12/1/2022
•
Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective January 1, 2023.
The Essential Plan, Medicaid, Medicare and Metal-Level Products grids have been updated as follows:
V. Outpatient and DME Services: The following services require prior authorization:
4. Gastroenterology Procedures
- Authorization is required for 43290 when performed in any place of service
B. Durable Medical Equipment/Supplies:
1. These DME codes that do not require an authorization: E0602 and E0603 were added.
H. Therapeutic Services:
11. Vision Therapy: 92066, 95919
The Medicaid grid has been updated as follows:
F. Applied Behavioral Health Analysis (ABA):
NYS Managed Medicaid/CHP
Effective January 1, 2023, Applied Behavior Analysis (ABA) services provided by Licensed Behavior Analyst (LBA), Certified Behavior Analyst Assistant (CBAA) working under the supervision of LBAs, or other individuals specified under Article 167 of NYS education law, will be included in the Medicaid managed care (MMC) benefit package.
Members may be eligible for ABA if they are under age 21 and have received a diagnosis of autism spectrum disorder and/or Rett Syndrome as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). The member must be referred by a NYS licensed physician (including psychiatrists and developmental/behavioral pediatricians), psychologists, psychiatric nurse practitioners, pediatric nurse practitioners, or physician assistants. ABA services are provided by Licensed Behavior Analyst (LBA), Certified Behavior Analyst Assistant (CBAA) working under the supervision of LBAs, or other individuals specified under Article 167 of NYS education law and must be enrolled in the NYS Medicaid Program.
NYS Managed Medicaid: Applied Behavioral Analysis covered by Medicaid Fee-For-Service for dates of services 8/1/2021-12/31/22 not by Fidelis Care.
I. Assertive Community Treatment (ACT – members age 18+) & Youth ACT (Children and Adolescents): H0040
Effective 1/1/23, these services are available to members enrolled in CHP. Requests for members can be made by email qhcmbh@fideliscare.org, fax (718) 896-1784 or by calling 1-888-FIDELIS (1-888-343-3547) and following the prompts for Behavioral Health.
K. Home and Community Based Services (HCBS) are available if determined to be eligible through enrollment in the adult HealthierLife plan and in conjunction with a completed evidence-based eligibility assessment. Effective January 1, 2023 prior authorization is not required for intake or service delivery.
M. Children and Family Treatment & Support Services (CFTSS)
Effective 4/1/2020, utilization management requirements for Children and Family Treatment and Support Services will be discontinued. Effective 1/1/23, CFTSS are covered under the CHP Benefit package. The CFTSS are as follows:
- OLP - Other Licensed Practitioner (90791, H0004, H2011, 90882)
- CPST – Community Psychiatric Supports and Treatment (H0036)
- PSR- Psychosocial Rehabilitation (H2017)
- FPSS- Family Peer Support Services (H0038)
- YPSS – Youth Peer Supports and Services (H0038)
- CI – Crisis Intervention (H2001, S9484, S9485) - no previous authorization requirements
O. Core Limited Health Related Services (CLHRS)
On July 1, 2021, Fidelis Care will cover the following 29-I Health Facility services for Medicaid Managed Care enrollees who are eligible to be served by a 29-I Health Facility, in accordance with the 29-I Billing Guidance. Effective 1/1/23, these services are also available for members enrolled in Child Health Plus who are eligible to be services by a 29-I Facility in accordance with NYS CHP Enhancement Guidance.
The Medicare grid has been updated as follows:
Behavioral Health (BH) Services Carve-In
Effective 1/1/2023, New York State (NYS) is carving additional Behavioral Health Services into the Medicaid Advantage Plus (MAP) Plan benefit package.
Behavioral Health Services Carve-in Crosswalk
Please see the charts on the authorization grid for clarification on OMH and OASAS services covered.
The Fidelis Care Turning Point Healthcare Solutions CPT code grid has the following additions:
- 0775T - Arthrodesis, sacroiliac joint, percutaneous, with image guidance, includes placement of intra-articular implant(s) (eg, bone allograft[s], synthetic device[s])
- 22860 - Total disc arthroplasty (artificial disc), anterior approach, including discectomy to prepare interspace (other than for decompression); second interspace, lumbar (List separately in addition to code for primary procedure)
New Century Health (NCH) will require review of the following codes as of 01/01/2023:
- J3590 eflapegtrasim-xnst injection (Rolvedon)
- J9999 tremelimumab-actl injection (Imjudo)
- J9999 teclistamab-cqyv inj (Tecvayli)
- J1456 fosaprepitant inj (Emend)
- J9046 bortezomib inj (dr. reddy’s)
- J9048 bortezomib inj (fresnius kabi)
- J9049 bortezomib inj (Hospira)
- J9393 fulvestrant inj (teva)
- J9394 fulvestrant inj (fresnius kabi)
- Q5126 bevacizumab-maly (Alymsys)
The following codes have been updated on the Essential Plan, Medicaid, Medicare, and Metal-Level Products grids and require prior authorization:
- J0225 vutrisiran (Amvuttra)
- J2327 risankizumab-rzaa (Skyrizi)
- J1453 fosaprepitant inj
- J1456 fosaprepitant inj (Teva)
- J9395 fulvestrant inj
- Q5107 bevacizumab-awwb (Myasi)
- Q5118 becacizumab-byzr (Zirabev)
Visit: Authorization Grids
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.