PA Lookup

If you have questions about prior authorizations, please call:

Member and Recipient Service Line: 1-877-685-2415

Provider Support Service Line: 1-855-250-1539

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12465 Results

0117-ROOM & BOARD-PRIVATE-ONCOLOGY

Service Code
0117 (Revenue) 0117-ROOM & BOARD-PRIVATE-ONCOLOGY
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

0118-Inpatient Rehabilitation Room and Board Private Room

Service Code
0118 (Revenue) 0118-Inpatient Rehabilitation Room and Board Private Room
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

Please submit your request to Trillium Health Resources

0119-ROOM & BOARD-PRIVATE-OTHER

Service Code
0119 (Revenue) 0119-ROOM & BOARD-PRIVATE-OTHER
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

Anesthesia for procedures on external, middle, and inner ear including biopsy; not otherwise specified

Service Code
00120 (CPT) Anesthesia for procedures on external, middle, and inner ear including biopsy; not otherwise specified
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

120 Inpatient Psychiatric -Room and Board

Service Code
0120 (Revenue) 120 Inpatient Psychiatric -Room and Board
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

0121-ROOM & BOARD-SEMI-PRIV MED/SURG/GYN

Service Code
0121 (Revenue) 0121-ROOM & BOARD-SEMI-PRIV MED/SURG/GYN
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

0122-ROOM & BOARD-SEMI-PRIV-OB

Service Code
0122 (Revenue) 0122-ROOM & BOARD-SEMI-PRIV-OB
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

Please submit your request to Trillium Health Resources

0123-ROOM & BOARD-SEMI-PRIV -PEDIATRIC

Service Code
0123 (Revenue) 0123-ROOM & BOARD-SEMI-PRIV -PEDIATRIC
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

Anesthesia for procedures on external, middle, and inner ear including biopsy; otoscopy

Service Code
00124 (CPT) Anesthesia for procedures on external, middle, and inner ear including biopsy; otoscopy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0124 Psychiatric

Service Code
0124 (Revenue) 0124 Psychiatric
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

Please submit your request to Trillium Health Resources

0125-ROOM & BOARD-SEMI-PRIV HOSPICE

Service Code
0125 (Revenue) 0125-ROOM & BOARD-SEMI-PRIV HOSPICE
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

Please submit your request to Carolina Complete Health

Anesthesia for procedures on external, middle, and inner ear including biopsy; tympanotomy

Service Code
00126 (CPT) Anesthesia for procedures on external, middle, and inner ear including biopsy; tympanotomy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

126 Inpatient Psychiatric -Semi Private Detox

Service Code
0126 (Revenue) 126 Inpatient Psychiatric -Semi Private Detox
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

Please submit your request to Trillium Health Resources

ONCOLOGY/2BED

Service Code
0127 (Revenue) ONCOLOGY/2BED
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

128 - OTHER REHABILITATION, SEMI-PRIVATE

Service Code
0128 (Revenue) 128 - OTHER REHABILITATION, SEMI-PRIVATE
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

Please submit your request to Trillium Health Resources

0129-ROOM & BOARD-SEMI-PRIV -OTHER

Service Code
0129 (Revenue) 0129-ROOM & BOARD-SEMI-PRIV -OTHER
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

0130-ROOM & BOARD- SEMI-PRIVATE THREE OR FOUR GEN CLASS

Service Code
0130 (Revenue) 0130-ROOM & BOARD- SEMI-PRIVATE THREE OR FOUR GEN CLASS
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

0131-ROOM & BOARD-SEMI-PRIV -THREE OR FOUR BEDS MED/SURG/GYN

Service Code
0131 (Revenue) 0131-ROOM & BOARD-SEMI-PRIV -THREE OR FOUR BEDS MED/SURG/GYN
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required

0132-ROOM & BOARD-SEMI-PRIV THREE OR FOUR BEDS OB

Service Code
0132 (Revenue) 0132-ROOM & BOARD-SEMI-PRIV THREE OR FOUR BEDS OB
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

Please submit your request to Trillium Health Resources

0133-ROOM & BOARD-SEMI-PRIV-THREE OR FOUR BEDS PEDIATRIC

Service Code
0133 (Revenue) 0133-ROOM & BOARD-SEMI-PRIV-THREE OR FOUR BEDS PEDIATRIC
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health, Mental Health

Authorization Guidelines

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100

Conditional Requirements

Inpatient Service Codes 0100 - 0219 should be requested under service code 0100, with the exception of 0160: Servicses Rendered in an IMD. For Behavioral Health, prior authorization is not required for the first 72 hours of service. For Physical Health, no prior authorization is required.

How to Submit

N/A - No authorization is required