ModifiedFidelis CarePolicy N/A

Prior Authorization and Utilization Review — Behavioral Health, SUD, DME, Imaging, and Related Services

Governs Fidelis Care prior authorization and utilization review requirements for inpatient, outpatient, behavioral health, substance use, DME, diagnostic testing, and certain delegated services in New York State; affects network providers and facilities providing these services.

Policy Summary

PayerFidelis Care

PolicyPrior Authorization and Utilization Review — Behavioral Health, SUD, DME, Imaging, and Related Services

Policy CodePolicy N/A

Change TypeMaterial updates and delegations to vendor partners

Effective DateN/A

Next Review DateN/A

Key ActionNotify Fidelis within two business days and submit LOCADTR/OMH Two-Day forms for eligible inpatient behavioral health and SUD admissions.

SourceLink

POLICY UPDATE CHANGES

OASAS-licensed in-state inpatient SUD services and OMH-licensed inpatient mental health for members under 18 are not subject to prior authorization for specified initial periods.

Certain behavioral health outpatient authorizations have been removed except for specific services (testing, ECT, PHP, IOP).

Delegation of prior authorization to TurningPoint for selected ENT, cardiac, orthopedic and spinal procedures effective for specific dates in 2021.

Outpatient home therapy (PT/OT/ST) requires prior authorization through NIA for dates of service on/after 10/1/2021.

Effective 9/20/2021 (for services on or after 10/1/2021) prior authorization for outpatient home therapy (PT/OT/ST) and many radiology and radiation therapy services has been delegated to National Imaging Associates, Inc. (NIA).

Outpatient therapy (PT/OT/ST) after the initial evaluation requires prior authorization through NIA; initial evaluations do not require authorization but other billed codes on same date do.

A specific list of orthotic (DME) HCPCS codes do not require authorization; all other DME/orthotic codes do require authorization.

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28 daysinpatient SUD concurrent review free period

14 daysOMH inpatient MH free period (<18)

10/4/2021TurningPoint delegation effective

10/1/2021NIA therapy delegation effective

8MNT visits/year without auth

10 hrs/20uDSMT allowance

Coverage Criteria and Exemptions

Inpatient SUD (OASAS-licensed) Initial Coverage

Inpatient Substance Use Disorder (OASAS-licensed, in-state, in-network) — coverage without prior authorization when ALL criteria met

ALL of the following

Facility is licensed, certified or otherwise authorized by the New York State Office of Addiction Services and Supports (OASAS).
Facility is participating in Fidelis Care's provider network (in-network).
Service is an inpatient SUD level of care (detoxification, inpatient rehabilitation, or inpatient residential treatment).
The facility notifies Fidelis Care of the inpatient admission and the initial treatment plan within two (2) business days of admission using the OASAS Appendix A Notification Form and the OASAS LOCADTR Medical Necessity Tool (fax to 646-829-1421 or email LOCADTR@fideliscare.org).
Notification requirement enables exemption from prior authorization and concurrent review during the initial period.
The facility performs daily clinical review of the patient during the admission (this does not require completion of the LOCADTR concurrent review module every day).
The facility participates in periodic consultation with Fidelis Care starting on or just prior to day fourteen (14) of treatment to ensure appropriate use of the LOCADTR clinical review tool and ongoing medical necessity determination.
Prior authorization and concurrent utilization review are not required for the first twenty-eight (28) days of the inpatient admission, provided the above conditions are met.
Services may be subject to utilization review after day twenty-eight (28) from admission or upon discharge using the LOCADTR clinical review tool; all services remain subject to retrospective review for medical necessity.
Prior authorization is still required for inpatient SUD services provided by facilities that are out-of-state, not OASAS-licensed/certified/authorized, or out-of-network; such facilities remain subject to concurrent review throughout the admission.

OMH-Licensed Inpatient Mental Health (Members <18) Initial Coverage

OMH-licensed inpatient mental health for members under 18 — coverage without prior authorization when ALL criteria met

ALL of the following

Facility is an OMH-licensed hospital in New York State.
Facility is participating in Fidelis Care's provider network (in-network).
Member is under age 18 at the time of admission.
The facility notifies Fidelis Care of both the admission and the initial treatment plan within two (2) business days of admission by completing the OMH 'Two-Day Notification and Initial Treatment Plan' form and submitting it to Fidelis Care by fax (718-896-1784) or email (Mental_Health_Admission@fideliscare.org).
Notification requirement enables exemption from prior authorization and concurrent review during the initial period.

Outpatient Behavioral Health — Authorization Exceptions and Exemptions

Outpatient behavioral health authorization exemptions and exceptions — lists services exempt and services that still require authorization

ALL of the following

Authorization requirement has been removed from all outpatient behavioral health services except the specific categories and codes listed below; providers should verify whether a requested service falls into an excluded category before assuming no authorization is required.
Services that continue to require authorization
- Psychological/Neuropsychological Testing: CPT codes 96116, 96121, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146. All requests must be submitted on the Psychological/Neuropsychological testing request form.
- Developmental Pediatric Testing: CPT codes 96112, 96113 require authorization. Note: CPT 96110 (developmental testing) is a non-covered service.

Codes and Code Groups

Provider Responsibilities, Submission and Authorization

Prior Authorization

Authorize all inpatient admissions (emergency stabilization excepted)

All inpatient admissions require prior authorization. Emergency department services or emergent stabilization do not require prior authorization, but post‑stabilization inpatient admissions do and all facility admissions are reviewed for medical necessity.

Authorization is required for all inpatient facility services (medical, substance abuse, behavioral health).
Post‑stabilization inpatient admissions after ER care require authorization.

Prior Authorization

Submit auth using the Psychological/Neuropsychological testing request form

Psychological and neuropsychological testing listed (e.g., CPT 96116, 96121, 96130–96133, 96136–96139, 96146) require prior authorization. Providers must submit requests using the Psychological/Neuropsychological testing request form.

Submit all psychological/neuropsychological testing authorization requests on the designated testing request form.
Codes requiring authorization are enumerated in the policy (see CPT list).

Policy Background and Scope

This policy establishes which services require prior authorization and defines limited exceptions. All inpatient admissions generally require authorization, but two in-state exceptions are described: (1) OASAS-licensed inpatient SUD services provided in New York State by network facilities are not subject to prior authorization review and are exempt from concurrent utilization review for the first 28 days of admission provided the facility notifies Fidelis Care within 2 business days and performs required daily clinical review and periodic consultation; (2) OMH-licensed inpatient mental health services for members under age 18 provided in New York State by network facilities are not subject to prior authorization and are exempt from concurrent utilization review for the first 14 days of admission when the facility submits the OMH Two-Day Notification and Initial Treatment Plan within 2 business days, performs daily clinical review, and participates in periodic consultation with Fidelis Care. Emergency department services for stabilization do not require authorization, but subsequent inpatient admissions following stabilization do require authorization.

Key Terms and Definitions

inv-66: LOCADTR Medical Necessity Tool definition / reference

ToolLOCADTR Medical Necessity Tool

UseUsed by OASAS-licensed inpatient SUD facilities for notification and clinical review; fax/email to LOCADTR@fideliscare.org or 646-829-1421

RoleDetermines medical necessity and informs discharge planning; used for retrospective or concurrent review after specified periods

inv-67: Two-Day Notification — OMH form and submission requirement definition

FormOMH 'Two-Day Notification and Initial Treatment Plan' form

RequirementFacility must submit the form within two business days of admission to Fidelis Care

Level of Care Criteria

Required Modalities Requiring Authorization

ECT — criteria group for authorization

Outpatient ECT authorization: Outpatient electroconvulsive therapy (CPT 90870) requires prior authorization.

[[chunk 14]]

Partial Hospitalization (MH) — criteria group for authorization

Partial Hospitalization authorization: Partial Hospitalization (Mental Health) requires prior authorization (revenue codes 912, 913, 944, 945 and HCPCS H0035).

[[chunk 14]]

Intensive Outpatient Program (IOP) — criteria group for authorization

Intensive Outpatient Program (IOP) authorization:

Visit Limits and Quantity Limits

inv-76: Medical Nutrition Therapy (MNT) — 8 visits per year covered without authorization

ServiceMedical Nutrition Therapy (MNT)

Limit8 visits per year covered without authorization

Billing codes97802, 97803, G0270, G0271

inv-77: Diabetes Self-Management Training (DSMT) — 10 hours / 20 units in a continuous 12-month period without authorization

ServiceDiabetes Self-Management Training (DSMT)

Limit10 hours (20 units) in a continuous 12-month period without authorization

Billing codes

Policy Summary

PayerFidelis Care

PolicyPrior Authorization and Utilization Review — Behavioral Health, SUD, DME, Imaging, and Related Services

Policy CodePolicy N/A

Change TypeMaterial updates and delegations to vendor partners

Effective DateN/A

Next Review DateN/A

Key ActionNotify Fidelis within two business days and submit LOCADTR/OMH Two-Day forms for eligible inpatient behavioral health and SUD admissions.

SourceLink

On This Page

The facility performs daily clinical review of the patient during the admission.

The facility participates in periodic consultation with Fidelis Care to ensure use of evidence-based, peer-reviewed clinical review criteria approved by OMH and appropriate to the patient's age to ensure medical necessity.

Prior authorization and concurrent utilization review will not be conducted by Fidelis Care during the first fourteen (14) days of the inpatient admission when the above conditions are met.

All inpatient mental health services may be reviewed retrospectively using the plan's clinical review criteria approved by OMH.

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 prior authorization for inpatient mental health treatment for members of all ages and are subject to concurrent review throughout the admission.

Outpatient Electroconvulsive Therapy (ECT): CPT code 90870 requires authorization.

Partial Hospitalization (Mental Health): Revenue codes 912, 913, 944, 945 and HCPCS code H0035 require authorization.

Intensive Outpatient Treatment: Bill type 131, Revenue code 905 or 912, CPT code 90899, S9480, and HCPCS code H2013 require authorization.

Operational note: Although outpatient behavioral health authorization has been broadly removed, providers must still follow authorization processes for the listed services and codes and submit required request forms where specified.

Prior Authorization

Authorize developmental pediatric testing; 96110 non‑covered

Developmental pediatric testing CPTs 96112 and 96113 require prior authorization. CPT 96110 is explicitly noted as a non‑covered service and should not be billed for coverage.

Obtain prior authorization for CPT 96112 and 96113 before providing services.
Do not bill CPT 96110 — it is a non‑covered service per policy.

Prior Authorization

Prior authorization required for outpatient ECT (90870)

Outpatient electroconvulsive therapy (ECT) billed with CPT 90870 requires prior authorization before services are rendered.

Obtain prior authorization for outpatient ECT (90870).

Prior Authorization

Authorize Partial Hospitalization (Revenue 912/913/944/945; H0035)

Partial hospitalization for mental health (identified by revenue codes 912, 913, 944, 945 or HCPCS H0035) requires prior authorization.

Request authorization for partial hospitalization using the applicable revenue/HCPCS codes listed in the policy.

Prior Authorization

Authorize Intensive Outpatient Treatment (IOP)

Intensive Outpatient Program (IOP) services identified by bill type 131, revenue 905 or 912, CPT 90899, S9480, or HCPCS H2013 require prior authorization.

Obtain prior authorization for IOP using the specified billing codes prior to service delivery.

Prior Authorization

Home therapy (PT/OT/ST) prior authorization via NIA for services on/after 10/1/2021

Outpatient home therapy services (PT, OT, ST) require prior authorization through National Imaging Associates, Inc. (NIA) for dates of service on or after 10/01/2021.

All services performed by a therapy provider in the home setting require prior authorization via NIA for services dated on/after 10/01/2021.

Note

NIA delegation effective 9/20/2021 for home therapy prior authorization

Delegation to NIA for outpatient home therapy prior authorization became effective 9/20/2021 for services with dates of service on or after 10/01/2021; providers must use NIA for authorization requests for those services.

Effective 9/20/2021 (for services on/after 10/01/2021), prior authorization for outpatient home therapy is delegated to NIA.
Initial evaluations in office/facility do not require authorization, but other billed therapy codes do (see submission timelines).

Note

Radiology and radiation therapy prior authorization — delegation and effective dates

Prior authorization for many radiology and radiation therapy services was delegated to NIA effective 9/20/2021 for dates of service on or after 10/01/2021; a full list of CPT codes requiring authorization is maintained by the delegated vendor.

Radiology and radiation therapy prior authorization delegated to NIA effective 9/20/2021 (services on/after 10/01/2021).
A full list of CPTs requiring prior authorization is available from NIA per the policy.

Prior Authorization

Non‑therapy providers must request post‑evaluation authorizations through Fidelis Care

Non‑therapy providers (MD, DO, DPM, etc.) must request prior authorization for all services after the initial evaluation directly through Fidelis Care rather than through the NIA therapy pathway.

Submit authorization requests for post‑evaluation services through Fidelis Care when you are an MD/DO/DPM (non‑therapy provider).
This applies when billed codes are other than the designated initial evaluation CPTs.

Prior Authorization

Authorize enteral therapy (HCPCS B4034–B4162) — applies to Part B

Enteral therapy items and formulas billed with HCPCS B4034–B4162 require prior authorization; the benefit applies to Medicare Part B services.

Obtain prior authorization for enteral therapy HCPCS codes B4034–B4162 before providing Part B enteral supplies/formulas.

Prior Authorization

Prior authorization required for Unlisted/Temporary codes (e.g., C‑codes)

All services billed with 'Unlisted' or 'Temporary' codes (such as C‑codes) require prior authorization; providers must obtain authorization before billing these codes.

Obtain prior authorization for any service billed with an Unlisted or Temporary code (e.g., C‑codes).
Lack of authorization may lead to denial or additional member financial responsibility.

Step Therapy

Pharmacy formulary, prior authorization, and step therapy information — website and submission fax

Formulary details, prior authorization criteria, and step therapy criteria for pharmacy are available on the Fidelis website and are updated monthly; prior authorization requests to the Pharmacy Team should be submitted electronically via e‑fax to 1‑877‑882‑5892.

Check https://www.fideliscare.org/Member/Medicare-Information/Prescription-Drug-Information for monthly formulary and step therapy updates.
Submit pharmacy prior authorization requests via e‑fax to 1‑877‑882‑5892.

Documentation Required

Fax Appendix A and LOCADTR within 2 business days for OASAS inpatient SUD admissions

For in‑state OASAS‑licensed inpatient SUD facilities participating in Fidelis Care's network, the facility must fax or email the OASAS Appendix A Notification Form and the LOCADTR Medical Necessity Tool to Fidelis Care within two business days of admission to avoid prior authorization requirements and enable the 28‑day concurrent‑review exemption.

Fax or email Appendix A and LOCADTR to 646‑829‑1421 or LOCADTR@fideliscare.org within two business days of admission.
Facility must perform daily clinical review and periodically consult with Fidelis Care starting on or just prior to day 14.

Documentation Required

Submit OMH Two‑Day Notification and Initial Treatment Plan within 2 business days

OMH‑licensed inpatient mental health facilities treating members under age 18 must submit the OMH 'Two‑Day Notification and Initial Treatment Plan' form to Fidelis Care within two business days of admission (fax 718‑896‑1784 or email Mental_Health_Admission@fideliscare.org) to qualify for the 14‑day concurrent‑review exemption.

Submit the Two‑Day Notification and Initial Treatment Plan to Fidelis Care by fax to 718‑896‑1784 or email to Mental_Health_Admission@fideliscare.org within two business days.
Perform daily clinical review and participate in periodic consultation with Fidelis Care.

Documentation Required

Submit NIA authorization within 1 business day (outpatient) or 2 business days (home health) when billing non‑evaluation codes

If submitting claims that include codes other than the designated initial‑evaluation CPT codes for outpatient therapy, providers must submit an authorization request to NIA within 1 business day for outpatient settings or within 2 business days for home health settings; all home therapy treatments (including evaluations) require authorization.

When billing codes beyond initial evaluation CPTs, send authorization requests to NIA within 1 business day (outpatient) or 2 business days (home health).
All home therapy treatments, including evaluations, require authorization through NIA.

Documentation Required

Send pharmacy prior authorization requests via e‑fax to 1‑877‑882‑5892

Pharmacy prior authorization requests should be submitted electronically to the Pharmacy Team via e‑fax to 1‑877‑882‑5892.

Use e‑fax 1‑877‑882‑5892 to submit pharmacy prior authorization requests to the Fidelis Pharmacy Team.

Billing Rule

Out‑of‑network services require authorization for MA Flex (003) and MA without RX (001)

Out‑of‑network services for the Medicare Advantage Flex Plan (003) and Medicare Advantage without RX (001) are covered only with an authorization; additional copays and deductibles may apply.

Obtain prior authorization to secure out‑of‑network coverage for MA Flex (003) and MA without RX (001).
Members may be subject to additional copays and deductibles for out‑of‑network services.

Denial Risk

Denial risk if inpatient authorization not obtained for non‑emergent admissions

Failure to obtain prior authorization for non‑emergent inpatient admissions may result in services being reviewed and potentially denied as not authorized.

Non‑emergent inpatient admissions billed without prior authorization may be subject to denial.
Emergency stabilization services are excluded from this requirement, but post‑stabilization inpatient admissions require authorization.

Denial Risk

Behavioral health outpatient services listed require authorization — risk of denial if not obtained

Requests for psychological/neuropsychological testing, developmental pediatric testing, outpatient ECT, Partial Hospitalization (MH), and Intensive Outpatient Treatment require prior authorization; failure to obtain authorization may trigger denial.

Obtain prior authorization for the listed behavioral health outpatient services prior to billing.
Failure to secure authorization for these services may result in claim denial.

Denial Risk

Authorization timing risk for outpatient and home therapy services

Failure to obtain prior authorization for outpatient therapy services (PT/OT/ST) beyond the initial evaluation — or for home therapy services — may result in denial if the authorization is not submitted within the required timelines.

Initial evaluations in office/facility do not require authorization, but all other billed therapy procedure codes on the same date do.
When billing non‑evaluation codes, submit authorization to NIA within 1 business day (outpatient) or 2 business days (home health) to avoid denial.

Denial Risk

DME/orthotic authorization risk — non‑exempt codes may be denied

Billing DME or orthotic HCPCS codes that are not listed as exempt in the policy without prior authorization may trigger claim denial; the policy lists specific orthotic/DME codes that do not require authorization and states other DME/orthotic codes require authorization.

Confirm that the HCPCS code is one of the listed exempt orthotic/DME codes before billing without authorization.
If the code is not in the exempt list, obtain prior authorization to avoid denial.

Denial Risk

Risk of denial or member liability if Unlisted/Temporary codes lack prior authorization

Services billed with 'Unlisted' or 'Temporary' codes (such as C‑codes) require prior authorization; failure to obtain authorization may trigger denial or additional member financial responsibility.

Obtain prior authorization for any Unlisted or Temporary code prior to service and billing.
Lack of authorization may result in denial or added member cost.

Submit by fax to 718-896-1784 or email to Mental_Health_Admission@fideliscare.org

inv-68: Durable Medical Equipment (DME) orthotic codes not requiring authorization — enumerated list reference

ScopeEnumerated orthotic HCPCS codes that do NOT require authorization

ExamplesIncludes codes such as A4565, A8000, A8001, L0220, L0861, L0970, L0972, L1010, L1600, L1902, L3913, L8035, V2624

Policy noteAll other DME and orthotic codes require prior authorization

inv-69: MNT and DSMT definitions and coverage context

MNT definitionMedical Nutrition Therapy is covered for members with specified diabetes or renal disease ICD-10 codes and is billed with 97802/97803 or G0270/G0271

MNT limitEight visits per year covered without authorization

DSMT definitionDiabetes Self-Management Training allows 10 hours/20 units in a continuous 12-month period and must be provided by certified providers

DSMT billingServices covered when billed with G0108 (individual) and G0109 (group)

Intensive Outpatient Treatment requires prior authorization (bill type 131; revenue code 905 or 912; CPT 90899; S9480; HCPCS H2013).

Medication (injectable/infusion) — medication J-code authorization criteria group

Injectable/Infusion medication authorization: Certain injectable or infusion medications referenced by J-/C- codes (including brexanolone/Brexanolone reference J1632) follow the policy's pharmacy prior authorization and billing pathways; authorization requirements depend on the specific J/C code as enumerated in the pharmacy sections.

See extensive pharmacy J-code listings and guidance in the policy (chunk 36 and related pharmacy sections).

G0108 (individual, per 30 minutes), G0109 (group, per 30 minutes)