Fidelis Care Authorization Grids Effective September 1, 2023
7/31/2023
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective September 1, 2023.
The Medicaid, Medicare, Essential Plan and Metal-Level grids have been updated as follows:
II. Inpatient Admissions: All inpatient admissions require an authorization.
Fidelis Care does not require authorization of emergency room services or any emergent service required to provide stabilization of an emergent condition. Fidelis Care does require authorization of post stabilization services and inpatient admissions after emergency room services are completed. All facility admissions are reviewed for medical necessity. Note: New fax number for Inpatient ER is 833-663-1602 (formerly 347-868-6411).
III. Outpatient surgery: The following services require prior authorization:
E. Services for the following codes 10060, 11100, 11900, 17000, 20600, 20605, and 20610* require preauthorization if performed in freestanding ambulatory surgery centers (bill type 0831).
*For any place of service, CPT code 20610 is non-covered for joint injection of hyaluronic acid when used for the treatment of osteoarthritis of the knee (diagnosis codes: M17.0, M17.10-M17.12, M17.2, M17.30, M17.31, M17.32, M17.4, M17.5, M17.9).
F. Outpatient Therapy
Office or Facility based PT, OT, and ST initial evaluations do not require a prior authorization. However, all other billed procedure codes, even if performed on the same date as the initial evaluation date, will require authorization prior to billing. If submitting claims using codes other than designated initial evaluation CPT Codes, an authorization request needs to be sent to NIA within 1 business day for the outpatient setting or 2 business days for the home health setting or to Fidelis within 1 business day for inpatient settings. For therapy services provided in Inpatient settings POS 31 & 32 (Skilled Nursing Facilities/ Sub-Acute Rehab in a SNF & Nursing Facility) Prior authorization requests are to be sent to the new fax number of 833-663-1611 (formerly 716-803-8307).
Utilization Management Messages - Voicemail Requirements
Messages may be left for providers with regard to Utilization Management (UM) activity only if the provider’s voicemail box is HIPAA complaint. Mailbox greetings need to specifically identify the owner of the mailbox, the name of the owner’s organization, and state that the mailbox is confidential and Personal Health Information (PHI) can be left.
If these requirements are met, a detailed message will be left. If the voicemail box is not deemed HIPAA compliant, the UM department will leave a generic message and request a call back. When attempting to notify the provider of a UM determination, a second attempt to reach the provider directly will be made, as required by the Department of Health Reasonable Effort Policy.
The Medicaid grid has been updated as follows:
III. Outpatient surgery:
B. Developmental Pediatric Testing:
Per Medicaid guidance, 96110 must be billed with diagnosis code Z13.41 (Encounter for autism screen) or Z13.42 (Encounter for screening for global developmental delays – milestones).
New Century Health (NCH) will require review of the following codes as of September 1, 2023 for Medicaid, Essential Plans and Metal-Level Products:
J9999 Glofitamab-Gxbm Injection
Visit: Authorization Grids