Important Prior Authorization Updates Effective October 1, 2026
2026/8/31
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Posted by Provider Relations
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Provider News
As part of our ongoing work to improve the prior authorization (PA) process for both providers and members, Fidelis Care wants to share some important updates to our PA requirements. Our goal is to reduce administrative burden, simplify submission and approval processes, and facilitate timely access to appropriate, high-quality care.
Code change details are noted in the table below. The changes may include:
- Removing PA requirements based on criticality of review and clinical need.
- Creating a more uniform set of prior authorization requirements across our markets and lines of businesses, including adding and changing some PA requirements, to simplify processes, reduce confusion for providers, and support future efforts to expand real-time responses to requests.
For questions about specific prior authorization codes or how these changes affect your practice, please reach out to your local Provider Engagement representative.
| Medicaid |
| Service Category | PA Rule | Services | Procedure codes |
| Behavioral Health | No PA Required for participating providers | Neurobehavioral Status Exam | 96116, 96121 |
| DME and Supplies | No PA Required for participating providers | Mobility Services | E0630 |
| Respiratory Devices and Supplies | E0443 |
| Wheelchairs | E0954, E0955, E2607, E2608, E2622, E2623, E2624, E2625 |
| Orthotic and Prosthetic | L1932, L2630, L5000, L5620, L5629, L5631, L5637, L5704, L5920, L5950 |
| Drug Codes | No PA Required CHP members only | Diabetic Drugs and Supplies | A4238 |
| Genetic Analysis | No PA Required for participating providers | Genetic Testing | 81161, 81200, 81206, 81207, 81240, 81241, 81242, 81243, 81250, 81251, 81255, 81260, 81279, 81297, 81304, 81319, 81338, 81339, 81400, 81401 |
| Hearing Services | No PA Required for participating providers | Implants and Supplies | L8624 |
| Hearing Aids | V5130, V5160, V5140 |
| Home Services | No PA Required for participating providers | Home Visit | S9211, T1028 |
| Nursing Services | T1001 |
| Other Medical Services | PA Required | Other Services | T1999 |
| No PA Required for participating providers | Wound Care | 97597 |
| Dental Care | G0330 |
| Waiver Services | T2023 |
| Incontinence Supplies | T4541 |
| Physician Services | PA Required | Diagnostic Testing | 91299 |
| No PA Required for participating providers | Diagnostic Testing | 91110, 91111, 91112 |
| Sleep Medicine | No PA Required for participating providers | Sleep Studies | 95800, 95805, 95806 |
| Surgery Procedures | No PA Required for participating providers | Eye and Ocular Adnexa | 67904 |
| Ambetter From Fidelis Care |
| Service Category | PA Rule | Services | Procedure codes |
| Anesthesia | PA Required | Anesthesia Services | 00170 |
| Genetic Analysis | PA Required | Genetic Testing | 0211U, 0345U |
| No PA Required for participating providers | Genetic Testing | 86813, 86817 |
| Home Services | No PA Required for participating providers | Home Visit | S9211, S9213, S9214 |
| Surgery Procedures | PA Required | Tonsil and Adenoid Procedures | 42835 |
| Transplant Services | No PA Required for participating providers | Transplant | 38208 |
| Medicare |
| Service Category | PA Rule | Services | Procedure codes |
| Testing | No PA Required | Psychological Testing/Neuropsychological Testing | 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146 |
| DME and Supplies | No PA Required | Equipment and Accessories | E0656, E0657 |
| Orthotic and Prosthetic | L0457, L0650, L1932, L1940, L1960, L2330, L3030 |
| Respiratory Devices and Supplies | E0470, E0471, E0562 |
| Supplies and Devices | E0935 |
| Wheelchairs | E1226, E2310, E2374, E2607, E2608, E2613, E2614, E2615, E2622, E2623, E2624, E2625 |
| DME Services | No PA Required | Wheelchairs | E1032, E1033, E1034 |
| Genetic Analysis | No PA Required | Genetic Testing | 88271, 88275, 88280 |
| Home Services | No PA Required | Infusion Services | 99601, 99602, S9500 |
| Other Medical Services | PA Required | Wound Care | 97605, 97606 |
| Pain Management | No PA Required | Surgery – Nervous System | 64566 |
| Physician Services | No PA Required | Diagnostic Testing | 91110, 91111, 91112, 91113 |
| Home Visit | 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350 |
| Surgery Procedures | No PA Required | Integumentary Services | 14000, 14001, 14020, 14021, 14040, 14041, 14060, 14061, 15100 |
| Musculoskeletal System | 29848 |
| Transportation Services | PA Required | Medical Transportation | A0100 |