Fidelis Care Coverage Criteria
Latest Fidelis Care coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-01Prior Authorization and Coverage Criteria — Fidelis Care Medicaid/CHP/HealthierLifeOperational and authorization guidance for Fidelis Care Medicaid/CHP/HealthierLife providers covering inpatient, outpatient, behavioral health, transplant, surgical, and substance use disorder services in New York State. Affects network and non-network providers rendering services to Fidelis Care members.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-09-01Personal Care Services (PCS) — Minimum Needs Requirements and Coverage CriteriaDefines coverage, eligibility, authorization, billing, and operational requirements for Personal Care Services for Fidelis Care members receiving community-based long term services in New York State.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-07-25Medical Necessity CriteriaDefines Fidelis Care's hierarchy of guidance and definitions used to make medical necessity determinations for all lines of business except Medicare; applies to providers and utilization reviewers evaluating coverage for member/enrollees.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-04-01Clinical Policy: Genetic TestingDefines medical necessity criteria for genetic tests when no specific policy exists for the requested test; includes general tumor biomarker analysis criteria and exclusions (e.g., DTC testing, genetic banking). Applies to all lines of business except Medicare.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-03-01Infusion Therapy Site of Care OptimizationDefines medical necessity criteria and authorization rules for the site of care for medically necessary specialty intravenous or injectable infusion services and lists affected HCPCS/J-codes. Applies to providers requesting outpatient hospital or non-hospital outpatient infusion site coverage for Fidelis Care members.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-02-01Clinical Policy: Nerve Blocks and Neurolysis for Pain ManagementDefines medical necessity criteria, limitations, and non-coverage determinations for various nerve block and neurolytic procedures (occipital, sympathetic, celiac plexus, intercostal, genicular, peripheral/ganglion, intraosseous basivertebral nerve ablation) for non‑Medicare Centene-affiliated plans; includes related coding implications.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Dental benefits — coverage criteria for CDT procedure codes, frequency limits, and provider requirementsThis document describes the Fidelis Care 2025 dental benefits package, listing covered dental procedure codes, frequency limits, and provider requirements for members of specific Fidelis/Wellcare plans (examples include several HMO D-SNP plans in NY). It affects providers submitting claims for covered dental services under the 2025 plan benefit package.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Prior Authorization and Coverage Criteria — Actemra (tocilizumab) subcutaneous and Tyenne productsThis policy governs prior authorization and coverage criteria for Actemra (subcutaneous and ACTPen) and Tyenne (autoinjector and subcutaneous) products for Fidelis Care members in North Carolina; it affects prescribers, pharmacists, and prior authorization reviewers.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Prior Authorization and Coverage Criteria — Inpatient, Outpatient and Behavioral Health ServicesGoverns 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.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Tocilizumab (Actemra/Tyenne) prior authorization and coverage criteriaDefines prior authorization, clinical criteria, prescriber and age restrictions, and continuation requirements for Actemra/Tyenne subcutaneous products for Fidelis Care members in North Carolina.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-04-01Family Planning and Infertility Services (Ovulation Induction Coverage Criteria)Defines Fidelis Care coverage for family planning and certain infertility (ovulation induction) services for NYS Medicaid members, including pharmacy prior authorization routing to NYRx; affects members and participating providers.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-01-01Authorization and Utilization Review Coverage CriteriaGoverns prior authorization, utilization review, and notification requirements for a range of inpatient, outpatient, surgical, and behavioral health services for Fidelis Care members in New York State (NC not applicable here).All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-07-01Oncology medications and supportive agents prior authorization (Coverage Criteria)Defines Evolent review and prior authorization requirements for oncology medications and supportive agents for Fidelis Care Medicaid Managed Care & HealthierLife members and lists HCPCS/CPT/J-codes that require review or are out of scope.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-07-01Oncology medications and supportive agents prior authorization (coverage criteria)Governance of prior review and prior authorization requirements for oncology medications and supportive agents for Fidelis Care Medicaid Managed Care & HealthierLife members (adults; pediatric inclusion noted). Applies to dispensing at pharmacy and administration in physician office, outpatient hospital, or ambulatory settings.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-04-01Authorization and Utilization Review Requirements (Coverage Criteria)Defines Fidelis Care authorization requirements, utilization review rules, and delegated prior authorization arrangements for inpatient, outpatient, behavioral health, SUD, and certain surgical services in New York State; applies to providers delivering services to Fidelis Care members.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-09-01Authorization and Utilization Review Requirements (Coverage Criteria)Governs prior authorization, utilization review, and related authorization/coding guidance for a range of inpatient, outpatient, behavioral health, diagnostic, and DME services for Fidelis Care members in New York State. Affects providers requesting authorization or notification for these services.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-06-01Authorization and Coverage Criteria — Inpatient, Outpatient, Behavioral Health, and Select ProceduresAll Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-02-01Clinical Policy: Autologous Hematopoietic Stem Cell Transplant (Pediatric)Medical necessity criteria for autologous hematopoietic stem cell transplant in patients younger than 18 years, specifying covered disease indications, performance status, infection/substance use/social support requirements, and related coding guidance.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-01-01Physical, Occupational, and Speech Therapy (PT/OT/ST) Coverage CriteriaRemoves prior service limits and covers medically necessary PT, OT, and ST visits ordered by a physician or other licensed professional for Fidelis Care members effective January 1, 2021.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-07-01Nutrition and Metabolism Non-Genetic TestingDefines coverage and reimbursement rules for non-genetic nutrition and metabolism laboratory tests (e.g., vitamin D, vitamin B12/folate, iron studies, homocysteine) for Fidelis Care Medicaid and Health Insurance Marketplace products and the conditions under which those tests are covered.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-03-01Golodirsen (Vyondys 53) CoverageGoverns prior authorization and medical necessity criteria for golodirsen (Vyondys 53) for treatment of Duchenne muscular dystrophy patients with DMD gene mutations amenable to exon 53 skipping for Fidelis Care (NY Medicaid and HIM lines of business). Applies to providers requesting coverage.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-01-01Authorization & Utilization Review — Facility, Behavioral Health, and SUD Services (Coverage Criteria)Governs prior authorization, utilization review, and related operational requirements for Fidelis Care Medicaid (and select lines) services in New York State, including inpatient, outpatient surgical, transplant, behavioral health, and SUD settings. Affects participating and nonparticipating providers/facilities rendering these services.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-01-01Authorization and Coverage Criteria — Administrative Prior Authorization and Coding GuidanceGoverns prior authorization, concurrent review, and coding guidance for inpatient admissions, outpatient procedures, behavioral health, diagnostic testing, DME, imaging, and therapy services for Fidelis Care members; affects in-network and out-of-network providers in the policy's jurisdiction.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-01-01Authorization and Prior Authorization Coverage CriteriaDefines prior authorization, notification, and utilization review expectations for Fidelis Care Medicaid/CHP/HealthierLife providers across inpatient, outpatient, behavioral health, SUD, transplant, surgical and delegated-review programs. Applies to providers delivering services to Fidelis Care members under the Medicaid programs referenced in the document.All Fidelis Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-01-01Authorization and Prior Authorization Coverage Criteria (Appendix I excerpt)This document describes Fidelis Care authorization, prior authorization delegation, inpatient/outpatient service requirements, behavioral health and substance use disorder authorization changes, and selected coding lists that affect providers serving Fidelis members in New York State.All Fidelis Care updates
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Tool Description
Search Fidelis Care coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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