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Fidelis Care Authorization Grids Effective January 1, 2019
11/29/2018 • Posted by Provider Relations

The following sections of the Fidelis Care authorization grids have been updated effective January 1, 2019.

The following services apply to all product lines of business and require prior authorization:

II. or III. – Outpatient Surgery:
     N.  Spinal surgery:  20932, 20933, 20934 (added)

III. or IV.  – Behavioral Health Outpatient Services:
     A.  Psychological/Neuropsychological Testing:
           96121, 96136, 96137, 96138, 96139, 96130, 96131, 96132, 96133, 96146 (added)

     B.  Developmental Pediatric Testing:
           96112, 96113 (added)

IV or V.  – Outpatient and DME Services
     H.  Therapeutic Services:
           3. or 4.  Pain Management Codes:
                64553 - 64595 (code range clarified due to terminated code 64550)

Behavioral Health Update

Effective 1/1/2019, three Children and Family Treatment and Support Services will be available to Medicaid recipients under age 21 who meet medical necessity criteria:

       1.    OLP - Other Licensed Practitioner (90791, H0004, H2011, 90882)
       2.    CPST – Community Psychiatric Supports and Treatment (H0036)
       3.    PSR- Psychosocial Rehabilitation (H2017)

Prior authorization review is not required for the first 3 CFTS visits. Concurrent review is required prior to the 4th visit. Providers must notify Fidelis Care by telephone or email before providing services.

Family Planning and Reproductive Health Benefits update:

Starting January 1, 2019, Fidelis Care members, except for Medicare Advantage and Dual Advantage, will obtain family planning and reproductive health benefits by using their Fidelis Care Member ID card. 

•    Members do not need a referral from their PCP to obtain these benefits. 
•    There are no changes to our members’ covered family planning and reproductive health benefits.
•    Members, who see a Fidelis Care network provider, will obtain these benefits from Fidelis Care rather than
      from an outside vendor.  

Therefore, Sections VIII. - Services Provided by Outside Vendors:  Items D. Family Planning and E. Infertility Treatment have been removed from Essential Plan and Metal-Level Products:

Section VIII. – Services Provided by Outside Vendors:  
Essential Plan and Metal-Level Products:

        D. Family Planning (deleted)
        E. Infertility Treatment (deleted)   

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Important Information on Coverage Decisions

Each day, Fidelis Care's Utilization Management (UM) Department makes decisions on numerous health insurance claims. These decisions are based only on appropriateness of care and the existence of coverage. 

Fidelis Care does not reward practitioners or other individuals for issuing denials of coverage, and does not offer financial incentives to UM staff that would encourage decisions that result in underutilization of services. 

Fidelis Care is committed to ensuring that members have the care and services they need. 

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