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As part of our ongoing work to improve the prior authorization (PA) process for both providers and members, Fidelis Care wants to share some important updates to our PA requirements. Our goal is to reduce administrative burden, simplify submission and approval processes, and facilitate timely access to appropriate, high-quality care.
Code change details are noted in the table below. The changes may include:
For questions about specific prior authorization codes or how these changes affect your practice, please reach out to your local Provider Engagement representative.
Medicaid
Service Category
PA Rule
Services
Procedure codes
Behavioral Health
No PA Required for participating providers
Neurobehavioral Status Exam
96116, 96121
DME and Supplies
Mobility Services
E0630
Respiratory Devices and Supplies
E0443
Wheelchairs
E0954, E0955, E2607, E2608, E2622, E2623, E2624, E2625
Orthotic and Prosthetic
L1932, L2630, L5000, L5620, L5629, L5631, L5637, L5704, L5920, L5950
Drug Codes
No PA Required CHP members only
Diabetic Drugs and Supplies
A4238
Genetic Analysis
Genetic Testing
81161, 81200, 81206, 81207, 81240, 81241, 81242, 81243, 81250, 81251, 81255, 81260, 81279, 81297, 81304, 81319, 81338, 81339, 81400, 81401
Hearing Services
Implants and Supplies
L8624
Hearing Aids
V5130, V5160, V5140
Home Services
Home Visit
S9211, T1028
Nursing Services
T1001
Other Medical Services
PA Required
Other Services
T1999
Wound Care
97597
Dental Care
G0330
Waiver Services
T2023
Incontinence Supplies
T4541
Physician Services
Diagnostic Testing
91299
91110, 91111, 91112
Sleep Medicine
Sleep Studies
95800, 95805, 95806
Surgery Procedures
Eye and Ocular Adnexa
67904
Ambetter From Fidelis Care
Anesthesia
Anesthesia Services
00170
0211U, 0345U
86813, 86817
S9211, S9213, S9214
Tonsil and Adenoid Procedures
42835
Transplant Services
Transplant
38208
Medicare
Testing
No PA Required
Psychological Testing/Neuropsychological Testing
96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146
Equipment and Accessories
E0656, E0657
L0457, L0650, L1932, L1940, L1960, L2330, L3030
E0470, E0471, E0562
Supplies and Devices
E0935
E1226, E2310, E2374, E2607, E2608, E2613, E2614, E2615, E2622, E2623, E2624, E2625
DME Services
E1032, E1033, E1034
88271, 88275, 88280
Infusion Services
99601, 99602, S9500
97605, 97606
Pain Management
Surgery – Nervous System
64566
91110, 91111, 91112, 91113
99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350
Integumentary Services
14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 15100
Musculoskeletal System
29848
Transportation Services
Medical Transportation
A0100