Bienvenidos, Corredores!

The following sections of the Fidelis Care authorization grids have been updated effective January 1, 2026.             The following codes have been updated on the Medicaid, CHP, Essential Plan, AmBetter Metal-Level Plans, and Medicare Authorization Grids and require prior authorization: C9307 linvoseltamab-gcpt inj C9308 carboplatin (Avyxa) inj J0013  esketamine, nasal spray J1073  testosterone pellet, implant J3387  elivaldogene autotemcel (Skysona) J3389  prademagene zamikeracel (Zevaskyn) J7528  mycophenolate mofetil, suspension J9184  gemcitabine (Avyxa) inj J9256  nipocalimab-aahu inj J9282  mitomycin intravesical J9326  telisotuzumab vedotin-tllv inj (Emrelis) Q5160 bevacizumab-nwgd (Jobevne)   For Medicaid, CHP, Essential Plan, AmBetter Metal-Level Plans, and Medicare, the following codes have been added to the list of drugs that require NCH review: C9307 linvoseltamab-gcpt inj C9308 carboplatin (Avyxa) inj J9184 

The Clinical Laboratory Improvement Amendments of 1988 is federal legislation with the objective of ensuring quality laboratory testing. It applies to any facility or individual Provider that performs laboratory services and wants to receive payments under Medicare and Medicaid programs. Fidelis Care will continue to uphold the Federal and State guidelines to ensure laboratory claims submitted by providers meet these requirements: A valid CLIA certificate for the type of tests performed at each location An active CLIA certificate Exceptions are based on both NYS and CMS Regulations          Providers should submit their CLIA number on the claim as follows: Electronic Claim: Loop

The following sections of the Fidelis Care authorization grids have been updated effective January 1, 2026.             The following has been added to the Medicaid Authorization Grid and requires prior authorization: IV.       Behavioral Health - Outpatient Services                R. Family Psychotherapy Covered; Authorization Required for CPT Codes 90847 Starting January 1, 2026, Fidelis Care will require notification and concurrent review for Group Psychoeducation (Mental Health) services for any requests beyond the initial 30 visits per calendar year.  Note: Substance Use Disorder (SUD) group/family therapy do not require authorization. Requests for members can be made by email qhcmbh@fideliscare.org, fax (833-561-0098)

Fidelis Care will host two Provider Office Hours in December 2025. During the webinars, Fidelis Care staff will be available to share information, provide an overview of provider resources, and answer your questions. Provider Office Hours – December 2025   Topic: Fidelis Care – Back to Basics When:  Thursday, December 11th – 12 PM – 1 PM EST Click here to register*   Topic: Fidelis Care and Wellcare - Quality Programs When:  Wednesday, December 17th – 10 AM – 11

Access to quality care is important to eliminate health disparities and increase the quality and years of healthy life for all New Yorkers. The NYSDOH requires that certain Access and Availability Standards be met by PCPs, OB/GYNs, specialists, and behavioral health providers where applicable. Click here to view the full list of standards, including situations and timeframes.   For additional questions, or if we can be of assistance in any way, please contact your Fidelis Care Provider Engagement Account Manager. To find your designated representative, please click here.