Fidelis Care Authorization Grids Effective December 1, 2022
10/31/2022
•
Posted by Provider Relations
in
Provider News
The following sections of the Fidelis Care authorization grids have been updated effective December 1, 2022.
The Essential Plan, Medicare and Metal-Level Products grids have been updated as follows:
V. Outpatient and DME Services: The following services require prior authorization:
- Penile Prosthesis - 54405
The Medicaid grid has been updated as follows:
III. Outpatient surgery: The following services require prior authorization:
- 11719 (Trimming of Nondystrophic Nails, any number) has been removed from the authorization grid because it is not a covered code per the Medicaid fee
N. Children’s Home and Community Based Services:
The following additional services are available to members age 20 and younger, if determined to be HCBS-eligible by a Health Home or the Children and Youth Evaluation Service (C-YES) and effective 12/01/2022, require notification to Fidelis Care of the identified service requested prior to the member’s initial appointment:
6. Respite Services (Planned Respite and Crisis Respite)
The Medicare grid has been updated as follows:
New Century Health (NCH) will require review of the following codes as of 12/01/2022:
- J8999 Futibatinib
- J9999 Bevacizumab-adcd
The following codes have been updated on the Essential Plan, Medicaid, and Metal-Level Products grids and require prior authorization:
- C9055 brexanolone (Zulresso)
- J9274 tebentafusp-tebn (Kimmtrak)
Visit: Authorization Grids
COVID-19 UPDATE: Please refer to this link: Important Updates Regarding Coronavirus COVID-19, for authorization and coding guidelines related to the COVID-19 Pandemic.