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

0385 Leucocytes

Service Code
0385 (Revenue) 0385 Leucocytes
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0386 Other components

Service Code
0386 (Revenue) 0386 Other components
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0387 Other derivatives (cryoprecipitates)

Service Code
0387 (Revenue) 0387 Other derivatives (cryoprecipitates)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0389 Other blood

Service Code
0389 (Revenue) 0389 Other blood
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0390 General

Service Code
0390 (Revenue) 0390 General
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0391 Administration (e.g. transfusions)

Service Code
0391 (Revenue) 0391 Administration (e.g. transfusions)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

BLOOD PROCESSING/STORAGE

Service Code
0392 (Revenue) BLOOD PROCESSING/STORAGE
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0399 Other processing and storage

Service Code
0399 (Revenue) 0399 Other processing and storage
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified

Service Code
00400 (CPT) Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; not otherwise specified
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0401 Diagnostic mammography

Service Code
0401 (Revenue) 0401 Diagnostic mammography
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; reconstructive procedures on breast (eg, reduction or augmentation mammoplasty, muscle flaps)

Service Code
00402 (CPT) Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; reconstructive procedures on breast (eg, reduction or augmentation mammoplasty, muscle flaps)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0403 Screening mammography

Service Code
0403 (Revenue) 0403 Screening mammography
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; radical or modified radical procedures on breast

Service Code
00404 (CPT) Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; radical or modified radical procedures on breast
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0404 Positron emission tomography (PET)

Service Code
0404 (Revenue) 0404 Positron emission tomography (PET)
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

Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; radical or modified radical procedures on breast with internal mammary node dissection

Service Code
00406 (CPT) Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; radical or modified radical procedures on breast with internal mammary node dissection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0409 Other imaging services

Service Code
0409 (Revenue) 0409 Other imaging services
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; electrical conversion of arrhythmias

Service Code
00410 (CPT) Anesthesia for procedures on the integumentary system on the extremities, anterior trunk and perineum; electrical conversion of arrhythmias
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0412 Inhalation services

Service Code
0412 (Revenue) 0412 Inhalation services
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Hyperbaric Oxygenation Therapy

Service Code
0413 (Revenue) HYPERBARIC O2
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Hyperbaric oxygen (HBO) therapy consists of the exposure of the entire body to 100% oxygen at pressures greater than one atmosphere absolute (ATA) in accordance with accepted clinical protocols for duration and pressure in a mono- or multi-place pressurized chamber.

Authorization Guidelines

The provider(s) shall submit:

  • a. the prior approval request; and
  • b. all health records and any other records that support the beneficiary has met

the specific criteria in Subsection 3.2 of this policy. Prior approval for home health services is required for the following:

  • a. Miscellaneous Therapeutic Items and Supplies: Supply Procedure Code.

Refer to Attachment A: Code(s) for prior approval and limit specifications.

Submit prior approval requests via the secure NC Tracks Provider portal. PA requests cannot be submitted by paper via fax, email, postal service, or by phone.b. Medical supplies, appliances, and equipment not listed on the fee schedule may be considered for coverage, if submitted for prior authorization (PA) review of medical necessity. For a beneficiary aged 21 or older, please follow the procedure detailed in Attachment B and posted on the Home Health Services webpage at https://medicaid.ncdhhs.gov/.

Limits

Initial prior approval covers 30 days; treatment beyond 30 calendar days requires a second prior approval request.

The entire body must be pressurized, and 100% oxygen must be inhaled via the chamber environment, hood tent, face mask, endotracheal tube, or tracheostomy tube.

Limited to two sessions per date of service.

Exclusions

Hyperbaric Oxygenation Therapy is not covered for acute cerebral edema; acute or chronic cerebral vascular insufficiency; acute thermal and chemical pulmonary damage including smoke inhalation with pulmonary insufficiency; aerobic septicemia; anaerobic septicemia and infection other than clostridial; arthritic diseases; cardiogenic shock; chronic peripheral vascular insufficiency except as specifically allowed per the CCP; congenital conditions such as cerebral palsy, autism, and mental retardation; cutaneous, decubitus, and stasis ulcers; exceptional blood loss anemia; hepatic necrosis; multiple sclerosis; myocardial infarction; nonvascular causes of chronic brain syndrome including Pick's disease, Alzheimer's disease, and Korsakoff's disease; organ storage; organ transplantation; pulmonary emphysema; senility; sickle cell crisis; thermal skin burns; systemic aerobic infection; tetanus; and traumatic brain injury. Topical application of oxygen does not meet the definition of HBO therapy and is not covered. HBO therapy is also not covered as a replacement for other standard successful therapeutic measures. The use of hyperbaric oxygen for any type of cutaneous ulcer other than Meleney ulcers is not covered. The policy also states that treatment of multiple sclerosis and brain injury, including autism, cerebral palsy, and stroke, is not approved due to lack of evidence-based medicine.

Place of Service

Inpatient, Outpatient.

Additional Service Specifics

Prior approval is given for an initial period of 30 days. Treatment beyond 30 calendar days requires a second prior approval request.

How to Submit

Please submit your request to Trillium Health Resources

Resources

0419 Other respiratory services

Service Code
0419 (Revenue) 0419 Other respiratory services
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required