CurrentFidelis CarePolicy N/A

COVID-19 UPDATE

Provider-facing update describing prior authorization, utilization review, delegated vendor responsibilities, code-level prior authorization requirements, and specific coverage/authorization exceptions across inpatient, outpatient, behavioral health, DME, imaging, therapeutic, pharmacy and vendor services for Fidelis Care members (part 1 of 2). Covers delegation to Evolent and TurningPoint, OMH/OASAS exceptions, and long Appendix I list of HCPCS/CPT/J-codes requiring prior authorization.

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE

Policy CodePolicy N/A

Change TypeProvider update (administrative)

Effective Date

Next Review Date

Key ActionObtain authorization for all inpatient admissions (except emergency stabilization) and use fax 833-663-1602 for inpatient/ER authorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes were reported in this update.

1Inpatient admissions require authorization

28OASAS inpatient SUD no-review period (days)

14OMH pediatric no-review period (days)

60Rehab visit limit per condition

Appendix I length

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.

Appendix I codes (extensive)

1Ophthalmic indication exception

Policy summary and scope

This update consolidates prior authorization, utilization review, and delegation guidance across multiple service types, reflecting changes implemented during/after the COVID-19 period and incorporating state-specific OMH and OASAS exceptions. It identifies delegated vendors — Evolent (NIA) and TurningPoint Healthcare Solutions, LLC — for prior authorization and medical necessity review of many procedure groups and associated HCPCS device codes, and clarifies when Fidelis Care will continue to require or conduct authorization and concurrent review.

It describes specific exceptions for New York State behavioral health: OASAS-licensed inpatient SUD in-network admissions are not subject to prior authorization or concurrent utilization review for the first 28 days if the facility notifies Fidelis Care within two business days using Appendix A/LOCADTR, and OMH-licensed inpatient mental health admissions (all ages) are not subject to authorization with utilization review triggers limited to defined clinical criteria (and pediatric OMH admissions have a 14-day no-concurrent-review period when notification and other criteria are met).

The document contains an extensive Appendix I listing numerous HCPCS/C/J/CPT codes that require prior authorization (with an explicit exception that ophthalmic indications do not require authorization) and directs delegated authorization requests to Evolent or TurningPoint where indicated. Scope: Provider-facing update describing prior authorization, utilization review, delegated vendor responsibilities, code-level prior authorization requirements, and specific coverage/authorization exceptions across inpatient, outpatient, behavioral health, DME, imaging, therapeutic, pharmacy and vendor services for Fidelis Care members (part 1 of 2).

Quick thresholds & limits

OMH pediatric non-review periodFirst 14 days of admission — no authorization or concurrent review if OMH Two-Day Notification & initial treatment plan submitted within 2 business days

OMH adult utilization-review trigger>30 days (concurrent review from day 31 onwards)

OASAS inpatient SUD non-review periodFirst 28 days of admission — no prior authorization or concurrent review if facility notifies Fidelis within 2 business days via Appendix A/LOCADTR to fax 833-663-1608

Rehabilitation visit limit60 visits per condition per plan year (rehabilitation and habilitation each)

Home health visits maximum40 visits per plan year (skilled home health services)

Hospice coverage maximumUp to 210 days when medically necessary

BRCA / genetic testing limitsCPT 81220: 1 per lifetime; CPTs 81329 and 81336: combined limit of 1 per lifetime; authorization not required for CPTs 81220, 81329, 81336, 81420

Authorization & utilization review rules (by setting)

General Prior Authorization and Utilization Review Rules

Policies and exceptions for authorization and utilization review across settings; follow delegated vendor requirements where indicated.

All inpatient admissions require an authorization (except emergency department services and emergent stabilization). Facility admissions are reviewed for medical necessity.

OASAS Licensed Inpatient Substance Use Disorder (Inpatient SUD)

Effective 01/01/2020: In-network, in-state OASAS licensed inpatient SUD services are not subject to prior authorization or concurrent utilization review for first 28 days if notification requirements met.

Inpatient SUD provided by NYS OASAS-licensed facilities in-network are not subject to prior authorization review and not subject to concurrent utilization review during the first 28 days of admission, provided facility notifies Fidelis Care of admission and initial treatment plan within 2 business days (via OASAS Appendix A Notification Form and LOCADTR Medical Necessity Tool to fax 833-663-1608).28 days

Codes and code groups requiring (or exempt from) prior authorization

Transplant-related CPT Codes (authorization required)CPTCovered

32850	Transplant-related procedure code
32851	Transplant-related procedure code
32852	Transplant-related procedure code
32853	Transplant-related procedure code
32854	Transplant-related procedure code
32855	Transplant-related procedure code
32856	Transplant-related procedure code
33930	Transplant-related procedure code
33931	Transplant-related procedure code
33932	Transplant-related procedure code

1–10 of 131

1/14

Outpatient Surgery CPT Codes (prior authorization required)CPTCovered

15820	Blepharoplasty - upper eyelid
15821	Blepharoplasty - lower eyelid
15822	Blepharoplasty - combined
15823	Blepharoplasty - extensive
43770	Laparoscopic bariatric procedure
43771	Laparoscopic bariatric procedure
43772	Laparoscopic bariatric procedure
43773	Laparoscopic bariatric procedure
43774	Laparoscopic bariatric procedure
43775	Laparoscopic bariatric procedure

1–10 of 72

1/8

Behavioral health testing and procedure codes (authorization required)CPTCovered

(See Behavioral Health Delegation Lists)

Behavioral health testing/procedure codes delegated or requiring authorization per behavioral health policy and TurningPoint/Evolent delegations

Durable Medical Equipment (selected HCPCS) — no prior authorization required (exceptions effective 04/01/2024 noted)HCPCS

(selected DME HCPCS)	Certain DME items do not require prior authorization. Exceptions effective 04/01/2024: specified items (per policy) require authorization starting 04/01/2024 — providers should verify item-level exceptions.
S0040	Non-emergency medical transportation — ensure correct billing; S0040 preserved in this section (verify prior auth per benefit)

Imaging: Breast tomosynthesis (77089-77092)CPTCovered

77089	Screening digital breast tomosynthesis, unilateral
77090	Screening digital breast tomosynthesis, bilateral
77091	Diagnostic digital breast tomosynthesis, unilateral
77092	Diagnostic digital breast tomosynthesis, bilateral

Therapy visit limits and speech therapy CPT codesCPTCovered

92507	Treatment of speech, language, voice, communication, and/or auditory processing disorders; individual
92508	Group speech therapy
92526	Treatment of swallowing dysfunction (dysphagia)

Cardiac and Pulmonary Rehabilitation Codes (authorization as applicable)CPTCovered

93797	Physician or other qualified health care professional services for cardiac rehabilitation with continuous ECG monitoring
93798	Cardiac rehab without continuous ECG monitoring
94010	Breathing capacity test (pulmonary rehab assessment)

Appendix I: Codes Requiring Prior Authorization (HCPCS/J/C-codes excerpt)mixedCovered

(Extensive list)

This is an excerpt — extensive list of HCPCS/J/C codes require prior authorization. See Appendix I for full list. All listed codes in Appendix I are subject to prior authorization review; status: covered when authorized.

J‑codes requiring prior authorization (excerpt — Part 2)HCPCSCovered

J1551	Injection, fentanyl buccal soluble film (example J-code range J1551-J1599 included in policy excerpt)
J1552	(See Appendix for full descriptions)
J1599	Unclassified drugs — included in J1551-J1599 range; require prior authorization as applicable

What providers must do (submissions, contacts, and billing rules)

Prior Authorization

Authorization required for inpatient admissions

Obtain authorization for all inpatient admissions (emergency stabilization excluded). Submit inpatient/ED authorization requests via fax to 833-663-1602.

Prior Authorization

OASAS inpatient SUD notification and submission

For in-network, in‑state OASAS‑licensed inpatient SUD facilities, notify Fidelis Care within 2 business days of admission using the Appendix A Notification Form and the LOCADTR tool; fax submissions to 833-663-1608. When notification requirements are met, prior authorization and concurrent review are not required for the first 28 days of admission (facilities must still perform daily clinical review and periodic consultation beginning about day 14).

Documentation Required

OMH two-day notification for pediatric inpatient mental health

Definitions, appendices, and reference notes

OMH → New York State Office of Mental Health

OASAS → New York State Office of Addiction Services and Supports

LOCADTR → Level of Care Determination and Documentation Tool used for SUD reviews

Evolent (NIA) → Delegated vendor for utilization review/authorizations for select services (e.g., radiation, oncology medications, therapy prior auths, rehabilitation program management)

TurningPoint → Delegated vendor for prior authorization of certain CPT groups (cardiac, ENT, select physician-office procedures); associated HCPCS device codes are also reviewed by the delegate

UM → Utilization Management

PHI → Personal Health Information

Appendix I is an extensive, code-level appendix listing HCPCS, J-, C- and other codes that require prior authorization. It maps many specialty drug and device HCPCS/C-codes to corresponding J-codes and provides grouped entries for biologics, infused drugs, and other high-cost items.

Providers must consult the Appendix I code list (or the code_table in the CODING section referenced in the policy) to determine whether a specific HCPCS/J/C/PT code requires prior authorization before claim submission; Appendix I is separate from — and may overlap with — the Evolent delegated review lists.

Note: the policy explicitly states that authorization is not required for ophthalmic indications despite codes appearing in Appendix I.

Document changes and effective dates

revision_history_noteLatest

No dated revision history entries were provided in the extracted source. Consult the full source document (Appendix I and related sections) for the official revision log and effective dates.

Policy Summary

PayerFidelis Care

PolicyCOVID-19 UPDATE

Policy CodePolicy N/A

Change TypeProvider update (administrative)

Effective Date

Next Review Date

Key ActionObtain authorization for all inpatient admissions (except emergency stabilization) and use fax 833-663-1602 for inpatient/ER authorization.

SourceLink

On This Page

Facilities must perform daily clinical review (this does not require daily use of the LOCADTR concurrent review module) and periodically consult with Fidelis Care starting on or just prior to day 14 to ensure medical necessity using the LOCADTR tool.

After 28 days from admission or upon discharge, services may be subject to utilization review; facilities must provide a written discharge plan and indicate whether services in discharge plan are secured or reasonably available.post-28 days

Facilities outside New York State, not OASAS-licensed, or out-of-network must request authorization and are subject to concurrent review throughout admission.

OMH Licensed Inpatient Mental Health Treatment

Effective 06/01/2021 (and 01/01/2020 exception for <18): Inpatient mental health at OMH-licensed NYS hospitals generally not subject to authorization; utilization review applies only when specific triggers met.

Inpatient mental health treatment for all ages at OMH-licensed hospitals in NYS are not subject to authorization review by Fidelis Care; facility must notify insurer within 2 business days of admission (call 1-888-FIDELIS ext 16072 or fax 833-561-0094).

Utilization review (prior authorization and concurrent) conducted only for members who meet ANY of:

Individuals subject to a current Assisted Outpatient Treatment (AOT) court order.
Individuals who had an AOT court order that expired within the past five years.5 years
High utilization in prior 12 months
- Three (3) or more psychiatric inpatient hospitalizations in the prior 12 months.3
- Four (4) or more psychiatric emergency department (ED) visits in the prior 12 months.4
- Three (3) or more medical inpatient hospitalizations in the prior 12 months.3
Individuals readmitted to any mental health inpatient unit within thirty (30) days of discharge from a mental health inpatient admission.30 days
Individuals not meeting any triggers above whose length of stay exceeds 30 days (concurrent review from day 31 onwards).>30 days

Pediatric OMH exception: Effective 01/01/2020: Inpatient mental health for members under age 18 in-network at OMH-licensed hospitals are not subject to authorization review and Fidelis Care will not conduct concurrent review during first 14 days if facility: i) notifies Fidelis Care of admission and initial treatment plan within 2 business days using OMH Two-Day Notification and Initial Treatment Plan form (fax 833-561-0094 or email Mental_Health_Admission@fideliscare.org); ii) performs daily clinical review; iii) participates in periodic consultation with Fidelis Care.14 days

All inpatient mental health services provided by out-of-network facilities are subject to concurrent review throughout the admission.

Inpatient Rehabilitation Services

Authorization requirements for acute inpatient rehabilitation, sub-acute and skilled nursing rehabilitation.

Inpatient Rehabilitation Services (acute, sub-acute and skilled nursing rehabilitation) require authorization.

Medical rehabilitation authorizations must be obtained prior to service as required; follow Fidelis Care authorization processes.

Transplants

Tissue and organ transplants require authorization at time of transplant evaluation.

Transplants require authorization at the time of the transplant evaluation.

Includes but is not limited to the CPT codes listed in the Transplant code group (see Appendix/ code groups for full code list).

Operational note: refer to code_groups for transplant CPTs

Elective Surgical Procedures and Outpatient Surgery

Authorization rules for elective surgeries, outpatient surgeries, and specific CPTs including delegation to Evolent/TurningPoint.

Surgical and medical procedures completed within 24 hours will not be approved at an inpatient level of care; when performed outpatient within network they may not require inpatient authorization.24 hours

Delegation: Musculoskeletal and certain orthopedic/spinal authorizations delegated to Evolent (effective 1/1/24); cardiac, ENT and certain physician-office procedures delegated to TurningPoint — if CPT delegated, associated HCPCS device codes are reviewed by the delegate.

See code_groups for exact CPT lists

Outpatient surgery codes requiring PA: Specific outpatient surgery CPTs (blepharoplasty, bariatric, breast reconstruction, selected skin/derm codes, freestanding ASC codes, ear repair, abdominoplasty, reduction mammoplasty, vascular/vein procedures, speech processor implants, esophageal procedures, spinal surgery, CAR-T, urology, etc.) require prior authorization as listed.

Refer to code_groups for exact CPT lists

Non-covered: 20610 is non-covered when billed with hyaluronic acid J-codes and diagnosis of osteoarthritis of the knee.

Behavioral Health Outpatient and Partial/Intensive/IOP

Authorization rules and utilization review triggers for outpatient behavioral health services including testing, partial hospitalization, intensive outpatient, TMS, ASD/ABA rules and submission pathways.

Testing: Psychological/Neuropsychological testing (96116,96121,96130-96139,96146) require authorization; submit on Psychological/Neuropsychological testing request form. Codes 96112 and 96113 require authorization; 96110 is non-covered.

Partial Hospitalization: Partial hospitalization (rev codes 912,913,944,945; HCPCS H0035) utilization review conducted only for members meeting OMH Best Practice Manual triggers (AOT, high utilization, readmission within 30 days, or length of stay >30 days).

Intensive Outpatient: Intensive outpatient (rev 905 or 912, CPT 90899, S9480, H2013) utilization review only for members meeting OMH triggers. Requests for members under 21 can be made via chmmc@fideliscare.org, fax 833-663-1604 or 1-888-FIDELIS with Children’s Medicaid prompts.

TMS: Transcranial Magnetic Stimulation covered; authorization required for CPTs 90867, 90868, 90869. Eligibility includes >18 years, FDA‑cleared device, labeled indications, confirmed MDD and prior treatment failures. Submit requests via ghcmbh@fideliscare.org, fax 833-561-0098 or 1-888-FIDELIS ext 16072.

ASD/ABA: ASD: authorization required for DME speech generation equipment; ABA requires authorization from Behavioral Health; attestation of ASD diagnosis by licensed physician or psychologist required at time of request.

Outpatient and DME Services

Prior authorization requirements for sleep studies, BRCA testing limits, wireless capsule endoscopy, GI procedure POS rules, DME PA status, and other outpatient PA rules.

Sleep studies, including home studies, require authorization.

BRCA testing: Breast cancer genetic testing: authorization not required for CPTs 81220, 81329, 81336, 81420. CPT 81220 has lifetime limit 1; CPTs 81329 and 81336 have a combined lifetime limit of 1.lifetime limits noted

Wireless capsule endoscopy (91110-91113) requires authorization.

GI procedure POS rules: Certain GI procedures (43235,43239,43248,45378,45380,45384,45385,46255,46260,46270) require authorization when performed in POS 19 or 22 if office/ASC available; authorization not required in POS 11 or 24.POS-specific

DME PA exceptions: Selected DME codes do not require prior authorization (A4239, A4287, A4590, A4670, A6533, A6540, A6591, A7021, L3702, L3762, L3915, L4350, L5991, L7360, L7362, L7364, L7366, L8678, S8421, S8424, V5010, V5020, V2625, V2626, V5266). Effective 4/1/24 additional codes A4271, 44438, A4564 also do not require PA. Other DME (compression garments, electric heat pads, protective helmets, surgical stockings, wigs, insulin pumps/infusion pumps, etc.) require authorization.

Other outpatient PAs: Other outpatient services listed (e.g., 97037, 42975, 10060, 11100, 11900, 17000, 20600, 20605, penile prosthesis 54405, 43290) require authorization as specified by place of service or listing.

Imaging Studies

Imaging PA rules including OB ultrasound thresholds, delegation of radiology PA to Evolent, TurningPoint cardiac ultrasound delegation, and TBS scans.

OB ultrasound thresholds: First four OB ultrasounds for a normal pregnancy can be performed without authorization; five or more ultrasounds for a normal pregnancy require authorization. OB ultrasounds for high-risk pregnancy do not require authorization.4 then 5+

Delegation: Prior authorization for radiology services has been delegated to Evolent (NIA). Cardiac ultrasounds are delegated to TurningPoint; many other ultrasounds may not require authorization. Refer to delegated lists for full CPT details.

TBS scans (77089-77092) require authorization.

Therapeutic Services

Authorization and coverage rules for phototherapy, hyperbaric oxygen, pain management, cardiac/pulmonary rehab, CGM, radiation delegation, bronchial thermoplasty, RFA of fibroids, vision therapy and related therapeutic services.

Phototherapy & HBO: Phototherapy (96567, 96573, 96574, 96900, 96910, 96912, 96913, 96920-96922) and Hyperbaric Oxygen Therapy (99183) require authorization.

Pain management and interventional pain management codes listed (e.g., 20526,20550-20553,21073,27096,62263-62264,62273,62280,63650,63655,63661-63664,63685,63688 and device HCPCS C1778,C1787,C1883,C1897) require authorization; specific low back pain interventions are non-covered.

Cardiac/Pulmonary rehab & CGM: Cardiac (S9472,93797,G0422,G0423,rev0943) and pulmonary rehab (G0237-G0239,S9473,rev0943) require authorization. Ambulatory continuous glucose monitoring (95249) requires authorization.

Radiation delegation & other therapies: Radiation therapy prior authorization delegated to Evolent (NIA). Bronchial thermoplasty (31660,31661), radiofrequency ablation of uterine fibroids (58674), vision therapy (92066,95919) require authorization.

Chiropractic Services

Authorization required for listed chiropractic CPTs.

Chiropractic codes 98940, 98941, 98942, 98943 and revenue code 0940 require authorization.

Counseling Services and DSMT

Coverage limits and authorization status for counseling and education services.

Counseling allowance: Members are allowed 10 hours/20 units in a continuous 12-month period for counseling services billed with G0108 and G0109; these services must be provided by certified providers and no longer require authorization.10 hours/20 units per 12 months

DSMT: Diabetes Self-Management Training (DSMT) and patient self-management education code 98960 referenced.

Services Provided by Outside Vendors

Authorization vendors for dental, vision and other outside vendor services and ambulance transport rules.

Dental: Orthodontic and major dental services require authorization by DentaQuest (1-800-516-9615).

Vision prior authorizations managed by Davis Vision (1-800-601-3383).

Ambulance transport: Non-emergency ambulance transport may be covered between facilities when transport is from non-participating to participating hospital; to a more cost-effective acute care facility; to a hospital providing a higher level of care unavailable at original hospital; or from an acute facility to a sub-acute setting. Emergency air/water ambulance reviewed for medical necessity.

Pharmacy and Enteral Therapy

Authorization rules for enteral therapy, oncology medication delegation to Evolent, exclusions, submission e-fax, and Appendix I relationship to Evolent.

Enteral therapy HCPCS codes B4034-B4162 require authorization; non-prescription enteral formulas for home use require a physician written order stating medical necessity for disease-specific treatment.

Oncology/ Evolent: Oncology medications and supportive agents require authorization from Evolent before dispensing or administration in outpatient/physician/ambulatory settings; clinical trials may be sent to Evolent. For list, see Evolent Resources Pharmacy-Services.

Excluded items (e.g., antibiotics, bone marrow transplants, CAR-T, inpatient drug requests) should not be sent to Evolent.

Submission & Appendix I: Submit prior authorization requests to the Pharmacy Team electronically via e-fax 1-844-235-5090. Appendix I lists codes requiring prior authorization and is separate from the Evolent program (some overlap).

Prior Authorization Requirement

Codes listed in Appendix I require prior authorization before claims will be approved, with an ophthalmic indication exception.

Each HCPCS/J/S code or other procedure code shown in Appendix I requires prior authorization before claims will be approved.

Ophthalmic exception: Authorization is not required for ophthalmic indications (explicit exception noted in Appendix I).

Utilization Management Voicemail Requirements

When leaving UM voicemail messages for providers:

HIPAA-compliant voicemail: Voicemail mailbox greetings must be HIPAA-compliant: identify mailbox owner, owner's organization, and state that mailbox is confidential and PHI can be left.

Detailed vs generic message: If HIPAA-compliant, a detailed UM message will be left; if not, a generic message requesting a call back will be left.

Second contact attempt: A second attempt to reach the provider directly will be made when notifying the provider of a UM determination per Department of Health Reasonable Effort Policy.

For members under 18 at OMH‑licensed hospitals, complete the OMH Two‑Day Notification and Initial Treatment Plan and submit within 2 business days by fax to 833-561-0094 or by email to Mental_Health_Admission@fideliscare.org to avoid concurrent review for the first 14 days.

Prior Authorization

Delegated prior authorization to Evolent and TurningPoint

When a CPT code appears on the Evolent or TurningPoint delegated lists, send prior authorization requests to the delegated vendor. If a CPT is delegated, associated HCPCS device codes will also be reviewed by the delegate.

Prior Authorization

Submit behavioral health testing authorization

Submit behavioral health testing authorization requests using the Psychological/Neuropsychological testing request form. Authorizations are required for CPTs 96112, 96113, 96116, 96121, 96130–96139, and 96146. Note: CPT 96110 is non‑covered.

Testing CPTs: 96112, 96113, 96116, 96121, 96130-96139, 96146
96110 is non-covered

Prior Authorization

TMS authorization submission

TMS (CPTs 90867, 90868, 90869) requires authorization. Requests may be submitted via email to ghcmbh@fideliscare.org, fax to 833-561-0098, or by calling 1-888-FIDELIS and following Behavioral Health prompts (ext. 16072).

TMS CPTs: 90867, 90868, 90869
Email: ghcmbh@fideliscare.org
Fax: 833-561-0098
Phone: 1-888-FIDELIS ext 16072

Prior Authorization

Pharmacy prior authorization submissions

Submit pharmacy prior authorization requests to the Pharmacy Team electronically via e-fax 1-844-235-5090. Oncology outpatient medication requests should be submitted to Evolent per the oncology section.

Pharmacy e-fax: 1-844-235-5090
Oncology outpatient requests → Evolent

Documentation Required

ASD attestation and ABA authorization

For ASD requests, include an attestation of ASD diagnosis signed by a licensed physician or psychologist at the time of the request. Authorization from Behavioral Health is required for Applied Behavior Analysis (ABA); authorization is also required for DME speech generation equipment.

Attestation must be by licensed physician or psychologist at time of request
Behavioral Health authorization required for ABA
Authorization required for DME speech generation equipment

Billing Rule

OB ultrasound authorization thresholds

OB ultrasound authorization thresholds: the first four ultrasounds for a normal pregnancy do not require authorization; five or more ultrasounds for a normal pregnancy require prior authorization. Ultrasounds for high‑risk pregnancy do not require authorization.

Normal pregnancy: 1–4 ultrasounds no PA; 5+ require PA
High‑risk pregnancy ultrasounds do not require PA

Prior Authorization

Radiology prior authorization delegated

Prior authorization for radiology services has been delegated to Evolent (NIA). Cardiac ultrasound/CUS delegations are handled by TurningPoint. When services are delegated, follow the delegated vendor's submission instructions and refer to the delegated code lists.

Radiology PA → Evolent (NIA)
Cardiac ultrasounds → TurningPoint (follow delegate instructions)

Prior Authorization

Appendix I: use for PA determination

Use Appendix I to determine which HCPCS/C/J/CPT codes require prior authorization. Appendix I is the source list for PA determination; note that Appendix I is separate from the Evolent program and some codes may overlap with delegated reviews.

Prior Authorization

Obtain prior authorization for listed codes

Providers must obtain prior authorization before billing for any HCPCS/J/S codes listed in Appendix I. Authorization is not required for ophthalmic indications (explicit exception).

Obtain PA for Appendix I codes before billing
Exception: ophthalmic indications do not require authorization

Documentation Required

Ensure voicemail is HIPAA-compliant for detailed UM messages

Voicemail greetings must be HIPAA‑compliant: they must identify the mailbox owner, the owner's organization, and state that the mailbox is confidential and PHI can be left. If compliant, detailed UM messages will be left; if not, only a generic message requesting a callback will be left.

Voicemail must identify owner and organization
Voicemail must state mailbox is confidential and PHI can be left
Non‑compliant mailboxes receive only a generic message

Denial Risk

Second contact attempt required for UM determinations

UM staff will make a second direct attempt to reach the provider when notifying of a UM determination per the Department of Health Reasonable Effort Policy. Failure to receive timely provider response or reasonable effort may affect authorization decisions.

Contact & submission quick-reference

Inpatient / ER fax (authorization)833-663-1602

LOCADTR submission fax (OASAS notifications)833-663-1608

OMH two-day notification — fax / emailFax 833-561-0094 or Mental_Health_Admission@fideliscare.org

TMS submission — fax / emailFax 833-561-0098 or ghcmbh@fideliscare.org

Pharmacy e-fax for PA requests1-844-235-5090 (e-fax to Pharmacy Team)

Dental & Vision authorizationsDentaQuest (orthodontic/major dental) 1-800-516-9615; Davis Vision (prior auth) 1-800-601-3383