Fidelis Care New York ABA coverage (Medicaid Managed Care).

Follows the New York Medicaid rule: ABA is covered for members “under 21 years of age with a diagnosis of Autism Spectrum Disorder (ASD) as defined by… (DSM-5) and/or Rett Syndrome.” No minimum age and no adult pathway — the 21st birthday is a hard cliff. Fidelis applies the same under-21 eligibility and adds F84.3 to the diagnosis list it will accept.^[3][1]

The strictest recency stack in New York, and it runs on two clocks. The diagnostic evaluation supporting the request must be within 2 years of the authorization request, and an initial request additionally needs a DSM-5 diagnosis made with a validated assessment tool administered within the past 60 months (the instrument rule does not re-trigger for continuing services). Fidelis also publishes a genuine waitlist workaround: where a diagnostic assessment cannot be obtained within 6 months of the request, it will accept a letter of confirmation from a NYS-licensed qualified professional to start services, provided the member is in or recently was in ABA. Treatment plans then update every 6 months, and the Medical Director may tighten review frequency.^[1][2]

Follows the New York Medicaid rule: the diagnosis and referral must come from a NYS-licensed, NYS Medicaid-enrolled physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner or physician assistant, following DSM-5 criteria and NYSDOH’s Clinical Practice Guideline on ASD. LBAs and CBAAs sit outside that list — they may not diagnose and may not self-refer. Fidelis adds its own escape hatch rather than its own credential: where the diagnostic assessment cannot be scheduled within 6 months, a letter of confirmation from a NYS-licensed qualified professional will start services for a member already in or recently in ABA.^[3][1]

Named instruments, with graphs — this is where Fidelis departs hardest from the state baseline. The treatment request must show results from at least one specified functional behavior assessment (descriptive FBA, traditional functional analysis, or IISCA) and/or a named skill assessment — VB-MAPP, ABLLS-R, AFLS, PEAK, SSIS, EFL or Socially Savvy — with graphs and tables attached; a Vineland alone is explicitly insufficient. Initial requests separately need the DSM-5 diagnosis made with a validated diagnostic tool administered within the past 60 months. Concurrent review is the heaviest in the state: updated graphs and goal-grid performance, one session note per month for each authorized CPT code including supervision and family-guidance notes, an updated assessment scoring grid, an updated treatment plan, and a signed visit attestation.^[1]

Follows the New York Medicaid rule: the member “must be referred for ABA services by a NYS-licensed and NYS Medicaid-enrolled physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner, or physician assistant,” the referral is “valid for no more than two years,” and it must carry age, the ASD/Rett diagnosis, date of initial diagnosis, co-morbid diagnoses, symptom severity level, a statement the patient needs ABA, and the DSM-5 Diagnostic Checklist. On top of that, Fidelis is authorization-based: a behavioral assessment by a BCBA/LBA-equivalent must be completed before treatment is requested, and requests run through the Fidelis Provider Portal with the ABA form on the Provider Policies page. Every ABA practitioner must complete both Fidelis credentialing and MMIS Medicaid enrollment before serving members.^[3][1][2]

Fidelis publishes a clock tighter than the state model contract: a non-urgent pre-service request is decided “within 3 business days of receipt of necessary information,” and “for standard service authorizations the decision and notification will be made no more than seven (7) calendar days from receipt of the request (unless an extension is requested)”; urgent requests within 72 hours of receipt. A continuing (non-urgent concurrent) request gets a verbal decision “within 1 business day,” “extended up to 14 calendar days with request for additional clinical information,” and “Preservice and concurrent review timeframes may be extended by an additional 14 days.” No ABA reauth lead time is published, but the ABA policy puts reviews on a 6-month cycle and the tip sheet says concurrent reviews “require updated graphs and charts,” monthly session notes per authorized CPT code, an updated treatment plan and a signed visit attestation — so assemble the packet well before the auth ends.^[4][1][2]

Bill the other insurance first. “In the event a claim is initially filed with Fidelis Care for which another carrier is determined to be the primary payer, the provider will be notified on a remittance advice to file with the primary insurer.” After the primary pays or denies, “File the claim with Fidelis Care along with the primary carrier’s Explanation of Benefits (EOB) attached” within 90 calendar days of receiving that EOB; “Fidelis Care will coordinate benefits up to Fidelis Care’s allowable as secondary payer.” This sits on the state rule that Medicaid pays last and that the plan must “alert the provider and ask them to bill the TPHI that should be primary.” The manual does not say whether Fidelis’s own ABA prior authorization is still required when it is secondary — confirm with Provider Services (1-888-343-3547) before starting on the primary’s approval alone.^[4][5]

Not published. Neither Fidelis’s ABA clinical policy nor its provider tip sheet states which ABA codes may be delivered by telehealth or under which place-of-service code, and the state’s own ABA manual answers telehealth only for supervision. What Fidelis does publish about setting cuts the other way: no ABA in school settings since September 1, 2023, and treatment during school hours requires contacting the local Committee on Special Education for an independent evaluation first.^[1][2]

Ask the plan: Fidelis provider services and the ABA form on the fideliscare.org Provider Policies page — confirm telehealth code eligibility and POS in writing before scheduling remote sessions.

Follows the New York Medicaid rule, which the state applies to FFS and managed care alike: “an LBA can supervise no more than six CBAAs/unlicensed individuals at a time,” “LBAs are required to supervise unlicensed individuals for a minimum of five percent of the hours the unlicensed individual spends providing behavior analysis services each calendar month,” and “supervision must include at least two face-to-face, real-time contacts per month” with the LBA observing service delivery in at least one. Supervision may run over synchronous audio-and-video where on-site is impractical. 97155 counts toward the 5% “only when the LBA joins the patient and the unlicensed individual during a treatment session to direct the unlicensed individual/technician in implementing a new or modified treatment protocol.” CBAAs need direct supervision, and the supervisor “should assess each patient’s/client’s progress at least every 6 months… and review and sign treatment notes and reports prepared by the CBAA supervisee.” Fidelis adds a documentation consequence rather than a different ratio: concurrent review requires one session note per month for each authorized CPT code, supervision notes included.^[3][1]

No hard cap — Fidelis frames intensity as a model rather than a ceiling: Focused ABA at 10–25 hours per week versus Comprehensive at 30–40, with requested hours justified against the member’s age, school attendance and daily activities. Discharge is expected “when there’s no measurable improvement for 6+ months without a reasonable expectation that a revised plan would help.” The practical ceiling is the authorized units, and claims are due within 90 days of the date of service — a short window that punishes slow authorization cleanup.^[1][2]

Fidelis requires “a signed visit attestation” at concurrent review alongside one session note per month for every authorized CPT code (supervision and family-guidance notes included), updated graphs and goal-grid performance, an updated assessment scoring grid and an updated treatment plan. The signer of the individual session note is not specified by Fidelis, so the state rule governs underneath: the supervising LBA must review and sign treatment notes and reports prepared by a CBAA supervisee.^[1][3]

Stricter than the state baseline in one respect and equal in the rest. New York Medicaid already does not reimburse ABA in a school setting; Fidelis stopped covering school-setting ABA specifically on September 1, 2023, and adds a coordination gate for treatment during school hours — providers “must first contact the local Committee on Special Education for an independent evaluation,” which makes a school-hours request a coordination project rather than a form field. Home, clinic and community remain available per the state’s any-legally-authorized-setting rule.^[2][3]

Fidelis publishes no rendering-versus-supervising NPI convention of its own; what it does require is that “every ABA practitioner must complete both Fidelis credentialing and MMIS Medicaid enrollment before serving members,” which mirrors the state’s enrollment architecture. At the fee-for-service layer New York is explicit: LBAs bill “using the LBA’s National Provider Identification (NPI) number for the ‘Billing’ provider and/or ‘Supervising’ provider,” with “the NPI number of the CBAA that provided the ABA service… reported as the ‘Rendering’ provider on each claim”; for unlicensed aides and LBA limited-permit holders the supervising LBA’s NPI fills all three roles. CBAAs cannot bill directly and enroll as OPRA providers. Confirm the managed-care claim format with Fidelis, since the state manual directs MMC providers to their plan for billing guidance.^[2][3]

Ask the plan: Fidelis provider services for the MMC claim format — the eMedNY convention above is the FFS reference, not a Fidelis-published rule.

Not published. Fidelis’s ABA policy governs medical necessity and documentation, not claim edits, and says nothing about billing 97153 and 97155 for the same clock time; the state manual is silent too.^[1][3]

Ask the plan: Fidelis provider services and the plan’s claim-editing/reimbursement policies on fideliscare.org.