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Fidelis Care Authorization Grids Effective January 1, 2020
11/30/2019 • Posted by Provider Relations

The following sections of the Fidelis Care authorization grids have been updated
effective January 1, 2020.

The following services apply to Medicaid, Essential Plan, Medicare, and Qualified Health Plans (Metal-Level Products) and require or exclude prior authorization as indicated:

II. or III.  Outpatient surgery:
           These codes require authorization:
            D.
  Skin surgery and other dermatological procedures:
                        15769 – 15829
            G.  Eyelid & ocular surgery: 
                        66987 – 66988

VIII. or IX.  Pharmacy:  (no changes to the Medicare grid)
            B.  These codes require authorization:
                        
J0887  epoetin beta, ESRD (Marker)
                        J0888  epoetin alpha, non-ESRD (Epogen, Procrit)
                        J7328  hyaluronan (Gelsvn)
                  Prior-authorization removed:
                        C9036  patisiran (Onpattro)
                        C9048  dexamethasone ophthalmic insert (Dextenza)
                        C9049  tagraxofusp (Elzonris)
                        C9050  emapalumab (Gamifant)
                        C9052  ravulizumab (Ultomiris)     

             Medicaid Only:
                        Added Note: 
                       
J9035 (Avastin), J9355 (Herceptin), and J9306 (Perjeta) are available through the medical
                        benefit without prior authorization (PA).  Xolair is available through the pharmacy/medical
                        benefit and requires PA. Clinical criteria for Xolair may be found on the provider portal.

The following services apply to Medicaid and require or exclude prior authorization as indicated:

IV.  Behavioral Health – Outpatient services

Effective 1/1/20, two additional CFTSS will be available in Medicaid to recipients under age 21:
      1.  YPSS – Youth Peer Supports and Services (H0038)  
      2.  CI – Crisis Intervention (H2001, S9484, S9485)

There is no prior authorization or concurrent review for Crisis Intervention.  For all other CFTSS, Fidelis Care will not conduct prior authorization review for the first 3 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.

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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