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
Home Health Services
Home Health Services include medically necessary skilled nursing services, specialized therapies (physical therapy, speech-language pathology, and occupational therapy), home health aide services, and medical supplies provided to a beneficiary in any setting in which normal life activities take place, other than a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities. Home health services may be provided in an intermediate care facility for Individuals with Intellectual Disabilities that are not required to be provided by the facility under subpart I of part 483 or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board. Home health services cannot be limited to services furnished to a beneficiary who is homebound in accordance with 42 CFR 440.70.
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/.
Unit Value
1 visit
Limits
Covered only as a home health service when furnished in a setting in which normal life activities take place, not in a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities except as allowed by rule, or any setting where Medicaid inpatient payment includes room and board.
Home health services cannot be limited to beneficiaries who are homebound.
Services are provided on a per-visit basis.
If multiple services can be performed during the same visit, all services must be completed in one visit.
Type, amount, frequency, and duration of occupational therapy treatment visits are limited to what is ordered by the physician and documented in the plan of care.
Exclusions
This service is not covered when it was not ordered by a physician and included on the authorized plan of care or verbal order; when there is no evidence that home health services are the most appropriate setting; when there is no signed and dated clinical or progress-note documentation supporting that the service was provided in accordance with policy and supported by the plan of care; or when the service is related to a terminal illness for a beneficiary who has elected Medicare or Medicaid hospice benefits, except when the home health service is unrelated to the terminal illness. Providers subject to EVV that have not enrolled with an EVV solution as required are also not covered.
Place of Service
Services are provided in any setting in which normal life activities take place, other than a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board. Home health services cannot be limited to services furnished to beneficiaries who are homebound in accordance with (42 CFR 440.70).
Additional Service Specifics
The home health agency furnishing the service shall bill for services with its individual NPI. Providers may bill only for those services ordered by a physician and documented in the beneficiary’s individual POC.
How to Submit
Please submit your request to Trillium Health Resources
Resources
0421 Visit charge
How to Submit
N/A - No authorization is required
0422 Hourly charge
How to Submit
N/A - No authorization is required
0423 Group rate
How to Submit
N/A - No authorization is required
Home Health Services
Home Health Services include medically necessary skilled nursing services, specialized therapies (physical therapy, speech-language pathology, and occupational therapy), home health aide services, and medical supplies provided to a beneficiary in any setting in which normal life activities take place, other than a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities. Home health services may be provided in an intermediate care facility for Individuals with Intellectual Disabilities that are not required to be provided by the facility under subpart I of part 483 or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board. Home health services cannot be limited to services furnished to a beneficiary who is homebound in accordance with 42 CFR 440.70.
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/.
Unit Value
1 visit
Limits
Covered only as a home health service when furnished in a setting in which normal life activities take place, not in a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities except as allowed by rule, or any setting where Medicaid inpatient payment includes room and board.
Home health services cannot be limited to beneficiaries who are homebound.
Services are provided on a per-visit basis.
If multiple services can be performed during the same visit, all services must be completed in one visit.
Type, amount, frequency, and duration of occupational therapy treatment visits are limited to what is ordered by the physician and documented in the plan of care.
Exclusions
This service is not covered when it was not ordered by a physician and included on the authorized plan of care or verbal order; when there is no evidence that home health services are the most appropriate setting; when there is no signed and dated clinical or progress-note documentation supporting that the service was provided in accordance with policy and supported by the plan of care; or when the service is related to a terminal illness for a beneficiary who has elected Medicare or Medicaid hospice benefits, except when the home health service is unrelated to the terminal illness. Providers subject to EVV that have not enrolled with an EVV solution as required are also not covered.
Place of Service
Services are provided in any setting in which normal life activities take place, other than a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board. Home health services cannot be limited to services furnished to beneficiaries who are homebound in accordance with (42 CFR 440.70).
Additional Service Specifics
The home health agency furnishing the service shall bill for services with its individual NPI. Providers may bill only for those services ordered by a physician and documented in the beneficiary’s individual POC.
How to Submit
Please submit your request to Trillium Health Resources
Resources
0429 Other physical therapy
How to Submit
N/A - No authorization is required
Home Health Services
Home Health Services include medically necessary skilled nursing services, specialized therapies (physical therapy, speech-language pathology, and occupational therapy), home health aide services, and medical supplies provided to a beneficiary in any setting in which normal life activities take place, other than a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities. Home health services may be provided in an intermediate care facility for Individuals with Intellectual Disabilities that are not required to be provided by the facility under subpart I of part 483 or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board. Home health services cannot be limited to services furnished to a beneficiary who is homebound in accordance with 42 CFR 440.70.
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/.
Unit Value
1 visit
Limits
Covered only as a home health service when furnished in a setting in which normal life activities take place, not in a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities except as allowed by rule, or any setting where Medicaid inpatient payment includes room and board.
Home health services cannot be limited to beneficiaries who are homebound.
Services are provided on a per-visit basis.
If multiple services can be performed during the same visit, all services must be completed in one visit.
Type, amount, frequency, and duration of occupational therapy treatment visits are limited to what is ordered by the physician and documented in the plan of care.
Exclusions
This service is not covered when it was not ordered by a physician and included on the authorized plan of care or verbal order; when there is no evidence that home health services are the most appropriate setting; when there is no signed and dated clinical or progress-note documentation supporting that the service was provided in accordance with policy and supported by the plan of care; or when the service is related to a terminal illness for a beneficiary who has elected Medicare or Medicaid hospice benefits, except when the home health service is unrelated to the terminal illness. Providers subject to EVV that have not enrolled with an EVV solution as required are also not covered.
Place of Service
Services are provided in any setting in which normal life activities take place, other than a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board. Home health services cannot be limited to services furnished to beneficiaries who are homebound in accordance with (42 CFR 440.70).
Additional Service Specifics
The home health agency furnishing the service shall bill for services with its individual NPI. Providers may bill only for those services ordered by a physician and documented in the beneficiary’s individual POC.
How to Submit
Please submit your request to Trillium Health Resources
Resources
0431 Visit charge
How to Submit
N/A - No authorization is required
0432 Hourly charge
How to Submit
N/A - No authorization is required
0433 Group rate
How to Submit
N/A - No authorization is required
Home Health Services
Home Health Services include medically necessary skilled nursing services, specialized therapies (physical therapy, speech-language pathology, and occupational therapy), home health aide services, and medical supplies provided to a beneficiary in any setting in which normal life activities take place, other than a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities. Home health services may be provided in an intermediate care facility for Individuals with Intellectual Disabilities that are not required to be provided by the facility under subpart I of part 483 or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board. Home health services cannot be limited to services furnished to a beneficiary who is homebound in accordance with 42 CFR 440.70.
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/.
Unit Value
1 visit
Limits
Covered only as a home health service when furnished in a setting in which normal life activities take place, not in a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities except as allowed by rule, or any setting where Medicaid inpatient payment includes room and board.
Home health services cannot be limited to beneficiaries who are homebound.
Services are provided on a per-visit basis.
If multiple services can be performed during the same visit, all services must be completed in one visit.
Type, amount, frequency, and duration of occupational therapy treatment visits are limited to what is ordered by the physician and documented in the plan of care.
Exclusions
This service is not covered when it was not ordered by a physician and included on the authorized plan of care or verbal order; when there is no evidence that home health services are the most appropriate setting; when there is no signed and dated clinical or progress-note documentation supporting that the service was provided in accordance with policy and supported by the plan of care; or when the service is related to a terminal illness for a beneficiary who has elected Medicare or Medicaid hospice benefits, except when the home health service is unrelated to the terminal illness. Providers subject to EVV that have not enrolled with an EVV solution as required are also not covered.
Place of Service
Services are provided in any setting in which normal life activities take place, other than a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board. Home health services cannot be limited to services furnished to beneficiaries who are homebound in accordance with (42 CFR 440.70).
Additional Service Specifics
The home health agency furnishing the service shall bill for services with its individual NPI. Providers may bill only for those services ordered by a physician and documented in the beneficiary’s individual POC.
How to Submit
Please submit your request to Trillium Health Resources
Resources
0439 Other occupational therapy (may include restorative therapy)
How to Submit
N/A - No authorization is required
Home Health Services
Home Health Services include medically necessary skilled nursing services, specialized therapies (physical therapy, speech-language pathology, and occupational therapy), home health aide services, and medical supplies provided to a beneficiary in any setting in which normal life activities take place, other than a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities. Home health services may be provided in an intermediate care facility for Individuals with Intellectual Disabilities that are not required to be provided by the facility under subpart I of part 483 or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board. Home health services cannot be limited to services furnished to a beneficiary who is homebound in accordance with 42 CFR 440.70.
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/.
Unit Value
1 visit
Limits
Covered only as a home health service when furnished in a setting in which normal life activities take place, not in a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities except as allowed by rule, or any setting where Medicaid inpatient payment includes room and board.
Home health services cannot be limited to beneficiaries who are homebound.
Services are provided on a per-visit basis.
If multiple services can be performed during the same visit, all services must be completed in one visit.
Type, amount, frequency, and duration of occupational therapy treatment visits are limited to what is ordered by the physician and documented in the plan of care.
Exclusions
This service is not covered when it was not ordered by a physician and included on the authorized plan of care or verbal order; when there is no evidence that home health services are the most appropriate setting; when there is no signed and dated clinical or progress-note documentation supporting that the service was provided in accordance with policy and supported by the plan of care; or when the service is related to a terminal illness for a beneficiary who has elected Medicare or Medicaid hospice benefits, except when the home health service is unrelated to the terminal illness. Providers subject to EVV that have not enrolled with an EVV solution as required are also not covered.
Place of Service
Services are provided in any setting in which normal life activities take place, other than a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board. Home health services cannot be limited to services furnished to beneficiaries who are homebound in accordance with (42 CFR 440.70).
Additional Service Specifics
The home health agency furnishing the service shall bill for services with its individual NPI. Providers may bill only for those services ordered by a physician and documented in the beneficiary’s individual POC.
How to Submit
Please submit your request to Trillium Health Resources
Resources
Home Health Services
Home Health Services include medically necessary skilled nursing services, specialized therapies (physical therapy, speech-language pathology, and occupational therapy), home health aide services, and medical supplies provided to a beneficiary in any setting in which normal life activities take place, other than a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities. Home health services may be provided in an intermediate care facility for Individuals with Intellectual Disabilities that are not required to be provided by the facility under subpart I of part 483 or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board. Home health services cannot be limited to services furnished to a beneficiary who is homebound in accordance with 42 CFR 440.70.
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/.
Unit Value
1 visit
Limits
Covered only as a home health service when furnished in a setting in which normal life activities take place, not in a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities except as allowed by rule, or any setting where Medicaid inpatient payment includes room and board.
Home health services cannot be limited to beneficiaries who are homebound.
Services are provided on a per-visit basis.
If multiple services can be performed during the same visit, all services must be completed in one visit.
Type, amount, frequency, and duration of occupational therapy treatment visits are limited to what is ordered by the physician and documented in the plan of care.
Exclusions
This service is not covered when it was not ordered by a physician and included on the authorized plan of care or verbal order; when there is no evidence that home health services are the most appropriate setting; when there is no signed and dated clinical or progress-note documentation supporting that the service was provided in accordance with policy and supported by the plan of care; or when the service is related to a terminal illness for a beneficiary who has elected Medicare or Medicaid hospice benefits, except when the home health service is unrelated to the terminal illness. Providers subject to EVV that have not enrolled with an EVV solution as required are also not covered.
Place of Service
Services are provided in any setting in which normal life activities take place, other than a hospital, nursing facility, or intermediate care facility for individuals with intellectual disabilities or any setting in which payment is or could be made under Medicaid for inpatient services that include room and board. Home health services cannot be limited to services furnished to beneficiaries who are homebound in accordance with (42 CFR 440.70).
Additional Service Specifics
The home health agency furnishing the service shall bill for services with its individual NPI. Providers may bill only for those services ordered by a physician and documented in the beneficiary’s individual POC.
How to Submit
Please submit your request to Trillium Health Resources
Resources
Anesthesia for procedures on clavicle and scapula; not otherwise specified
How to Submit
N/A - No authorization is required
0451 EMTALA emergency medical screening services
How to Submit
N/A - No authorization is required
0452 ER beyond EMTALA screening
How to Submit
N/A - No authorization is required
Anesthesia for procedures on clavicle and scapula; biopsy of clavicle
How to Submit
N/A - No authorization is required
0456 Urgent care
How to Submit
N/A - No authorization is required
0459 Other ER
How to Submit
N/A - No authorization is required
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