12/1/2020
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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 January 1, 2021.
The following changes have been applied to Medicaid, Medicare, Essential Plan, and Metal Level Plan authorization grids:
Removed C9572 and C9753 from Pain Management Codes.
Added language “(such as C-codes)” to section X: All services for “Unlisted” or “Temporary” Codes…
The list of Inpatient Only procedures has been updated for 2021.
Information regarding benefits and benefit limitations has been removed from the Medicaid authorization grid:
“The Medicaid and MLTC benefit is limited to 20 visits per member for Occupational and Speech Therapy per calendar year, and effective 7/1/18, 40 visits for Physical therapy beginning with the calendar year 2018. There is no visit limit for CHP. Services received at home are not included in this restriction.”
Authorization for podiatric services has been amended on the Medicare authorization grid in section IV: Outpatient and DME Services as follows:
G. Podiatry Services
Authorization is no longer required for podiatric services however, authorization requirements will apply to individual services that are indicated on this grid and rendered by podiatrists.
The following services apply to Medicare and require prior authorization:
VIII. Pharmacy
Added:
J3357 Ustekinumab (Stelara)
J3262 Tocilizumab (Actemra)
J0178 Aflibercept (Eylea)
J2323 Natalizumab (Tysabri)
J0129 Abatacept (Orencia)
J9145 Daratumumab (Darzalex)
J1300 Eculizumab (Soliris)
J9176 Elotuzumab (Empliciti)
J1602 Golimumab (Simponi)
J2353 Octreotide (Sandostatin Depot)
J2354 Octreotide (Sandostatin subcutaneous or intravenous)
J3380 Vedolizumab (Entyvio)
J2796 romiplostim (Nplate)
J9035 bevacizumab 10mg (Avastin)
C9257 Bevacizumab 0.25mg (Avastin)
Q5107 bevacizumab-awwb (Mvasi)
Q5118 bevacizumab-bvzr, (Zirabev)
Q5115 rituximab-abbs (Truxima)
J9308 Ramucirumab (Cyramza)
Q2043 Sipuleucel-T (Provenge)
J0800 Corticotropin (H.P. Acthar)
J2503 Pegaptanib (Macugen)
J0179 brolucizumab-dbll (Beovu)
J1930 Lanreotide (somatuline depot)
UPDATE: The following services apply to Metal-Level, Essential Plan, Medicare & Medicaid lines of business unless otherwise noted:
VIII. Pharmacy
Removed:
C9062 daratumumab and hyaluron (Metal-Level, Essential Plan, & Medicaid plans only)
C9064 mitomycin pyelocalyceal
C9066 sacituzumab govitecan
Added:
C9069 belantamab mafodontin-blmf (Blenrep) (Medicare Only)
C9070 tafasitamab-cxix (Monjuvi) (Medicare Only)
C9071 viltolarsen (Viltepso) (Medicare Only)
C9072 immune globulin (asceniv) (Medicare Only)
C9073 Brexucabtagene autoleucel (Tecartus) (Medicare Only)
J0693 cefiderocol (Fetroja) (Metal-Level, Essential Plan, & Medicaid plans only)
J1823 inebilizumab-cdon (Uplizna)
J7212 factor VIIa recomb (Sevenfact)
J7352 afamelanotide implant
J9144 daratumumab and hyaluron
J9223 lurbinectedin
J9281 mitomycin
J9316 pertuzumab, trastuzumab,hyal
J9317 sacituzumab govitecan
Visit: Authorization Grids