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Fidelis Care Authorization Grids Effective July 1, 2019
5/23/2019 • Posted by Provider Relations

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

The following services apply to Medicaid, Child Health Plus, and HealthierLife (HARP) lines of business and require prior authorization:

IV. Behavioral Health – Outpatient Services:

D.  Partial Hospitalization (Mental Health and/or Substance Abuse):

Requests for members under 21 can be made by email chmmc@fideliscare.org, fax (347) 690-7362 or by calling 1-888-FIDELIS (1-888-343-3547) and following the prompts for Children’s Medicaid. (added)

G.  Mental Health Continuing Day Treatment: 
Requests for members ages 18-20 can be made by email chmmc@fideliscare.org, fax, (347) 690-7362 or by calling 1-888-FIDELIS
(1-888-343-3547) and following the prompts for Children’s Medicaid. (added)

H.  Personalized Recovery Oriented Services (PROS): 
Requests for members ages 18-20 can be made by email chmmc@fideliscare.org, fax, (347) 690-7362 or by calling 1-888-FIDELIS
(1-888-343-3547) and following the prompts for Children’s Medicaid.  (added)

I.  Assertive Community Treatment (ACT):
Requests for members ages 18-20 can be made by email chmmc@fideliscare.org, fax, (347) 690-7362 or by calling 1-888-FIDELIS
(1-888-343-3547) and following the prompts for Children’s Medicaid.  (added)
 
O.  Children and Family Treatment and Support Services (CFTSS):
Effective July 1, 2019, an additional CFTSS will be available to Medicaid recipients under age 21:

      4.  FPSS – Family Peer Support Services (H0038)
      Fidelis Care will not conduct prior authorization review for the first 3 CFTSS visits.
      However, concurrent review is required prior to the 4th visit.  Providers must submit the
      CFTSS Authorization Request Form by email or fax, (347) 690-7362 prior to the 4th visit. 
      Providers may also contact Fidelis by telephone at 1-888-FIDELIS (1-888-343-3547) and
      follow the prompts. (added)

P.  Children’s BH Carve-In:  Effective July 1, 2019:

Name of Service

Authorization Requirement

Age Requirement

Medicaid Benefit Status (New or Previously covered)

Medicaid -SSI Benefit Status  (New, Previously covered, Carve-In)

OMH designated Serious Emotional Disturbance (SED) Clinic Services

None

Under 19

New

New

OMH Outpatient Services

None

Under 21

Previously covered

New

Psychiatric Services

None

Under 21

Previously covered

New

Psychological Services

None

Under 21

Previously covered

New

Partial Hospitalization Program

Prior Auth, Concurrent Review

Under 21

New

New

Assertive Community Treatment (ACT)

Prior Auth, Concurrent Review

18-20

New

New

Continuing Day Treatment

Prior Auth, Concurrent Review

18-20

New

New

Personalized Recovery Oriented Services (PROS)

Prior Auth, Concurrent Review

18-20

New

New

Inpatient Psychiatric Services

Prior Auth, Concurrent Review

Under 21

Previously covered

New

Comprehensive Psychiatric Emergency Program

None

Under 21

Previously covered

New

Outpatient – Clinic

None

Under 21

New

New

Outpatient – Rehabilitation Programs

Concurrent

Under 21

New

New

Opioid Treatment Program Services

Concurrent

Under 21

New

New

Chemical Dependence Inpatient Rehabilitative Services

Prior, Concurrent

Under 21

Previously covered

New

 
     Requests for services listed above for members under age 21 can be made by email
     chmmc@fideliscare.org, fax, (347) 690-7362 or by calling 1-888-FIDELIS (1-888-343-3547)
     and following the prompts for Children’s Medicaid.
     (added)

Visit:  Authorization Grids
 

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