Welcome, Providers!

The following sections of the Fidelis Care authorization grids have been updated effective October 1, 2023.

The Medicaid, Medicare, Essential Plan and Metal-Level grids have been updated as follows:    

E. OASAS Licensed Inpatient Substance Use Disorder Treatment:                 

The facility may fax or email the OASAS Appendix A Notification Form and OASAS LOCADTR Medical Necessity Tool to 833-663-1608 (formerly 646-829-1421) or LOCADTR@fideliscare.org.                         

H. OMH Licensed Inpatient Mental Health Treatment                             

The facility is required to notify the insurer within 2 business days of admission by calling 1-888-FIDELIS (1-888-343-3547), extension 16072 for Behavioral Health or by fax 833-561-0094 (formerly 718-896-1784).                                                     

Requests for members under 21 can be made by email chmmc@fideliscare.org, by fax 833-663-1604 (formerly 347-690-7362) or by calling 1-888-FIDELIS (1-888-343-3547) and following the prompts for Children’s Medicaid.                                               

IX.        Pharmacy                              

D. See Appendix I for codes that require authorization.  Please submit prior authorization requests to our Pharmacy Team electronically via fax (e-fax) to: 1-844-235-5090.       

The Medicaid grid has been updated as follows:

IV.        Behavioral Health - Outpatient services               

              G. Mental Health Continuing Day Treatment (Adults and Children) (H2012): 

Requests for members can be made by email qhcmbh@fideliscare.org, fax 833-561-0094 (formerly 718-896-1784) or by calling 1-888-FIDELIS (1-888-343-3547) and following the prompts for Behavioral Health.

            L. Community Oriented Recovery and Empowerment (CORE) Services:           

The Service Initiation Form is required to be submitted to Fidelis Care by e-mail (QHCMHARPBH@FidelisCare.org) or fax 833-561-0089 (formerly 347-868-6427) within 3 business days of the first service visit.                        

            N. Children’s Home and Community Based Services                             

In order to comply with the New York State guidance received on December 13, 2022, the short-term Children’s Respite Services flexibility will end immediately and providers are required to revert to the original guidance provided in the HCBS Manual:

• Short-term Respite Services may no longer be billed if delivered via telehealth or telephonically to an individual or group;

• All short-term Respite Services must be delivered in-person, as remote delivery will no longer be allowable;

• Short-term Respite Services may be delivered by qualified practitioners in a home or residence, out-of-home/residence by staff in community-based sites (e.g., community centers, camps, parks), or in allowable facilities; and

• Billing for short-term Respite must be based on in-person interactions with the Waiver enrolled children/youth.                       

Additionally, short-term Planned and Crisis Respite services may not exceed the 14 days (1,344 15-minute units) annual limits (per calendar year) without medical necessity. Short-term Planned and Crisis Respite beyond these limits MUST be supported by medical necessity, such as, documentation through a Licensed Practitioner of the Healing Arts (LPHA) Attestation form along with NYS DOH Children’s HCBS Authorization and Care Manager Notification form by email to SM_Childrens_HCBS@fideliscare.org, by fax 833-663-1604 (formerly 347-690-7362) or by calling 1-888-FIDELIS (1-888-343-3547) and following the prompts for Children’s Medicaid. 

The following codes have been updated on the Medicare Authorization Grid and require prior authorization:

J1460  immune glob (Gamastan)

J1560  immune glob (Gamastan)

J3520  Edetate disodium

J7180  factor XIII human (Corifact)

J7183  vWF human (Wilate)

J7185  factor VIII recombinant (Xyntha)

J7186  VIII/VWF complex human (Alphanate)

J7187  vWF complex (Humate-P)

J7189  factor VIIa recombinant (Novoseven)

J7190  factor VIII antihemophilic human (Hemofil M, KoateDVI, Monoclate-P)

J7191 factor VIII antihemophilic factor [porcine])

J7192 factor VIII recom NOS

J7193  factor IX non-recomb (AlphaNine/ Mononine)

J7194  factor IX complex (Bebulin, Profilnine)

J7195  factor IX recombinant (not otherwise specified)

J7196  antithrombin (Atryn)

J7197  antithrombin (Thrombate III)

J7198  anti-inhibitor (Feiba)

J7199  hemophilia Clot Factor Noc

J7294  Segesterone acetate and ethinyl estradiol

J7295  Ethinyl estradiol and etonogestrel

J8515  cabergoline, oral

The following codes have been updated on the Medicaid, Medicare, Essential Plan, and Metal-Level Products Authorization Grids and require prior authorization:

C9154 buprenorphine ER (Brixadi)

C9155 epcortiamab-bysp (Epkinly)

C9157 tofersen injection (Syfovre)

J0174  lecanemab-irmb (Leqembi)

J0801  corticotropin (Acthar gel)

J0802  corticotropin (ANI)

J0889  daprodustat oral ESRD

J2781  pegcetacoplan injection (Empavli)

J7214  factor VIII recomb (Altuviiio)

J9051  bortezomib injection (Maia)

J9064  cabazitaxel injection (Sandoz)

J9345  retifanlimab-dlwr (Zynyz)

The following code has been updated on the Medicaid, Essential Plan, and Metal-Level Products Authorization Grids and require prior authorization:

C9152 aripiprazole injection (Abilify Asimtufii)

C9158 risperidone injection (Uzedy)

New Century Health (NCH) will require review of the following codes as of October 1, 2023 for Medicaid, Medicare, Essential Plans and Metal-Level Products:

C9155  epcoritamab-bysp,0.16 mg

J8999  quizartinib (Vanflyta) – (for Medicare, Part D only)

J8999  niraparib 50mg/abiraterone 500mg – (for Medicare, Part D only)

J9051  bortezomib

J9064  cabazitaxel

J9345  retifanlimab-dlwr

J9999  elranatamab-bcmm injection (Elrexfio)

J9999  melphalan injection (Hepzato)

Visit:  Authorization Grids