The following sections of the Fidelis Care authorization grids have been updated effective October 1, 2023.
The Medicaid, Medicare, Essential Plan and Metal-Level grids have been updated as follows:
E. OASAS Licensed Inpatient Substance Use Disorder Treatment:
The facility may fax or email the OASAS Appendix A Notification Form and OASAS LOCADTR Medical Necessity Tool to 833-663-1608 (formerly 646-829-1421) or LOCADTR@fideliscare.org.
H. OMH Licensed Inpatient Mental Health Treatment
The facility is required to notify the insurer within 2 business days of admission by calling 1-888-FIDELIS (1-888-343-3547), extension 16072 for Behavioral Health or by fax 833-561-0094 (formerly 718-896-1784).
Requests for members under 21 can be made by email chmmc@fideliscare.org, by fax 833-663-1604 (formerly 347-690-7362) or by calling 1-888-FIDELIS (1-888-343-3547) and following the prompts for Children’s Medicaid.
IX. Pharmacy
D. See Appendix I for codes that require authorization. Please submit prior authorization requests to our Pharmacy Team electronically via fax (e-fax) to: 1-844-235-5090.
The Medicaid grid has been updated as follows:
IV. Behavioral Health - Outpatient services
G. Mental Health Continuing Day Treatment (Adults and Children) (H2012):
Requests for members can be made by email qhcmbh@fideliscare.org, fax 833-561-0094 (formerly 718-896-1784) or by calling 1-888-FIDELIS (1-888-343-3547) and following the prompts for Behavioral Health.
L. Community Oriented Recovery and Empowerment (CORE) Services:
The Service Initiation Form is required to be submitted to Fidelis Care by e-mail (QHCMHARPBH@FidelisCare.org) or fax 833-561-0089 (formerly 347-868-6427) within 3 business days of the first service visit.
N. Children’s Home and Community Based Services
In order to comply with the New York State guidance received on December 13, 2022, the short-term Children’s Respite Services flexibility will end immediately and providers are required to revert to the original guidance provided in the HCBS Manual:
• Short-term Respite Services may no longer be billed if delivered via telehealth or telephonically to an individual or group;
• All short-term Respite Services must be delivered in-person, as remote delivery will no longer be allowable;
• Short-term Respite Services may be delivered by qualified practitioners in a home or residence, out-of-home/residence by staff in community-based sites (e.g., community centers, camps, parks), or in allowable facilities; and
• Billing for short-term Respite must be based on in-person interactions with the Waiver enrolled children/youth.
Additionally, short-term Planned and Crisis Respite services may not exceed the 14 days (1,344 15-minute units) annual limits (per calendar year) without medical necessity. Short-term Planned and Crisis Respite beyond these limits MUST be supported by medical necessity, such as, documentation through a Licensed Practitioner of the Healing Arts (LPHA) Attestation form along with NYS DOH Children’s HCBS Authorization and Care Manager Notification form by email to SM_Childrens_HCBS@fideliscare.org, by fax 833-663-1604 (formerly 347-690-7362) or by calling 1-888-FIDELIS (1-888-343-3547) and following the prompts for Children’s Medicaid.
The following codes have been updated on the Medicare Authorization Grid and require prior authorization:
J1460 immune glob (Gamastan)
J1560 immune glob (Gamastan)
J3520 Edetate disodium
J7180 factor XIII human (Corifact)
J7183 vWF human (Wilate)
J7185 factor VIII recombinant (Xyntha)
J7186 VIII/VWF complex human (Alphanate)
J7187 vWF complex (Humate-P)
J7189 factor VIIa recombinant (Novoseven)
J7190 factor VIII antihemophilic human (Hemofil M, KoateDVI, Monoclate-P)
J7191 factor VIII antihemophilic factor [porcine])
J7192 factor VIII recom NOS
J7193 factor IX non-recomb (AlphaNine/ Mononine)
J7194 factor IX complex (Bebulin, Profilnine)
J7195 factor IX recombinant (not otherwise specified)
J7196 antithrombin (Atryn)
J7197 antithrombin (Thrombate III)
J7198 anti-inhibitor (Feiba)
J7199 hemophilia Clot Factor Noc
J7294 Segesterone acetate and ethinyl estradiol
J7295 Ethinyl estradiol and etonogestrel
J8515 cabergoline, oral
The following codes have been updated on the Medicaid, Medicare, Essential Plan, and Metal-Level Products Authorization Grids and require prior authorization:
C9154 buprenorphine ER (Brixadi)
C9155 epcortiamab-bysp (Epkinly)
C9157 tofersen injection (Syfovre)
J0174 lecanemab-irmb (Leqembi)
J0801 corticotropin (Acthar gel)
J0802 corticotropin (ANI)
J0889 daprodustat oral ESRD
J2781 pegcetacoplan injection (Empavli)
J7214 factor VIII recomb (Altuviiio)
J9051 bortezomib injection (Maia)
J9064 cabazitaxel injection (Sandoz)
J9345 retifanlimab-dlwr (Zynyz)
The following code has been updated on the Medicaid, Essential Plan, and Metal-Level Products Authorization Grids and require prior authorization:
C9152 aripiprazole injection (Abilify Asimtufii)
C9158 risperidone injection (Uzedy)
New Century Health (NCH) will require review of the following codes as of October 1, 2023 for Medicaid, Medicare, Essential Plans and Metal-Level Products:
C9155 epcoritamab-bysp,0.16 mg
J8999 quizartinib (Vanflyta) – (for Medicare, Part D only)
J8999 niraparib 50mg/abiraterone 500mg – (for Medicare, Part D only)
J9051 bortezomib
J9064 cabazitaxel
J9345 retifanlimab-dlwr
J9999 elranatamab-bcmm injection (Elrexfio)
J9999 melphalan injection (Hepzato)
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