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

0350 General

Service Code
0350 (Revenue) 0350 General
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

0351 Head scan

Service Code
0351 (Revenue) 0351 Head scan
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for procedures on major vessels of neck; simple ligation

Service Code
00352 (CPT) Anesthesia for procedures on major vessels of neck; simple ligation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0352 Body scan

Service Code
0352 (Revenue) 0352 Body scan
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See Evolent site for specific requirements

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

0359 Other CT scans

Service Code
0359 (Revenue) 0359 Other CT scans
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Evolent site for specific requirements. If your request is for INPATIENT services, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

Sterilization Procedures

Service Code
0360 (Revenue) OR SERVICES
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
Medicaid Adult (Age 21+)
Diagnosis Group
Physical Health

Sterilization means any medical procedure, treatment or an operation for the sole purpose of rendering an individual permanently incapable of reproducing and not related to the repair of a damaged or dysfunctional body part.

Limits

Medicaid shall not cover sterilization:

  • a. when the Specific Criteria requirements have not been met; or
  • b. for a permanent birth control system by bilateral occlusion of the fallopian

tubes or hysteroscopic tubal sterilization or transcervical sterilization (Essure).

Note: If a judicial court orders a sterilization procedure for a Medicaid beneficiary who is a ward of the county and mentally incompetent, the beneficiary is not eligible for sterilization procedures.

Length of Stay

Sterilization procedures are covered once in a lifetime unless documentation supports repeat due to failed procedure.

Exclusions

Medicaid shall not cover procedures for the reversal of sterilization. Sterilization reversal procedures are reverse bilateral fallopian tube trans-section by means of bilateral salpingoplasty and reversal of a bilateral vasectomy by means of a bilateral vasovasostomy. There is no EPSDT exception to the requirement that the beneficiary be at least 21 years old at the time consent is obtained.If a judicial court orders sterilization for a Medicaid beneficiary who is a ward of the county and mentally incompetent, the beneficiary is not eligible for sterilization procedures.

Additional Service Specifics

Consent is required for all voluntary sterilization. Sterilization consent must be obtained at least 30 and no more than 180 consecutive days before sterilization, except for preterm delivery or emergency abdominal surgery, when at least 72 hours must have passed since consent.

Sterilization procedures are covered once in a lifetime unless documentation supports repeat due to failed procedure.

Other Information

All providers, except ambulatory surgical centers, must append modifier FP to the procedure code when billing for sterilization procedures.

How to Submit

N/A - No authorization is required

Resources

0361 Minor surgery

Service Code
0361 (Revenue) 0361 Minor surgery
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0362 Organ transplant-Other than kidney

Service Code
0362 (Revenue) 0362 Organ transplant-Other than kidney
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0367 Kidney transplant

Service Code
0367 (Revenue) 0367 Kidney transplant
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0369 Other OR services

Service Code
0369 (Revenue) 0369 Other OR services
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0370 General

Service Code
0370 (Revenue) 0370 General
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0371 Anesthesia incident to radiology

Service Code
0371 (Revenue) 0371 Anesthesia incident to radiology
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0372 Anesthesia incident to other diagnostic services

Service Code
0372 (Revenue) 0372 Anesthesia incident to other diagnostic services
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0374 Acupuncture

Service Code
0374 (Revenue) 0374 Acupuncture
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0379 Other anesthesia

Service Code
0379 (Revenue) 0379 Other anesthesia
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0380 General

Service Code
0380 (Revenue) 0380 General
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0381 Packed red cells

Service Code
0381 (Revenue) 0381 Packed red cells
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0382 Whole blood

Service Code
0382 (Revenue) 0382 Whole blood
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0383 Plasma

Service Code
0383 (Revenue) 0383 Plasma
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0384 Platelets

Service Code
0384 (Revenue) 0384 Platelets
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required