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

0460 General - Pulmonary Function

Service Code
0460 (Revenue) 0460 General - Pulmonary Function
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0469 Other pulmonary function

Service Code
0469 (Revenue) 0469 Other pulmonary function
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for partial rib resection; not otherwise specified

Service Code
00470 (CPT) Anesthesia for partial rib resection; not otherwise specified
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0471 Diagnostic

Service Code
0471 (Revenue) 0471 Diagnostic
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for partial rib resection; thoracoplasty (any type)

Service Code
00472 (CPT) Anesthesia for partial rib resection; thoracoplasty (any type)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for partial rib resection; radical procedures (eg, pectus excavatum)

Service Code
00474 (CPT) Anesthesia for partial rib resection; radical procedures (eg, pectus excavatum)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0479 Other audiology

Service Code
0479 (Revenue) 0479 Other audiology
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0480 General - Cardiology

Service Code
0480 (Revenue) 0480 General - Cardiology
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0481 Cardiac cath lab

Service Code
0481 (Revenue) 0481 Cardiac cath lab
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0482 Stress test

Service Code
0482 (Revenue) 0482 Stress test
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

If your request is for OUTPATIENT services, please see the Turning Point site for specific requirements. If your request is for INPATIENT services, 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 Turning Point. 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 Turning Point. If your request is for INPATIENT services, please submit the request to Trillium.

0483 Echocardiology

Service Code
0483 (Revenue) 0483 Echocardiology
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.

0489 Other cardiology

Service Code
0489 (Revenue) 0489 Other cardiology
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Sterilization Procedures

Service Code
0490 (Revenue) AMBUL SURG
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

0499 Other ambulatory surgical care

Service Code
0499 (Revenue) 0499 Other ambulatory surgical care
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for all procedures on esophagus

Service Code
00500 (CPT) Anesthesia for all procedures on esophagus
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0509 Other outpatient services

Service Code
0509 (Revenue) 0509 Other outpatient services
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0510 General - Medication Mgmt

Service Code
0510 (Revenue) 0510 General - Medication Mgmt
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0511 Chronic pain center

Service Code
0511 (Revenue) 0511 Chronic pain center
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0512 Dental clinic

Service Code
0512 (Revenue) 0512 Dental clinic
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0513 Psychiatric clinic

Service Code
0513 (Revenue) 0513 Psychiatric clinic
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required