11/30/2019
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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