Welcome, Providers!

The following sections of the Fidelis Care authorization grids have been updated effective October 1, 2021.

The Inpatient Admissions section of the Medicaid, Medicare, Essential Plan, & Metal Level Plan grids now include the following notice regarding TurningPoint Healthcare Solutions:

Inpatient Admissions:  All inpatient admissions require an authorization.

• Ears, Nose, & Throat (ENT) Surgical Procedures, performed in inpatient, outpatient, physician’s office, and in-home settings, effective 9/20/2021 for dates of service rendered on or after 10/4/2021, prior authorization has been delegated to TurningPoint Healthcare Solutions, LLC.  For a list of codes requiring prior authorization, click here. If a CPT code is delegated to TurningPoint, associated devices (HCPCS codes) will also be reviewed by TurningPoint for medical necessity.
• Cardiac Surgical Procedures, performed in inpatient, outpatient, physician’s office, and in-home settings, effective 9/20/2021 for dates of service rendered on or after 10/4/2021, prior authorization has been delegated to TurningPoint Healthcare Solutions, LLC.  For a list of codes requiring prior authorization, click here. If a CPT code is delegated to TurningPoint, associated devices (HCPCS codes) will also be reviewed by TurningPoint for medical necessity.

 

The Outpatient surgery section of the Medicaid, Medicare, Essential Plan, & Metal Level Plan grids now include the following notice regarding TurningPoint Healthcare Solutions:

Outpatient surgery: The following services require prior authorization:

• Effective 9/20/2021 for dates of service rendered on or after 10/4/2021, prior authorization has been delegated to TurningPoint Healthcare Solutions, LLC for certain inpatient, outpatient, physician’s office, and in-home services Ears, Nose, & Throat (ENT) surgical procedures. For a list of codes requiring prior authorization, click here.
• Effective 9/20/2021 for dates of service rendered on or after 10/4/2021, prior authorization has been delegated to TurningPoint Healthcare Solutions, LLC for certain inpatient, outpatient, physician’s office, and in-home services Cardiac surgical procedures. For a list of codes requiring prior authorization, click here.
• Removed: Sinuplasty:  31295, 31296, 31297
• Clarifying statement added - Facial cosmetic, septoplasty, rhinoplasty: 21120-21296, 30400-30450, , 30465-30520, 30620-30802, 30999, 31298, C9749, Q2028 *For CPT codes that appear on the TurningPoint delegated CPT codes list, request for prior authorization should be directed to TurningPoint

 

The Outpatient and DME Services section of the Medicaid, Medicare, Essential Plan, & Metal Level Plan grids now include the following update regarding National Imaging Associates, Inc. (NIA):

Outpatient and DME Services: The following services require prior authorization:

• Imaging Studies: Effective 9/20/2021 for dates of service rendered on or after 10/1/2021, prior authorization has been delegated to National Imaging Associates, Inc. (NIA) healthcare for radiology services. A full list of CPT codes can be found by clicking here.
• Therapeutic Services: Effective 9/20/2021 for dates of service rendered on or after 10/1/2021, prior authorization has been delegated to NIA for radiation therapy services. (NIA) healthcare. A full list of CPT codes can be found by clicking here.

The following verbiage has been added to the Outpatient and DME Services section of the Medicare grid only:

 

Outpatient and DME Services: The following services require prior authorization:

• Home Health Care: Effective 9/20/2021 for dates of service rendered on or after 10/1/2021, Outpatient Home Therapy: Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST): all services performed by a therapy provider will require prior authorization through National Imaging Associates, Inc. (NIA).
• Effective 9/20/2021 for dates of service rendered on or after 10/1/2021, Outpatient Therapy, including services rendered in the home:  Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST): all services performed by a therapy provider after the initial evaluation will require prior authorization through National Imaging Associates (NIA). Excludes PT, OT, ST performed in an Inpatient setting, Emergency Room, Skilled Nursing Facility, or during an Observation stay.)

Services rendered on or after 10/1/2021, require prior authorization*

*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.

Non-Therapy Providers (MD, DO, DPM, etc.) should request prior authorization for all services after the initial evaluation directly through Fidelis Care.

 

The following services apply to Medicaid, Essential Plan, & Metal Level Plans and require prior authorization:

VIII. Pharmacy

Added:

            J1943  aripiprazole lauroxil, (Aristada Initio

J1944  aripiprazole lauroxil (Aristada)

J2358  olanzapine LA (Zyprexa Relpr)

J2426  paliperidone pal ER (Invega Sustenna)

J2794  risperidone (Risperdal Consta)

J2798  risperidone (Perseris)

 

The following service applies to Medicare and require prior authorization:

            J9043  cabazitaxel (Jevtana)

*Additional changes will be effective October 1^st, 2021:*

Language has been updated in the Outpatient and DME Services section of the October 2021 Authorization Grids:

Verbiage Removed, Medicaid, Essential Plan, & Metal Level Plan grids: Outpatient and DME Services: Imaging Studies - "The following services require authorization"

Verbiage Added, All Lines of Business: Outpatient and DME Services: Imaging Studies – “For radiology services, effective 9/20/2021 for dates of service rendered on or after 10/1/2021, prior authorization has been delegated to National Imaging Associates, Inc. (NIA).”

VIII. Pharmacy – New codes added as requiring authorization:

All Lines of Business:

J0741  cabotegravir and rilpivirine inj

J1426     casimersen inj

J1448     trilaciclib inj

J9247     melphalan flufenamide inj

J9318     romidepsin nonlyophilized inj

J9319     romidepsin lyophilized inj

Q2054   lisocabtagene maraleucel

 

Medicaid, Essential Plan, & Metal Level Plan Only:

J0699 cefiderocol 10mg (Fetroja)

J2406 oritavancin (Kimyrsa)

 

Medicare & Metal Level Plan Only: J1305     evinacumab-dgnb

 

Medicare Only:          

C9081        Idecabtagene vicleucel (Abecma)

C9082    dostarlimab-gxly (Jemperli)

C9083    amivantamab-vmjw (Rybrevant)

C9084    loncastuximab tesirine-lpyl (Zynlonta)

J2406     oritavancin (Kimyrsa)

J7294    Segesterone acetate and ethinyl estradiol 0.15 mg, 0.013 mg per 24 hours; yearly vaginal system (Annovera)

J7295    Ethinyl estradiol and etonogestrel 0.015 mg, 0.12 mg per 24 hours; monthly vaginal ring, (Nuvaring)

 

The following codes are removed from the October 2021 Authorization Grids:

All Lines of Business:

C9075 casimersen

C9076  lisocabtagene maraleucel

C9077    cabotegravir and rilpivirine

C9078    trilaciclib

C9079    evinacumab-dgnb

C9080    melphalan flufenamide

 

Medicaid, Essential Plan, & Metal Level Plan Only:

C0965           romidepsin

J0693     cefiderocol (Fetroja)

 

Medicare Only:          

J7303        contraceptive hormone vaginal ring

J9314     romidepsin (Istodax)

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.