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

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
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); dynamic

Service Code
29126 (CPT) Application of short arm splint (forearm to hand); dynamic
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 short arm splint (forearm to hand); dynamic

Service Code
29126 (CPT) Application of short arm splint (forearm to hand); dynamic
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 finger splint; static

Service Code
29130 (CPT) Application of finger splint; 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.

Application of finger splint; static

Service Code
29130 (CPT) Application of finger splint; static
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 finger splint; dynamic

Service Code
29131 (CPT) Application of finger splint; dynamic
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 finger splint; dynamic

Service Code
29131 (CPT) Application of finger splint; dynamic
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.

Strapping; thorax

Service Code
29200 (CPT) Strapping; thorax
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.

Strapping; shoulder (eg, Velpeau)

Service Code
29240 (CPT) Strapping; shoulder (eg, Velpeau)
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.

Strapping; shoulder (eg, Velpeau)

Service Code
29240 (CPT) Strapping; shoulder (eg, Velpeau)
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.

Strapping; elbow or wrist

Service Code
29260 (CPT) Strapping; elbow or wrist
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.

Strapping; elbow or wrist

Service Code
29260 (CPT) Strapping; elbow or wrist
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.

Strapping; hand or finger

Service Code
29280 (CPT) Strapping; hand or finger
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.

Strapping; hand or finger

Service Code
29280 (CPT) Strapping; hand or finger
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 hip spica cast; 1 leg

Service Code
29305 (CPT) Application of hip spica cast; 1 leg
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 hip spica cast; 1 and one-half spica or both legs

Service Code
29325 (CPT) Application of hip spica cast; 1 and one-half spica or both legs
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 leg cast (thigh to toes);

Service Code
29345 (CPT) Application of long leg cast (thigh to toes);
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 leg cast (thigh to toes); walker or ambulatory type

Service Code
29355 (CPT) Application of long leg cast (thigh to toes); walker or ambulatory 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 long leg cast brace

Service Code
29358 (CPT) Application of long leg cast brace
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 cylinder cast (thigh to ankle)

Service Code
29365 (CPT) Application of cylinder cast (thigh to ankle)
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.