Fidelis Care Prior Auth Policy Update

Policy overview and scope

This update consolidates COVID-19-related guidance with Fidelis Care's general prior authorization and utilization review policies and lists the delegations and vendor-managed programs used for specialty reviews. It affirms that all inpatient admissions require authorization and reiterates COVID-19 guidance referral link for pandemic-related coding/authorization rules.

Fidelis Care delegates specialty prior authorization and utilization review work to third-party vendors: the Musculoskeletal/orthopedic and radiology/radiation therapy and outpatient therapy programs are delegated to Evolent (NIA) effective 1/1/24 (Musculoskeletal Management Program); ENT and cardiac surgical prior authorization is delegated to TurningPoint Healthcare Solutions, LLC; oncology and supportive agents (previously New Century Health) are reviewed by Evolent/New Century Health (Evolent/NCH) via their portal or phone.

OMH- and OASAS-licensed in-state facility exceptions are clarified: OMH inpatient mental health and OASAS inpatient SUD in-network NYS facilities have notification and limited concurrent review exceptions when the facility notifies Fidelis within required timeframes and submits the required forms (Two-Day Notification, Appendix A/LOCADTR) — these admissions are not subject to routine authorization or concurrent review for the stated initial periods.

The document includes an extensive Appendix (Appendix I) enumerating many C-, J-, S-, Q- and other HCPCS/CPT codes that require prior authorization and maps many C-codes to J-code drug equivalents; providers must follow delegated vendor instructions and the appendix when requesting prior authorization for specialty drugs and procedures.

Scope and Key Thresholds

PayerFidelis Care

PolicyCOVID-19 UPDATE - Prior Authorization and Authorization Guidelines

Policy NumberN/A

StatusCURRENT

Primary code familyJ-codes

Scope summaryProvides updated authorization, utilization review, and coding guidance across inpatient, outpatient surgical, behavioral health, DME, imaging, therapy, pharmacy and other services; includes lists of CPT/HCPCS/J-codes requiring prior authorization or delegated review.

OMH triggers (utilization review)Any of: current AOT; AOT expired within 5 years; ≥3 psychiatric inpatient hospitalizations in prior 12 months; ≥4 psychiatric ED visits in prior 12 months; ≥3 medical inpatient hospitalizations in prior 12 months; readmission within 30 days; length of stay >30 days (concurrent review from day 31).

OB ultrasound ruleFirst 4 OB ultrasounds for a normal pregnancy can be performed without authorization; five or more require authorization. High-risk OB ultrasounds require authorization.

Rehab visit limitRehabilitation benefit: 60 visits per condition per plan year (all therapies combined).

Habilitation visit limitHabilitation benefit: 60 visits per condition per plan year (all therapies combined).

Home health maxHome care benefit maximum: 40 visits per plan year.

Hospice maxHospice coverage available up to 210 days when medically necessary.

General authorization and utilization review requirements

General Authorization Requirements

Covered when ALL of the following general authorization and utilization review rules apply:

ALL of the following

Inpatient admission and ER stabilization
- All acute inpatient facility services require prior authorization. All inpatient admissions are reviewed for medical necessity.
- Fidelis Care requires authorization of emergency room services or any emergent service required to provide stabilization of an emergent condition; authorization of post-stabilization services and inpatient admissions after emergency room services is required.
- Elective surgical procedures and medical procedures that require less than a 24-hour stay will not be approved at an inpatient level of care; when billed as outpatient within the Fidelis Care network such procedures do not require authorization.

Outpatient surgery and ambulatory services requiring prior authorization

Outpatient Surgery - Services Requiring Prior Authorization

Listed CPT/HCPCS codes require prior authorization when performed as outpatient/ambulatory surgery or per place-of-service exceptions noted.

Outpatient Surgery Codes and POS Rules

Selected Procedures - sample list: Blepharoplasty: 15820-15823; Bariatric: 43770-43775; Breast reconstruction and related codes including 11920-11971, 19300, 19316-19342, 19355, 19370-19396; Skin surgery/dermatology: codes requiring auth in any POS include 11200,11201,11719,15769-15829,17340-17999; skin codes requiring auth if POS 24 include 10040,11300-11313,11400-11471,11721; codes requiring preauthorization in freestanding ASCs (bill type 0831) include 10060,11100,11900,17000,20600,20605.
Orthopedic/Spinal/Delegated Procedures: Certain outpatient orthopedic and spinal procedures require authorization and have been delegated to Evolent (NIA). Spinal surgery examples: 20932-20934, 22867-22870, 62380. Musculoskeletal Management Program transitioned to Evolent (NIA) effective 1/1/24.

Behavioral health: authorization rules and triggers

Documentation Required

Notify Fidelis Care for OMH and OASAS inpatient admissions

OMH and OASAS inpatient facilities must notify Fidelis Care per the instructions and submit LOCADTR/Appendix A where applicable.

OMH notification phone: 1-888-FIDELIS ext 16072
LOCADTR submission fax/email for OASAS: fax 833-663-1608 or LOCADTR@fideliscare.org
OMH fax for Two-Day Notification and Initial Treatment Plan: 833-561-0094

Prior Authorization

TMS and psychological testing require prior authorization

Transcranial Magnetic Stimulation (TMS) and psychological/neuropsychological testing require prior authorization as specified; use the appropriate request forms and Behavioral Health contact methods.

TMS CPT codes: 90867, 90868, 90869

DME, imaging, therapy and pharmacy authorization rules

DME codes that do NOT require authorizationHCPCSCovered

A4239
A4287
A6590
A6540
A6591
A7021
A7049
E0130
E0135
E0168

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Billing Rule

Therapy authorization submission timing

When outpatient therapy services beyond the initial evaluation are billed, authorization must be requested through Evolent (NIA) and timing rules must be followed for submission.

Submit auth within 1 business day for outpatient settings (or 2 business days for home health) when billing services beyond the initial evaluation
Use the Evolent (NIA) portal for therapy authorization requests

Billing Rule

Submit pharmacy PA requests via e-fax

Submit pharmacy prior authorization requests to the Pharmacy Team via electronic fax; oncology/offloading to Evolent/New Century Health uses the vendor portal or NCH phone number.

Therapeutic services, interventional pain, and non-covered procedures

Prior Authorization

Interventional pain and certain therapeutic services require prior authorization

Interventional pain and specified therapeutic services require prior authorization; refer to listed CPT/HCPCS codes when requesting authorization.

Select interventional pain and spine codes: 63650, 63655, 63661-63664, 63685, 63688
Select therapeutic/phototherapy codes: 96567, 96573-96574, 96900, 96910, 96912, 96913, 96920-96922
Cardiac/pulmonary rehab codes: S9472, 93797, G0422, G0423; pulmonary rehab G0237-G0239, S9473

Chiropractic and counseling services

Billing Rule

Counseling units allowed and no longer require authorization

Counseling services billed with G0108 and G0109 are covered for up to 10 hours/20 units in a continuous 12‑month period and no longer require prior authorization.

Allowed: 10 hours / 20 units in a continuous 12-month period
Relevant codes: G0108, G0109

Services managed through external vendors

Services provided by outside vendors include dental and vision prior authorization and vendor-managed transport rules. Major dental and orthodontic services require authorization through DentaQuest at 1-800-516-9615.

Vision prior authorizations are managed by Davis Vision at 1-800-601-3383.

Non-emergency ambulance transport between facilities may be covered when transport is to a higher level of care or from an acute facility to a sub-acute setting, subject to the conditions described in the policy.

Specialty prior authorization delegations include orthopedics/musculoskeletal management and radiology/radiation therapy to Evolent (NIA) and ENT and cardiac surgical prior authorization to TurningPoint Healthcare Solutions, LLC; oncology medication and supportive agent reviews are handled via Evolent/New Century Health (formerly NCH) per the oncology program instructions.

Prior Authorization

Use delegated vendor portals/contacts for specialized reviews

Use delegated vendor portals or contacts for specialty reviews per the delegations: Evolent (NIA) for musculoskeletal, radiology, radiation therapy and outpatient therapy; TurningPoint for ENT and Cardiac; New Century Health/Evolent for oncology — follow each vendor's portal/fax/phone instructions when submitting authorizations.

Evolent (NIA): musculoskeletal, radiology, radiation therapy, outpatient PT/OT/ST (portal/fax as specified)
TurningPoint: ENT and Cardiac surgical procedures (use TurningPoint portal/contact)

Appendix I: Codes requiring prior authorization (selected examples)

Appendix I contains an extensive list of C-, J-, S-, Q- and other codes that require prior authorization and includes many mappings of C-codes to J-code drug equivalents and product names.

Only selected examples are presented in the body of this summary; the full Appendix I in the document provides the comprehensive, detailed code listings and cross-mappings that providers must consult prior to billing or administering specialty drugs or services.

Transplant and major surgical CPTs listed requiring authorizationCPTCovered

32850
32851
32852
32853
32854
32855
32856
33930
33931
33932

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Codes requiring prior authorization - J-codes (fragmented list in Part 2)HCPCSCovered

J2277	listed multiple product mappings (motixafortide; toripalimab-tpzi Loqtorzi; treprostinil Remodulin; others) - fragmented entries
J2327	risankizumab-rzaa (Skyrizi); triamcin acet PF ER mic; J3304; J7191 listed
J2329	Zilretta and other fragmented mapping
J2350	ocrelizumab (Ocrevus); triptorelin pamoate (Trelstar); J3315; J7192
J2353	octreotide depot (Sandostatin); triptorelin ER (Triptodur); J3316; J7193
J2354	tezepelumab-ekko (Tezspire); urofollitropin (Bravelle); J7194
J2356	tezepelumab-ekko (Tezspire); ustekinumab SC/IV; Profilnine
J2357	omalizumab (Xolair); J3358; ustekinumab IV; J7195
J2358	olanzapine LA (Zyprexa Relprevv); vedolizumab (Entyvio)
J7196	antithrombin (Atryn); J7504; anti-thymocyte glob equine; J9021; asparaginase rec (Rylaze)

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Codes requiring prior authorization - S- and Q- and other Sxx group codesmixedCovered

S0170	anastrozole oral; S0179; megestrol oral; S4990; nicotine patches legend
S0172	chlorambucil oral; S0182; procarbazine oral; S4991; nicotine patches non-legend
S0174	dolasetron oral; S0183; prochlorperazine oral; S4995; smoking cessation gum
S0175	flutamide oral; S0187; tamoxifen citrate oral
S0176	hydroxyurea oral; S0189; testosterone pellet (Testopel)
S0177	levamisole oral; S0194; vitamin supplement 100 caps; S9430
S0178	lomustine (Gleostine); S0197; prenatal vitamins; dispensing services
S0160	site-of-service or supply group referenced multiple times (contextual cross-maps)
S0169	site-of-service or supply group referenced repeatedly (contextual cross-maps)
S0137	billing group referenced for bevacizumab-bvzr

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Prior Authorization

Prior authorization required for listed HCPCS J- and S- codes

Prior authorization is required before billing for the HCPCS J- and S- codes listed in Appendix I; providers should obtain PA per the appendix mappings and guidance.

Obtain PA for J-codes and S/Q cross-mapped codes listed in Appendix I prior to billing
Refer to Appendix I for full code-to-product mappings and details

Key provider actions and submission requirements

Documentation Required

Voicemail/HIPAA-compliant UM notification requirements

When leaving voicemail messages related to Utilization Management, ensure the provider voicemail is HIPAA-compliant; if compliant, detailed messages may be left, otherwise a generic callback request is left and a second direct attempt is made per Department of Health policy.

Voicemail greeting must identify mailbox owner, organization, and that PHI may be left to be considered HIPAA-compliant
If not HIPAA-compliant, leave a generic message requesting a callback
A second direct attempt to reach the provider is required per Department of Health Reasonable Effort Policy

Definitions

Definitions / Key Terms

Evolent (NIA)Delegated vendor for musculoskeletal, radiology, radiation therapy, and outpatient therapy prior authorization and utilization review (effective 1/1/24 for musculoskeletal; radiology/radiation and outpatient therapy delegations noted).

TurningPoint Healthcare Solutions, LLCDelegated vendor for ENT and Cardiac surgical prior authorization; if CPT code delegated to TurningPoint, associated devices (HCPCS) are also reviewed by TurningPoint.

Prior Authorization (PA)Authorization required for inpatient admissions and for many outpatient surgical, imaging, therapy, DME and pharmacy services as specified; follow delegated vendor instructions and use specified fax numbers/portals.

Utilization Management (UM)UM includes prior authorization and concurrent review; voicemail/contact communications require HIPAA‑compliant provider voicemail greetings and a second direct attempt per DOH Reasonable Effort Policy.

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98941
98942
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OpenPayer

COVID-19 UPDATE

Policy overview and scope

General authorization and utilization review requirements

Outpatient surgery and ambulatory services requiring prior authorization

Behavioral health: authorization rules and triggers

DME, imaging, therapy and pharmacy authorization rules

Therapeutic services, interventional pain, and non-covered procedures

Chiropractic and counseling services

Services managed through external vendors

Appendix I: Codes requiring prior authorization (selected examples)

Key provider actions and submission requirements

Definitions

Revision history and effective dates

15820	Blepharoplasty
15821
15822
15823
43770	Bariatric
43771
43772
19300	Breast reconstruction / other breast procedures
19316
19318	Reduction mammoplasty