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Fidelis Care Authorization Grids Effective June 1, 2019
4/29/2019 • Posted by Fidelis Care

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

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

IV. or V.   Outpatient and DME Services:    
                  E.  Imaging Studies*: 
                        Five or more ultrasounds for a normal pregnancy:  diagnosis code Z32.01 (added)
                        (*refer to the online authorization grid for the full description on E. Imaging Studies)

VIII. or IX.  Pharmacy:
                  •    These injectable codes require prior authorization: J2787, Q4081 (excludes Medicare) (added)
                  •    These injectable codes do not require authorization: 
                        C9035, C9037, J2358, J2426, J2794 (removed)    
    
Visit:  Authorization Grids
 

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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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