5/31/2023
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective July 1, 2023.
The Medicaid grid has been updated as follows:
IX. Pharmacy
A. See Appendix I for codes that require authorization. Please submit prior authorization requests to our Pharmacy Team electronically via fax (e-fax) to: 1-877-533-2405.
1. ONCOLOGY-RELATED REQUESTS, SEE SECTION B: Please see section B for outpatient oncology-related requests that require prior authorization and review by New Century Health. Appendix I is not related to the New Century Health program.
2. S codes are benefit exclusions except for S0013, S0190, S0191, S9435. Use prescription benefit for S codes for oral medications. Please note, prescription benefit transferred to FFS on 4/1/2023 for NYM and HARP line of business.
3. HCPCS codes for medications that are not FDA approved (e.g. J1726) are considered a benefit exclusion.
4. J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332, 7333 are non-covered when billed with CPT code 20610 or 20611 or any of the following diagnosis: M17.0, M17.10-M17.12, M17.2, M17.20-M17.32, M17.4, M17.5, M17.
5. Maximum unit edits apply to all HCPCS codes regardless of authorization status. The policy for Maximum Units of Service can be found at the following link: https://www.fideliscare.org/Portals/0/Providers/CC.PP.007-Maximum-Units-of-Service.pdf
The Medicare, Essential Plan and Metal-Level grids have been updated as follows:
V. Outpatient and DME Services: The following services require prior authorization:
B. Durable Medical Equipment/Supplies:
2. These DME codes that do not require an authorization:
E0130, E0135, E0168, E0182, E0184, E0235, E0274, E0305, E0310, E0424, E0431, E0434, E0439, E0570, E0575, E0580, E0602, E0603, E0621, E0655, E0660, E0776, E0890, E0900, E0942, E2361, E2363, L0130, L0140, L0150, L0160, L0170, L0172, L0174, L0180, L0190, L0200, L1652, L1902, L2132, L2134, L2136, L3100, L3221, L3762, L4350 (new code), L7360, L7362, L7364, L7366, S8421, S8424, V5266
Effective 4/1/23, the following codes are new and do not require PA: A4341, A4342, A4560, A6590, A6591, A7049, E0677, E0711, K1035, L8678.
IX. Pharmacy
A. See Appendix I for codes that require authorization. Please submit prior authorization requests to our Pharmacy Team electronically via fax (e-fax) to: 1-877-533-2405.
1. ONCOLOGY-RELATED REQUESTS, SEE SECTION B: Please see section B for outpatient oncology-related requests that require prior authorization and review by New Century Health. Appendix I is not related to the New Century Health program.
2. S codes are benefit exclusions except for S0013, S0190, S0191, S9435. Use prescription benefit for S codes for oral medications.
3. HCPCS codes for medications that are not FDA approved (e.g. J1726) are considered a benefit exclusion.
4. Maximum unit edits apply to all HCPCS codes regardless of authorization status. The policy for Maximum Units of Service can be found at the following link: https://www.fideliscare.org/Portals/0/Providers/CC.PP.007-Maximum-Units-of-Service.pdf
New Century Health (NCH) will require review of the following codes as of July 1, 2023 for Medicare, Medicaid, Essential Plans and Metal-Level products:
J7308 Aminolevulinic Acid 20% Topical (Levulan Kerastick)
J9999 Bexarotene 1% Topical Gel (Tagretin)
J9999 Fluorouracil 0.5% Topical Cream (Carac)
J9999 Fluorouracil 1% Topical Cream (Flouroplex)
J9999 Fluorouracil 5% Topical Cream (Efudex)
J9999 Imiquimod 5% Topical Cream (Aldara)
J9999 Tirbanibulin 1% Topical Ointment (Klisyri)
J7520 Sirolimus Oral
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