3/30/2023
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective May 1, 2023.
The Medicaid grid has been updated as follows:
Child Health Plus: Effective 4/1/23, Residential Rehabilitation Services for Youth (RRSY) is covered benefit. Services to be provided in a facility issued a Part 817 operating certificate from the Office of Addiction Services and Supports (OASAS), pursuant to Article 32 of the Mental Hygiene Law. Includes all services provided by the RRSY, as described in OASAS Part 817. These services include, but are not limited to, clinical services, recovery support services, educational and vocational assessments and services, Medication for Addiction Treatment (MAT) and food and nutrition services. Clinical services include individual, group, and family counseling, assessment and referral services for patients and significant others (e.g., parent/guardian(s), sibling(s), partner(s), etc.), medical and psychiatric consultation, and HIV and AIDS, hepatitis C, tuberculosis, and other communicable diseases education, risk assessment, supportive counseling and referral.
V. Outpatient and DME Services:
K. DME, Services, and pharmaceutical treatment for Erectile Dysfunction (note: these items and services are not covered for registered sex offenders): 37788, 37790, L7902
IX. Pharmacy:
B. Oncology medications and supportive agents will require prior authorization (PA) from New Century Health before being dispensed at a pharmacy or administered in a physician’s office, outpatient hospital, or ambulatory setting for members of all ages. This requirement applies to Medicaid Managed Care and HARP (medical benefit only), and excludes Child Health Plus line of business. Requests can be submitted by visiting NCH’s Web portal at https://um.newcenturyhealth.com/Account/Logon/frm or calling 1-888-999-7713, option 1.
Starting 4/1/2023, the Medicaid/HARP pharmacy benefit will be transitioned to NYS Fee for Service (FFS). For oncology medications through the pharmacy benefit, please see NYRx, the Medicaid FFS Pharmacy Program.
The following code has been updated on the Medicaid DME Authorization Grid and requires prior authorization:
E0604 Hospital Grade Breast Pump
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.