Fidelis Care Outpatient Physical Therapy prior authorization requirements (2026)
What Fidelis Care generally requires to approve Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035), for Medicaid plans. Yes. Fidelis Care generally requires prior authorization for Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035).
Medical-necessity criteria Fidelis Care generally applies
The initial PT evaluation does not require prior authorization; all therapy visits after the initial evaluation require prior authorization through Evolent (formerly NIA). Medical-necessity review is based on submitted clinical documentation: history and physical, prior diagnostic tests, and the prescription/plan of care from the prescribing provider. Continued therapy is supported by a skilled plan of care with measurable functional goals and documented progress, or maintenance therapy to prevent decline where the benefit covers it. Verify the member benefit plan and the current Evolent clinical guideline.
Source
Source: Fidelis Care Provider Manual and the NIA/Evolent Physical Medicine Prior Authorization program (fideliscare.org/Provider/Authorization-Requests). Last verified 2026-06-11.
Frequently asked questions
Does Fidelis Care require prior authorization for Outpatient Physical Therapy?
Yes. Fidelis Care generally requires prior authorization for Outpatient Physical Therapy (CPT 97161, 97162, 97163, 97164, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97535, 97542, 97750, 97760, 97761, 97010, 97012, 97014, 97032, 97035).
What does Fidelis Care require to approve Outpatient Physical Therapy?
The initial PT evaluation does not require prior authorization; all therapy visits after the initial evaluation require prior authorization through Evolent (formerly NIA). Medical-necessity review is based on submitted clinical documentation: history and physical, prior diagnostic tests, and the prescription/plan of care from the prescribing provider. Continued therapy is supported by a skilled pl… Always confirm against the current Fidelis Care policy.
How long does a Fidelis Care prior authorization take?
Turnaround varies by plan and submission method. Check the Fidelis Care portal for current timeframes.
Submitting Outpatient Physical Therapy to Fidelis Care?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.