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Fidelis Care Authorization Grids Effective April 1, 2020
2/25/2020 • Posted by Fidelis Care

The following sections of the Fidelis Care authorization grids have been updated effective April 1, 2020, and require prior authorization.

Medicaid:

Section IV.  Behavioral Health – Outpatient Services

O. Children and Family Treatment & Support Services (CFTSS)

Effective 4/1/2020, utilization management requirements for Children and Family Treatment and Support Services will be discontinued. The CFTSS are as follows:

1. OLP - Other Licensed Practitioner (90791, H0004, H2011, 90882)
2. CPST – Community Psychiatric Supports and Treatment (H0036)
3. PSR- Psychosocial Rehabilitation (H2017)
4. FPSS- Family Peer Support Services (H0038)
5. YPSS – Youth Peer Supports and Services (H0038)
6. CI – Crisis Intervention (H2001, S9484, S9485) - no previous authorization requirements

Prior authorization was never required for these services. Concurrent review is no longer required. If there are questions related to these changes, providers may contact Fidelis Care by telephone at 1-888-FIDELIS (1-888-343-3547) and follow the prompts.

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):

1. Community Habilitation
2. Day Habilitation
3. Caregiver/Family Support and Services
4. Community Self Advocacy Training and Support:
5. Prevocational Services - must be age 14 and older
6. Supported Employment - must be age 14 and older
7. Respite Services (Planned Respite and Crisis Respite)
8. Palliative Care
9. Environmental Modifications
10. Vehicle Modifications
11. Adaptive and Assistive Equipment

Services 1-6: HCBS eligibility and POC are required for an initial authorization of 96 units or 24 hours (total) of service within 60 days from the time notification is received from an HCBS Provider. Concurrent review is required for continued stay.

Respite Services do not require Prior Authorization. Concurrent review is required after 7 consecutive days of Planned Respite Services.  Fidelis Care will conduct concurrent review for Crisis Respite stays that exceed 72 hours.

Palliative Care services require prior authorization and concurrent review.

Services 9-11 require prior authorization with service limits at $15,000 annually.

Requests for all services listed above for eligible 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.

Medicaid, Essential Plans, and Qualified Health Plans (Metal-Level Products):

Section IX.  Pharmacy: 

B.  These codes require authorization.

C9399  unclassified drugs/biologics
J1458   galsulfase (Naglazyme)
J1744   icatibant
J2502   pasireotide LA
J3060   taliglucerase alfa (Elylyso)
J7196   antithrombin (Atryn)
J7197   antithrombin (Thrombate III)
J9216   interferon gamma 1b

Medicare:

Section VIII.  Pharmacy:

B.  These codes require authorization.

C9399  unclassified drugs/biologics

Visit:  Authorization Grids

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Important Information on Coverage Decisions

Each day, Fidelis Care's Utilization Management (UM) Department makes decisions on many health insurance claims. These decisions are based only on appropriateness of care and the existence of coverage. 

Fidelis Care does not reward providers or other individuals for issuing denials of coverage, and does not offer financial incentives to UM staff based on decisions that promote underutilization of services. 

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