Fidelis Care Authorization Grids Effective November 1, 2022
9/30/2022
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Posted by Provider Relations
The following sections of the Fidelis Care authorization grids have been updated effective November 1, 2022.
The Essential Plan, Medicaid, Medicare and Metal-Level Products grids have been updated as follows:
III. Outpatient surgery: The following services require prior authorization:
A. Bariatric surgery: 43770-43775 (Note: S2083 no longer requires authorization as of 8/1/22)
The Medicaid grid has been updated as follows:
G. Mental Health Continuing Day Treatment (Adults and Children) (H2012): The first 7 service days do not require authorization; additional service days do require authorization.
Requests for members can be made by email qhcmbh@fideliscare.org , fax (718) 896-1784 or by calling 1-888-FIDELIS (1-888-343-3547) and following the prompts for Behavioral Health.
N. Children’s Home and Community Based Services:
3. Caregiver/Family Advocacy and Support Services: Retroactively effective from April 1, 2022, ‘Caregiver and Family Support and Services’ and ‘Community Self-Advocacy Training and Support’ are consolidated into a new service referred to as ‘Caregiver/Family Advocacy and Support Services’ to allow a broader array of providers to deliver the service. It also broadens the definition of caregivers eligible for training to include all individuals who supervise and care for members.
11. Adaptive and Assistive Technology
The Medicare grid has been updated as follows:
The Fidelis Website provides further details on Formulary Drug List, Prior Authorization Criteria, Step Therapy Criteria, Coverage Determination process, Redetermination process. https://www.fideliscare.org/Member/Medicare-Information/Prescription-Drug-Information
B. For a list of drugs that require step therapy, please click on the following link: Part B Step Therapy Policy
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.