Prior Authorization and Coverage Criteria — Inpatient, Outpatient and Behavioral Health Services
Customize your policy alerts
Sign up for all Fidelis Care policy alerts
Know when Fidelis Care releases new policies or updates existing guidance.
Monitor payer policy activity
Governs Fidelis Care authorization requirements for inpatient admissions, selected outpatient surgeries, and behavioral health services (including carve-ins and specific services requiring authorization) for providers and facilities in New York State network.
Additional Behavioral Health Services are carved into the MAP Plan benefit package effective 1/1/2023 for New York State.
Coverage and Authorization Criteria
Inpatient authorization and exception criteria
Covered when admission and notification criteria are met for OMH/OASAS in-state facilities:
Services may be reviewed retrospectively.
Services may be subject to utilization review after day 28 or retrospectively.
Prior authorization required at time of admission except as noted for OMH/OASAS exceptions.
Behavioral health outpatient exceptions
Outpatient behavioral health coverage and authorization stance:
Out-of-state or out-of-network providers may still require authorization.
Use designated testing request forms for authorization submission.
Authorization required prior to service.
Follow facility/billing instructions for authorization.
Authorization requests may be submitted via email, fax, or phone following Behavioral Health prompts.
Behavioral Health Carve‑In Coverage
Coverage changes for OMH/OASAS behavioral health services effective Jan 1, 2023 in MAP Plan:
See the policy crosswalk for per‑category hospital vs freestanding coverage status.
Therapy and Counseling Coverage Rules
Authorization and coverage rules for therapy, counseling, MNT, and DSMT:
Prior authorization delegations to Evolent for certain services are noted.
Medical Nutrition Therapy (MNT)
Covered without prior authorization when ALL of the following are met:
Diabetes Self-Management Training (DSMT)
Covered when ALL of the following are met:
Prior Authorization Requirements
Prior authorization required for certain services:
See Fidelis website/Evolent portal for drug lists and submission details.
Authorization required prior to provision.
Specific J/C codes are listed in the policy extracts (see code lists).
Facilities that are outside New York State, are not licensed/certified/authorized by OASAS/OMH, or are outside Fidelis Care's provider network must continue to request prior authorization for inpatient substance use disorder (SUD) services. Such facilities remain subject to concurrent review throughout the admission. (Providers with questions may contact Fidelis Care behavioral health during business hours.)
For members with a diagnosis of Low Back Pain, the policy explicitly lists services that are not covered, including prolotherapy and therapeutic injections of steroids into intervertebral discs. Additionally, topical oxygen is not a covered service. These items should not be submitted for coverage when Low Back Pain is the diagnosis.
The policy clarifies that self‑administered medications are handled under the pharmacy benefit and are not treated as Part B physician‑administered drugs. Providers should route these medications and any associated prior authorization or formulary requirements through the pharmacy/drug benefit processes described on the Fidelis website and related pharmacy resources.
Within the extract provided, there are no broad, programmatic coverage exclusions beyond the specific code-to-drug mappings and product cross‑references shown. The content in this segment is limited to HCPCS/J‑code mappings and related references rather than narrative exclusion language.
Out‑of‑network services may be covered when an authorization is obtained for certain Medicare Advantage products; however, members may incur additional co‑pays and deductibles even when such services are authorized. The policy cites the Medicare Advantage Flex Plan (003) and Medicare Advantage without RX (001) as examples where authorized out‑of‑network coverage is available but cost sharing can differ.
The policy states that CPT code 96110 (noted in the developmental testing section) is a non‑covered service. Providers should not submit claims for 96110 as a covered developmental testing service under this policy.
Topical oxygen is explicitly listed as not covered. In addition, for Low Back Pain the policy names specific non‑covered services — prolotherapy and therapeutic steroid injections into intervertebral discs — reinforcing that these interventions are excluded from coverage in that clinical context.
In the portions of the document that contain code‑to‑drug cross‑references and HCPCS/J‑code mappings, the extract does not include explicit statements using the phrase 'not medically necessary.' That segment focuses on billing code mappings and product identifiers rather than clinical necessity determinations.
Code Lists and Billing Identifiers
| 32850 | listed solid organ transplant codes (examples) |
| 38204-38242 | bone marrow / tissue transplant related codes (examples) |
| 43770-43774, 43888 | Bariatric surgery |
| 15820-15823 | Blepharoplasty |
| 11920-11971, 19300, 19316-19342, 19355, 19370-19396 | Breast reconstruction |
| 15011, 15012 | Skin surgery |
| 10040, 11300-11313, 11400-11471, 11721 | Ambulatory surgery codes requiring auth if POS 24 |
| 11200, 11201, 11719, 15769-15829, 17340-17999 | Codes that require authorization in any place of service |
| 10060, 11100, 11900, 17000, 20600, 20605 | Codes requiring preauthorization in freestanding ASCs (bill type 0831) |
| 65760-65775, 66683, 66987-66991, 67900-67911, 68841 | Eyelid & ocular surgery |
| 15830, 15832-15839, 15847, 15876-15879 | Abdominoplasty, lipectomy, panniculectomy |
| 19300, 19318 | Reduction mammoplasty |
| 43235 | esophagoscopy procedure (listed as requiring authorization in POS 19/22 when office/ASC available) |
| 43239 | esophagoscopy procedure (authorization rule as above) |
| 43248 | esophagogastroduodenoscopy procedure (authorization rule as above) |
| 45378 | colonoscopy (authorization rule as above) |
| 45380 | colonoscopy with biopsy (authorization rule as above) |
| 45384 | colonoscopy with removal (authorization rule as above) |
| 45385 | colonoscopy with other procedures (authorization rule as above) |
| 46255 | sigmoidoscopy related code (authorization rule as above) |
| 46260 | sigmoidoscopy related code (authorization rule as above) |
| 46270 | sigmoidoscopy related code (authorization rule as above) |
| A4239 | DME code listed as not requiring authorization |
| A4287 | DME code listed as not requiring authorization |
| A4341 | DME code listed as not requiring authorization |
| A4342 | DME code listed as not requiring authorization |
| A4457 | DME code listed as not requiring authorization |
| A4564 | DME code added effective 4/1/24 does not require PA |
| A4593 | DME code added effective 4/1/24 does not require PA |
| A4594 | DME code added effective 4/1/24 does not require PA |
| E0152 | DME code added effective 4/1/24 does not require PA |
| E0736 | DME code added effective 4/1/24 does not require PA |
| E08.00 | Example diabetes diagnosis listed for Medical Nutrition Therapy (MNT) coverage |
| E10.10 | Example diabetes diagnosis listed for MNT coverage |
| N18.1 | Chronic kidney disease diagnosis listed for MNT coverage |
| Z32.01 | OB pregnancy diagnosis referenced for OB ultrasound authorization rules |
| 97802 | Medical Nutrition Therapy - initial assessment and intervention, individual, face-to-face |
| 97803 | Medical Nutrition Therapy - re-assessment and intervention, individual, face-to-face |
| G0270 | Medical Nutrition Therapy; group (2 or more individuals), per session |
| G0271 | Medical Nutrition Therapy; group (2 or more individuals), each additional 15 minutes |
| B4034-B4162 | Enteral formulas and disposable items (HCPCS range) that require authorization under Part B |
| multiple J/C/G codes listed | Numerous injectable and infusion HCPCS/Codes (e.g., C9047, J0275, J0596, C9145 series, J0129 series, J0223, J1300, J1322, J1305, J1411, J1434, J1440, J1551, etc.) identified as requiring authorization or noted in the Part D/Part B drug lists |
| J7183 | Listed with Profilnine or inhalation compound references |
| J7185 | Listed in compound/inhalation sequence |
| J7186 | Appears in compound/inhalation sequence |
| J7187 | Appears paired with J7306/J7307 and V25.1 dates |
| J7188 | Appears in compound code listing |
| J7189 | Appears in compound code listing |
| J7190 | Appears with Profilnine, J7307, and other pairings |
| J7191 | Appears in sequence with J7190-J7194 |
| J7192 | Multiple references tied to bitolterol and other inhalation solutions |
| J7193 | Multiple references tied to bitolterol and other inhalation solutions |
| J7634 | budesonide comp con inh sol |
| J7635 | atropine comp conc inh sol |
| J7636 | atropine comp inh sol |
| J7637 | dexamethasone comp con inh |
| J7638 | dexamethasone comp inh sol |
| J7639 | dornase alfa (Pulmozyme) |
| J7641 | flunisolide comp inh sol |
| J7642 | glycopyrrolate comp con inh |
| J7643 | glycopyrrolate comp inh sol |
| J7680 | terbutaline comp conc inh sol |
| J9021 | asparaginase, recombinant (Rylaze) |
| J9022 | atezolizumab (Tecentriq) |
| J9035 | bevacizumab (Avastin)** |
| J9041 | listed with J9248 mapping |
| J9042 | listed with J9249 mapping |
| J9043 | cabazitaxel (Jevtana) |
| J9048 | bortezomib (fresnius kabi) |
| J9049 | bortezomib (Velcade) |
| J9051 | bortezomib (maia) |
| J9052 | carmustine (Accord) |
| J9292 | Listed in mapping to multiple drugs in document |
| J9359 | Referenced in chunk 90 |
| J9321 | Referenced in chunk 90 |
| J9323 | Referenced in chunk 90 |
| J9281 | Referenced in chunk 90 |
| J9286 | Referenced in chunk 91 |
| J9196 | Referenced in chunk 91 |
| J9203 | Referenced in chunk 91 |
| J9204 | Referenced in chunk 91 |
| J9176 | Referenced in chunk 91 |
Provider Responsibilities and Submission Requirements
Prior Authorization Required
Prior authorization is required for the outpatient, diagnostic, therapeutic and drug-related services listed in this section. Failure to obtain prior authorization when required may result in claim denial or financial liability to the provider or member.
- Outpatient surgery, specified behavioral health testing and services, diagnostic testing, imaging, outpatient therapy after the initial evaluation, therapeutic services, enteral therapy HCPCS B4034–B4162, and many injectable/Part B drugs (HCPCS J‑codes) listed below require prior authorization.
- Authorization delegated to Evolent (NIA) for many radiology and radiation therapy services; oncology medications/supportive agents require PA via Evolent (my.newcenturyhealth.com) for participating providers.
HCPCS J‑codes Referenced for Prior Authorization
Many HCPCS J‑codes and related Q/QS codes are referenced in the drug listing and require prior authorization. Providers must include the specific HCPCS/J‑code and the drug/product name on authorization requests to support review.
Verify PA Requirements for Listed J‑codes
Verify whether a listed J‑code requires prior authorization before billing; some codes are subject to Evolent (NCH) review and some to Fidelis Pharmacy Team review (e‑fax).
- Oncology medications/supportive agents: PA required via Evolent (my.newcenturyhealth.com) for participating providers.
- Non‑oncology injectable drugs: submit PA requests to Fidelis Pharmacy Team via e‑fax to 1‑844‑235‑5090 (new as of 10/1/2023).
- Non‑participating providers may have different submission routes for oncology requests (see plan guidance).
Potential Denial for Incorrect Coding
Claims may be denied if coding is incorrect, inconsistent with the documented drug product, or if an incorrect J‑code is submitted for the drug administered. Ensure mappings between drug name and J‑code are accurate on PA requests and claims.
- Include both HCPCS/J‑code and drug/product name on the authorization request to reduce risk of denial for incorrect coding or inconsistent mappings.
No Explicit Authorization or Denial Rule
Some segments of the drug/code mapping listing do not state an explicit authorization or denial rule within the text. When an explicit PA requirement is not present for a specific code in this section, verify coverage rules with Evolent or Fidelis prior to service.
- The large HCPCS/J‑code list includes entries where no explicit PA/denial rule is stated in the excerpted text — confirm operational PA rules in the plan formulary or via the Evolent/Fidelis portals.
Admission Notification Requirements
Admission notification and limited prior‑authorization waivers apply for certain licensed facilities. OMH‑licensed inpatient pediatric facilities and OASAS‑licensed inpatient SUD facilities have notification requirements in lieu of immediate PA for initial days of admission — providers must notify Fidelis within the stated timelines.
- OMH licensed inpatient mental health (members <18): notify Fidelis of admission and initial treatment plan within two business days using the OMH Two‑Day Notification form; fax to 833‑561‑0094 or email Mental_Health_Admission@fideliscare.org.
- OASAS licensed Inpatient SUD facilities: notify Fidelis within two business days using the OASAS Appendix A Notification Form and LOCADTR tool; fax to 833‑663‑1608 or LOCADTR@fideliscare.org.
- All inpatient admissions require authorization except emergency stabilization; inpatient reviews occur for medical necessity.
Timing for Authorization Requests when Initial Evaluation Rendered
Timing rules: initial evaluations for therapy and some outpatient services have special authorization timing. If services other than the designated initial evaluation CPT codes are billed on the same date, an authorization must be submitted within the plan’s specified business‑day window.
- Office/facility PT/OT/ST initial evaluations do not require PA; however, all other billed procedure codes—even on the same date—require authorization prior to billing.
- When initial evaluation rendered in outpatient setting, send authorization to Evolent within 1 business day (outpatient) or 2 business days (home health); inpatient settings to Fidelis within 1 business day.
- For therapy services in inpatient settings (POS 31 & 32), send PA requests to fax 833‑663‑1611.
Oncology PA Process
Oncology prior authorization process: participating providers must request PA through Evolent (formerly New Century Health). Non‑participating providers and certain oncology requests may route to Fidelis or Wellcare by Fidelis Care per plan directions.
- Participating providers: request oncology medication/supportive agent PA at my.newcenturyhealth.com or via the 'Evolent Oncology Program' link on Fidelis provider resources.
- Non‑participating providers: oncology requests may require review by the Wellcare By Fidelis Care plan via e‑fax to 1‑844‑235‑5090; follow plan instructions for non‑participating workflows.
Coding Documentation Required for PA
Coding documentation: authorization requests must include the specific HCPCS/J‑code and the drug name/product. Use the designated request forms (e.g., Psychological/Neuropsychological testing request form) when required.
- For psychological/neuropsychological testing (96116–96146) submit the designated testing request form.
- For J‑code drug requests include HCPCS/J‑code + drug/product name to support correct mapping and reduce denials.
No Provider Documentation or Submission Instructions in All Listings
There are areas in the source listing where provider submission instructions or documentation pathways are not specified. In those cases, providers should confirm the required submission method with Fidelis or Evolent prior to delivery of service.
- If no provider documentation or submission instruction is present for a given code in this excerpt, verify the correct PA submission route (Fidelis UM portal, Evolent portal, or Pharmacy e‑fax) before billing.
Voicemail HIPAA‑Compliance Requirement
Voicemail HIPAA‑compliance: UM messages may be left only if the provider’s voicemail is HIPAA compliant. Greetings must identify the mailbox owner and organization and state the mailbox is confidential and that PHI may be left. If voicemail is not HIPAA compliant, only a generic message will be left and a callback requested.
- If voicemail meets HIPAA requirements, a detailed UM message will be left; otherwise UM will leave a generic message and attempt direct contact again per Department of Health Reasonable Effort Policy.
No Step Therapy Rules Present in This Section
No step therapy rules are present in this section excerpt; drug/code listings are extensive but do not include detailed step therapy steps here. Providers should consult the Part B Step Therapy Policy link and the plan formulary for complete step therapy requirements.
- For a list of drugs that require step therapy, see the Part B Step Therapy Policy on the Fidelis website.
- This section contains drug/code listings but does not detail step therapy algorithms.
Drug/Code Listings (No Step Therapy Detailed Here)
Drug/code listings are included in the plan materials but many entries in this excerpt are code mappings without embedded step therapy details. Treat the listing as a reference of PA‑sensitive codes and verify clinical rules and step therapy elsewhere.
Definitions and Term Clarifications
Level-of-Care Specific Criteria
Modality-Specific Coverage Rules
TMS
Authorization request routes: email qhcmbh@fideliscare.org, fax 833-561-0098, or phone 1-888-FIDELIS (follow Behavioral Health prompts).
ECT
Authorization required prior to service.
PH, CPEP, ACT, CDT, PROS, Crisis Residence, Psychiatric Inpatient
Refer to the carve-in crosswalk for per-category details and setting-specific coverage.
Visit and Unit Limits
Policy Background
This policy establishes the authorization and utilization review framework for inpatient admissions (medical, behavioral health, and substance use disorder), and for specific outpatient surgeries and behavioral health services. It defines exceptions for in‑state OMH‑licensed pediatric inpatient admissions (a 14‑day notification‑based no‑authorization period when the facility notifies Fidelis within two business days) and OASAS‑licensed SUD inpatient admissions (a 28‑day notification‑based no‑authorization period when the facility notifies Fidelis within two business days and uses LOCADTR), and it requires authorization for all other inpatient facility services and listed outpatient procedures. Providers are instructed to follow the notification, prior authorization, and delegated PA submission processes described in the policy.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.