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As a reminder, providers now have access the Availity Clinical Quality Validation (CQV) tool designed to help providers close care gaps quickly and accurately. Through the Availity Essentials portal, CQV streamlines documentation and improves quality scores while reducing administrative burden.   What is CQV? Clinical Quality Validation (CQV) is an Availity Essentials application that helps providers: ·         Monitor targeted care gaps/measures for the measurement year. ·         View and respond to payer requests for clinical/medical data. ·         Improve quality scores and reduce administrative burden.   Benefits ·         Streamlined workflow for care gap closure. ·         Faster access to clinical data. ·         Enhanced provider experience across multiple markets.   Availity-led Training for Providers: A live webinar, Centene

Effective July 1, 2026, the following procedures will be removed from prior authorization.   The following RADIOLOGY AND DIAGNOSTIC CARDIOLOGY (RBM) codes have been removed from the Evolent’s Utilization Review Matrix and no longer require prior authorization for Medicaid. Modality Impacted CPT CT ORBIT/EAR/FOSSA WITH O DYE 70480,70481,70482 CT MAXLOFCE AREA; W/O CONTRAST MATL

The following section of the Fidelis Care authorization grids has been updated effective July 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: C9310 leucovorin calcium (avyxa), inj J1289 narsoplimab-wuug, inj (Yartemlea) J1577 immune globulin, inj (Qivigy) J2361 depemokimab-ulaa, inj (Exdensur) J2789 riboflavin 5'-phosphate, ophthalmic (Epioxahd/Epioxa) J3386 etuvetidigene autotemcel, inj (Waskyra) J3405 onasemnogene abeparvovec-brve, inj (Itvisma) J9053 belantamab mafodotin-blmf, inj (Blenrep) J9062 amivantamab and hyaluronidase-lpuj, inj (Rybrevant) J9232 docetaxel (hospira), inj Q5164 ustekinumab-hmny, inj (Starjemza) Q5165 denosumab-mobz, inj (Oziltus) Q5166 denosumab-desu, inj (Osvyrti/Jubereq) Q5167 denosumab-qbde, inj (Enoby/Xtrenbo) Q5168 ranibizumab-leyk, inj (Nufymco) Q5169 pegfilgrastim-unne, inj (Amlupeg) Q5170 aflibercept-boav, inj (Eydenzelt) Q5171 denosumab-mobz, inj (Boncresa)   For

Reminder: Billing for Contrast Agents in Radiological Procedures Fidelis Care would like to remind providers of billing expectations related to contrast agents used in radiological testing, in alignment with New York State Medicaid guidance. Overview Radiological procedures that require the use of contrast agents must be billed in accordance with New York State Medicaid program requirements and applicable coding guidelines. Any contrast agents used for radiological testing are not reimbursable, as they are included in the fee of the radiologist. Providers are encouraged to review Medicaid resources to ensure proper billing and reimbursement. Reference Resources Providers may review the following New York State Medicaid resources for

Effective January 1, 2026, providers were required to submit an authorization request for Group and Family Therapy services that exceed 30 visits in a calendar year. The concurrent review requirements will include Mental Health Group and Family Therapy, but excludes Substance Use Disorder (SUD) treatment when the provider/service(s) is/are Article 32 licensed, certified, or otherwise authorized.   The following Mental Health services will require concurrent authorization once the initial 30 visits have been completed: Family Psychotherapy - CPT Code 90847 Fidelis Care will have notification & concurrent review requirements for Family Psychoeducation for any requests after the initial 30 visits per calendar