Fidelis Care Prior Auth Policy Update

Coverage and Utilization Review Criteria

Inpatient Substance Use Disorder (OASAS) — initial waiver

Inpatient SUD (OASAS-licensed, in-state, in-network) are not subject to prior authorization or concurrent utilization review during initial period when conditions are met.

OASAS inpatient SUD initial authorization waiver: All of the following must be true: facility is licensed, certified, or otherwise authorized by OASAS in New York State; facility participates in Fidelis Care's provider network; the facility notifies Fidelis Care of the inpatient admission and the initial treatment plan within two (2) business days (OASAS Appendix A Notification Form and LOCADTR may be faxed or emailed); and the facility performs daily clinical review of the patient.28 days

Concurrent utilization review may occur after the 28th day of admission or upon discharge; facilities must periodically consult with Fidelis Care starting on or just prior to day 14 to ensure appropriate use of the LOCADTR tool.

OMH inpatient mental health — utilization review triggers

Inpatient mental health treatment provided by OMH-licensed hospitals in NY State has limited utilization review per NYS OMH Best Practice Manual; some populations and triggers require review.

Triggers for utilization review for OMH-licensed inpatient MH: Any of the following: current Assisted Outpatient Treatment (AOT) court order or an AOT order that expired within the past five years; high utilization in the prior 12 months as defined by thresholds (three psychiatric inpatient hospitalizations OR four psychiatric ED visits OR three medical inpatient hospitalizations); readmission to any mental health inpatient unit within thirty (30) days of a prior mental health inpatient discharge; or length of stay exceeding 30 days (concurrent review from Day 31 onwards).see threshold nodes

Facility must notify Fidelis Care within two (2) business days of admission; for members under 18, if the OMH Two-Day Notification and Initial Treatment Plan form is submitted and daily clinical review and periodic consultation occur, Fidelis will not conduct concurrent review during the first 14 days.

Partial Hospitalization and Intensive Outpatient — review criteria

Partial hospitalization and Intensive Outpatient Programs (OMH-licensed in NY) utilization review will be conducted only for members who meet defined clinical triggers per NYS OMH Best Practice Manual.

PH/IOP/IOP utilisation review triggers: Any of the following: current or recent AOT court order (or expired within five years); high utilization in the past 12 months as defined by thresholds (three psychiatric inpatient hospitalizations OR four psychiatric ED visits OR three medical inpatient hospitalizations); readmission within 30 days of prior mental health inpatient discharge; or length of stay/activity exceeding 30 days (concurrent review from Day 31).see threshold nodes

Out-of-network facilities remain subject to concurrent review throughout the admission.

Autism Spectrum Disorder services

Autism Spectrum Disorder (ASD) services

ASD authorization requirements: Authorization is required for DME speech generation equipment and for Applied Behavior Analysis (ABA). Attestation of an ASD diagnosis by a licensed physician or psychologist must be provided at the time of the request.

Authorization for ABA is obtained from Behavioral Health.

Rehab / Habilitation Limits

Rehabilitation and habilitation visit limits

Rehabilitation and Habilitation visit limits: The benefit is limited to 60 visits per condition per plan year for Rehabilitation; the visit limit applies to all therapies combined. Habilitation is limited to 60 visits per condition per plan year; the visit limit applies to all therapies combined.60 visits

Applies per condition per plan year.

Home Health and Hospice

Home health and hospice coverage limits

Home health and hospice limits: Home care approvals are based on medical need for skilled services with a benefit maximum of 40 visits per plan year. Hospice care must be provided as part of a certified Hospice Care program and, when medically necessary, coverage is available for up to 210 days.40 visits; 210 days

Home health measured in visits; hospice measured in days.

Not Covered for Low Back Pain

Services not covered for members with Low Back Pain

Low Back Pain exclusions: The following services are not covered for members with a diagnosis of Low Back Pain: prolotherapy; therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT fluoroscopic image guidance); therapeutic injections of steroids into intervertebral discs; and continuous or intermittent traction.

Explicit exclusion list for Low Back Pain diagnoses.

Outpatient Therapy Authorization

Outpatient therapy prior authorization delegation and workflow

Outpatient PT/OT/ST authorization: Effective 10/1/2021, outpatient therapy services (PT, OT, ST) performed after the initial evaluation require prior authorization through National Imaging Associates (NIA). Initial evaluations do not require prior authorization. All other billed procedure codes, even if performed on the same date as an initial evaluation, require authorization prior to billing. Non-therapy providers should submit prior authorization requests directly to Fidelis Care. If submitting claims using codes other than designated initial evaluation CPT codes, an authorization request must be sent to NIA within 1 business day for outpatient or within 2 business days for home health.

Delegated to NIA effective 10/1/2021; initial evaluations excluded.

For substance use disorder (SUD) services, out‑of‑state or out‑of‑network OASAS providers must request prior authorization for both inpatient and outpatient care. Effective January 1, 2020, Fidelis Care does not require prior authorization, provider notification, or concurrent review for in‑network, in‑state outpatient OASAS services (including outpatient office/therapy visits, outpatient clinic treatment, intensive outpatient programs, outpatient rehabilitation, and opioid treatment programs), but the exception does not apply to providers located out of state or outside the network.

CPT code 20610 is included among ambulatory surgery center procedures that require authorization when billed from freestanding ASCs (bill type 0831), but it is explicitly non‑covered when billed with knee osteoarthritis diagnosis codes in the M17.* series

The policy states that orthotics are not covered. Home health and hospice limits are specified elsewhere, and DME rules note that some DME codes do not require authorization while other DME and supply items do; orthotics are explicitly listed as excluded from coverage in the DME section.

Outpatient oncology‑related requests for members age 18 and over in Medicaid Managed Care, the Essential Plan, and Qualified Health Plan (excluding Child Health Plus) must be routed for prior authorization and clinical review by New Century Health. The policy directs providers to Section B for the detailed outpatient oncology prior authorization process and specifies this delegation to New Century Health for the stated member groups.

The policy lists the specific knee osteoarthritis diagnosis codes (the M17.* series) that render CPT 20610 non‑covered when billed together. The non‑covered diagnosis list includes: M17.0, M17.10–M17.12, M17.2, M17.20–M17.32, M17.4, M17.5, and M17.9.

For members with a diagnosis of Low Back Pain, the policy identifies several procedures and therapies that are not covered: prolotherapy; therapeutic facet joint steroid injections in the lumbar and sacral regions (with or without CT fluoroscopic guidance); therapeutic injections of steroids into intervertebral discs; and continuous or intermittent traction. These exclusions apply specifically when the member’s diagnosis is Low Back Pain.

Codes and Authorization Status

Transplant CPT codes requiring authorizationCPTCovered

32850-32856	Listed transplant-related CPT range
33930-33945	Listed transplant-related CPT range
38204-38215	Bone marrow/transplant related
38230-38242	Bone marrow/transplant related
44133-44136	Transplant-related/listed
47133-47147	Transplant-related/listed
48160	Transplant-related/listed
48550-48556	Transplant-related/listed
50300-50380	Transplant-related/listed
50547	Transplant-related/listed

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Selected outpatient surgical CPT codes requiring authorizationCPTCovered

43770-43775	Bariatric surgery
S2083	Bariatric surgery
15820-15823	Blepharoplasty
11920-11971	Breast reconstruction
19300	Breast reconstruction/reduction
19316-19342	Breast reconstruction
19355	Breast reconstruction
19370-19396	Breast reconstruction
10040	Skin surgery (ambulatory POS24 authorization)
11300-11313	Skin surgery

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ASC and vascular/orthopedic CPT codesCPTCovered

20600	Orthopedic procedure requiring authorization in ASC billing 0831
20605	Orthopedic procedure requiring authorization in ASC billing 0831
20610	Orthopedic procedure; note non-covered when billed with certain knee Dx codes
36465-36466	Vascular procedures
36468-36479	Vascular procedures
36482-36483	Vascular procedures
37718-37785	Vascular procedures
37241-37244	Vascular procedures

Behavioral health testing and ECT codesCPTCovered

96116	Psychological testing
96121	Psychological testing
96130	Psychological testing
96131	Psychological testing
96132	Psychological testing
96133	Psychological testing
96136	Psychological testing
96137	Psychological testing
96138	Psychological testing
96139	Psychological testing

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Behavioral health program codes (PH, IOP, Residential)mixedCovered

Revenue 912, 913, 944, 945	Partial hospitalization revenue codes
HCPCS H0035	Partial hospitalization HCPCS
Revenue 905 or 912	Intensive outpatient
CPT 90899	Intensive outpatient (listed)
S9480	Intensive outpatient
HCPCS H2013	Intensive outpatient HCPCS
CPT 1001-1002	Residential treatment CPTs listed
HCPCS H0017-H0019	Residential treatment HCPCS
HCPCS H2036	Residential treatment HCPCS

Diagnostic testing and GI procedure codes requiring authCPTCovered

91110-91111	Wireless capsule endoscopy
91112-91113	Wireless motility capsule
43235	Gastroenterology procedures requiring auth in POS19/22 when office/ASC available
43239	Gastroenterology procedure
43248	Gastroenterology procedure
45378	Gastroenterology procedure
45380	Gastroenterology procedure
45384	Gastroenterology procedure
45385	Gastroenterology procedure
46255	Gastroenterology procedure

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Residential Treatment CodesCPT | HCPCS

1001	residential treatment
1002	residential treatment
H0017	HCPCS residential treatment
H0018	HCPCS residential treatment
H0019	HCPCS residential treatment
H2036	HCPCS

Diagnostic/Imaging and GI Codes Requiring AuthorizationCPTCovered

91110	Wireless Capsule Endoscopy
91111	Wireless Capsule Endoscopy
91112	Wireless Motility capsule
91113	Wireless Motility capsule
43235	Gastroenterology procedure
43239	Gastroenterology procedure
43248	Gastroenterology procedure
45378	Gastroenterology procedure
45380	Gastroenterology procedure
45384	Gastroenterology procedure

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Therapeutic Services CodesCPT | HCPCSCovered

96567	Phototherapy
96573	Phototherapy
96574	Phototherapy
96900	Phototherapy
96910	Phototherapy
96912	Phototherapy
96913	Phototherapy
96920	Phototherapy
96921	Phototherapy
96922	Phototherapy

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Chiropractic CodesCPT | RevenueCovered

98940-98943	Chiropractic services
0940	Revenue code associated

DME codes not requiring authorization (partial list)HCPCS

E0130	DME not requiring authorization (example list)
E0135	DME not requiring authorization (example list)
E0168	DME not requiring authorization (list)

Pharmacy/HCPCS codes listed for authorization/reviewHCPCS | C-codes | J-codesCovered

C9054	lefamulin (Xenleta)
C9055	brexanolone
C9047	caplacizumab-yhdp (Cablivi)
C9063	eptinezumab-jjmr (Vyepti)
C9074	lumasiran (Oxlumo)
C9085	avalglucosidase alfa-ngpt inj
J0129	abatacept (Orencia) and related cross-references
J0135	adalimumab (Humira) and related
J0172	adacanumab-avwa (Aduhelm) and related
J0401	aripiprazole ER inj (Abilify) and related

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Benefit applies (partial list)HCPCS

J0490	galsulfase (Naglazyme) — listed
J0565	bezlotoxumab (Zinplava) and multiple immune glob references — listed
J1459	listed in association with J0565