NYM, FHP, CHP 1 V14.2-03/31/14
Medicaid, Family Health Plus, Child Health Plus Authorization Grid
FIDELIS CARE AUTHORIZATION REQUIREMENTS
SERVICES AND PROCEDURES WHICH REQUIRE AUTHORIZATION
I. Inpatient Admissions-All inpatient admissions require an authorization.
Fidelis Care does not require authorization of emergency room services or any emergent
service required to provide stabilization of an emergent condition. Fidelis Care does
require authorization of post stabilization services and inpatient admissions after
emergency room services are completed. All facility admissions are reviewed for
A. All acute inpatient facility services Inpatient Detoxification and Mental Health
services are limited for FHP to 30 days per calendar year of combined inpatient mental
health/substance abuse admissions. CHP and Medicaid benefits are unlimited when
B. Inpatient Rehabilitation Services: (acute, sub acute and skilled nursing
rehabilitation) require prior authorization.
1. Medical rehabilitation can be completed at an acute or sub acute level of care.
2. Inpatient substance abuse rehabilitation requires prior authorization.
C. Out of Network: Any Medicaid, FHP and CHP service provided by a nonparticipating
provider/facility/physician requires authorization.
All solid organ and bone marrow / tissue transplants require authorization at the time of
the transplant evaluation.
Includes but not limited to: 32850-32856, 33930-33945, 38204-38215, 38230-38242,
44133-44136, 47133-47147, 48160, 48550-48556, 50300-50380, 50547, 65710-65757.
E. Breast Cancer Surgery Centers:
Fidelis Care Medicaid members must receive mastectomy and lumpectomy procedure
associated with a breast cancer diagnosis, at high volume facilities. This link provides
information regarding New York State policies.
F. Elective Surgical Procedures:
Many surgical and medical procedures which are completed within 24 hours will not be
approved at an in-patient level of care. These same services when billed as an out-patient
level of care do not require authorization if performed within the Fidelis Care network.
Such procedures include, but are not limited to, cardiac catheterization and stenting,
laparoscopic procedures, and thyroid surgery if completed within 24 hours from the onset
The link provides a list of inpatient only procedures for Medicaid, FHP and CHP.
II. Outpatient surgery: The following services require prior authorization:
A. Obstetrical procedure: 58340
B. Bariatric surgery: 43770-43774, S2083
C. Blepharoplasty: 15820-15823
D. Breast reconstruction: 11920-11971, 19300, 19316-19342, 19355, 19370-19396
NYM, FHP, CHP 2 V14.2-03/31/14
E. Skin surgery and other dermatological procedures:
The auth requirement for many skin surgery treatments and repairs has been removed if
performed in the office or outpatient facility (POS 11 and 22). The following codes will
continue to require authorization if completed as ambulatory surgery (POS 24): 10040,
11300-11313, 11400 – 11471, 11721
Only the following codes continue to require authorization for any place of service:
11200-11201, 11719, 15775-15829, 17340-17999
F. Services for the following codes performed in free standing ambulatory surgery
centers billing with bill type 0831 require an authorization (10060, 11100, 11900 and
17000, 20600, 20605, and 20610).
G. Ear repair and ear piercing: 69300 and 69090
H. Eyelid & ocular surgery: 65760-65771, 65772-65775, 67900-67911
I. Abdominoplasty, lipectomy, panniculectomy: 15830-15839, 15847, 15876-15879
J. Reduction mammaplasty: 19300, 19318
K. Facial cosmetic, septoplasty, rhinoplasty: 21120-21296, 30400-30450, 30465-30520,
L. Vascular procedures i.e. vein stripping, ligation, ablation and sclerotherapy: 36468-
36479, 37718-37785, 36011, and 37204.
III. 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:
A. Psychological/Neuropsychological Testing:
96101, 96102, 96103, 96116, 96118, 96119, 96120, 96125. All requests should
be submitted on the Neuropsychological testing form.
B. Developmental Pediatric Testing:
96105, 96111 Note: 96110 is a non-covered service
C. Outpatient ECT: 90870
D. Partial Hospitalization (Mental Health and/or Substance Abuse)
Bill type 131, Revenue code 913,944, and 945
E. Intensive Outpatient Treatment
Bill type 131, Revenue code 912, CPT code 90899
F. Autism Spectrum Disorder (ASD):
The State has expanded benefits for CHP members with ASD to include increased
case management services, certain DME items to assist speech performance, and
Applied Behavioral Analysis, a form of enhanced behavioral modification.
1. Authorization is required for DME speech generation equipment.
2. Authorization is required from Behavioral Health for Applied Behavioral
3. Attestation of the diagnosis of ASD must be provided, at the time of request, by a
licensed physician or psychologist.
IV. Outpatient and DME Services: The following services require prior authorization:
A. Diagnostic testing
1. Sleep Studies
2. Breast Cancer testing (BRCA) and other Genetic Testing
3. Wireless Capsule Endoscopy
B. Durable Medical Equipment:
DME coverage information is available in the Medicaid DME Program Manual at:
NYM, FHP, CHP 3 V14.2-03/31/14
1. For Medicaid, supplies and disposable items are covered by Fidelis Care.
Disposable items and supplies are not covered by Fidelis Care for FHP and CHP
lines of business. Sections 4.1 to 4.3 in the DME Manual describe the specific
codes for Supplies that are covered and do not require authorization.
2. These DME codes that do not require an authorization:
E0130, E0135, E0168, E0182, E0184, E0235, E0274, E0305, E0310, E0424,
E0431, E0434, E0439, E0570, E0575, E0580, E0621, E0655, E0660, E0776,
E0890, E0900, E0942, E2361, E2363, L0130, L0140, L0150, L0160, L0170,
L0172, L0174, L0180, L0190, L0200, L1652, L2106, L2108, L2112, L2114,
L2116, L2126, L2128, L2132, L2134, L2136, L3100, L3762, L7360, L7362,
L7364, L7366, S8421, S8424, V5266
3. These orthotic codes do not require an authorization:
A4565 A8000, A8001, L0220, L0861, L0970, L0972, L0974, L0976, L0978,
L0980, L0982, L0984, L1010, L1020, L1030, L1040, L1050, L1060, L1070,
L1080, L1085, L1090, L1100, L1120, L1240, L1250, L1260, L1270, L1280,
L1290, L1600, L1610, L1620, L1630, L1650, L1660, L1810, L1820, L1902,
L2180, L2182, L2184, L2190, L3650, L3710, L3913, L3919, L3921, L3923,
L3925, L3929, L3931, L3933, L3935, L3995, L8010, L8035, L8300, L8310,
L8320, L8330, L8400, L8410, L8415, L8417, L8420, L8430, L8435, L8440,
L8460, L8465, L8470, L8480, L8485, L8505, V2624
4. Other DME and orthotic codes require an authorization.
5. Compression and Surgical Stockings: For Medicaid, FHP and MLTC, the
following codes do require authorization: A6540, A6541, A6549. The following
codes do not require authorization: A4495, A4500, A4510, A6530-A6539,
A6544. Benefit limits as defined in the DME Manual apply.
6. The footwear benefit for Medicaid and FHP is described in Section 4.6 of the
Medicaid DME Manual for Medicaid, FHP, and CHP. Prescription footwear
means orthopedic shoes, shoe modifications and shoe additions. The following
codes do require authorization: A5501, L3000 – L3003, L3010, L3020, L3160,
L3230, L3250, L3330. The following codes do not require authorization: A5500,
A5503-A5505, A5507, A5512, A5513, L3030-L3100, L3140, L3150, L3170,
3201-L3209,L3211-L3217, L3219, L3221, L3222, L3224, L3225, L3252-L3255,
L3257, L3260, L3265, L3300-L3320, L3332, L3334, L3340,-L3485, L3540,
L3570, L3580, L3600-L3640, L3649. Benefit limits as defined in the DME
C. Home Health Care: Home care approvals are based on the medical need for
skilled services. The FHP benefit maximum is 40 skilled visits per calendar year.
1. Personal Care Services for Medicaid and Managed Long Term Care (MLTC-
Fidelis Care at Home and MAP).
All services require authorization and use of the following codes:
T1001-for a nursing assessment (not for nurse supervision)
T1019-Personal Care Level I- 15 minute intervals, maximum of 8 hours a
T1020-Personal Care Level II-hourly intervals, up to 24 hours a day
G0162 – Nursing Supervision of Personal Care Providers is applicable to
bill for services outside of New York City.
2. Personal Emergency Response System (PERS) is a Medicaid and MLTC benefit
and requires an authorization.
NYM, FHP, CHP 4 V14.2-03/31/14
3. Consumer Directed Personal Assistance services (CDPAS) is a benefit for
Medicaid and Medicare and requires authorization.
D. Effective October 1, 2013, Hospice requests for Medicaid members should be
submitted to Fidelis Care.. FHP and CHP requests also should continue to be
submitted to Fidelis Care. For Medicaid members enrolled in Hospice prior to
October 1, 2013, the services will be covered by Medicaid FFS until member is
no longer enrolled in Hospice.
E. Imaging Studies: The following services below require authorization:
1. The first 3 OB ultrasounds can be performed without an authorization. Four or
more ultrasounds require authorization
2. The authorization requirement for PET scans (CPT codes 78608 and 78811-
78816) with a cancer diagnosis (ICD 9 codes 140.x-239.x) has been removed. All
other diagnosis codes continue to require authorization.
F. Outpatient Therapy: Physical, Occupational, Speech Therapy:
The initial evaluation does not require prior authorization. Additional visits require
authorization. The Medicaid, FHP and MLTC benefit is limited to 20 visits per member
for each service per calendar year. There is no visit limit for CHP. Services received at
home are not included in this restriction.
G. Podiatry Services:
Authorization is no longer required for podiatric services rendered to members with a
confirmed diagnosis of Diabetes Mellitus. The Diabetes diagnosis must be included on
the claim when services are billed. Podiatric services to members without a diagnosis of
diabetes will continue to require authorization. Podiatrists will continue to require
authorization for all DME and orthotic codes that are supplied in the office, regardless of
H. Therapeutic Services:
1. Phototherapy (96900, 96910, 96912, 96913)
2. Hyperbaric Oxygen Therapy
3. Pain Management Codes (i.e. injections, TENS, therapeutic services):
20526, 20550-20553, 21073, 62263-62264, 62273, 62280-62282, 62310-62311,
62318-62319, 63650-63688, 64400-64530, 64550-64595, 64600-64640 (for nonorthopedists
4. The following services are not covered for members with a diagnosis of Low
b. Therapeutic facet joint steroid injections in the lumbar and sacral regions
with or without CT fluoroscopic image guidance;
c. Therapeutic injections of steroids into intervertebral discs; and
d. Continuous or intermittent traction.
5. Topical oxygen requires prior authorization.
I. Long Term Home Health Care Services
Medical Social Services (S9127) and Home Delivered Meals (S5170) are covered
with an authorization for Medicaid Managed Care enrollees who have transitioned
from the Medicaid Fee-for-Services Long Term Home Health Care Program
(LTHHCP) and were in receipt of these services at the time of transition into
Medicaid Managed Care.
NYM, FHP, CHP 5 V14.2-03/31/14
J. Adult Day Health Care/AIDS Adult Day Health Care (ADHC/AADHC)
Authorization is required for any new ADHC/AADHC patient. Prior
authorization is also required for the initial assessment, up to two visits. Members
already enrolled in an ADHC/AADHC program as of 8/1/13 may remain in their
current care plan for up to 90 days. Requests for continuation of services beyond
that time period will be reviewed for medical necessity.
V. Counseling Services
A. Diabetes Self-Management Training (DSMT)
Members are allowed 10 hours/20 units in a continuous 12 month period. These services
must be provided by certified providers and no longer require authorization. Services are
covered when billed with codes G0108 and G0109
B. Asthma Self-Management Training (ASMT):
Asthma self-management training services may be provided in individual sessions, or in
group sessions of no more than eight patients. Authorization is required for codes S9441,
S9445, S9446, 98960-98962.
Members, including pregnant women, with newly diagnosed asthma or with asthma and a
medically complex condition (such as an exacerbation of asthma, poor asthma control,
diagnosis of a complication, etc.) will be allowed up to ten (10) hours of ASMT during a
continuous six-month period. Members with asthma who are medically stable may
receive up to one (1) hour of ASMT during a continuous six-month period.
C. Smoking Cessation Counseling (SCC):
Billing for FHP and Medicaid members must meet the following criteria. No
authorization is required.
1. Smoking cessation counseling will be reimbursed for up to 6 visits per calendar
year using the sum of codes 99406 or 99407 and billed ONLY with DX code
VI. New Technology/Experimental Treatment: Prior authorization is required and
based on medical necessity.
VII. Services provided by outside vendors
A. Dental and fluoride varnish treatment- Medicaid and CHP members up to and
including age 6 can receive fluoride varnish treatments.
Prior authorizations are completed by DentaQuest 1-800-516-9615.
Fluoride varnish treatment (D1206) is authorized by DentaQuest. Pediatricians,
Family and Nurse Practitioners can also obtain authorization through DentaQuest
to provide these treatments.
Orthodontic services are available for Medicaid members under age 21. Services
require prior authorization by DentaQuest 1-800-516-9615.
B. Vision: Prior authorizations by Davis Vision 1-800-601-3383
C. Transportation Link:
VIII. Pharmacy: As per formulary for Medicaid, FHP and CHP.
A. Enteral Therapy-HCPCS codes B4034-B4162 describe the available enteral
formulas or disposable items that require authorization.
NYM, FHP, CHP 6 V14.2-03/31/14
Benefit applies to:
1)Tube-fed individuals who can only obtain nutrition through a tube, 2) Individuals with
inborn metabolic disorders requiring specific nutritional formulas not available through
any other means, 3) Children under age 21 who require medical formulas due to
mitigating growth and development factors. 4) Adults with a diagnosis of HIV infection,
AIDS, or HIV-related illness, or other disease or condition, who are oral-fed, and who
require supplemental nutrition, demonstrate documented compliance with an
appropriate medical and nutritional plan of care, and have a body mass index
(BMI) under 18.5 as defined by the Centers for Disease Control, up to 1,000
calories per day; or
(b) require supplemental nutrition, demonstrate documented compliance with an
appropriate medical and nutritional plan of care, and have a body mass index
under 22 as defined by the Centers for Disease Control and a documented,
unintentional weight loss of 5 percent or more within the previous 6 month
period, up to 1,000 calories per day; or
(c) require total nutritional support, have a permanent structural limitation that
prevents the chewing of food, and the placement of a feeding tube is medically
Pharmacy supplies do not require an authorization (supplies not covered for FHP and
CHP, please refer to benefit plan).
B. These injectable codes require authorization.
J0129, J0135, J0150, J0180, J0205, J0215, J0220, J0221, J0256, J0257, J0270,
J0476, J0480, J0490, J0585, J0586, J0587, J0588, J0592, J0597, J0598, J0638,
J0706, J0718, J0725, J0775, J0897, J1290, J1300, J1325, J1438, J1459, J1460,
J1557, J1559, J1560, J1561, J1566, J1568, J1569, J1572, J1595, J1599, J1740, J1742,
J1743, J1745, J1786, J1826, J1830, J1835, J1930, J1931, J2020, J2170, J2323, J2357,
J2358, J2426, J2440, J2503, J2507, J2562, J2778, J2793, J2794, J2796, J3262, J3285,
J3355, J3357, J3385, J3396, J3490, J3590, J7180, J7183, J7185, J7187, J7189,J7190,
J7192, J7193, J7194, J7195, J7198, J7199, J7302, J7307, J7308, J7309, J7312, J7321,
J7323, J7324, J7325, J7326, J7335, J7511, J7515, J7516, J7517, J7518, J7520, J7525,
J7527, J7599, J7607, J7609, J7610, J7622, J7624, J7626, J7629, J7633, J7634, J7635,
J7636, J7637, J7638, J7639, J7641, J7642, J7643, J7680, J7681, J7683, J7684, J7685,
J7686, J8510, J8515, J8520, J8521, J8560, J8562, J8597, J8600, J8650, J8700, J8999,
J9228, J9302, J9310
NYM, FHP, CHP 1 V14.2-03/31/14
|LCD and Policy Article Revisions Summary for March 27, 2014
Outlined below are the principal changes to DME MAC Local Coverage Determinations (LCDs) and a Policy Articles (PA) that have been revised and posted. Please review the entire LCD and each related PA for complete information.
Oral Anticancer Drugs
Pneumatic Compression Devices
Spinal Orthoses: TLSO and LSO
Note: The information contained in this article is only a summary of revisions to LCDs and Policy Articles. For complete information on any topic, you must review the LCD and/or Policy Article.
Billing Reminder: Modifier Usage for Urological Supplies –
The Urological Supplies Local Coverage Determination (LCD) provides for the use of modifiers with each submitted HCPCS code to indicate whether the applicable payment criteria are met (KX modifier) and to provide other information related to coverage and/or liability (GA, GZ and GY modifiers) when the policy criteria are not met. This article reviews the appropriate use of each modifier to ensure correct use. Instructions for the GA and GZ modifiers were recently included in this LCD for proper consideration of usage (December 2013).
Proper selection of the correct G modifier requires an assessment of the possible cause for a denial. Some criteria are based upon statutory requirements. A failure to meet a statutory requirement justifies the use of the GY modifier. When Reasonable and Necessary (R&N) criteria are not met, either the GA or GZ modifier is appropriate based upon Advance Beneficiary Notice of Noncoverage (ABN) status.
Urological supplies are payable under the Prosthetic Device benefit (Social Security Act § 1861(s)(8)). Urinary catheters and external urinary collection devices are covered to drain or collect urine for a beneficiary who has permanent urinary incontinence or permanent urinary retention. Permanent urinary retention is defined as retention that is not expected to be medically or surgically corrected in the affected beneficiary within 3 months. These requirements are statutory benefit requirements. When a beneficiary does not meet these requirements, the GY modifier must be used.
Aside from the above statutory coverage criteria, the remaining payment requirements are classified as R&N requirements. Examples (not all-inclusive) include utilization limits, medical necessity criteria for sterile kits, correct coding, etc. For those situations where R&N criteria are not met, either the GA or GZ modifier would be the appropriate choice depending upon ABN status.
Use of these modifiers is mandatory. Claims lines billed without a KX, GA, GY or GZ modifier will be rejected as missing information.
KX – Requirements specified in the medical policy have been met
The KX modifier must be appended to a catheter code, an external urinary collection device or a supply item when all of the statutory and R&N requirements have been met. Suppliers are not required to secure all of the required documentation prior to claim submission, however, appending the KX modifier to each of the urological codes billed serves as an attestation by the supplier that the requirements for its use have been met.
GA – Waiver of liability (expected to be denied as not reasonable and necessary, ABN on file)
When a Medicare claim denial is expected because an item or service does not meet the R&N criteria, the supplier must issue an ABN to the beneficiary before furnishing the item or service. When the beneficiary accepts financial responsibility and signs a valid ABN, the supplier submits the claim to Medicare appending modifier GA to each corresponding Healthcare Common Procedural Coding System (HCPCS) code. Modifier GA indicates that the supplier has a waiver of liability statement on file. Modifier GA must not be submitted if a valid ABN is not issued. Claims submitted with the GA modifier will receive a medical necessity denial holding the beneficiary liable.
GZ – Item or service not reasonable and necessary (expected to be denied as not reasonable and necessary, no ABN on file)
When a Medicare claim denial is expected because an item or service does not meet the R&N criteria, the supplier is expected to issue an ABN to the beneficiary. If the beneficiary refuses to sign the ABN accepting financial responsibility, or the supplier fails to issue the ABN for items and services furnished when ABN issuance is required, the supplier must append the GZ modifier to the claim line. Claims submitted with the GZ modifier will receive a medical necessity denial holding the supplier liable.
GY – Item or service statutorily excluded or does not meet the definition of any Medicare benefit
The GY modifier indicates that an item or service is statutorily excluded or does not meet the definition of any Medicare benefit. For urological supplies, the prosthetic benefit requires that the beneficiary must have a permanent impairment of urination.
In cases where the statutory criteria are not met, suppliers are required to code their claims for urological supplies with the GY modifier. Claims submitted with the GY modifier will be denied as statutorily noncovered holding the beneficiary liable for the excluded services.
Refer to the Urological Supplies LCD and related Policy Article for additional information about the payment rules, coding and documentation requirements.
- Bill Medicare and obtain an official decision;
- File a claim with the beneficiary’s secondary insurer once the Medicare decision is received
- Collect a payment or partial payment from the beneficiary for the item if Medicare and/or the secondary insurer do not pay.