4/1/2020
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Posted by Provider Relations
COVID-19 UPDATE:
Please refer to this link: Important Updates Regarding Coronavirus COVID-19, for authorization and coding guidelines related to the COVID-19 Pandemic.
The following sections of the Fidelis Care authorization grids have been updated effective May 1, 2020.
Prior Authorization for substance abuse treatment has been removed from all lines of business:
I or II. Removed the prior authorization requirement as follows:
B. 2. Inpatient substance abuse rehabilitation
E. Effective January 1, 2020, Fidelis Care does not require provider notification, prior
authorization, or concurrent authorization review of the following in-network and
in-state outpatient substance use services:
- Outpatient office visits, therapy visits, or counseling visits
- Outpatient clinic visits for substance use disorder treatment
- Intensive outpatient treatment programs
- Outpatient rehabilitation treatment
- Opioid Treatment Programs
Prior Authorization has been added or removed for the lines of business as indicated:
IX. Pharmacy:
B. Applies to Essential Plan, Medicaid, and Metal-Level Products (Qualified Health Plans):
Added:
J7999 misc compounded drug
J9999 misc chemo
Applies to Essential Plan and Metal-Level Products (Qualified Health Plans):
Removed:
J0570 (buprenorph impl (Probuphine)
Q9991 buprenorphine ER < 100mg (Sublocade)
Q9992 Buprenorphine ER >100MG (Sublocade)
Added to the Pharmacy section for all lines of business:
Self-administered medications are covered under the pharmacy benefit. Self-administered medications are medications that are typically administered by a patient or caregiver, safely and effectively, without medical supervision or direct observation.
Visit: Authorization Grids