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Fidelis Care Authorization Grids Effective May 1, 2020
4/1/2020 • 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

 

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Utilization Management (UM)

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