CurrentFidelis CarePolicy N/A

COVID-19 UPDATE Authorization and Coding Guidelines

Authorization and coding guidance for Fidelis Care covering inpatient admissions, outpatient procedures, behavioral health (OMH/OASAS) changes, DME, imaging, therapy, specialty drug billing codes and delegated authorizations during the COVID-19 period and related policy updates (includes lists of CPT/HCPCS codes that require or do not require prior authorization and vendor routing).

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE Authorization and Coding Guidelines

Policy CodePolicy N/A

Change TypeOperational/coding update

Effective Date

Next Review Date

Key ActionObtain authorization for all inpatient admissions (except ED stabilization) and for all inpatient facility services unless specific OMH/OASAS in-network exceptions apply.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — this update provides guidance and coding/authorization rules but does not introduce a material change.

28 daysOASAS in-state inpatient SUD concurrent review exempt period

14 daysOMH in-state inpatient mental health concurrent review exempt period (age <18)

4OB ultrasounds without authorization

8MNT visits per year without authorization (diabetes/renal)

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10 hoursDSMT allowance in 12 months

Policy overview and scope

This Fidelis Care COVID-19 update provides authorization and coding guidance including delegated authorizations and vendor routing: all inpatient admissions require prior authorization (except ED stabilization) and many specified outpatient and specialty procedure CPT/HCPCS codes listed in the policy require prior authorization; radiology and radiation therapy require authorization through eviCore Healthcare (see full CPT list), and certain transplant, outpatient surgery, behavioral health testing, diagnostic/GI, DME/orthotic, telehealth, genetic testing, infectious agent detection, and pharmacy J/C codes are addressed by the scope and code lists in the document. Authorization for orthopedic and spinal surgical procedures was delegated to TurningPoint Healthcare Solutions, LLC for dates of service on/after 12/23/2019 (authorization required beginning 10/01/2019 per notice). The policy includes in‑state exceptions: OMH‑licensed inpatient mental health facilities treating members <18 are not subject to prior authorization or concurrent utilization review for the first 14 days if the facility notifies Fidelis Care and meets clinical review/consultation requirements; OASAS‑licensed in‑state inpatient SUD facilities are exempt from authorization and concurrent review for the first 28 days if the facility notifies Fidelis Care and uses the LOCADTR tool. The block of CPT/HCPCS code groups in the source enumerates codes that require or do not require authorization (transplant-related codes, selected outpatient surgery codes, behavioral health testing codes, ECT, partial hospitalization/intensive outpatient codes, diagnostic/GI and capsule endoscopy codes, select genetic testing exceptions, DME/orthotic lists, telehealth codes, and others).

Quick thresholds

OMH 14 daysNo concurrent utilization review during first 14 days for in-state OMH-licensed, in-network facilities for members <18 when notification and other requirements met

OASAS 28 daysNo concurrent utilization review during first 28 days for in-state OASAS-licensed, in-network inpatient SUD facilities when notification and other requirements met

OB ultrasoundFirst 4 OB ultrasounds can be performed without authorization; five or more for high‑risk pregnancy also do not require authorization per listed DX codes

MNT visitsMedical Nutrition Therapy: 8 visits per year covered without authorization for diabetes/renal diagnoses (97802/97803 or G0270/G0271)

DSMT allowanceDiabetes Self‑Management Training: 10 hours (20 units) in a continuous 12‑month period; covered without authorization when billed by certified providers with G0108/G0109

Authorization / coverage criteria

Inpatient Admissions Authorization

All inpatient admissions require authorization except specified emergency and select licensed behavioral health/substance use facilities under conditions below:

ALL of the following

All inpatient admissions require an authorization.
Emergency room services or emergent services required to provide stabilization do NOT require authorization; post-stabilization services and inpatient admissions after ED services are completed require authorization and are reviewed for medical necessity.
All inpatient facility services for Medical, Substance Abuse, and Behavioral Health admissions require authorization.
Acute and sub-acute rehabilitation are authorized when skilled services are provided (authorization required).

Code lists and routing

Inpatient/transplant-related codes requiring authorizationCPTCovered

32850-32856	Transplant-related (includes but not limited to listed codes)
33930-33945
38204-38215
38230-38242
44133-44136
47133-47147
48160
48550-48556
50300-50380
50547

1–10 of 11

1/2

Outpatient surgery codes requiring prior authorization (selected list)CPTCovered

15820-15823	Blepharoplasty
43770-43888	Bariatric surgery; includes S2083
11920-11971
19300
19316-19342
19355
19370-19396
10040
11300-11313
11400-11471

1–10 of 22

1/3

Additional outpatient surgery / specialty procedure codes requiring authorizationCPTCovered

69300
69090
15830-15839	Abdominoplasty/lipectomy/panniculectomy
15847
15876-15879
65760-65771	Eyelid & ocular surgery
65772-65775
66987-66988
67900-67911
19318	Reduction mammoplasty

1–10 of 27

1/3

Psychological/Neuropsychological testing codes still requiring authorizationCPTCovered

96116
96121
96130
96131
96132
96133
96136
96137
96138
96139

1–10 of 14

1/2

Outpatient ECTCPTCovered

90870

Partial Hospitalization / Intensive Outpatient codesmixedCovered

Revenue 912, 913, 944, 945	Partial Hospitalization (Mental Health)
HCPCS H0035	Partial Hospitalization
Bill type 131, Revenue 905 or 912, CPT 90899, S9480, HCPCS H2013	Intensive Outpatient Treatment

Diagnostic/GI and capsule endoscopy codesCPTCovered

43235
43239
43248
45378
45380
45384
45385
46255
46260
46270

1–10 of 12

1/2

Genetic testing codes without authorization (BRCA etc.)CPT

81220	No authorization required; lifetime limit = 1
81329	No authorization required; combined lifetime limit with 81336 = 1
81336	No authorization required; combined lifetime limit with 81329 = 1

Infectious agent detectionCPTCovered

87483

Infectious agent detection by DNA or RNA

DME codes that DO NOT require authorizationHCPCS

A4604
E0130
E0135
E0168
E0182
E0184
E0235
E0274
E0305
E0310

1–10 of 49

1/5

Orthotic codes that DO NOT require authorizationHCPCS

L3650
L3710
L3913
L3919
L3921
L3923
L3925
L3929
L3931
L3933

1–10 of 22

1/3

Therapeutic services / not covered or restricted codesmixedNot Covered

C1823	Pain management code (non-orthopedists only) - not covered for Low Back Pain members
C9752
C9753
95249	Ambulatory continuous glucose monitoring (requires authorization)

Telehealth codes requiring authorizationHCPCSCovered

G2010
G2012

MNT and DSMT codesCPT/HCPCSCovered

97802	MNT visits (8/yr without authorization for diabetes/renal diagnoses)
97803
G0270
G0271
G0108	DSMT - covered without authorization when provided by certified providers
G0109

Radiology and Radiation Therapy authorization routingCPTCovered

See eviCore full CPT list

Radiology and Radiation Therapy require authorization through eviCore Healthcare

Routing notes and vendor contacts: Radiology and radiation therapy authorizations are handled through eviCore Healthcare (full CPT list and portal at evicore.com/healthplan/fideliscare). Authorization for many orthopedic and spinal surgical procedures was delegated to TurningPoint Healthcare Solutions, LLC for dates of service on or after 12/23/2019 (authorization requirement effective 10/01/2019); providers must follow TurningPoint routing for those codes. Prior authorization requests for injectable/pharmacy-administered medications (J/C codes) must be submitted to the Fidelis Pharmacy Team electronically via e-fax: 1-877-882-5892. For OMH in‑state inpatient mental health notification (to avoid concurrent review for the first 14 days) submit the OMH Two‑Day Notification and Initial Treatment Plan by fax to 718-896-1784 or by email to Mental Health Admission@fideliscare.org. For OASAS in‑state inpatient SUD notification submit the OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool by fax to 646-829-1421 or by email to LOCADTR@fideliscare.org; providers with questions may call Fidelis Care at 1-888-FIDELIS (1-888-343-3547), extension 16072 for Behavioral Health.

What providers must do

Prior Authorization

Authorization required for inpatient admissions

Obtain authorization for all inpatient admissions (except ER stabilization). All inpatient facility services — medical, substance abuse, and behavioral health admissions — require prior authorization and are reviewed for medical necessity.

Authorization required for all inpatient admissions except emergent ER stabilization; post-stabilization inpatient admissions require authorization.

Documentation Required

OMH Two-Day Notification and Initial Treatment Plan

OMH-licensed in-state hospitals treating members under 18 must submit the OMH Two-Day Notification and Initial Treatment Plan within two business days to avoid concurrent review for the first 14 days. Submit by fax to 718-896-1784 or email to Mental Health Admission@fideliscare.org.

Two-business-day notification requirement to Fidelis Care using OMH Two-Day Notification and Initial Treatment Plan.

Key terms

POSPlace of Service (billing location codes used to determine authorization requirements)

Common questions

Quick contacts & submission channels

Fidelis general Behavioral Health phone1-888-FIDELIS (1-888-343-3547), ext. 16072

OMH Two-Day Notification submissionFax: 718-896-1784; Email: Mental Health Admission@fideliscare.org

OASAS Appendix A / LOCADTR submissionFax: 646-829-1421; Email: LOCADTR@fideliscare.org

TurningPoint delegated authorizationsFollow TurningPoint Healthcare Solutions routing for orthopedic/spinal codes (delegation effective 12/23/2019)

Radiology/Radiation authorization portaleviCore Healthcare portal: https://www.evicore.com/healthplan/fideliscare

Pharmacy injectable PA e-fax1-877-882-5892

Policy changes and history

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE Authorization and Coding Guidelines

Policy CodePolicy N/A

Change TypeOperational/coding update

Effective Date

Next Review Date

Key ActionObtain authorization for all inpatient admissions (except ED stabilization) and for all inpatient facility services unless specific OMH/OASAS in-network exceptions apply.

SourceLink

On This Page

OMH Licensed Inpatient Mental Health Treatment (Members under age 18)

Effective 01/01/2020: conditions under which authorization is not required for in-state OMH-licensed hospitals for members <18:

ALL of the following

Facility is OMH licensed in New York State and participating in Fidelis Care provider network.
Facility notifies Fidelis Care of both the admission and the initial treatment plan within two business days using OMH Two-Day Notification and Initial Treatment Plan form (fax 718-896-1784 or email Mental Health Admission@fideliscare.org).
Facility performs daily clinical review of the patient.
Facility participates in periodic consultation with Fidelis Care to ensure use of evidence-based, peer-reviewed clinical review criteria approved by OMH appropriate to age of patient.
When above met, prior authorization and concurrent utilization review are not required during the first 14 days of inpatient admission; services remain subject to retrospective review.

Exceptions

Inpatient mental health services for members age 18 and older require prior authorization and are subject to concurrent review throughout the admission.
Out-of-state and out-of-network providers must request authorization and are subject to concurrent review throughout the admission for members of all ages.

OASAS Licensed Inpatient Substance Use Disorder Treatment

Effective 01/01/2020: in-state OASAS-licensed, network facilities rules:

ALL of the following

Inpatient SUD services provided by NY State OASAS licensed and participating Fidelis Care network facilities are not subject to authorization review and not subject to concurrent utilization review during the first twenty-eight (28) days of admission provided facility notifies Fidelis Care of the inpatient admission and initial treatment plan within two business days (fax/email of OASAS Appendix A and LOCADTR Medical Necessity Tool to 646-829-1421 or LOCADTR@fideliscare.org).
Facility must perform daily clinical review of the patient and periodically consult with Fidelis Care starting on or just prior to the 14th day to ensure use of the LOCADTR tool to establish medical necessity.
Inpatient SUD services may be subject to utilization review after the 28th day or upon discharge using LOCADTR; prior to discharge, facility must provide member and Fidelis Care with a written discharge plan indicating whether services are secured or reasonably available.

Facilities outside New York State, not licensed/certified by OASAS, or outside Fidelis Care's network must request authorization and are subject to concurrent review throughout the admission.

Elective and Outpatient Surgical Procedures Authorization

Authorization required for certain outpatient surgeries and codes; ambulatory procedures completed within 24 hours are not approved as inpatient; some services do not require authorization when performed in network outpatient settings.

ANY of the following

All facility admissions for inpatient-only procedures require authorization; surgical and medical procedures completed within 24 hours will not be approved as inpatient level of care and when billed as outpatient do not require authorization if performed within Fidelis Care network.
Certain outpatient surgery codes require prior authorization (see code_groups).
Refer to Outpatient surgery code lists and code_groups in document.
Authorization delegated to TurningPoint Healthcare Solutions, LLC for orthopedic and spinal surgical procedures for dates of service on or after 12/23/2019 (authorization required beginning 10/01/2019).

Behavioral Health Outpatient Authorization — Psychological/Neuropsychological Testing

Authorization removed for most outpatient behavioral health services except listed codes which still require authorization:

ALL of the following

Codes still requiring authorization
- 96116
- 96121
- 96130
- 96131
- 96132
- 96133
- 96136
- 96137
- 96138
- 96139
- 96146
- 96112 (Authorization required; submit requests on Psychological/Neuropsychological testing request form)
- 96113 (Authorization required)
96110 is a non-covered service.

Outpatient Therapy and Services Authorization

Authorization rules for therapy, podiatry, imaging, DME, and other therapeutic services:

ALL of the following

Outpatient therapy initial evaluation does not require authorization; all subsequent visits require authorization (includes swallow function and therapy).
Members in Fidelis Dual Advantage Flex (Plan 017) have separate annual dollar limits: $2,010 combined for Physical and Speech Therapy and $2,010 for Occupational Therapy.
Podiatric services no longer require authorization for members with a confirmed diagnosis of Diabetes Mellitus (diagnosis must be included on claim). Podiatric services for members without diabetes continue to require authorization. Podiatrists require authorization for all DME and orthotic codes supplied in office regardless of diagnosis.
First 4 OB ultrasounds can be performed without authorization; five or more OB ultrasounds for a high risk pregnancy (specified ICD-9 codes) do not require authorization.
Radiology services require authorization through eviCore Healthcare (full CPT list at evicore.com/healthplan/fideliscare).
Sleep studies, including home sleep studies, require prior authorization.
Certain diagnostic and genetic testing require authorization; BRCA/genetic testing: CPT 81220, 81329, 81336 do NOT require authorization; CPT 81220 lifetime limit = 1; CPTs 81329 and 81336 combined limit = 1 per lifetime.
Gastroenterology procedures listed require authorization if performed in POS 19 and 22 when office-based or ASC are available (codes listed in code_groups).
Wireless Capsule Endoscopy (91110, 91111) requires authorization.
Infectious agent detection by DNA/RNA: 87483 (authorization required).

Durable Medical Equipment (DME) Authorization

Some DME and orthotic HCPCS codes do not require authorization; others do require authorization.

ALL of the following

Listed DME codes do NOT require authorization (see code_groups for complete list).
Listed orthotic codes do NOT require authorization (see code_groups).
All other DME and orthotic codes require authorization.

Telehealth and Counseling Authorization

Selected telehealth and counseling billing codes requiring authorization or covered without authorization:

ANY of the following

Telehealth: Authorization is required for G2010 and G2012.
Medical Nutrition Therapy (MNT) covered without authorization for diabetes or renal diagnoses — eight visits per year covered using 97802/97803 or G0270/G0271 (diagnosis ICD-10 list provided).8 visits per year
Diabetes Self-Management Training (DSMT): Members allowed 10 hours/20 units in continuous 12-month period; services provided by certified providers and are covered when billed with G0108 and G0109 without authorization.10 hours / 20 units per 12 months

Oncology and Specialty Drug Authorization Note

General formulary and PA routing guidance for infused/HCPCS J/C codes and certain C-codes:

ALL of the following

Many J-/C-/G- and other injectable HCPCS codes map to specific drugs and may require authorization; specific mapping and monthly formulary updates are available at the Fidelis website.
Providers must submit prior authorization requests for injectable medications to the Fidelis Pharmacy Team via e-fax 1-877-882-5892.
Authorization is not required for oncology indications.

Email: Mental Health Admission@fideliscare.org

Documentation Required

OASAS Appendix A Notification and LOCADTR submission

In-state OASAS-licensed, participating facilities must notify Fidelis Care within two business days using the OASAS Appendix A and LOCADTR Medical Necessity Tool to avoid concurrent review during the first 28 days. Facilities may fax the forms to 646-829-1421 or email LOCADTR@fideliscare.org. Inpatient SUD services may be subject to utilization review after day 28 or upon discharge.

Two-business-day notification requirement using OASAS Appendix A and LOCADTR Medical Necessity Tool.
Fax: 646-829-1421
Email: LOCADTR@fideliscare.org
No concurrent review during first 28 days if conditions met; may be reviewed after 28 days or at discharge.

Billing Rule

Podiatry billing for diabetes

Podiatric services for members with a confirmed diagnosis of Diabetes Mellitus do not require authorization when the diabetes diagnosis is included on the claim. Podiatric services for members without diabetes continue to require authorization. Podiatrists must obtain authorization for any DME or orthotic codes supplied in the office regardless of diagnosis.

Include confirmed Diabetes Mellitus diagnosis on the claim to avoid prior authorization.
Podiatry for non-diabetes members still requires authorization.
Podiatrists need prior authorization for in-office DME and orthotics regardless of diagnosis.

Prior Authorization

Orthopedic/spinal surgery authorization delegated

Authorization for certain orthopedic and spinal surgical procedures was required beginning 10/01/2019 and, for dates of service on or after 12/23/2019, authorization has been delegated to TurningPoint Healthcare Solutions, LLC. Providers must follow TurningPoint routing for authorization.

Authorization required beginning 10/01/2019 for orthopedic and spinal procedures.
Delegated to TurningPoint for dates of service on or after 12/23/2019 — follow TurningPoint routing.

Prior Authorization

Radiology and radiation therapy routing

Radiology and radiation therapy require authorization through eviCore Healthcare per Fidelis Care guidance. Providers should obtain authorizations via eviCore (see eviCore portal/list for full CPT coverage).

Radiology and radiation therapy authorization routing through eviCore Healthcare.
Refer to eviCore for the full CPT list and portal for submissions.

Prior Authorization

Pharmacy injectable prior authorization submission

Prior authorization requests for injectable medications must be submitted to the Fidelis Pharmacy Team electronically via e-fax to 1-877-882-5892. The pharmacy team handles submissions for injectable codes requiring authorization.

Submit injectable prior authorization requests via e-fax: 1-877-882-5892.
Pharmacy team is the required recipient for these PA submissions.

Billing Rule

OB ultrasound counting

Count OB ultrasounds: the first four OB ultrasounds may be performed without prior authorization. For high-risk pregnancies, defined by specific ICD codes, five or more OB ultrasounds do not require authorization per the listed high-risk diagnosis criteria.

First 4 OB ultrasounds without prior authorization.
Five or more OB ultrasounds for high-risk pregnancy (specified ICD codes listed in policy) are exempt from authorization.

Documentation Required

Discharge planning for inpatient SUD

Prior to discharge from inpatient SUD care, the facility must provide the member and Fidelis Care a written discharge plan indicating whether services are secured or reasonably available.

Written discharge plan required prior to member discharge.
Discharge plan must state whether post-discharge services are secured or reasonably available.

Vision prior authorizations (vendor)Davis Vision: 1-800-601-3383