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Fidelis Care Authorization Grids Effective November 1, 2020
10/14/2020 • 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 November 1, 2020.


Under Therapeutic Services, Pain Management Codes: prior authorization for codes 62370 and C1823 has been removed from the Essential Plan, Medicaid, Medicare, & Metal-Level lines of business.

Added to the Essential Plan, Medicaid, & Metal-Level grids for November:

IX.        Pharmacy

C.        Oncology medications and supportive agents will require prior authorization (PA) from New Century Health before being dispensed at a pharmacy or administered in a physician’s office, outpatient hospital, or ambulatory setting for members 18 and over.  This requirement applies in the Medicaid Managed Care, Essential Plan, and Qualified Health Plan (excluding Child Health Plus) lines of business. PA can be requested by visiting NCH’s Web portal at my.newcenturyhealth.com or calling 1-888-999-7713, option 1. 

D.        These codes require authorization  

C9062 daratumumab and  hyaluron

C9064 mitomycin pyelocalyceal

C0965 romidepsin

C9066 sacituzumab govitecan

J1632  brexaolone (Zulresso)

J3032  eptinezumab-jjmr

J3241  teprotumumab

J7351  bimatoprost implant

J9227 isatuximab

J9304  pemetrexed (Pemfexy)

Q4074 iloprost (Ventavis) *Essential Plan & Medicaid Only*

Q5114 trastuzumab-dkst (Ogivri)

 

Removed:

Q5117 trastuzumab-anns               

 

Removed from Medicaid only:

Q9991 buprenorphine ER

Q9992 buprenorphine ER >100mg

 

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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