Update - Fidelis Care Authorization Grids Effective January 1, 2020
12/23/2019
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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:
I. or II. Inpatient surgery:
F. or G. Orthopedic Surgical Procedures and Spinal Surgical Procedures, performed in both
inpatient and outpatient settings, require prior authorization for dates of service beginning 10/1/2019.
Effective for dates of service rendered on or after 12/23/19, prior authorization has been delegated to
TurningPoint Healthcare Solutions, LLC. For a list of codes requiring prior authorization, click here.
II. or III. Outpatient surgery:
These codes require authorization:
D. Skin surgery and other dermatological procedures:
15769 – 15829
G. Eyelid & ocular surgery:
66987 – 66988
O. or P. Certain outpatient orthopedic and spinal surgical procedures require prior authorization for
dates of service beginning 10/1/2019. Effective for dates of service rendered on or after 12/23/19, prior
authorization has been delegated to TurningPoint Healthcare Solutions, LLC. Refer to Section II –
item # G above. For a list of codes requiring prior authorization, click here.
VIII. or IX. Pharmacy: (no changes to the Medicare grid)
B. These codes require authorization:
C9054 Iefamulin (Xenleta)
C9055 brexanolone
J0179 brolucizumab-dbll
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.
V. Durable Medical Equipment
These codes require authorization:
E0787 - External ambulatory infusion pump, insulin, dosage rate adjustment using
therapeutic continuous glucose sensing
E2398 - Wheelchair accessory, dynamic positioning hardware for back
K1001 - Electronic positional obstructive sleep apnea treatment, with sensor,
includes all components and accessories, any type
K1002 - Cranial electrotherapy stimulation (CES) system, includes all supplies
and accessories, any type
K1004 - Low frequency ultrasonic diathermy treatment device for home use,
includes all components and accessories
K1005 - Disposable collection and storage bag for breast milk, any size, any type,
each
L2006 - Knee-ankle-foot (KAF) device, any material, single or double upright,
swing and/or stance phase microprocessor control with adjustability,
includes all components (e.g., sensors, batteries, charger), any type
activation, with or without ankle joint(s), custom fabricated
L8033 - Nipple prosthesis, custom fabricated, reusable, any material, any type, ea
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