October 14, 2025
Good afternoon,Thanks to our Billing Geeks group, the NYS Council recently became aware of a notice Fidelis sent to its ‘in network’ Medicaid providers indicating that as of November 1, the insurer would be implementing what it is now referring to as ‘concurrent review’ for certain services. Upon receiving this information we immediately went to OMH and OASAS, seeking clarification as to whether Fidelis can implement such a requirement. Today I (finally) received the following information from OMH but clearly it is coming from both state agencies. Please review below.
Earlier this year the NYS Council informed OMH that 3 insurers – Fidelis, United and HealthFirst informed their ‘in network’ providers that they would begin requiring ‘concurrent review’ for certain CAFTAS services, and as it turns out only some ‘in network’ providers are required to comply. When providers inquired as to why they were being required to comply, they were met with a scripted response from a plan representative, with no real explanation. We quickly went to the state seeking technical assistance and support. When there was no meaningful response, the NYS Council approached The Legal Action Center and together we sent a letter to state leaders objecting to this new requirement and calling into question the tactics being used here. I am still waiting for a formal response to our letter re: concurrent review for some CAFTAS services.
Obviously we have growing concerns regarding the tactics being implemented by some insurers as well as the state’s current surveillance, monitoring and enforcement of the ground rules for implementing these new requirements. At a minimum, surveillance should be robust with meaningful and escalating sanctions against any insurer that misuses these powers.
———- Forwarded message ———
From: Hetzel, Emily (OMH) <Emily.Hetzel@omh.ny.gov>
Date: Tue, Oct 14, 2025 at 4:48 PM
Subject: RE: SEEKING ASSISTANCE: Fidelis Care Authorization Grids Effective November 1, 2025
To: lauri@nyscouncil.org <lauri@nyscouncil.org>
Cc: Moon, Bob (OMH) <Bob.Moon@omh.ny.gov>, Barnett, Pieter (OMH) <Pieter.Barnett@omh.ny.gov>, Katagiri, Joe (OMH) <Joe.Katagiri@omh.ny.gov>, Allen, Trishia (OASAS) <Trishia.Allen@oasas.ny.gov>, Lincourt, Pat (OASAS) <Pat.Lincourt@oasas.ny.gov>, Morris, Maria (OASAS) <Maria.Morris@oasas.ny.gov>
Hello Lauri,
I’m following up from my previous email sent last week regarding Fidelis’ recent announcement about implementing concurrent review requirements for family and group psychotherapy.
OASAS and OMH reviewed Fidelis’ updated authorization grid information for family and group psychotherapy against existing State utilization management (UM) guidance.
OMH Services:
A review of OMH billing codes was completed to confirm the two procedure codes 90847 and 90853 are only Medicaid billable in MHOTRS programs.
- Fidelis’ initial notice stating that concurrent review would be conducted after an enrollee received 24 units of family or group psychotherapy was problematic. Their revised notice shifting to 30 visits is now in line with existing OMH guidance.
- For MHOTRS services, Fidelis cannot require prior authorization but is permitted to conduct concurrent review.
- The Prior and concurrent authorization for ambulatory behavioral health services document states that MMCPs must pay for at least 30 outpatient mental health office and clinic service visits per calendar year without requiring authorization (see page 3). The 30-visit limit does not apply to services the MMCP does not cover/pay for, or psychiatric assessment and medication management visits. MMCPs are required to count multiple services received on the same day as a single visit.
- Fidelis may require providers to engage in a concurrent review process for their MMC enrollees once the 30 MHOTRS program visit threshold in a calendar year is met. Fidelis’ concurrent review requirements are specific to 30 visits for group or family psychotherapy, which is less restrictive than OMH’s 30 total visit threshold.
OASAS Services:
For OASAS-certified programs the following utilization management guidance applies to family and group psychotherapy:
· MMCPs may not conduct concurrent review within the first four weeks (not to exceed 28 visits) of continuous treatment.
· Thereafter, for Medicaid enrollees, concurrent review is permitted only for outlier programs identified by OASAS, as listed here: https://omh.ny.gov/omhweb/bho/policy-guidance/prior-concurrent-auth-ambulatory.pdf, and summarized below:
o OASAS encourages plans to identify individual or program service patterns that fall outside of expected clinical practice but does not permit routine requests for treatment plan updates for otherwise typical outpatient or opioid treatment utilization.
o Expected average frequencies:
§ 30–50 visits per year for OASAS outpatient clinic services.
§ 150–200 visits per year for opioid treatment clinic services.
· OASAS does not set a specific visit limit for SUD outpatient services.
· Applying a 30-visit threshold to trigger concurrent review conflicts with OASAS policy and may result in noncompliant utilization management practices.
Fidelis’ Application of Concurrent Review Requirements:
- OASAS and OMH reached out to Fidelis to reiterate the State utilization management guidance outlined above and clarify application of the new concurrent review requirements and related processes. We expect a response this week and will circle back when we have additional information.
- Fidelis must comply with federal and state parity laws in their decision to perform concurrent review for these services as concurrent review is a type of nonquantitative treatment limitation. This requirement is in addition to their compliance with State-issued UM guidance.
- OMH and OASAS are not required to preapprove an MMCP’s utilization management requirement(s) as parity compliant, however, the State has been conducting ongoing parity testing of MMCPs since 2018.
Please let us know if you would like to meet with OASAS and OMH to discuss in more detail.
Thank you.
Emily Hetzel
Acting Director, Bureau of Medicaid Policy
Medicaid Compliance Officer
Office of Mental Health