Authorization and Utilization Review — New York State (OMH/OASAS, enteral therapy, specialty drugs, and procedural PA guidance)
Updates to Fidelis Care authorization, utilization review, and coding guidance affecting inpatient, outpatient, and behavioral health services in New York State; includes COVID-19 reference and specific rules for OMH/OASAS-licensed facilities and selected procedures. Affects providers rendering services to Fidelis Care members.
OMH licensed inpatient mental health treatment in NYS is not subject to prior authorization effective 06/01/2021, with notification and limited utilization review triggers.
OASAS licensed inpatient SUD services in-network and in-state are not subject to prior authorization or concurrent review for first 28 days effective 01/01/2020, with notification and LOCADTR process requirements.
Prior authorization for orthopedic and certain spinal surgical procedures delegated to TurningPoint Healthcare Solutions effective 12/23/2019 for services beginning 10/1/2019.
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.