans: Women >65 one 77080/77081 every 2 years with diagnosis Z13.820; Men >70 one every 2 years with Z13.820; Women 51-64 and Men 51-69 one every 2 years when accompanied by qualifying diagnosis codes; other ages/diagnoses require authorization. TBS scans CPTs 77089-77092 referenced.\",\"threshold\":\"age/diagnosis based\",\"note\":\"Requests outside rules require authorization.\",\"children\":[]}"],"ref":"b1_12","title":"Imaging Studies and DXA"},{"citations":["38"],"intro":"Prior authorization required for many pain management and therapeutic services; several procedures not covered for low back pain.

nodes":["{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Pain management and injection codes listed require authorization (62281,62282,62290,62320-62327,63622,64400-64530,64553-64595,64600-64640,64582-64583,64628-64629,63685,63688 and related codes).\",\"threshold\":\"\",\"note\":\"63622 does not require authorization for requests from orthopedic specialties.\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"Non-covered for Low Back Pain\",\"text\":\"Services not covered for members with diagnosis of Low Back Pain include therapeutic facet joint steroid injections in lumbar/sacral regions, prolotherapy, and therapeutic injections of steroids into intervertebral discs.\",\"threshold\":\"Low Back Pain dx","note":"Do not bill for these non-covered services.","children":[]}","{\"operator\":\"all\",\"n\":0,"label":"","text":"Topical oxygen and continuous or intermittent traction require authorization.","threshold":"","note":"Radiation therapy prior auth delegated to NIA; ambulatory continuous glucose monitoring CPT 95249 noted; bronchial thermoplasty 31660/31661 noted.","children":[]}"]","ref":"b1_13","title":"Therapeutic Services and Pain Management"},{"citations":["39"],"intro":"Certain LTHHCP services are covered with authorization for transitioned Medicaid Managed Care enrollees.

nodes":["{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Medical Social Services (S9127) and Home Delivered Meals (S5170) are covered with an authorization for Medicaid Managed Care enrollees who transitioned from FFS LTHHCP and were receiving services at transition.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}"],"ref":"b1_14","title":"Long Term Home Health Care (LTHHCP) Transitioned Services"},{"citations":["41","42","43"],"intro":"Counseling and self-management services do not require authorization; specific limits apply.

nodes":["{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Counseling services: members allowed 10 hours/20 units in a continuous 6-month period; provided by certified providers and no longer require authorization (codes G0108 and G0109).\",\"threshold\":\"10 hours/6 months\",\"note\":\"\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Diabetes Self-Management Training (DSMT) and Asthma Self-Management Training: specified limits (ASMT up to 10 hours in 6 months for newly diagnosed/medically complex; stable members up to 1 hour in 6 months); no authorization required.\",\"threshold\":\"varies by program\",\"note\":\"\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Smoking Cessation Counseling reimbursed up to 8 visits per calendar year using codes 99406 and 99407 billed only with diagnosis F17.200; no authorization required.\",\"threshold\":\"8 visits/year\",\"note\":\"\",\"children\":[]}"],"ref":"b1_15","title":"Counseling / Self-Management Training / Smoking Cessation"},{"citations":["45","46"],"intro":"Pharmacy benefits for Fidelis Medicaid and HARP members transitioned to NYRx (FFS) effective 4/1/23; enteral therapy HCPCS B4034-B4162 require authorization (CHP applicability noted).","nodes":["{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Effective 4/1/23, Fidelis Medicaid Managed Care and HealthierLife (HARP) pharmacy benefits are administered through NYRx FFS. Physician-administered drugs listed on the Medicaid Pharmacy List of Reimbursable are available through NYRx.\",\"threshold\":\"4/1/2023\",\"note\":\"\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Enteral therapy HCPCS B4034-B4162 require authorization; applicable to Child Health Plus as of 4/1/2023 with defined clinical eligibility criteria.\",\"threshold\":\"HCPCS B4034-B4162\",\"note\":\"Pharmacy supplies do not require authorization; supplies not covered for CHP per benefit plan.\",\"children\":[]}"]","ref":"b1_16","title":"Pharmacy and Enteral Therapy"},{"citations":["46"],"intro":"Benefit applies when ALL of the following conditions are met:","nodes":["{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Require supplemental nutrition; demonstrate documented compliance with an appropriate medical and nutritional plan of care; have BMI under 18.5 (CDC) — up to 1,000 calories per day.\",\"threshold\":\"BMI < 18.5\",\"note\":\"\",\"children\":[]}","{\"operator\":\"any\",\"n\":0,\"label\":\"AND one of\",\"text\":\"One of the following must apply:\",\"threshold\":\"\",\"note\":\"\",\"children\":[{"operator":"all","n":0,"label":"","text":"Tube-fed individuals who can only obtain nutrition through a tube","threshold":"","note":"","children":[]},{"operator":"all","n":0,"label":"","text":"Individuals with inborn metabolic disorders requiring specific nutritional formulas not available through any other means","threshold":"","note":"","children":[]},{"operator":"all","n":0,"label":"","text":"Children under age 21 who require medical formulas due to growth/development factors","threshold":"<21","note":"","children":[]},{"operator":"all","n":0,"label":"","text":"Adults with diagnosis of HIV/AIDS or related illness who are oral-fed and require supplemental nutrition","threshold":"","note":"","children":[]}]}]","ref":"b1_17","title":"Enteral Therapy Benefit Conditions (Child Health Plus applicability noted)"},{"citations":["46"],"intro":"Covered when ALL of the following are met:","nodes":["{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Require supplemental nutrition; demonstrate documented compliance with an appropriate medical and nutritional plan of care; have BMI under 22 (CDC).\",\"threshold\":\"BMI < 22\",\"note\":\"Up to 1,000 calories per day.\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Documented, unintentional weight loss of 5 percent or more within the previous 6 month period.\",\"threshold\":\">=5% in 6 months\",\"note\":\"\",\"children\":[]}"]","ref":"b1_18","title":"Alternate Enteral Therapy Criterion (weight loss)"},{"citations":["46"],"intro":"Covered when ALL of the following are met:","nodes":["{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Require total nutritional support.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Have a permanent structural limitation that prevents chewing of food.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Placement of a feeding tube is medically contraindicated.\",\"threshold\":\"\",\"note\":\"\",\"children\":[]}"]","ref":"b1_19","title":"Total Nutritional Support (enteral)"},{"citations":["46","48"],"intro":"Oncology medications and supportive agents require authorization from Evolent (formerly New Century Health) for Medicaid Managed Care and HARP (excludes CHP); requests routed per vendor instructions.","nodes":["{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Oncology medications and supportive agents require authorization (PA) from Evolent (formerly New Century Health) before pharmacy dispensing or administration in office/outpatient/ambulatory settings for Medicaid Managed Care and HARP (medical benefit only).\",\"threshold\":\"\",\"note\":\"Excludes Child Health Plus. Requests can be submitted via 1-888-999-7713 option 1 or the vendor website.\",\"children\":[]}","{\"operator\":\"all\",\"n\":0,\"label\":\"\",\"text\":\"Appendix I lists numerous HCPCS/CPT/drug HCPCS codes requiring prior authorization; follow plan-specific authorization processes and do NOT send excluded items to NCH/Evolent (e.g., antibiotics, transplants, certain S codes).\",\"threshold\":\"\",\"note\":\"See Appendix I for full code list and exclusions.\",\"children\":[]}"]","ref":"b1_20","title":"Oncology medications and supportive agents (PA routing)"}]} является неверным JSON объектом, пожалуйста проверьте формирование блоков.

Facilities must notify Fidelis Care within the required timeframe and use the specified OMH/OASAS notification forms. For OASAS inpatient SUD admissions, the facility must notify Fidelis Care of the admission and initial treatment plan within 2 business days and may fax/email the OASAS Appendix A Notification Form and LOCADTR tool. For OMH‑licensed inpatient mental health admissions, facilities must notify Fidelis Care within 2 business days using the OMH Two‑Day Notification and Initial Treatment Plan form.

Prior Authorization

Use delegated reviewers for specific services

Certain service lines have prior authorization delegated to external reviewers. Send authorization requests per the delegated workflows: TurningPoint Healthcare Solutions handles ENT and cardiac surgical procedures (including associated HCPCS devices); Evolent (NIA) handles many radiology services, certain outpatient orthopedic/surgical procedures, and home/outpatient therapy after the initial evaluation. Follow each delegated vendor's code lists and submission process.

Delegated vendor lists: TurningPoint (ENT, Cardiac) and Evolent/NIA (radiology, orthopedic/surgical, therapy)
Follow delegated code lists and workflows when a CPT code is delegated

Billing Rule

OB ultrasound frequency billing

OB ultrasound frequency rules for billing and authorization: the first four OB ultrasounds may be performed without prior authorization. Five or more ultrasounds for a normal pregnancy require prior authorization. Ultrasounds for high‑risk pregnancies do not require authorization. Ensure OB ultrasound claims are billed with the appropriate pregnancy diagnosis codes.

First 4 OB ultrasounds: no prior authorization
5 or more for a normal pregnancy: prior authorization required
High‑risk pregnancy ultrasounds: no authorization required — bill with relevant pregnancy diagnosis codes

Documentation Required

Developmental screening billing and coding

Developmental screening CPT 96110 should be billed with diagnosis code Z13.41 (autism screening) or Z13.42 (global developmental delay screening) per Medicaid guidance. 96110 does not require authorization (excluding CHP) and may be reimbursed in the first three years of life subject to frequency guidance; observe the frequency limits for ASD and global developmental delay screening in the child’s first three years.

96110

Prior Authorization

DME MLTC authorization

For MLTC members, obtain prior authorization for the listed DME supply HCPCS codes before billing. The policy identifies a specific set of MLTC supply codes that require authorization and applies Medicaid DME Program Manual limits.

A4335
A4554
T4521
T4522
T4523
T4524
T4529
T4530
T4533
T4535
T4537
T4539
T4540
T4543

Documentation Required

HCBS/CORE/PROS notification

HCBS/CORE/PROS programs require providers to submit required initiation/enrollment forms within the stated timelines to Fidelis Care to prevent claims processing disruptions. CORE Service Initiation Forms must be submitted within three business days of the first service visit; other HCBS notification and plan‑of‑care submission timelines are specified in the HCBS workflow.

CORE Service Initiation Form: submit within 3 business days of first service visit
Submit Plan of Care / Children’s HCBS forms per HCBS workflow to avoid claim disruptions

Prior Authorization

Home & outpatient therapy authorization

Home and outpatient PT/OT/ST performed after the initial evaluation require authorization through NIA. Effective 10/1/2021, home therapy requires authorization for the initial evaluation; outpatient therapy performed after the initial evaluation must be authorized via the NIA delegated process.

Authorization through NIA required after the initial evaluation
Effective date: 10/1/2021

Denial Risk

Non-covered procedures for low back pain

The policy lists services not covered for members with a diagnosis of Low Back Pain. Do not bill for these procedures for low back pain: therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT guidance), prolotherapy, and therapeutic intradiscal steroid injections.

Therapeutic facet joint steroid injections — lumbar/sacral
Prolotherapy
Therapeutic injections of steroids into intervertebral discs (intradiscal)

Prior Authorization

Oncology medications PA routing

Oncology medications and supportive agents require prior authorization from Evolent (formerly New Century Health) before dispensing at a pharmacy or administration in a physician office, outpatient hospital, or ambulatory setting for Medicaid Managed Care and HARP members (excludes Child Health Plus). Requests can be submitted via phone or the vendor website; use phone 1‑888‑999‑7713, option 1, or submit via the Evolent/New Century Health website per the policy.

Submit oncology PA requests to Evolent/New Century Health prior to dispensing or administration
Phone: 1-888-999-7713, option 1; or use the vendor website per instructions

Prior Authorization

Appendix I listed HCPCS/J/Q/G codes require prior authorization

Appendix I contains a long list of HCPCS/J/Q/G/C codes that require prior authorization. Providers must follow plan‑specific authorization processes and submit requests for codes enumerated in Appendix I per the policy and appendix instructions.

Follow Appendix I and submit prior authorization requests for the listed HCPCS/J/Q/G codes

Documentation Required

Enteral therapy documentation

Enteral therapy authorizations require documentation of a medical and nutritional plan of care and evidence supporting BMI and weight‑loss criteria as applicable. Providers must document compliance with the plan of care, BMI measurements, and any documented unintentional weight loss to support authorization for enteral formulas (HCPCS B4034‑B4162).

Documented medical/nutritional plan of care
BMI and evidence of weight loss (when applicable) to meet enteral therapy criteria

Billing Rule

Pharmacy benefit transition

Pharmacy benefits for Fidelis Medicaid Managed Care and HARP transitioned to NYRx (NYS Medicaid FFS) effective April 1, 2023. Physician‑administered drugs listed on the Medicaid Pharmacy List of Reimbursable are available through NYRx per the transition guidance.

Pharmacy transition effective 4/1/2023 — Medicaid Managed Care and HARP to NYRx (FFS)
Physician‑administered drugs on the Medicaid Reimbursable List are available through NYRx

Billing Rule

Maximum units enforcement

Maximum unit edits apply to all HCPCS codes regardless of authorization status. These maximum unit edits may result in claims edits or denials per the policy's maximum units statement.

Maximum unit edits apply to all HCPCS codes and can cause claim edits/denials

Documentation Required

Utilization Management voicemail requirements

Utilization Management voicemail messages may only include detailed UM information if the provider voicemail is HIPAA‑compliant. Mailbox greetings must identify the mailbox owner and organization and state that the mailbox is confidential and PHI can be left. If voicemail is not HIPAA‑compliant, only a generic message will be left and a callback requested.

Voicemail must be HIPAA‑compliant and identify owner/organization and confidentiality to receive detailed UM messages
Non‑HIPAA‑compliant mailboxes receive generic message and callback request

Documentation Required

UM attempt to notify provider

When attempting to notify a provider of a UM determination, Fidelis Care will make a second attempt to reach the provider directly as required by the Department of Health Reasonable Effort Policy.

A second direct attempt to contact the provider will be made for UM determinations per DOH Reasonable Effort Policy