Fidelis Care Authorization Grids Effective September 1, 2026
7/28/2026
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Posted by Provider Relations
The following section of the Fidelis Care authorization grids has been updated effective September 1, 2026.
The following section of the Medicaid, CHP, Essential Plan, Ambetter Metal-Level Plans, and Medicare Authorization Grids and requires prior authorization:
III. Outpatient surgery: The following services require prior authorization:
D. Skin surgery and other dermatological procedures: Q4110, Q4111
The following codes have been added to the Medicaid, CHP, Essential Plan, Ambetter Metal-Level Plans, and Medicare Authorization Grids and require prior authorization:
J0528 fosfomycin disodium
J2374 apraclonidine hcl
J7176 fibrinogen-chmt (Fesilty)
Visit: Authorization Grids