6/30/2023
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective August 1, 2023.
The Medicaid grid has been updated as follows:
G. Podiatry Services:
Authorization is no longer required for podiatric services however, authorization requirements will apply to individual services that are indicated on this grid and rendered by podiatrists.
NOTE: 11719 is a non-covered code for Medicaid when rendered by a physician per the Medicaid Fee Schedule. When rendered by a facility using POS 11, it is covered and requires prior authorization.
The Medicaid, Medicare, Essential Plan and Metal-Level grids have been updated as follows:
II. Outpatient surgery: The following services require prior authorization:
D. Services for the following codes (10060, 11100, 11900, 17000, 20600, 20605, and 20610) should not need to be performed in freestanding ambulatory surgery centers- If performed in freestanding ambulatory surgery centers billing with bill type 0831, they require an authorization. CPT code 20610 is non-covered for joint injection of hyaluronic acid ONLY when billed with any of the following osteoarthritis diagnosis codes: M17.0, M17.10-M17.12, M17.2, M17.30, M17.31 (new codes), M17.32, M17.4, M17.5, M17.9.
The Medicare grid has been updated as follows:
B. Durable Medical Equipment:
1. The following DME codes do not require an authorization: Removed code V5266 as this is a non-covered code.
New Century Health (NCH) will require review of the following codes as of August 1, 2023 for Medicare:
J9999 Epcoritamab-bysp (Epkinly)
The following codes have been updated on the Medicare Authorization Grid and require prior authorization:
J1439 Injectafer (ferric carboxymaltose)
J1437 Monoferric (ferric derisomaltose)
Q0138 Feraheme (non-ESRD)
Visit: Authorization Grids