ModifiedFidelis CarePolicy N/A

Prior Authorization and Coverage Criteria — Behavioral Health and Ancillary Services

Updates and reminders about prior authorization, delegation, and authorization exemptions across inpatient, outpatient, behavioral health, substance use, and ancillary services for Fidelis Care providers. Affects in-network and out-of-network providers in the jurisdictions referenced (primarily New York).

Policy Summary

PayerFidelis Care

PolicyPrior Authorization and Coverage Criteria — Behavioral Health and Ancillary Services

Policy CodePolicy N/A

Change TypeDelegation and operational clarifications (authorizations delegated to NIAtiming requirements)

Effective Date9/20/2021 (delegations effective for dates of service on/after 10/1/2021)

Next Review DateN/A

Key ActionSubmit prior authorization requests for outpatient home PT/OT/ST and delegated radiology services to NIA within the required timelines.

SourceLink

POLICY UPDATE CHANGES

Effective 9/20/2021 for dates of service on or after 10/1/2021, outpatient home therapy (PT/OT/ST) services require authorization through National Imaging Associates (NIA).

Effective 9/20/2021 for dates of service on or after 10/1/2021, authorization for radiology services has been delegated to NIA.

Office or facility-based initial PT/OT/ST evaluations do not require prior authorization; other billed procedure codes (even on same date) do require authorization and have specific submission timing requirements.

Authorization delegation for radiation therapy services to NIA effective 9/20/2021 for dates of service on or after 10/1/2021.

Require authInpatient admissions

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Coverage and Authorization Criteria

Inpatient authorization and licensed behavioral health exemptions

Covered when authorization or notification rules are followed; exceptions noted for emergency services and certain licensed in-state facilities

General inpatient admissions: All inpatient admissions require authorization; emergency room services and emergent stabilization do not require prior authorization but post-stabilization services and inpatient admissions after ER completion require authorization and medical necessity review.

See policy for exceptions and submission guidance.

OASAS-licensed Inpatient SUD exemption: In-network, in-state OASAS-licensed inpatient SUD services are not subject to authorization review and are not subject to concurrent utilization review for the first 28 days if the facility notifies Fidelis Care of the inpatient admission and initial treatment plan within two business days and submits the OASAS Appendix A Notification Form and LOCADTR tool; facilities must perform daily clinical review and periodically consult with Fidelis Care; services may be subject to utilization review after 28 days or retrospectively.28 days

Notification may be faxed or emailed to the addresses specified by Fidelis Care.

OMH-licensed pediatric inpatient MH exemption: In-network OMH-licensed hospitals providing inpatient mental health treatment for members under age 18 are not subject to authorization review and Fidelis Care will not conduct concurrent utilization review during the first 14 days if the facility notifies Fidelis Care of admission and the initial treatment plan within two business days using the OMH Two-Day Notification and Initial Treatment Plan form, performs daily clinical review, and participates in periodic consultation with Fidelis Care; services may be reviewed retrospectively using plan clinical review criteria approved by OMH.14 days

Notification must be submitted by fax or email to the Fidelis Care contacts specified in the policy.

Therapy (PT/OT/ST) Coverage and Authorization

Coverage and authorization rules for therapy services

Therapy authorization rules: Outpatient home therapy (PT/OT/ST) services performed by a therapy provider require authorization through National Imaging Associates (NIA) for dates of service on or after 10/1/2021; office or facility-based initial evaluations do not require prior authorization, but all other billed procedure codes (even on the same date) require authorization; the initial evaluation for home therapy requires authorization.

Authorization requests to NIA must be submitted within 1 business day for outpatient or 2 business days for home health; prior auth process differs for inpatient SNF settings as specified.

Imaging and Radiation Therapy

Imaging and radiation therapy authorization

Imaging authorization delegation: Authorization for many radiology and radiation therapy services has been delegated to NIA effective 10/1/2021; a full external CPT list identifies which imaging codes require authorization. The first four OB ultrasounds may be performed without authorization; five or more require authorization. Select TBS scan codes are identified separately.

Cardiac ultrasounds may be delegated to TurningPoint as noted elsewhere.

DSMT and Medical Nutrition Therapy

Education and nutrition services coverage

DSMT and MNT coverage: Diabetes self-management training (DSMT) is covered up to 10 hours (20 units) in a continuous 12-month period when provided by certified providers and billed with G0108 (individual) or G0109 (group); DSMT no longer requires authorization. Medical Nutrition Therapy (MNT) for diabetes is covered without authorization when billed with CPT 97802 or 97803 or HCPCS G0270 or G0271.10 hours/20 units

Services must be provided by certified or licensed providers as required by the program.

Pharmacy Prior Authorization

Pharmacy and specialty drug coverage controls

Oncology and specialty drug prior authorization: Oncology medications and supportive agents require prior authorization from New Century Health for participating providers before dispensing or administration. Certain injectable and specialty HCPCS codes require authorization for both participating and non-participating providers and PA requests must be submitted to the Pharmacy Team via e-fax (1-877-882-5892).

Medications must be prescribed for medically accepted indications supported by Medicare-accepted compendia; oncology NCH portal and contact information are provided in the policy.

All inpatient facility admissions require prior authorization. However, emergency room services and any emergent services required to provide stabilization of an emergent condition do not require prior authorization. After emergency department stabilization is complete, post-stabilization services and any resulting inpatient admissions are subject to authorization and medical necessity review.

The policy identifies specific services that are not covered or are excluded from coverage. Topical oxygen is explicitly listed as not a covered service. In addition, certain procedures (for example, prolotherapy and other items noted under therapeutic services for low back pain) are not covered for members with a low back pain diagnosis. The policy also notes situational authorization requirements for some procedures when rendered in specific settings (see the ambulatory surgery center guidance).

For Medicare-related ophthalmic uses, authorization is not required for ophthalmic indications. This exemption is stated in the Medicare section of the policy and applies to ophthalmic indications noted there.

The policy lists examples of services that are non-covered in specific coding/diagnosis circumstances. For example, CPT 20610 (joint injection of hyaluronic acid) is non-covered when billed with specified osteoarthritis diagnosis codes (the policy cites osteoarthritis diagnosis examples). Providers should check claim-level diagnosis when submitting CPT 20610 to determine coverage.

Topical oxygen is explicitly listed as not a covered service (not medically necessary) in the therapeutic services section of the policy. Providers should not expect coverage for topical oxygen treatments.

Code Lists and Coding Notes

Transplant CPT codes requiring authorizationCPTCovered

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

Psychological/Neuropsychological testing — require authorizationCPTCovered

96116
96121
96130
96131
96132
96133
96136
96137
96138
96139

1–10 of 11

1/2

Developmental pediatric testing / relatedCPT

96112
96113
96110	non-covered service
90870

Intensive Outpatient Treatment codesmixedCovered

H0035	Intensive Outpatient Treatment HCPCS
90899
S9480
H2013

DME codes not requiring authorization (partial list)HCPCS

E0274
E0305
E0310
E0424
E0439

TBS scansCPT

77089	TBS scan
77090	TBS scan
77091	TBS scan
77092	TBS scan

Therapy codes not requiring authorization (selected)CPTCovered

92610	Evaluation of oral and pharyngeal swallowing function
92611	Flexible fiberoptic endoscopic evaluation of swallowing

DSMT codesHCPCSCovered

G0108	Diabetes outpatient self-management training services, individual
G0109	Diabetes outpatient self-management training services, group

Medical Nutrition Therapy codesCPT|HCPCSCovered

97802	MNT initial assessment and intervention
97803	MNT re-assessment and intervention
G0270	MNT, individual; reassessment
G0271	MNT group

Pharmacy injectable/specialty codes requiring PA (selected list)HCPCSCovered

C9047	caplacizumab-yhdp (Cablivi)
C9048	dexameth ophthalmic insert
C9049	tagraxofusp (Elzonris)
C9050	emapalumab (Gamifant)
C9051	omadacycline (Nuzyra)
C9052	ravulizumab (Ultomiris)
C9063	eptinezumab-jjmr (Vyepti)
C9142	bevacizumab-maly (Alymsys)
C9257	bevacizumab (Avastin)
C9399	unclassified drugs/biologics

1–10 of 13

1/2

Other therapeutic procedure codes (selected)CPT

58674	Radiofrequency ablation of uterine fibroids
95249	Ambulatory continuous glucose monitoring
31660	Bronchial thermoplasty
31661	Bronchial thermoplasty
61736	Other related code
61737	Other related code

Pharmacy HCPCS mappings (sample)HCPCS

J0791	listed in mappings with multiple biologics (e.g., corticotropin, infliximab, ustekinumab) as shown in chunk 36
J3304	mentioned in chunk 36
J1632	mentioned in chunk 36
J1740	mentioned in chunk 36
J3316	mentioned in chunk 36
J3355	mentioned in chunk 36
J3357	mentioned in chunk 36

Pharmacy HCPCS mappings continuedHCPCS

J3358	mapped to ustekinumab (Stelara) and other items (chunk 37)
J3396	mapped to verteporfin (Visudyne) (chunk 37)
J3397	mapped to vestronidase alfa-vjbk (chunk 37)
J3398	mapped to voretigene neparvovec-rzyl (Luxturna) (chunk 37)
J3590	unclassified drug/biological mapping including laetrile/amygdalin (chunk 38)
J3591	ESRD Prothrombin complex concentrate (human) and mappings (chunk 38)
J7169	coagulation factor Xa recombinant, inactivated-zhzo (Andexxa) (chunk 38)
J7175	(Andexxa) emicizumab-kxwh mapping (chunk 38)
J7181	factor X human (Coagadex) vWF recombinant (Vonvendi) (chunk 39)
J7182	recombinant factor VIII entries (NovoEight, Tretten) (chunk 39)

1–10 of 14

1/2

Hemostasis/Factor product HCPCS mappingsHCPCS

J7204	factor viii recombinant glycopegylated and related mappings (chunk 40)
J7205	glycopegylated-exei (Esperoct) and factor VIII Fc fusion protein recombinant (Eloctate) mappings (chunk 40-41)
J7208	recombinant (Eloctate) factor VIII recomb pegylated (Adynovate) (chunk 41)
J7209	factor VIII recomb pegyl (Jivi) and others (chunk 41)
J7210	factor VIII recomb (Nuwiq) Afstyla Kovaltry mappings (chunk 41)
J7211	factor VIII recomb group and immunoglobulin mappings (chunk 42)
J7212	factor VIIA recombinant and related mappings (chunk 42-43)

Medicare chemotherapy/biologic HCPCS mappingsHCPCS

J9176	elotuzumab (Empliciti) and mapping entries (chunk 44)
J9177	Enfortumab vedotin-ejfv (Padcev) and related (chunk 44)
J9203	gemtuzumab (Mylotarg) mapping (chunk 44)
J9204	mogamulizumab-kpkc (Poteligeo) mapping (chunk 44)
J9210	interferon gamma-lb (Actimmune) mapping (chunk 44)
J9223	lurbinectedin (Zepzelca) mapping (chunk 44)
J9225	histrelin implant (Vantas) and naxitamab-gqgk (Danyelza) (chunk 45)
J9227	isatuximab-irfc (Sarclisa) mapping (chunk 45)
J9229	inotuzumab (Besponsa) mapping (chunk 45)
J9247	melphalan flufenamide (Pepaxto) mapping (chunk 45)

1–10 of 20

1/2

Linked Q-codesHCPCS

Q2042	associated miscellaneous code referenced with J9299 (chunk 46-48)
Q4081	associated code referenced with J9316 (chunk 48)

inv-27: OB ultrasound count without authorization — first four OB ultrasounds do not require authorization

PolicyThe first 4 OB ultrasounds can be performed without an authorization.

Operational detailApplies to outpatient imaging studies; high-risk pregnancy ultrasounds noted in the policy text are included in authorization guidance.

Related noteA full list of ultrasound and imaging CPT codes requiring authorization is maintained externally (see policy for link).

Provider Responsibilities and Submission Instructions

Prior Authorization

Out‑of‑Network Authorization Required

Authorization is required for certain Medicare Advantage out-of-network services. For the Medicare Advantage Flex Plan (003) and Medicare Advantage without RX (001), out-of-network services are covered only when an authorization has been obtained; additional copayments and deductibles may apply.

Medicare Advantage Flex Plan (003)
Medicare Advantage without RX (001)

Denial Risk

Failure to Obtain Authorization Carries Denial Risk

Failure to obtain prior authorization for inpatient admissions may result in claim denial or financial liability to the provider. All inpatient facility services (medical, substance use, and behavioral health) require authorization unless specifically exempted (see OMH/OASAS exceptions).

Level-of-Care Criteria

Treatment Modality Criteria and Limits

Intensive Outpatient (IOP)

IOP/Partial codes: Intensive Outpatient Treatment revenue and HCPCS codes include revenue codes 912, 913, 944, 945 and HCPCS H0035, H2013; applicable CPT/HCPCS codes include 90899 and S9480 as noted.

DSMT / MNT

DSMT / MNT: Members are allowed 10 hours/20 units of DSMT in a continuous 12-month period when services are provided by certified providers and billed with G0108/G0109; MNT visits for diabetes billed with CPT 97802/97803 or G0270/G0271 are covered without authorization.10 hours/20 units

DSMT no longer requires authorization.

Visit Limits and Quantity Rules

inv-58: Diabetes Self-Management Training (G0108/G0109) — 10 hours (20 units) allowed in continuous 12-month period

Allowed units/hoursMembers are allowed 10 hours (20 units) of DSMT in a continuous 12-month period.

Billing codesServices are covered when billed with G0108 (individual) and G0109 (group).

Provider requirementServices must be provided by certified providers; DSMT no longer requires prior authorization.

Defined Terms

inv-50: OMH-licensed inpatient MH — definition reference

DefinitionOMH-licensed inpatient MH: Inpatient mental health treatment for members under age 18 provided by OMH-licensed hospitals in New York State that participate in Fidelis Care's provider network.

Authorization exemptionSuch in-network OMH pediatric inpatient admissions are not subject to authorization review for the first 14 days if the facility notifies Fidelis Care within two business days and meets documentation and review requirements.

Notification requirementFacility must submit the OMH Two-Day Notification and Initial Treatment Plan form to Fidelis Care by fax (718-896-1784) or email (Mental_Health_Admission@fideliscare.org).

inv-51: OASAS-licensed inpatient SUD — definition reference

DefinitionOASAS-licensed inpatient SUD: Inpatient detoxification, inpatient rehabilitation and inpatient residential treatment services provided by facilities in New York State that are licensed, certified or otherwise authorized by OASAS and participating in Fidelis Care's provider network.

Additional Coding Notes

Documentation Required

Follow OMH/OASAS notification and clinical review processes to maintain exemption

Facilities must notify Fidelis Care per the OMH and OASAS notification procedures described in the policy to qualify for the temporary authorization exemptions and must perform required daily clinical review and periodic consultation with Fidelis Care.

OMH pediatric MH exemption: daily clinical review and periodic consultation with Fidelis Care; facility submits Two‑Day Notification and Initial Treatment Plan.
OASAS SUD exemption: daily clinical review, LOCADTR tool use, and submission of Appendix A and LOCADTR within two business days.

inv-28: Home therapy authorization delegation date (callout duplicate for emphasis)

Effective dateAuthorization delegated to National Imaging Associates (NIA) for outpatient/home PT, OT, and ST for dates of service on or after 10/1/2021.

ScopeAll therapy services performed by a therapy provider after the initial evaluation require authorization through NIA; CPT codes 92610 and 92611 do not require authorization.

Background and Scope

This policy window provides operational details about prior authorization requirements and delegated review processes. Key operational points: all inpatient facility admissions require authorization (with the emergency stabilization exemption), and failure to obtain required authorization for inpatient admissions may result in denial of payment. Effective 9/20/2021 for dates of service on or after 10/1/2021, certain authorizations (including outpatient/home therapy and many radiology/radiation therapy services) have been delegated to National Imaging Associates (NIA); outpatient home therapy authorization requests and other imaging requests must be submitted per the delegated vendor’s process. Oncology and supportive oncology agents for participating providers are routed to an external vendor (New Century Health) for prior authorization. Providers should follow the specified vendor submission channels and timing requirements to avoid authorization or claim denials.

Policy Revision History

2021-09-20delegationLatest

Authorization for outpatient home therapy (PT/OT/ST) and many radiology/radiation therapy services was delegated to National Imaging Associates (NIA) effective for dates of service on or after 2021-10-01.

2021-09-20policy_clarification

Clarified timing and scope: outpatient home therapy services performed after the initial evaluation require authorization through NIA, and initial evaluations performed in-office/facility do not require prior authorization; CPT codes 92610 and 92611 are exempt from authorization.

2021-09-20

Policy Summary

PayerFidelis Care

PolicyPrior Authorization and Coverage Criteria — Behavioral Health and Ancillary Services

Policy CodePolicy N/A

Change TypeDelegation and operational clarifications (authorizations delegated to NIAtiming requirements)

Effective Date9/20/2021 (delegations effective for dates of service on/after 10/1/2021)

Next Review DateN/A

Key ActionSubmit prior authorization requests for outpatient home PT/OT/ST and delegated radiology services to NIA within the required timelines.

SourceLink

On This Page

inv-28: Home therapy authorization delegation date — NIA delegation for outpatient/home PT/OT/ST

Effective dateAuthorization for outpatient/home PT, OT, and ST services delegated to National Imaging Associates (NIA) for dates of service on or after 10/1/2021.

ScopeAll services performed by a therapy provider after the initial evaluation require authorization through NIA; office/facility-based initial evaluations do not require authorization (except initial evaluation for home therapy requires authorization).

Submission timingAuthorization requests must be submitted to NIA within required timeframes as specified in the policy (see therapy documentation and timely submission sections).

Billing Rule

Timely Authorization Submission Required

Timely submission of authorization requests is required for therapy and other services: for outpatient therapy services (non‑initial evaluation codes) an authorization request must be submitted to the delegated vendor (NIA) within 1 business day; for home health therapy submit within 2 business days. For inpatient therapy prior authorizations, send requests to the designated Fidelis contact number.

Outpatient non‑initial therapy codes: authorization to NIA within 1 business day
Home health therapy: authorization to NIA within 2 business days
Inpatient therapy (POS 31 & 32): prior authorization requests to 716-803-8307

Note

OMH‑Licensed Inpatient MH — Notification and Temporary Authorization Exception for Members <18

OMH‑licensed inpatient mental health treatment for members under age 18 provided by participating New York State OMH hospitals is not subject to authorization review for the first 14 days of the admission if the facility: (1) notifies Fidelis Care of the admission and initial treatment plan within two business days using the OMH Two‑Day Notification and Initial Treatment Plan form (fax 718-896-1784 or email Mental_Health_Admission@fideliscare.org); (2) performs daily clinical review; and (3) participates in periodic consultation with Fidelis Care. Inpatient MH services for members age 18 and older and out‑of‑network providers continue to require prior authorization and concurrent review throughout the admission.

Notification fax: 718-896-1784
Email: Mental_Health_Admission@fideliscare.org
No concurrent review first 14 days if conditions met

Documentation Required

Therapy Service Documentation Required

Document whether each therapy visit is an initial evaluation or another billed procedure code. Initial evaluations in office/facility settings do not require prior authorization; however, any other billed procedure codes, even if on the same date as the initial evaluation, require authorization. When submitting authorizations/claims, ensure records clearly indicate which code represents the initial evaluation.

Office/facility initial evaluations: no prior authorization required
Other therapy codes on same date: authorization required
Ensure documentation states initial evaluation vs other service

Prior Authorization

Pharmacy Authorization and Documentation Requirements

When requesting prior authorization for pharmacy‑covered drugs (including injectable, oncology, and vendor‑managed agents), include the HCPCS/J‑code (when applicable) and the clinical indication supported by Medicare‑approved compendia or other accepted references. Oncology medications and supportive agents require prior authorization via New Century Health for participating providers (mynewcenturyhealth.com or 1-888-999-7713, option 1). Submit non‑oncology injectable authorization requests to the Fidelis Pharmacy Team via e‑fax: 1-877-882-5892.

Include HCPCS/J‑code and clinical indication per DRUGDEX, AHFS, NCCN, etc.
Oncology meds/supportive agents: prior authorization via New Century Health (mynewcenturyhealth.com or 1-888-999-7713)
Non‑oncology injectable codes: e‑fax to Pharmacy Team 1-877-882-5892