Authorization Grids

Authorization Grids are now available for Medicare, Medicaid, Child Health Plus, and NY State of Health Marketplace plans, and are effective for dates of service occurring on or after the dates below.

Coding - Updated 6/15/2022

Fidelis Care has updated our claims systems to be able to receive new codes associated with COVID-19 testing and has added Healthcare Common Procedure Coding System (HCPCS) codes as they become available. Providers should continue to follow evolving CDC ICD-10-CM Official Coding Guidelines available here: https://www.cdc.gov/nchs/icd/icd10cm.htm when selecting a diagnosis code and procedure code to ensure proper reporting.

*Please Note:The coding guidelines referenced below is not a guarantee of reimbursement in all products, as codes may not have published rates for all products.In addition, coding may be subject to National Correct Coding Initiatives or CMS standards. 


 

Code Type

Code

Effective*

Testing (CDC)

U0001

2/4/2020

Testing (Non-CDC)

U0002

2/4/2020

Testing (Industry Standard)

87635

3/13/2020

Testing (Infectious Disease)

0202U

5/20/2020

Testing (Throughput)

U0003

4/14/2020

Testing (Throughput)

U0004

4/14/2020

Testing (Antigen)

0223U

6/25/2020

Testing (Antigen)

0224U

6/25/2020

Testing (Infectious Disease)

0225U

8/10/2020

Testing (sVNT)

0226U

8/10/2020

Testing

86413

9/8/2020

Testing (Infectious Disease)

0240U

10/6/2020

Testing (Infectious Disease)

0241U

10/6/2020

Testing (Infectious Agent Detection)

87636

10/6/2020

Testing (Infectious Agent Detection)

87637

10/6/2020

Testing (Infectious Agent Detection)

87811

10/6/2020

Mutation identification SARS CoV-2

87913

2/21/2022

Testing (Add-On Payment)

U0005

1/1/2021

OTC At Home COVID Tests

N/A

1/15/2022

Screening

Z03.818

2/4/2020

Screening (Specimen Transfer)

G2023

3/1/2020

Screening (Specimen Transfer)

G2024

3/1/2020

Screening (Specimen Transfer)

C9803

3/1/2020

Screening (Antibody Testing)

86328

4/10/2020

Screening (Antibody Testing)

86769

4/10/2020

Screening (Antigen Detection)

87426

6/25/2020

Screening (Antigen Detection)

87428

11/10/2020

Screening (Neutralizing Antibody)

86408

8/10/2020

Screening (Neutralizing Antibody)

86409

8/10/2020

Encounter for Screening COVID-19

Z11.52

1/1/2021

Contact with and (suspected) exposure to COVID-19

Z20.822

1/1/2021

VEKLURY Antiviral Medication

J0248

12/23/2021

Convalescent Plasma

C9507

12/28/2021

Multisystem inflammatory syndrome (MIS)

M35.81

1/1/2021

Treatment

U07.1

4/1/2020

Treatment

B97.29

1/27/2020-3/31/2020

AstraZeneca – Tixagev and Cilgav Injection

Q0220

12/8/2021

AstraZeneca – Tixagev and Cilgav Injection

M0220

12/8/2021

AstraZeneca – Tixagev and Cilgav Injection

M0221

12/8/2021

AstraZeneca – Tixagev and Cilgav Injection

Q0221

2/24/2022

Eli Lily – Bebtelovimab Injection

Q0222

2/11/2022

Eli Lily – Bebtelovimab Injection

M0222

2/11/2022

Eli Lily – Bebtelovimab Injection

M0223

2/11/2022

Eli Lily Monoclonal - Bamlan/Etesev Injection

Q0245

2/9/2021

Eli Lily Monoclonal - Bamlan/Etesev Infusion

M0245*

2/9/2021

Eli Lily Monoclonal - Bamlan/Etesev Infusion

M0246

5/6/2021

GSK Monoclonal - Sotrov Injection

Q0247

5/26/2021

GSK Monoclonal - Sotrov Infusion

M0247*

5/26/2021

GSK Monoclonal - Sotrov Infusion In Home

M0248

5/26/2021

Genentech Monoclonal - Tocili Injection

Q0249

6/24/2021

Genentech Monoclonal - Tocili 1st Infusion

M0249*

6/24/2021

Genentech Monoclonal - Tocili 2nd Infusion

M0250*

6/24/2021

Eli Lily Monoclonal - Bamlan Injection

Q0239

11/10/2020 - 5/6/21

Eli Lily Monoclonal - Bamlan Infusion

M0239*

11/10/2020 - 5/6/21

Regeneron Monoclonal - Casiri/Imdev Injection

Q0243

11/21/2020-1/23/22

Regeneron Monoclonal - Casiri/Imdev Infusion

M0243*

11/21/2020-1/23/22

Regeneron Monoclonal - Casiri/Imdev Injection

Q0244

6/3/2021-1/23/22

Regeneron Monoclonal - Casiri/Imdev Infusion

M0244

5/6/2021-1/23/22

Regeneron Monoclonal - Casiri/Imdev Injection

Q0240

7/30/2021-1/23/22

Regeneron Monoclonal - Casiri/Imdev Infusion

M0240

7/30/2021-1/23/22

Regeneron Monoclonal - Casiri/Imdev Infusion

M0241

7/30/2021-1/23/22

Home Vaccine Admin

M0201

6/8/2021

Pfizer Vaccine

91300

12/11/2020

Pfizer Vaccine Admin - 1st Dose

0001A

12/11/2020

Pfizer Vaccine Admin - 2nd Dose

0002A

12/11/2020

Pfizer Vaccine Admin - 3rd Dose

0003A

8/12/2021

Pfizer Vaccine Admin - Booster

0004A

9/22/2021

Moderna Vaccine

91301

12/18/2020

Moderna Vaccine Admin - 1st Dose

0011A

12/18/2020

Moderna Vaccine Admin - 2nd Dose

0012A

12/18/2020

Moderna Vaccine Admin - 3rd Dose

0013A

8/12/2021

Moderna Vaccine (Low Dose)

91306

10/20/2021

Moderna Vaccine (Low Dose) - Booster

0064A

10/20/2021

Janssen Vaccine

91303

2/27/2021

Janssen Vaccine Admin - Single Dose

0031A

2/27/2021

Janssen Vaccine Admin – Booster

0034A

10/20/21 

Pfizer Vaccine (Pediatric)

91307

10/29/2021

Pfizer Vaccine (Pediatric) Admin - 1st Dose

0071A

10/29/2021

Pfizer Vaccine (Pediatric) Admin - 2nd Dose

0072A

10/29/2021

NEW - SARS-COV2 Vaccine, mRNA-LNP 10MCG/0.2mL for 5 - 11 years - Booster

0074A

5/17/2022

Pfizer Vaccine (Ready to use)

91305

1/3/2022

Pfizer Vaccine (Ready to use) Admin - 1st Dose

0051A

1/3/2022

Pfizer Vaccine (Ready to use) Admin - 2nd Dose

0052A

1/3/2022

Pfizer Vaccine (Ready to use) Admin - 3rd Dose

0053A

1/3/2022

Pfizer Vaccine (Ready to use) Admin – Booster

0054A

1/3/2022

Administration  - Moderna COVID-19 Vaccine 50MCG/0.5ML – Booster

0094A

3/7/2022

SARS-COV2 Vaccine, mRNA-LNP 50MCG/0.5mL

91309

3/7/2022

Administration - SARS-COV2 Vaccine, mRNA-LNP 3MCG/0.2mL for 6 months – 5 years – 1st Dose

0081A

2/2/2022

Administration - SARS-COV2 Vaccine, mRNA-LNP 3MCG/0.2mL for 6 months – 5 years – 2nd Dose

0082A

2/1/2022

SARS-COV2 Vaccine, mRNA-LNP 3MCG/0.2mL for 6 months – 5 years

91308

2/1/2022


*On April 16, 2021, the FDA revoked the EUA that allowed for the investigational monoclonal antibody therapy bamlanivimab, when administered alone, to be used for the treatment of mild-to-moderate COVID-19 in adults and certain pediatric patients. Due to this revocation, the Medicaid and Medicare programs will not pay for claims with HCPCS codes M0239 or Q0239 with dates of service after 4/16/2021.

 

Part II: Formulary Removals & PA/ST/QL Additions


Drug Action Formulary Alternatives Effective Date
Siliq* Remove • Actemra, Stelara, Humira, Enbrel, Cosentyx, Infliximab 04/01/2022
Kevzara* Remove • Actemra, Stelara, Humira, Enbrel, Cosentyx, Infliximab 04/01/2022
Xeljanz* Remove • Actemra, Stelara, Humira, Enbrel, Cosentyx, Infliximab 04/01/2022
Xyrem Remove

• Modafinil, Armodafinil
• Venlafaxine IR/ER, Fluoxetine, Atomoxetine

04/01/2022

* Change for CHP Only; Change will not affect NYM/HARP

Medicaid Formulary and Q2 Updates


Medicaid, Child Health Plus, and Healthier Life:
Formulary Changes and Effective Dates

Fidelis Care has made changes to our Medicaid Managed Care, Child Health Plus (CHP), and HealthierLife (HARP) Formulary effective April 1, 2022. Some of the changes relate to quantity limitations, authorization requirements, as well as drugs being removed and added to the formulary. Please see the full list here.


 

Drug Action Effective Date
Buprenorphine/Naloxone (Zubsolv)** • Add with QL 03/22/2022
Buprenorphine/Naloxone film (Suboxone)**  • Add generic with QL (Brand already Formulary) 03/22/2022
Naloxone (Kloxxado)** • Add 03/22/2022
Memantine ER • Add with ST of memantine IR 04/01/2022
Procrit/Epogen • Add with PA 04/01/2022
Ruconest • Add with PA 04/01/2022
Cinryze • Add with PA 04/01/2022
Invega Hafyera • Add with PA 04/01/2022
Teriflunomide (Aubagio) • Add QL 04/01/2022
Ambrisentan (Letairis) • Add QL 04/01/2022
Fingolimod (Gilenya) • Add QL 04/01/2022
Sponimod (Mayzent) • Add QL 04/01/2022
Sponimod (Mayzent) Titration Pack • Add with QL 04/01/2022
Actemra* • Add with PA/QL 04/01/2022
Stelara* • Add with QL 04/01/2022
Buprenorphine/Naloxone (Zubsolv)** • Add with QL 04/01/2022

* Change for CHP Only; Change will not affect NYM/HARP
** Change for NYM/HARP Only; Change will not affect CHP

Medicaid, Child Health Plus, and Healthier Life:
Formulary Changes and Effective Dates

Fidelis Care has made changes to our Medicaid Managed Care, Child Health Plus (CHP), and HealthierLife (HARP) Formulary effective April 1, 2022. Some of the changes relate to quantity limitations, authorization requirements, as well as drugs being removed and added to the formulary. Please see the full list here.


 

Drug Action Effective Date
Buprenorphine/Naloxone (Zubsolv)** • Add with QL 03/22/2022
Buprenorphine/Naloxone film (Suboxone)**  • Add generic with QL (Brand already Formulary) 03/22/2022
Naloxone (Kloxxado)** • Add 03/22/2022
Memantine ER • Add with ST of memantine IR 04/01/2022
Procrit/Epogen • Add with PA 04/01/2022
Ruconest • Add with PA 04/01/2022
Cinryze • Add with PA 04/01/2022
Invega Hafyera • Add with PA 04/01/2022
Teriflunomide (Aubagio) • Add QL 04/01/2022
Ambrisentan (Letairis) • Add QL 04/01/2022
Fingolimod (Gilenya) • Add QL 04/01/2022
Sponimod (Mayzent) • Add QL 04/01/2022
Sponimod (Mayzent) Titration Pack • Add with QL 04/01/2022
Actemra* • Add with PA/QL 04/01/2022
Stelara* • Add with QL 04/01/2022
Buprenorphine/Naloxone (Zubsolv)** • Add with QL 04/01/2022

* Change for CHP Only; Change will not affect NYM/HARP
** Change for NYM/HARP Only; Change will not affect CHP

 

eviCore Healthcare

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