Provider Quality

Fidelis Care is postponing the new Group and Family Therapy authorization requirements.  Providers do not need to submit Member Rosters for 2025 and may continue to submit claims for both 90853 and 90847 without authorization through December 31, 2025.

Effective January 1, 2026, requests for services that exceed 30 visits in a calendar year for Group and Family Therapy may be submitted through the standard authorization request channels. The concurrent review requirements will include Mental Health Group and Family Therapy, but excludes Substance Use Disorder (SUD) treatment when the provider/service(s) is/are Article 32 licensed, certified, or otherwise authorized.

Please note that beginning January 1, 2026, the following Mental Health services will require concurrent authorization once the initial 30 visits have been completed:

• Family Psychotherapy - CPT Code 90847
  • Fidelis Care will have notification & concurrent review requirements for Family Psychoeducation for any requests after the initial 30 visits per calendar year.       
• Group Psychotherapy - CPT Codes 90853         
  • Fidelis Care will have notification & concurrent requirements for Group Psychoeducation for any requests after the initial 30 visits per calendar year.  

After the first 30 visits have been rendered, providers must submit a concurrent authorization request along with the treatment plan to support continued medical necessity. To ensure the initial 30 visits per year are covered without authorization, providers must indicate the first date of service in their request and verify that the initial 30 visits have been completed.

The below FAQ was created to address provider questions related to the updated authorization requirements, which are in effect for dates of service exceeding 30 visits per calendar year, January 1, 2026, and thereafter.

Frequently Asked Questions

Q:  Will Fidelis Care be conducting concurrent review on 90847 and 90853?

A:  Yes, Fidelis Care will be conducting concurrent review on 90847 and 90853 for Mental Health Services, but not for Substance Use Disorder (SUD) services when the provider/service(s) is/are Article 32 licensed, certified, or otherwise authorized.

Q:  Are the 30 visits counted per provider or per member?

A:  The 30 visits are per code, at the member-level, over a calendar year.

Q:  How is calendar year defined?

A:  January 1^st through December 31st

Q:  Will 29-I Providers have the same concurrent authorization requirements?

A:  29-I providers are excluded from authorization requirements at this time.

Q:  How should providers submit concurrent review requests?

A:  Requests may be submitted through the below:

• Email: qhcmbh@fideliscare.org
• Fax: (833) 561-0094
• Phone: (718) 896-6500 extension 16072
• Availity Portal
• Fidelis Care Provider Portal

Q:  What information is required on the Concurrent Authorization Request?

A:  The following information is required on the request:

• Member and provider information, such as Member Full Name, ID and Date of Birth, Provider ID/TIN and Servicing Address
• Type of service requested & CPT codes (Family Psychotherapy 90847 or Group Psychotherapy 90853)
• First service date
• Duration and intensity of requested services
• Clinical goals, objectives, and rationale
• Place of service (e.g. office)
• For Mental Health treatment, please include the below details:
  • Risk of Harm (suicidal ideation: thoughts, plans, attempts [current/ past])
  • Functional Status
  • List any Medical, Substance Use Disorder, Mental Health Diagnoses/Concerns
  • Recovery Environment (Level of Stress)
  • Recovery Environment (Environmental Support)- To what extent does family and community resources address child’s needs? 
  • Resiliency and Response to Services: How well does the individual cope with adversity, use supports, and community resources? 
  • Treatment & Recovery History
  • Engagement in Services and Recovery Status: Is member engaged in treatment? 

Q:  What is the significance of the first service date on the concurrent review request?

A:  Providers must indicate the date of the first service to ensure the first thirty (30) visits are recognized and prevent claims delays.

The initial service date is critical for aligning the review period with the service timeline. This date triggers the “first thirty visits” count. If the date is inaccurate or missing, it may cause billing or authorization mismatches.

Q:  What documentation is required?

A:  To request services beyond the 30th visit, providers must submit a request for continuing service, which includes the below recommended documentation:

• A treatment plan with measurable goals
• Recent progress notes
• Recent psychiatric evaluation/biopsychosocial
• Please also include the below details:
  • Risk of Harm (suicidal ideation: thoughts, plans, attempts [current/ past])
  • Functional Status
  • List any Medical, Substance Use Disorder, Mental Health Diagnoses/Concerns
  • Recovery Environment (Level of Stress)
  • Recovery Environment (Environmental Support)- To what extent does family and community resources address child’s needs? 
  • Resiliency and Response to Services: How well does the individual cope with adversity, use supports, and community resources? 
  • Treatment & Recovery History
  • Engagement in Services and Recovery Status: Is member engaged in treatment? 

Q:  What level of detail is expected regarding frequency and intensity of services?

A:  To help reviewers assess appropriateness based on diagnosis, needs, and goals, providers must specify:

• Number of sessions per week/month (e.g. 1 session per week)
• Expected service duration per session (e.g. 45 minutes per session)
• Clinical justification for intensity and frequency

Q:  What is expected regarding Treatment Plan goals?

A:  Goals should be:

• Results-oriented
• Measurable
• Person-Centered
• Achievable within the treatment timeframe

Q:  How should claims be submitted?

A:  The first 30 visits should be submitted in chronological order. The best practice is to submit these claims in their own claims batch. Submitting claims out of sequence may lead to review misalignment, denied claims, and/or delayed payments.

Q:  What are common reasons for denied claims?

A:  Claims may be denied due to administrative issues including:

• Submitting claims out of consecutive date order
• Claims submitted past timely filing timeframes
• Member eligibility mismatches
• Incomplete or inaccurate information (e.g., missing modifiers, incorrect billing codes)

Q:  How should providers approach the transition for members who are already receiving group or family therapy?

A:  Providers may submit requests up to 30 days in advance of approaching the 30-visit count in a calendar year.

For additional questions, or if we can be of assistance in any way, please contact your Fidelis Care Behavioral Health Provider Engagement Account Manager. To find your designated representative, please visit Contact Your Designated Provider Relations Specialist.