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Fidelis Care Authorization Grids Effective July 1, 2021
6/2/2021 • Posted by Provider Relations

The following sections of the Medicaid, Child Health Plus and HealthierLife (HARP) Fidelis Care authorization grid has been updated effective July 1, 2021.

Additional verbiage related to 29-I Health Facility services has been added and includes the following:

R. Core Limited Health Related Services (CLHRS)

On July 1, 2021,Fidelis Care will cover the following 29-I Health Facility services for enrollees who are eligible to be served by a 29-I Health Facility, in accordance with the 29-I Billing Guidance.  CLHRS will be paid on a per diem basis and are inclusive of:

a. Nursing Services

b. Skill Building Licensed Behavioral Health Practitioner (LBHP)

c. Medicaid Treatment Planning and Discharge Planning

d. Clinical Consultation/Supervision Services

e. VFCA Managed Care Liaison/Administration

No Utilization Review will be conducted for these services.


S. Other Limited Health Related Services (OLHRS)

Fidelis Care will not conduct Utilization Review on OLHRS listed below that will be delivered by 29-I Facilities:

Service Description

Alcohol and/ or Drug Screening, Testing, Treatment

Developmental Test Administration

Psychotherapy (Individual or Family)

Psychotherapy Group

Neuropsychological Testing/Evaluation Services

Psychiatric Diagnostic Examination

Office Visit

Smoking Cessation Treatment


Screening - Developmental/ Emotional/ Behavioral

Hearing and Evaluation of Speech

Immunization (Administration)

Lab Services (see 29-I Health Facility Laboratory Fee Schedule for complete list of waived laboratory services and pricing)


29-I Facilities providing Children and Family Treatment and Support Services or Children’s Home and Community Based Services are subject to authorization requirements as outlined in sections O & Q respectively.

Visit:  Authorization Grids


Authorization Resources

To submit prior authorization request types, use the Fidelis Care provider portal.

Electronic Transactions

Submit claims electronically with Fidelis Care.

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Submit Authorization Requests

Utilization management systems available to submit authorization requests.