Fidelis Care Authorization Grids Effective July 1, 2021 (Updated)
6/29/2021
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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:
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Service Description
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Alcohol and/ or Drug Screening, Testing, Treatment
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Developmental Test Administration
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Psychotherapy (Individual or Family)
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Psychotherapy Group
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Neuropsychological Testing/Evaluation Services
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Psychiatric Diagnostic Examination
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Office Visit
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Smoking Cessation Treatment
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ECG
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Screening - Developmental/ Emotional/ Behavioral
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Hearing and Evaluation of Speech
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Immunization (Administration)
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Lab Services (see 29-I Health Facility Laboratory Fee Schedule for complete list of waived laboratory services and pricing)
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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.
The following services apply to Medicaid, Medicare, Essential Plan, and Metal Level Plans and require prior authorization:
VIII. Pharmacy
Added:
C9075 casimersen
C9076 lisocabtagene maraleucel
C9077 cabotegravir and rilpivirine
C9078 trilaciclib
C9079 evinacumab-dgnb
C9080 melphalan flufenamide
J0224 lumasiran
J1951 leuprolide acet (Fensolvi)
J7168 prothrombin comp (Kcentra)
J9314 romidepsin nonlyophilized
J9348 naxitamab-gqgk
J9353 margetuximab-cmkb
Q5123 rituximab-arrx (Riabni
The following services apply to Medicare and have been removed from the prior authorization grid:
C9065 romidepsin, non-lyophilized (Istodax)
C9074 lumasiran (Oxlumo)
Visit: Authorization Grids