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Fidelis Care Authorization Grids Effective October 1, 2019
8/30/2019 • Posted by Provider Relations

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

The following services require prior authorization based on the health insurance product as outlined below:

Medicaid, Child Health Plus, HealthierLife (HARP), Essential Plan, Medicare, Metal-Level Products:

I. or II.  Inpatient Admissions:  all inpatient admissions require an authorization:

F. or G.  Effective 10/1/2019 Orthopedic Surgical Procedures and Spinal Surgical Procedures performed in both inpatient and outpatient settings, require prior authorization.

Services rendered on or after 10/1/2019 require prior authorization.

For a list of codes requiring prior authorization, click here.

Please note: the delegation of utilization review to TurningPoint is pending state approval. All requests should be submitted directly to Fidelis Care until further notice.

II. or III.  Outpatient surgery:  The following services require prior authorization:

O. or P.   Certain outpatient orthopedic and spinal surgical procedures require prior authorization; refer to Section I – item #F or Section II – item # G above. For a list of codes requiring prior authorization, click here.

V.  Outpatient and DME Services: (Excludes Medicare)

F. Effective 10/1/2019 Outpatient Therapy, including services rendered in the home:  Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST): all services performed by a therapy provider after the initial evaluation will require prior authorization through National Imaging Associates (NIA), pending New York State approval.  (Excludes PT, OT, ST performed in an Inpatient setting, Emergency Room, Skilled Nursing Facility, or during an Observation stay.)

            Services rendered on or after 10/1/2019 require prior authorization*

            *PT, OT, and ST initial evaluations do not require a prior authorization. However, all other billed
            procedure codes, even if performed on the same date as the initial evaluation date, will require
            authorization prior to billing.

            Non-Therapy Providers (MD, DO, DPM, etc.) should request prior authorization for all services after the
            initial evaluation directly through Fidelis Care.

Medicaid:

IV.   Behavioral Health – Outpatient Services:
       Q. Children’s Home and Community Based Services, Effective 10/1/19:
       The following additional services are available to members age 20 and younger, if determined to
       be HCBS-eligible by a Health Home or the Children and Youth Evaluation Service (C-YES):

  • Community Habilitation
  • Day Habilitation
  • Caregiver/Family Support and Services
  • Community Self Advocacy Training and Support
  • Prevocational Services - must be age 14 and older
  • Supported Employment - must be age 14 and older
  • Respite Services (Planned Respite and Crisis Respite)
  • Palliative Care
  • Environmental Modifications
  • Vehicle Modifications
  • Adaptive and Assistive 
  • Youth Peer Support Services and Training
  • Crisis Intervention

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

Medicare:

IV.  Outpatient and DME Services:  These services require prior authorization:

       F.  Outpatient Therapy:

            Physical, Occupational, Speech Therapy - The initial evaluation does not require prior authorization.     
            All visits require authorization, including swallow function and therapy. 

IX.  Pharmacy: 

            B.  These injectable codes require authorization:
            The pharmacy code descriptions have been added to each code.    

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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