The Fidelis Care Blog

Fidelis Care has received new guidance from the New York State Office of Mental Health (OMH) regarding Assertive Community Treatment (ACT) utilization management for requested services. 

This new guidance will no longer require providers to obtain prior authorization from Fidelis Care for ACT services using code H0040.  Providers will need to follow the authorization process below when seeking ACT services for Fidelis Care members.

Utilization Management for ACT – Authorization Process

Effective June 1, 2023, Level of Service Determinations (LOSD) and prior authorization previously completed by New York State (NYS) Medicaid Managed Care Organizations (MMCOs) is no longer required. Individuals, including MMCO enrollees, should be referred for ACT services as follows:

• The provider submits the application for ACT to the local Single Point of Access (SPOA).
• The SPOA will:

1. Confirm the individual is eligible for ACT; and
2. Determine the urgency of the individual’s need for ACT services relative to other applicants.

• If the SPOA determines that ACT level of care is indicated, SPOA will manage the process, from the point of receipt of a complete application, for placement on a referral list for ACT (if applicable) to assignment to an ACT team. 
• When an individual is assigned to a referral list, the SPOA will communicate with the referral source and other service providers as needed to ensure adequate care coordination while waiting for ACT services.
• Once members are assigned to, and engaged in ACT services, the ACT provider may submit their claims to Fidelis Care for reimbursement. No authorization is required.

For more information related to ACT services, please see the following guidance from New York State (NYS).