Fidelis Care prior auth & coverage update

Coverage Summary & Scope

This update provides a consolidated summary of Fidelis Care prior authorization, notification, and utilization review requirements across inpatient, outpatient, behavioral health, DME, home health, imaging, therapy, pharmacy, and specialty services for New York State Medicaid/CHP/Managed Medicaid lines of business. It clarifies which admissions and services require prior authorization (including inpatient admissions and rehabilitation, transplant evaluations, selected outpatient surgeries and procedures, and specified HCPCS/CPT groups), and documents exceptions and special notification pathways for OMH- and OASAS-licensed facilities and other program-specific rules.

Authorization & Utilization Review Criteria

Inpatient Admissions and Emergency Services

Authorization and review rules for inpatient and emergency services:

All inpatient admissions require an authorization (Fidelis does not require authorization of emergency room services or any emergent service required to provide stabilization; post-stabilization services and inpatient admissions after ER services require authorization).

All acute inpatient facility services benefits are unlimited when medically necessary.

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

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

Specific transplant CPT/Codes listed in code_groups

OASAS Licensed Inpatient SUD Treatment

Authorization and concurrent review exceptions and requirements:

Effective 01/01/2020: In-network, in-state OASAS licensed inpatient SUD facilities participating in the Fidelis network are not subject to prior authorization and are not subject to concurrent utilization review for the first 28 days of the inpatient admission provided the facility notifies Fidelis Care of the inpatient admission and initial treatment plan within two business days and performs daily clinical review.28 days

Inpatient SUD services may be subject to utilization review after the 28th day or upon discharge.

Facilities outside New York State, not OASAS-licensed, or out-of-network must request authorization and are subject to concurrent review throughout the admission.

OMH Licensed Inpatient Mental Health Treatment

Authorization and utilization review triggers for OMH licensed inpatient mental health services in NYS:

Effective 06/01/2021: Inpatient mental health treatment for all ages provided by OMH licensed hospitals in NYS are not subject to prior authorization by Fidelis Care; the facility must notify the insurer within 2 business days of admission.

Utilization review will be conducted only for members meeting ANY of the following triggers:

Individuals who had an AOT court order that expired within the past five years
Individuals subject to a current Assisted Outpatient Treatment (AOT) court order
Four (4) or more psychiatric ED visits in the prior 12 months4 visits

Outpatient Surgery Prior Authorization

Services and CPT codes that require prior authorization for outpatient surgery:

Specific outpatient procedure groups require prior authorization (blepharoplasty, bariatric surgery, breast reconstruction, selected skin surgery in POS 24, ear procedures, abdominoplasty/lipectomy/panniculectomy, facial cosmetic/septoplasty, reduction mammoplasty, vascular and esophageal procedures, spinal surgery, selected ENT/cardiac/orthopedic/spinal procedures delegated to TurningPoint).

Authorization requirement for many skin surgery treatments removed for POS 11 and 22; listed CPTs continue to require authorization when performed in POS 24. Certain CPTs always require authorization regardless of place of service: 11200, 11201, 15769-15829, 17340-17999.

CPT 20610 is non-covered for joint injection of hyaluronic acid ONLY when billed with osteoarthritis diagnosis codes M17.0, M17.10-M17.12.

Non-covered condition specified

TurningPoint delegation: If a CPT code is delegated to TurningPoint, associated devices (HCPCS codes) will also be reviewed by TurningPoint for medical necessity.

Outpatient Behavioral Health Services

Authorization requirements for behavioral health outpatient services:

Authorization requirement removed from all outpatient behavioral health services except specific items (psychological testing, some developmental testing codes, partial hospitalization, intensive outpatient beyond initial days, H2012 continuing treatment beyond 7 days).

Psychological testing: Psychological/Neuropsychological Testing codes (96116, 96121, 96130-96133, 96136-96139, 96146) require authorization; requests must be submitted on the Psychological/Neuropsychological testing request form.

Developmental testing: Developmental Pediatric Testing: 96110 requires no authorization (excluding CHP) with reimbursement details for first three years; 96112 and 96113 require authorization; ASD and global developmental screening frequency limits described.

Partial/Intensive Outpatient: Partial Hospitalization and Intensive Outpatient: partial hospitalization utilization review follows OMH triggers; Intensive Outpatient requires no authorization for the first seven days of service; additional days require authorization.

NYS Managed Medicaid / CHP — ABA and ACT services

Authorization rules for Applied Behavior Analysis (ABA) and Assertive Community Treatment (ACT):

ABA eligibility: Applied Behavior Analysis (ABA) requires prior authorization from Behavioral Health; eligibility: under 21 with a diagnosis of autism spectrum disorder and/or Rett Syndrome, referral by specified NYS licensed providers, and providers must be enrolled in NYS Medicaid.<21

ACT update: Effective 6/1/23 providers will no longer need to obtain authorization from Fidelis Care for ACT services using code H0040; SPOA application/process must be followed for ACT placement.2023-06-01

PROS: Personalized Recovery Oriented Services (PROS): prior authorization not required effective February 1, 2022.2022-02-01

Children and Family Treatment & Support Services (CFTSS) and HCBS

Rules for CFTSS, Children's HCBS, respite, and related notification/authorization:

CFTSS utilization management requirements modified; many CFTSS covered under CHP effective 1/1/23; prior authorization was never required for these services and concurrent review is no longer required.2023-01-01

Respite limits: Children's Respite Services must be delivered in-person (no telehealth/telephone); planned and crisis respite annual limits: 14 days (1,344 15-minute units) unless supported by medical necessity.14 days

HCBS notification: Children's Home and Community Based Services available to members age 20 and younger if HCBS-eligible; some services require notification to Fidelis prior to initial appointment (effective 12/01/2021); providers must submit NYS Children's HCBS Authorization and Care Manager Notification Form and Plan of Care as required.<=20 years

Core Limited Health Related Services (CLHRS) and OLHRS

Coverage and utilization review rules for 29-I facility services:

Effective 07/01/2021 Fidelis will cover listed 29-I Health Facility services on a per diem basis for eligible Medicaid Managed Care enrollees; effective 01/01/2023 these services also available for CHP members eligible for 29-I; CLHRS per-diem coverage applies.per diem

No utilization review will be conducted for these CLHRS or OLHRS services when delivered by 29-I facilities.

Outpatient and DME Services Requiring Authorization

Diagnostic, imaging, DME and other outpatient services requiring prior authorization:

Selected diagnostic procedures (sleep studies including home sleep studies, diagnostic testing, breast/genetic testing with listed exceptions, wireless capsule and motility capsule 91110-91113, selected gastroenterology and endoscopic procedures) require authorization; some procedures require authorization in any place of service (e.g., 43290); certain codes require auth when done in POS 19/22 if office available.

DME: supplies and disposable items are covered for Medicaid (not covered for CHP); effective 4/1/23 specific DME supplies billed by physicians POS 12/14 transitioned to NYRx (FFS); MLTC supply codes listed require authorization; benefit limits per Medicaid DME Program Manual apply; DME items requiring authorization are listed in code_groups.2023-04-01

Home Health: Personal Care Services, PERS, and CDPAS require authorization and use specified HCPCS codes and billing units as outlined.

Imaging, Therapy and Delegated Prior Authorization

Delegations and authorization rules for imaging and therapy:

Delegations: Radiology prior authorization delegated to National Imaging Associates (NIA). TurningPoint delegated for many CPTs in ENT, cardiac, orthopedic/spinal procedures and associated devices (HCPCS); if delegated, send auth requests to the delegated vendor.

OB ultrasound: First four OB ultrasounds do not require authorization; five or more for a normal pregnancy require authorization; OB ultrasounds for high-risk pregnancy do not require authorization (diagnosis codes specified in source).4 vs >=5

DXA scans and therapy: DXA scans: authorization not required for specified age/diagnosis cohorts (women >65, men >70, selected ages 51-69 with listed diagnoses); other ages/diagnoses require authorization. Effective 10/01/2021, home & outpatient PT/OT/ST after initial evaluation require authorization through NIA (home therapy requires authorization for initial evaluation). CPT 92610 and 92611 do not require authorization.

Therapeutic and Other Services

Authorization and coverage rules for therapeutic procedures and other services:

Podiatry: Authorization is no longer required generally for podiatric services; however, authorization requirements apply to individual services indicated elsewhere. CPT 11719 is non-covered for Medicaid when rendered by a physician but covered and requires authorization when rendered by a facility POS 11.

Therapeutic services list: Pain management injections and related therapeutic codes (e.g., 20526, 20550-20553, 62263-62327, 64629), hyperbaric oxygen, topical oxygen, continuous glucose monitoring (95249), radiation therapy (delegated to NIA), radiofrequency ablation of uterine fibroids (58674), bronchial thermoplasty (31660,31661), vision therapy (92066,95919) are included; authorization rules vary by service and specific codes listed.

Some services explicitly non-covered for specific diagnoses (e.g., facet joint injections for low back pain, traction, intradiscal injections).

Non-covered examples: Explicit non-covered examples: therapeutic facet joint steroid injections in the lumbar/sacral regions for Low Back Pain; continuous or intermittent traction; therapeutic injections of steroids into intervertebral discs.

Pharmacy and Enteral Nutrition

Pharmacy benefit administration and enteral therapy authorization:

NYRx transition: Effective 04/01/2023, Fidelis Care Medicaid Managed Care and HARP pharmacy benefits will be administered through NYRx (Medicaid FFS Pharmacy Program); physician-administered drugs follow the Medicaid Pharmacy List of Reimbursable Drugs.2023-04-01

Enteral therapy HCPCS codes B4034-B4162 require authorization for Child Health Plus as of 04/01/2023; clinical eligibility criteria include tube-fed only, inborn metabolic disorders, children under 21 for growth/development reasons, adults with HIV with BMI/weight loss criteria, and total nutritional support when tube contraindicated.2023-04-01

Oncology PA: Oncology medications and supportive agents require prior authorization from New Century Health before dispensing or administration (applies to Medicaid Managed Care and HARP medical benefit; excludes CHP).

NCH PA required

General Authorization and Program Rules (extracted from text)

Operational rules and exclusions for prior authorization:

NCH oncology PA: Oncology medications and supportive agents require PA from New Century Health before dispensing at a pharmacy or administration in a physician office, outpatient hospital, or ambulatory setting for members of all ages; requirement applies to Medicaid Managed Care and HARP (medical benefit only) and excludes Child Health Plus.

FFS transition: Starting 04/01/2023, the Medicaid/HARP pharmacy benefit will be transitioned to NYS Fee for Service (FFS); for oncology medications through the pharmacy benefit, refer to NYRx.2023-04-01

Enteral CHP note: Certain HCPCS enteral therapy codes B4034-B4162 require authorization only for Child Health Plus as of 04/01/2023; check benefit plan for supplies not covered for CHP.2023-04-01

Codes Requiring Authorization / Special Coding Notes

Transplant and related procedures (require authorization at time of transplant evaluation)CPT|mixedCovered

32850
32851
32852
32853
32854
32855
32856
33930
33931
33945

1–10 of 48

1/5

Outpatient surgery codes requiring authorization (selected lists)CPTCovered

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

1–10 of 69

1/7

Spinal and orthopedic outpatient codes (require authorization / TurningPoint delegated)CPTCovered

20932
20933
20934
22867
22868
22869
22870
62380

Psychological/Neuropsychological Testing (authorization required)CPTCovered

96116
96121
96130
96131
96132
96133
96136
96137
96138
96139

1–10 of 11

1/2

Developmental Pediatric Testing and Screening codesCPT

96110	Developmental screening — no auth required (excluding CHP); reimbursement up to specified frequency for first 3 years
96112	Authorization required
96113	Authorization required

Partial Hospitalization / Intensive Outpatient / Related Revenue & HCPCSmixedCovered

4362
4363
Revenue code 912
Revenue code 913
H0035
S9484
Revenue code 905	Intensive Outpatient
Revenue code 906	Intensive Outpatient
CPT 90899	Intensive Outpatient (used)
S9480

1–10 of 11

1/2

Home Health / Personal Care / Consumer Directed codes (authorization required)HCPCSCovered

S5130	Level I housekeeping (note: original text S5130U1 but code group lists S5130U1 as HCPCS code)
T1019U3	Level II Mutual Case (multiple) Per 15 mins
T1019U2	Level II Shared Aide (up to two) Per 15 mins
T1019U4	Level II-Hard to Serve Per 15 mins
T1020	Live In Level II Per Diem
T1020U2	Live In Level II Mutual Case (multiple) Per Diem
T1020U5	Live In Level II Two Client Hard to Serve Per Diem
G0162	Nursing Supervision One per visit
T1019U6	Consumer Direct 1 Client Per 15 mins
T1019U7	Consumer Direct 2 Client Per 15 mins

1–10 of 13

1/2

Imaging and Therapy (delegated/authorization notes)CPT|Revenue|HCPCSCovered

77080	DXA scan
77081	DXA scan
92610	Speech therapy code — no auth required
92611	Speech therapy code — no auth required
43235	Endoscopic procedure — auth required in POS 19/22 if office available
43239
43248
45378
45380
45384

1–10 of 15

1/2

Therapeutic/Pain Management codes (authorization varied)CPT

20526
20550
20551
20552
20553
21073
27096
62263
62264
62273

1–10 of 31

1/4

Oncology medications and supportive agents (PA by New Century Health)neutralCovered

No codes listed

Enteral Therapy HCPCS (require authorization for CHP as of 4/1/2023)HCPCSCovered

B4034-B4162

Enteral formulas/disposable items — require authorization for CHP as of 4/1/2023

Podiatry special code noteCPTNot Covered

11719

Non-covered for Medicaid when rendered by a physician per Medicaid Fee Schedule; covered and requires authorization when rendered by facility POS 11

HCPCS/Codes listed in Appendix I requiring prior authorization (mapped entries)mixedCovered

C9054	C9054 (1 = lefamulin (Xenleta); 2 = J035; 3 = adalimumab (Humira); 4 = J0257; 5 = alpha 1-prot inhib (Glassia))
C9047	C9047 (1 = caplacizumab-yhdp (Cablivi); 2 = J0172; 3 = adacanumab-avwa (Aduhelm); 4 = J0270; 5 = alprostadil (Prostin VR))
C9055	C9055 (1 = brexanolone (Zulresso); 2 = J0174; 3 = lecanemab-irmb (Leqembi); 4 = J0275; 5 = alprostadil sup (Muse))
C9063	C9063 (1 = eptinezumab-jjmr (Vyepti); 2 = J0178; 3 = aflibercept (Eylea); 4 = J0401; 5 = aripiprazole ER inj (Abilify))
...	See Appendix I for full mapped entries

Operational note: Appendix I lists numerous mapped HCPCS/J/C/G (and related J-code) entries that require prior authorization. Prior authorization requests for Appendix I medication/HCPCS codes should be submitted to the Fidelis Pharmacy Team via e-fax (1-877-533-2405) except oncology medication/supportive-agent requests which must be submitted to New Century Health (NCH) via its portal or phone as specified. Providers should follow the delegated review routing noted in the policy when a code falls under the NCH oncology review program.

Prior Authorization, Notification & Billing Actions

Prior Authorization

Obtain authorization for inpatient admissions

Obtain prior authorization for all inpatient admissions (post-stabilization), inpatient rehabilitation, and at time of transplant evaluation.

Documentation Required

Notify Fidelis for OASAS/OMH admissions

Notify Fidelis within two (2) business days for OASAS and OMH inpatient admissions. OASAS: facility must notify Fidelis of the inpatient admission and the initial treatment plan within 2 business days to qualify for the 28‑day authorization/concurrent‑review exemption. OMH: facility must notify Fidelis within 2 business days of admission (call or fax) and, for members under 18, submit the OMH Two‑Day Notification and Initial Treatment Plan form to avoid concurrent review for the first 14 days.

Documentation Required

Submit OMH/LOCADTR forms

Background & Definitions

Background: The purpose of this update is to consolidate Fidelis Care authorization, notification, and utilization review rules for Medicaid Managed Care, Child Health Plus (CHP), and HealthierLife/HARP programs into a single reference that identifies service categories, code lists, delegated vendors, and exceptions. It defines authorization expectations for inpatient admissions (including rehabilitation and transplant evaluations), outpatient procedures, imaging, DME, home health, behavioral health, and pharmacy-administered items.

The update also documents program-specific exceptions: OMH-licensed inpatient mental health facilities in NYS and in-network OASAS-licensed inpatient SUD facilities have specified notification and limited review exemptions when the facility follows the required two-day (OASAS/OMH) notification processes and other conditions; delegations to external reviewers (NIA for radiology/radiation/therapy, TurningPoint for many ENT/cardiac/orthopedic-spinal CPTs, New Century Health for oncology medications) and service-specific guidance (e.g., enteral HCPCS rules and pharmacy transition to NYRx) are included.

Definitions:

OASAS: Office of Addiction Services and Supports (New York State) — OASAS-licensed in-network inpatient SUD facilities that notify Fidelis within two business days are not subject to authorization or concurrent utilization review for the first 28 days of admission.

OMH: Office of Mental Health (New York State) — OMH-licensed inpatient mental health hospitals in NYS are not subject to prior authorization; utilization review is limited to members who meet specified triggers and concurrent review may begin if length of stay exceeds 30 days (review from day 31 onward).

POS: Place of Service — used to determine authorization requirements for certain CPTs (examples: POS 11, 19, 22, 24 referenced for outpatient/ambulatory/office settings).

Delegations, Exclusions & Program Rules

Delegations and exclusions summary: Prior authorization for radiology and many radiation services has been delegated to National Imaging Associates (NIA). Many ENT, cardiac, and certain orthopedic/spinal CPTs (and associated device HCPCS) have been delegated to TurningPoint Healthcare Solutions (TurningPoint reviews apply to CPTs listed as delegated).

Oncology medications and supportive agents require prior authorization from New Century Health (NCH) before dispensing or administration for Medicaid Managed Care and HARP medical benefits (this excludes CHP). The policy provides an NCH exclusions list of items that should NOT be sent to NCH (examples include antibiotics, bone marrow/stem cell transplants and CAR-T, controlled substances, hemophilia drugs, immune globulins, inpatient drug requests, radiopharmaceuticals, surgeries/surgical procedures and others).

Pharmacy transition effective dates: the Medicaid/HARP pharmacy benefit (including physician-administered drugs listed on the Medicaid Pharmacy List) transitions to NYRx/Medicaid FFS effective 04/01/2023, and enteral HCPCS codes B4034-B4162 require authorization for CHP as of 04/01/2023.

NCH exclusions

Explicit categories excluded from New Century Health review:

NCH exclusions: Do not send the following to NCH review: Antibiotics; Bone marrow, stem cell transplants, CAR-T therapy; Cablivi; Controlled substances; Equipment requests; Genetic lab testing and laboratory services; Hemophilia drugs; Immune globulins; Inpatient drug requests; Iron preparations; Pain medications; Radiopharmaceuticals; Sickle cell diagnoses; Surgeries/surgical procedures.

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