7/1/2022
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective August 1, 2022.
The Essential Plan, Medicaid, Medicare and Metal-Level Products grids have been updated to provide further clarification as follows:
V. Outpatient and DME Services - The following services require prior authorization:
- Effective 10/1/2021, Home & Outpatient Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST): performed by a therapy provider (Office, home or facility) after the initial evaluation will require prior authorization through NIA (Home therapy requires authorization for the initial evaluation). Please note, CPT codes 92610 and 92611, do not require prior authorization. (This program excludes PT, OT, ST performed in an Inpatient setting, Emergency Room, Skilled Nursing Facility/ Sub-Acute Rehabilitation, or during an Observation stay. See below for instructions to request prior authorization in the inpatient settings.)
All other billed procedure codes, even if performed on the same date as the initial evaluation date, will require authorization prior to billing. If submitting claims using codes other than designated initial evaluation CPT Codes, an authorization request needs to be sent to NIA within 1 business day for the outpatient setting or 2 business days for the home health setting or to Fidelis within 1 business day for inpatient settings.
For all therapy services provided in Inpatient settings POS 31 & 32 (Skilled Nursing Facilities/ Sub-Acute Rehab in a SNF & Nursing Facility) Prior authorization requests are to be faxed to 716-803-8307.
Non-Therapy Providers (MD, DO, DPM, etc.) should request prior authorization for all services after the initial evaluation directly through Fidelis Care.
The Medicaid grid has been updated as follows:
IV. Behavioral Health - Outpatient services
The authorization requirement has been removed from all outpatient behavioral health services except the following, which will continue to require authorization:
B. Developmental Pediatric Testing:
96112, 96113. Authorization is required.
96110- No Authorization Required (excluding CHP): Fidelis Care will provide reimbursement for developmental screening CPT Code 96110 in the “First Three Years of Life” of a child, in addition to the payment for an Evaluation and Management (E&M) service, effective April 1, 2022. Developmental screening is a structured process that involves the use of one or more standardized, validated screening tools to identify and refine the recognized risk. The provider scores and documents the objective data including any delay in the attainment of developmental milestones and age-appropriate maturity of speech/language of a child using the measurable parameters of the standardized instrument. Developmental screening recommendations are based on the Bright Futures/American Academy of Pediatrics (AAP) Periodicity Schedule (ages 9, 18, and 30 months for screening for global developmental delay and ages 18 and 24 months for autism spectrum disorder (ASD) screening).
Developmental screening for ASD by a primary care provider using a validated screening tool may be reimbursed up to two times in the child’s “First Three Years of Life” of the child, beginning at 18 months of age. Developmental screening for global developmental delay by a primary care provider using a validated screening tool may be reimbursed up to one time per year in the “First Three Years of Life” of the child. Screening can be integrated into the well-childcare schedule.
The Medicare grid has been updated as follows:
VIII. Pharmacy
- Oncology medications and supportive agents will require prior authorization (PA) from New Century Health for all PARTICIPATING PROVIDERS before being dispensed at a pharmacy or administered in a physician’s office, outpatient hospital, or ambulatory setting for members of all ages. PA can be requested by visiting NCH’s Web portal at my.newcenturyhealth.com or calling 1-888-999-7713, option 1. For the list of drugs that require NCH review, please click on the following link: https://www.fideliscare.org/Portals/0/Providers/New-Century-Health-Oncology-Program-Medicare-2022.pdf
The following code has been updated on the Medicare authorization grid and requires prior authorization:
J2506 pegfilgrastim, excludes biosimilar (Neulasta)
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.