Fidelis Care Authorization Grids Effective November 1, 2020
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:
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
C9066 sacituzumab govitecan
J1632 brexaolone (Zulresso)
J7351 bimatoprost implant
J9304 pemetrexed (Pemfexy)
Q4074 iloprost (Ventavis) *Essential Plan & Medicaid Only*
Q5114 trastuzumab-dkst (Ogivri)
Removed from Medicaid only:
Q9991 buprenorphine ER
Q9992 buprenorphine ER >100mg
Visit: Authorization Grids