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

Unlisted procedure, foot or toes

Service Code
28899 (CPT) Unlisted procedure, foot or toes
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

Application of halo type body cast (see 20661-20663 for insertion)

Service Code
29000 (CPT) Application of halo type body cast (see 20661-20663 for insertion)
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.

Application of Risser jacket, localizer, body; only

Service Code
29010 (CPT) Application of Risser jacket, localizer, body; only
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.

Application of Risser jacket, localizer, body; including head

Service Code
29015 (CPT) Application of Risser jacket, localizer, body; including head
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.

Application of body cast, shoulder to hips;

Service Code
29035 (CPT) Application of body cast, shoulder to hips;
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.

Application of body cast, shoulder to hips; including head, Minerva type

Service Code
29040 (CPT) Application of body cast, shoulder to hips; including head, Minerva type
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.

Application of body cast, shoulder to hips; including 1 thigh

Service Code
29044 (CPT) Application of body cast, shoulder to hips; including 1 thigh
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.

Application of body cast, shoulder to hips; including both thighs

Service Code
29046 (CPT) Application of body cast, shoulder to hips; including both thighs
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.

Application, cast; figure-of-eight

Service Code
29049 (CPT) Application, cast; figure-of-eight
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.

Application, cast; shoulder spica

Service Code
29055 (CPT) Application, cast; shoulder spica
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.

Application, cast; plaster Velpeau

Service Code
29058 (CPT) Application, cast; plaster Velpeau
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.

Application, cast; shoulder to hand (long arm)

Service Code
29065 (CPT) Application, cast; shoulder to hand (long arm)
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.

Application, cast; elbow to finger (short arm)

Service Code
29075 (CPT) Application, cast; elbow to finger (short arm)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

Prior approval (PA) is required prior to the start of all treatment services. The provider shall submit a request to the DHHS utilization review contractor to start the PA process. Detailed information and instructions for registering and submitting requests is available on the DHHS utilization review contractor's website: https://choicepa.medicaidprograms.org/Account/Login.aspx?ReturnUrl=%2f The PA request must clearly indicate that the service of a licensed therapist is required. For a beneficiary under age 21, the provider shall submit information supporting that all EPSDT criteria are met and evidence-based literature supporting the request, if available. A written evaluation report must be completed within three months of the requested treatment start date. When continued treatment is requested, an annual re-evaluation of the beneficiary’s status and performance must be documented in a written evaluation report. Each reauthorization request must document the efficacy of treatment. When granted, the approval is for medical approval only and does not guarantee payment or ensure beneficiary eligibility on the date of service. Retroactive PA is considered when Medicaid coverage is granted with a retroactive eligibility date after a beneficiary receives a service. Medicaid does not guarantee approval of retroactive PA requests.

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.

Application, cast; elbow to finger (short arm)

Service Code
29075 (CPT) Application, cast; elbow to finger (short arm)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
Diagnosis Group
Physical Health

Authorization Guidelines

The prior approval process is deemed met by the IEP, IFSP, IHP, BIP or 504 Plan processes.

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.

Application, cast; hand and lower forearm (gauntlet)

Service Code
29085 (CPT) Application, cast; hand and lower forearm (gauntlet)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

Prior approval (PA) is required prior to the start of all treatment services. The provider shall submit a request to the DHHS utilization review contractor to start the PA process. Detailed information and instructions for registering and submitting requests is available on the DHHS utilization review contractor's website: https://choicepa.medicaidprograms.org/Account/Login.aspx?ReturnUrl=%2f The PA request must clearly indicate that the service of a licensed therapist is required. For a beneficiary under age 21, the provider shall submit information supporting that all EPSDT criteria are met and evidence-based literature supporting the request, if available. A written evaluation report must be completed within three months of the requested treatment start date. When continued treatment is requested, an annual re-evaluation of the beneficiary’s status and performance must be documented in a written evaluation report. Each reauthorization request must document the efficacy of treatment. When granted, the approval is for medical approval only and does not guarantee payment or ensure beneficiary eligibility on the date of service. Retroactive PA is considered when Medicaid coverage is granted with a retroactive eligibility date after a beneficiary receives a service. Medicaid does not guarantee approval of retroactive PA requests.

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.

Application, cast; hand and lower forearm (gauntlet)

Service Code
29085 (CPT) Application, cast; hand and lower forearm (gauntlet)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
Diagnosis Group
Physical Health

Authorization Guidelines

The prior approval process is deemed met by the IEP, IFSP, IHP, BIP or 504 Plan processes.

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.

Application, cast; finger (eg, contracture)

Service Code
29086 (CPT) Application, cast; finger (eg, contracture)
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.

Application of long arm splint (shoulder to hand)

Service Code
29105 (CPT) Application of long arm splint (shoulder to hand)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

Prior approval (PA) is required prior to the start of all treatment services. The provider shall submit a request to the DHHS utilization review contractor to start the PA process. Detailed information and instructions for registering and submitting requests is available on the DHHS utilization review contractor's website: https://choicepa.medicaidprograms.org/Account/Login.aspx?ReturnUrl=%2f The PA request must clearly indicate that the service of a licensed therapist is required. For a beneficiary under age 21, the provider shall submit information supporting that all EPSDT criteria are met and evidence-based literature supporting the request, if available. A written evaluation report must be completed within three months of the requested treatment start date. When continued treatment is requested, an annual re-evaluation of the beneficiary’s status and performance must be documented in a written evaluation report. Each reauthorization request must document the efficacy of treatment. When granted, the approval is for medical approval only and does not guarantee payment or ensure beneficiary eligibility on the date of service. Retroactive PA is considered when Medicaid coverage is granted with a retroactive eligibility date after a beneficiary receives a service. Medicaid does not guarantee approval of retroactive PA requests.

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.

Application of long arm splint (shoulder to hand)

Service Code
29105 (CPT) Application of long arm splint (shoulder to hand)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
Diagnosis Group
Physical Health

Authorization Guidelines

The prior approval process is deemed met by the IEP, IFSP, IHP, BIP or 504 Plan processes.

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.

Application of short arm splint (forearm to hand); static

Service Code
29125 (CPT) Application of short arm splint (forearm to hand); static
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Authorization Guidelines

Prior approval (PA) is required prior to the start of all treatment services. The provider shall submit a request to the DHHS utilization review contractor to start the PA process. Detailed information and instructions for registering and submitting requests is available on the DHHS utilization review contractor's website: https://choicepa.medicaidprograms.org/Account/Login.aspx?ReturnUrl=%2f The PA request must clearly indicate that the service of a licensed therapist is required. For a beneficiary under age 21, the provider shall submit information supporting that all EPSDT criteria are met and evidence-based literature supporting the request, if available. A written evaluation report must be completed within three months of the requested treatment start date. When continued treatment is requested, an annual re-evaluation of the beneficiary’s status and performance must be documented in a written evaluation report. Each reauthorization request must document the efficacy of treatment. When granted, the approval is for medical approval only and does not guarantee payment or ensure beneficiary eligibility on the date of service. Retroactive PA is considered when Medicaid coverage is granted with a retroactive eligibility date after a beneficiary receives a service. Medicaid does not guarantee approval of retroactive PA requests.

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.