1/31/2023
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Posted by Provider Relations
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Provider News
The following sections of the Fidelis Care authorization grids have been updated effective March 1, 2023.
The Medicaid grid has been updated as follows:
In order to comply with the New York State guidance received on December 13, 2022, the Children’s Respite Services flexibility will end immediately and providers are required to revert to the original guidance provided in the HCBS Manual:
• Respite Services may no longer be billed if delivered via telehealth or telephonically to an individual or group;
• All Respite Services must be delivered in-person, as remote delivery will no longer be allowable;
• Respite Services may be delivered by qualified practitioners in a home or residence, out-of-home/residence by staff in community-based sites (e.g., community centers, camps, parks), or in allowable facilities; and
• Billing for Respite must be based on in-person interactions with the Waiver enrolled children/youth.
Additionally, Planned and Crisis Respite services may not exceed the 14 days (1,344 15-minute units) annual limits without medical necessity. Planned and Crisis Respite beyond these limits MUST be supported by medical necessity, such as, documentation through a Licensed Practitioner of the Healing Arts (LPHA) Attestation form along with NYS DOH Children’s HCBS Authorization and Care Manager Notification form by email to SM_Childrens_HCBS@fideliscare.org, fax (347) 690-7362 or by calling 1-888-FIDELIS (1-888-343-3547) and following the prompts for Children’s Medicaid.
Notification should be submitted prior to rendering the service to prevent disruptions in claims processing. C-YES and Health Home providers are responsible for submitting the Plan of Care to Fidelis to comply with the Children’s HCBS workflow requirements. Once the required documentation is submitted, you will be notified verbally of the determination. You and the member will receive a letter communicating the details of the determination.
Providers should not wait until the initial authorization expires before requesting concurrent review. As soon as frequency, scope, and duration are determined, the form must be submitted before the end of the existing authorization to reduce risk of claims processing delays.
New Century Health (NCH) will require review of the following codes as of 03/01/2023:
Added to the list of drugs that require NCH review for Medicare, Medicaid, Essential Plan and Metal-level products:
- J1954 Leuprolide acetate injection (Lutrate Depot)
- J8999 Adagrasib oral (Krazati)
- J9314 Pemetrexed injection (Teva)
- J9999 Pemetrexed injection (Sandoz)
- J9999 Mosunetuzumab-AXGB injection (Lunsumio)
- J9999 Nadofaragene Firadenovec-VNCG injection (Adstiladrin)
The following codes have been updated on the Medicare grid and require prior authorization:
- J1954 leuprolide acetate
- J9042 brentuximab vedotin (Adcetris)
- J9314 pemetrexed
Visit: Authorization Grids
COVID-19 UPDATE: Please refer to this link: Important Updates Regarding Coronavirus COVID-19, for authorization and coding guidelines related to the COVID-19 Pandemic.