7/1/2019
•
Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated
effective August 1, 2019.
The following service applies to all lines of business and requires prior authorization:
IV. or V. Outpatient and DME Services:
4. Gastroenterology Procedures:
Place of Service (POS) 19 (added)
VIII. or IX. Pharmacy:
B. These injectable codes require authorization:
Medicaid, Child Health Plus, and HealthierLife:
• These injectable codes require prior authorization:
C9047, C9048, C9049, C9050, C9051, C9052, C9141, J7208, and J7677 (added)
• These injectable codes do not require authorization:
C9469, J1564, J1825, J7196, J7343, J7346 (removed)
Essential Plans and Metal-Level Products:
• These injectable codes require prior authorization:
C9047, C9048, C9049, C9050, C9051, C9052, C9141, J7208, and J7677 (added)
• These injectable codes do not require authorization: C9469 (removed)
Medicare:
• These injectable codes require prior authorization:
C9047, C9048, C9049, C9050, C9051, C9052, J7208, and J7677 (added)
Visit: Authorization Grids