CurrentFidelis CarePolicy N/A

Prior Authorization and Utilization Review — Inpatient, Outpatient, Behavioral Health, DME and Related Services

Defines which inpatient admissions, outpatient procedures, behavioral health services, durable medical equipment, diagnostic tests, and other services require prior authorization or are exempt, and describes special rules for OASAS/OMH-licensed facilities and delegated vendors; applies to Fidelis Care provider network in New York.

Policy Summary

PayerFidelis Care

PolicyPrior Authorization and Utilization Review — Inpatient, Outpatient, Behavioral Health, DME and Related Services

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for all inpatient admissions and for specified outpatient behavioral health, diagnostic, DME, and home therapy services as listed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All inpatientrequire authorization

28 daysOASAS SUD exemption

14 daysOMH under-18 exemption

Authorization removedOutpatient behavioral health

8/yrMNT visits

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

10 hrsDSMT allowance

Coverage and Prior Authorization Rules

Inpatient Admissions

Covered when PRIOR AUTHORIZATION is obtained as required below

General inpatient authorization: All inpatient admissions require an authorization and are reviewed for medical necessity.

Applies to medical, substance abuse, and behavioral health admissions

Inpatient Substance Use Disorder (OASAS)

OASAS-licensed Inpatient SUD special rules

OASAS in-state in-network facilities: Inpatient detoxification, inpatient rehabilitation and inpatient residential treatment services provided by New York State facilities licensed/certified by OASAS and participating in Fidelis Care's network are not subject to prior authorization or concurrent utilization review for the first twenty-eight (28) days of the inpatient admission provided the facility notifies Fidelis Care of the admission and initial treatment plan within two (2) business days and performs daily clinical review; facilities must periodically consult with Fidelis Care starting on or just prior to day 14. Services may be subject to utilization review after day 28 or retrospectively.28 days

Out-of-state, non‑OASAS‑licensed, or out‑of‑network facilities must request prior authorization and are subject to concurrent review throughout the admission

Inpatient Mental Health (OMH)

OMH-licensed inpatient mental health treatment special rules

OMH in-state under-18 facilities: Inpatient mental health treatment for members under age 18 provided by OMH‑licensed, in‑network facilities are not subject to prior authorization or concurrent utilization review for the first fourteen (14) days of the admission provided the facility 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, performs daily clinical review, and participates in periodic consultation; services may be reviewed retrospectively.14 days

Admissions age 18 and older require prior authorization and concurrent review; out‑of‑state or out‑of‑network facilities must request prior authorization for all ages

Behavioral Health-Outpatient

Outpatient behavioral health services authorization stance

Outpatient behavioral health: Authorization requirement has been removed for most outpatient behavioral health services; however, the following continue to require authorization as listed: psychological/neuropsychological testing (e.g., CPTs 96116, 96121, 96130–96139, 96146), developmental pediatric testing (96112, 96113), outpatient ECT (90870), partial hospitalization (revenue codes 912, 913, 944, 945; HCPCS H0035), and intensive outpatient treatment (bill type 131; revenue 905 or 912; CPT 90899; S9480; HCPCS H2013).

Out‑of‑network or out‑of‑state providers may still require authorization

Outpatient Surgery

Outpatient surgical and procedure authorization

Elective and outpatient procedures: Many elective outpatient surgical procedures require prior authorization per the specified CPT/HCPCS ranges (examples include bariatric surgery 43770–43888; blepharoplasty 15820–15823; breast reconstruction 11920–11971, 19300, etc.) and selected codes continue to require authorization for any place of service. Delegation to TurningPoint applies for specified ENT, cardiac, and certain orthopedic/spine codes per the policy.

Specific delegated lists and exact CPTs are provided in the policy

Diagnostics, DME, Home Therapy

Diagnostic testing, DME, and home therapy authorization

Diagnostic testing and DME: Certain diagnostic tests and many listed DME/orthotic codes do not require authorization (specified CPT/HCPCS lists); other DME and orthotic codes do require authorization. Effective dates noted: outpatient home therapy (PT/OT/ST) performed by a therapy provider requires prior authorization through National Imaging Associates, Inc. (NIA) for dates of service on/after 10/1/2021.

See policy lists for codes that do not require authorization (DME and orthotics) and for imaging/genetic test exceptions

MNT coverage

Medical Nutrition Therapy (MNT) and Diabetes-related counseling coverage

MNT coverage for diabetes or renal disease: Medical Nutrition Therapy provided by a licensed nutritional provider is covered for members with diabetes (specified ICD‑10 E08–E13 and related pregnancy/other diabetes codes) or renal disease (I12.0, I12.9, N18.1–N18.6, N18.9, N28.9, N29, Z48.22, Z94.0).

Eight visits per year are covered without authorization using CPT 97802, 97803 or G0270, G0271

DSMT coverage

Diabetes Self-Management Training (DSMT)

DSMT coverage: Members are allowed 10 hours (20 units) in a continuous 12‑month period for DSMT provided by certified providers; these services do not require prior authorization and are billed with codes G0108 and G0109.10 hours/20 units per 12 months

Services must be delivered by certified providers

Not covered therapeutic services for Low Back Pain

Therapeutic Services

Non-covered services for Low Back Pain: The following services are not covered for members with a diagnosis of Low Back Pain: a) Prolotherapy; b) Therapeutic injections of steroids into intervertebral discs. Topical oxygen is also not a covered service.

See therapeutic services list for other items

In-state, in-network OASAS-licensed inpatient substance use disorder (SUD) facilities are exempt from prior authorization and concurrent utilization review for the first 28 days of an admission provided the facility notifies Fidelis Care of the admission and initial treatment plan within two (2) business days and submits required LOCADTR documentation. Facilities must perform daily clinical review and begin periodic consultation with Fidelis Care around day 14; services may be subject to utilization review after day 28 or retrospectively.

OMH-licensed, in‑network inpatient mental health facilities providing care to members under age 18 are exempt from prior authorization and concurrent review for the first 14 days of an admission if the facility: submits the OMH two‑day notification and initial treatment plan to Fidelis Care within two business days; performs daily clinical review; and participates in periodic consultation to ensure use of the approved clinical review criteria.

Topical oxygen is explicitly listed as not a covered service and should not be billed as a covered therapy under this policy.

Within the code listing segment reviewed there are no additional explicit coverage exclusions noted beyond those stated elsewhere in the policy.

Out‑of‑network services may be covered for certain Medicare Advantage plans (e.g., Medicare Advantage Flex Plan 003 and Medicare Advantage without RX 001) but require authorization and may result in additional co‑pays and deductibles for the member.

CPT 20610 (hyaluronic acid joint injection) is identified as non‑covered when billed with specified osteoarthritis diagnosis codes (for example, M17.0, M17.10–M17.12, M17.2, M17.20–M17.32, M17.4, M17.5, M17.9); providers should not expect coverage in those diagnosis scenarios.

For members with a diagnosis of Low Back Pain, prolotherapy and therapeutic steroid injections into intervertebral discs are specifically listed as not covered services.

This portion of the document does not identify any additional services or specific codes as not medically necessary beyond the examples already described in the policy.

Code Lists and Coding Notes

DME codes not requiring authorizationHCPCSCovered

A4604	DME
E0130	DME
E0135	DME
E0168	DME
E0182	DME
E0184	DME
E0235	DME
E0274	DME
E0305	DME
E0310	DME

1–10 of 62

1/7

Orthotic codes not requiring authorizationHCPCSCovered

A4565	Orthotic
A8000	Orthotic
A8001	Orthotic
L0220	Orthotic
L0861	Orthotic
L0970	Orthotic
L0972	Orthotic
L0974	Orthotic
L0976	Orthotic
L0978	Orthotic

1–10 of 77

1/8

Outpatient surgery and procedure CPT codes requiring prior authorization (selected)CPTCovered

43770-43888	Bariatric surgery range
S2083	Bariatric related HCPCS
15820-15823	Blepharoplasty
11920-11971	Breast reconstruction range
19300	Breast procedures
19316-19342	Breast procedures range
19355	Breast procedures
19370-19396	Breast procedures range
10040	Skin surgery (amb surgery POS 24)
11300-11313	Skin repair codes (amb surgery POS 24)

1–10 of 11

1/2

Behavioral health outpatient CPT/HCPCS codes requiring authorizationmixedCovered

96116	Neuropsych testing
96121	Psych testing add-on
96130	Psych testing
96131	Psych testing
96132	Neurobehavioral status
96133	Neurobehavioral status
96136	Psych testing interpretation
96137	Psych testing interpretation
96138	Psych testing
96139	Psych testing

1–10 of 18

1/2

Diagnostic testing CPT/HCPCS codes (noted)mixed

91110	Wireless Capsule Endoscopy
91111	Wireless Capsule Endoscopy
91112	Wireless Motility Capsule
91113	Wireless Motility Capsule
87483	Infectious agent detection by DNA/RNA

Home therapy authorization delegationmixedCovered

NIA	National Imaging Associates - delegated prior authorization for outpatient home PT/OT/ST as of 10/1/2021

Orthotic/DME codes not requiring authorization (consolidated)HCPCSCovered

A4604	DME
E0130	DME
E0135	DME
E0168	DME
E0182	DME
E0184	DME
E0235	DME
E0274	DME
E0305	DME
E0310	DME

1–10 of 138

1/14

TBS scan CPT codesCPT

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

Speech CPT codes exempt from PACPTCovered

92610	Evaluation of speech and language
92611	Evaluation of speech and language

Therapeutic service CPT codes (noted)CPT

95249

Ambulatory continuous glucose monitoring

Provider Responsibilities and Authorization Procedures

Prior Authorization

Prior Authorization Requirements (selected items)

Prior Authorization Required: Providers must obtain prior authorization for all inpatient admissions and selected outpatient behavioral health services. All facility admissions (medical, substance use, and behavioral health) are reviewed for medical necessity. Failure to obtain required authorizations may result in retrospective review, claim denials, or member financial liability.

All inpatient facility services require authorization.
Inpatient rehabilitation (acute, sub-acute, skilled nursing) requires authorization when skilled services are provided.
Most outpatient behavioral health services no longer require authorization, except specific services (e.g., psychological/neuropsychological testing codes listed separately).

Billing Rule

Policy Background and Scope

This document describes Fidelis Care's utilization management and prior authorization requirements across care settings, including special program exceptions. It specifies that all inpatient admissions require authorization and details exceptions for New York State OASAS‑licensed inpatient SUD facilities (no prior authorization or concurrent review for the first 28 days with timely notification and LOCADTR submission) and OMH‑licensed inpatient mental health admissions for members under 18 (no prior authorization or concurrent review for the first 14 days with OMH two‑day notification and daily clinical review). The policy also explains delegated review arrangements (for example, NIA for outpatient/home therapy and New Century Health for certain oncology medications) and lists specific codes and services that remain subject to authorization or are excluded from coverage.

Key Definitions and Delegated Reviewers

inv-65: OASAS inpatient SUD services — definition and scope for exemption

DefinitionInpatient detoxification, inpatient rehabilitation, and inpatient residential treatment services provided by New York State facilities licensed, certified or otherwise authorized by OASAS

Network statusApplies when facility is participating in Fidelis Care's provider network and located in New York State

Prior authorization stanceNot subject to prior authorization review by Fidelis Care when notification and LOCADTR requirements are met

Concurrent review stanceNot subject to concurrent utilization review during the first 28 days of admission under specified conditions

Notification methodFacility may fax or email OASAS Appendix A Notification Form and LOCADTR to 646-829-1421 or LOCADTR@fideliscare.org

Level-of-Care Authorization Criteria

Inpatient / Residential

Admission criteria (Inpatient/Residential): All inpatient behavioral health admissions require authorization and are reviewed for medical necessity; OMH and OASAS in‑network licensed facilities have the limited initial-day exemptions described separately.

See OMH/OASAS special rules for exemption periods and notification requirements

Concurrent review: Inpatient admissions are subject to concurrent review throughout the admission unless exempted for the initial days by OMH/OASAS rules; OASAS in‑state in‑network SUD services may be subject to utilization review after day 28 or retrospectively.

Facilities must periodically consult with Fidelis Care starting on or just prior to day 14 for SUD

Partial Hospitalization / Intensive Outpatient

Partial Hospitalization and IOP:

Specific Treatment Modality Criteria

ECT

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

Partial Hospitalization (Mental Health)

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

Intensive Outpatient Program (IOP)

Intensive Outpatient Treatment: Intensive outpatient treatment billed with bill type 131, revenue code 905 or 912, CPT 90899, S9480, or HCPCS H2013 requires prior authorization.

Service Limits and Allowances

inv-75: Diabetes Self-Management Training (DSMT) — 10 hours / 20 units

DSMT allowance10 hours / 20 units in a continuous 12-month period

ServiceDiabetes Self-Management Training (DSMT) — provided by certified providers

AuthorizationNo prior authorization required

Billing codesG0108, G0109

inv-76: Medical Nutrition Therapy (MNT) — 8 visits

Allowance8 visits per year

ServiceMedical Nutrition Therapy (MNT)

Policy Summary

PayerFidelis Care

PolicyPrior Authorization and Utilization Review — Inpatient, Outpatient, Behavioral Health, DME and Related Services

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for all inpatient admissions and for specified outpatient behavioral health, diagnostic, DME, and home therapy services as listed.

SourceLink

On This Page

Orthotic Codes Exempt from Authorization

Orthotic Codes Exempt from Authorization: The listed orthotic HCPCS/L-codes do not require prior authorization. Providers may bill these codes without prior authorization.

Examples include A4565, A8000, A8001, L0220, L0861, L0970–L0984 range, L1010–L1100 series, L1120, L1240–L1290 series, L1600–L1660 series, L1810, L1820, L1902, L2180–L2190 series, L3650, L3710, L3913–L3935 series, L3995, L8010, L8035, L8300–L8485 series, L8505, V2624.

Prior Authorization

Other DME/Orthotics Require Authorization

Other DME and Orthotics: All other DME and orthotic codes not listed as exempt require prior authorization.

DME codes not on the exempt lists require authorization.
Providers should submit authorization requests per Fidelis Care processes prior to dispensing or billing.

Prior Authorization

Outpatient/Home Therapy PA to NIA

Outpatient and Home Therapy Prior Authorization to NIA: Effective 10/01/2021, outpatient PT/OT/ST services (after the initial evaluation) and home therapy services require prior authorization through National Imaging Associates (NIA). Initial evaluations do not require prior authorization, but any subsequent therapy codes do. If submitting authorization for non-initial-evaluation codes, requests must be sent to NIA within 1 business day for outpatient settings or 2 business days for home health settings. All home therapy treatments, including evaluations, require authorization.

Effective dates: services with dates of service on/after 10/01/2021 require NIA authorization.
CPT codes 92610 and 92611 (speech) do not require prior authorization.
Non-therapy providers should request authorizations directly through Fidelis Care.
Failure to obtain authorization prior to providing billed services may result in denial.

Prior Authorization

TBS Scans and Imaging PA Rules

TBS (Bone Densitometry) Scans: The following CPT codes for Trabecular Bone Score (TBS) scans are identified; imaging prior authorization rules apply per the radiology/imaging section and delegated reviews.

TBS scan CPT codes: 77089, 77090, 77091, 77092.
Radiology prior authorization may be delegated to NIA for dates of service on/after 10/01/2021; follow delegated review procedures when applicable.

Billing Rule

HCPCS / J-code Mapping (billing guidance)

Code Mapping and J-code Billing Guidance: This section provides HCPCS/J-code mappings and billing guidance. Providers should bill the exact J-code corresponding to the drug administered. The mappings do not, in this segment, change prior authorization requirements — specific drugs or J-codes may still require PA as noted elsewhere.

Refer to the Fidelis website and the listed provider resources for current J-code mappings and which drugs require prior authorization or New Century Health review.
Oncology and supportive agents for participating providers require PA through New Century Health.
Certain injectable non-oncology J-codes require prior authorization via the Pharmacy Team (e-fax 1-877-882-5892).

Denial Risk

Consequences of Not Obtaining Authorization

Failure to Obtain Authorization: Failure to obtain required prior authorization for inpatient admissions, outpatient/home therapy, DME/orthotics, or services billed with 'Unlisted' or 'Temporary' codes may result in retrospective medical necessity review, claim denials, and potential member financial liability.

All inpatient admissions require authorization; unauthorized admissions may be reviewed and denied.
Services billed with 'Unlisted' or 'Temporary' codes (such as C-codes) require authorization.
Outpatient/home therapy claims without prior authorization may be denied.

Note

Out-of-Network Authorization and Cost Risk

Out-of-Network Authorization and Cost Risk: Out-of-network services may require authorization on certain Medicare Advantage plans and can incur additional co-pays and deductibles; providers and members should verify benefits and authorization requirements prior to services.

Medicare Advantage Flex Plan (003) and Medicare Advantage without RX (001) require authorization for out-of-network services; additional member cost-sharing may apply.
Providers should obtain authorization to reduce member financial risk.

Documentation Required

OASAS/OMH Admission Notification Requirements

OASAS and OMH Notification Requirements for Inpatient Behavioral Health/SUD: OASAS-licensed inpatient SUD facilities and qualifying OMH-licensed inpatient mental health facilities must notify Fidelis Care of admissions and initial treatment plans within two business days using the specified notification forms/process. When timely notification requirements are met, the first portion of the admission may be exempt from prior authorization and concurrent review per the policy; out-of-state or non-participating facilities remain subject to authorization and concurrent review.

OASAS Inpatient SUD facilities participating in Fidelis' network are not subject to PA or concurrent review during the first 28 days if the facility notifies Fidelis within 2 business days and submits the OASAS Appendix A Notification Form and LOCADTR tool to LOCADTR@fideliscare.org or fax 646-829-1421.
OMH inpatient mental health for members under 18 in-network are not subject to PA during the first 14 days if the facility notifies Fidelis within 2 business days using the OMH Two-Day Notification and Initial Treatment Plan form (fax 718-896-1784 or email Mental_Health_Admission@fideliscare.org).
Out-of-state or non-network facilities must request prior authorization and are subject to concurrent review throughout admission.

inv-66: OMH licensed inpatient mental health treatment (under 18) — definition for exemption

DefinitionInpatient mental health treatment for members under age 18 provided by OMH-licensed hospitals in New York State

Prior authorization stanceNot subject to prior authorization review for the first 14 days when OMH two‑day notification and initial treatment plan submitted

Notification methodSubmit OMH 'Two-Day Notification and Initial Treatment Plan' by fax to 718-896-1784 or email Mental_Health_Admission@fideliscare.org

Clinical reviewFacility must perform daily clinical review and participate in periodic consultation using OMH‑approved criteria

inv-67: National Imaging Associates (NIA) — delegated reviewer for prior authorization of outpatient therapy and radiology services

RoleDelegated reviewer for prior authorization of outpatient PT/OT/ST services (after initial evaluation) and certain radiology/imaging authorization tasks

Effective date for home therapy PAPrior authorization through NIA required for outpatient/home therapy services for dates of service on/after 10/1/2021

Authorization timing requirementIf billing codes other than initial evaluation CPTs are used, authorization request must be sent to NIA within 1 business day (outpatient) or 2 business days (home health)

ExceptionsCPT codes 92610 and 92611 do not require prior authorization; inpatient/ED/SNF/observation settings excluded

inv-68: New Century Health (NCH) — delegated reviewer for oncology medications and supportive agents

RoleDelegated reviewer for prior authorization of oncology medications and supportive agents for participating providers

How to request PAPA can be requested via New Century Health web portal (my.newcenturyhealth.com) or by calling 1-888-999-7713, option 1

ScopeApplies to oncology medications/supportive agents before dispensing or administration in pharmacy, physician office, outpatient hospital, or ambulatory settings

ReferenceList of drugs requiring NCH review available on Fidelis Care website link provided in policy

inv-69: J-code definition — HCPCS Level II J-code for drugs administered other than oral/intravenous in outpatient settings

DefinitionHCPCS Level II J-code used for drugs administered other than oral or intravenous routes in outpatient settings

Usage noteJ-code mappings in the policy link specific J-codes to drug names for billing and review purposes

Examples in documentIncludes mappings such as J3396 (verteporfin/Visudyne), J3398 (voretigene neparvovec), J3399 (onasemnogene abeparvovec-xioi)

Partial hospitalization and Intensive Outpatient Programs require authorization when billed with the specified revenue/HCPCS/bill type/CPT codes (e.g., revenue codes 912, 913, 944, 945; HCPCS H0035 for PHP; bill type 131, revenue 905 or 912, CPT 90899, S9480, HCPCS H2013 for IOP).

Although most outpatient behavioral health services no longer require authorization, these higher‑intensity services remain authorized

Covered diagnosesDiabetes (selected E08–E13 and related pregnancy codes) or renal disease (I12.0, I12.9, N18.1–N18.6, N18.9, N28.9, N29, Z48.22, Z94.0)

Billing codes97802, 97803, G0270, G0271