Fidelis Care Authorization Grids Effective December 1, 2023
10/31/2023
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective December 1, 2023.
The following code has been added to the Medicare, Medicaid, Essential Plan, and Metal-Level Products Authorization Grids and requires prior authorization:
III. Outpatient surgery: The following services require prior authorization:
P. Other orthopedic procedures: 23140
The following codes have been added on the Medicaid DME Authorization Grid and require prior authorization:
K1036 Supplies for ultra diathermy
L1681 Ho bilateral hip abduction
L5991 Low pros ext osseo connector
New Century Health (NCH) will require review of the following codes as of December 1, 2023 for Medicare, Medicaid, Essential Plans and Metal-Level Products:
J3490 Motixafortide Injection
J8999 Momelotinib Oral
The following code has been removed from the list of drugs that require NCH review as of 7/8/2023 for Medicare, Medicaid, Essential Plans and Metal-Level Products:
J2425 Palifemin Injection
Visit: Authorization Grids