Fidelis Care Authorization Grids Effective February 1, 2023
12/29/2022
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective February 1, 2023.
The Medicaid grid has been updated as follows:
C. Home Health Care: Home care approvals are based on the medical need for skilled services.
- Personal Care Services for Medicaid and Managed Long Term Care (MLTC-Fidelis Care at Home and MAP). All services require authorization and use of the following codes:
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Service Description
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HCPCS Code
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Service Billing Units
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Level II Mutual Case (multiple)
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T1019U3
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Per 15 mins
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Level II Shared Aide (up to two)
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T1019U2
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Per 15 mins
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Level II-Hard to Serve
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T1019U4
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Per 15 mins
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Live In Level II
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T1020
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Per Diem (1 unit per day)
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Live In Level II Mutual Case (multiple)
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T1020U2
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Per Diem (1 unit per day)
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Live In Level II - Two Client Hard to Serve
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T1020U5
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Per Diem (1 unit per day)
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- Consumer Directed Personal Assistance services (CDPAS) is a benefit for Medicaid and Medicare and requires authorization.
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Service Description
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HCPCS Code
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Service Billing Units
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Consumer Direct 1 Client
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T1019U6
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Per 15 mins
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Consumer Direct 2 Client
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T1019U7
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Per 15 mins
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Consumer Direct 1 Client Enhanced
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T1019U8
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Per 15 mins
|
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Consumer Direct 2 Client Enhanced
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T1019U9
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Per 15 mins
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|
Consumer Direct Live In 1 Client
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T1020U6
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Per Diem (1 unit per day)
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Consumer Direct Live In 2 Client
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T1020U7
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Per Diem (1 unit per day)
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New Century Health (NCH) will require review of the following codes as of 02/01/2023:
Added to the list of drugs that require NCH review for Medicaid, Essential Plan and Metal-level products:
- J0893 Decitabine (SUN PHARMA) Injection
- J8999 Olutasidenib oral
Added to the list of drugs that require NCH review for Medicare:
- J0893 Decitabine (SUN PHARMA) Injection (DACOGEN) – Medicare Part B and D
- J8999 Olutasidenib (REZLIDHIA) –Medicare Part D only
The following codes have been updated on the Essential Plan grid and require prior authorization:
- J0219 avalglucosidase alfa-ngpt
- J0741 cabotegravir and rilpivirine inj
The following codes have been updated on the Medicare grid and require prior authorization:
- J0893 decitabine (Dacogen)
- J1453 fosaprepitant (Emend)
- J9041 bortezomib (Velcade)
- J9395 fulvestrant (Faslodex)
- Q0510 Pharmacy supply fee for initial immunosuppressive drug(s)
- Q0511 Pharmacy supply fee for oral anti-cancer, oral anti-emetic or immunosuppressive drug(s); for the first prescription in a 30-day period
- Q0512 Pharmacy supply fee for oral anti-cancer, oral anti-emetic or immunosuppressive drug(s); for a subsequent prescription in a 30-day period
- Q0513 Pharmacy dispensing fee for inhalation drug(s); per 30 days
- Q0514 Pharmacy dispensing fee for inhalation drug(s); per 90 days
The following codes have been updated on the Metal-Level grid and require prior authorization:
- C9094 sutimlimab-jome
- J0219 avalglucosidase alfa-ngpt
- J9298 nivolumab and relatlimab-rmbw (Opdualag)
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.