02/11/2021

Authorization Policy-Fidelis-No Auth for E&M

I am seeking clarification on the new authorization policy for Fidelis. Is it correct that as of 2/1/21 all plans-Medicaid, Medicare, Metal level plans and Essential level plans- do not require an authorization for an E&M code nor an E&M code billed with an additional CPT code. The exception to this would be those CPT codes that are specifically listed on the authorization grid. Thank you

That would be a correct interpretation of the current authorization grid from Fidelis Care. For E&M codes and many codes that are routinely performed in an office or outpatient hospital POS, no prior notification is needed for in network providers. Limitations would still apply in the following circumstances:

-Provider is out of network

-Services are provided in a POS where authorization is still required (home, nursing homes/assisted living, inpatient hospital, ASC, etc.)

-DME purchases

-Procedure codes explicitly listed that require authorization regardless of the provider specialty & POS