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

0514 OB/GYN clinic

Service Code
0514 (Revenue) 0514 OB/GYN clinic
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0515 Pediatric clinic

Service Code
0515 (Revenue) 0515 Pediatric clinic
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0516 Urgent care clinic

Service Code
0516 (Revenue) 0516 Urgent care clinic
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0517 Family practice clinic

Service Code
0517 (Revenue) 0517 Family practice clinic
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0519 Other clinic

Service Code
0519 (Revenue) 0519 Other clinic
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for closed chest procedures; (including bronchoscopy) not otherwise specified

Service Code
00520 (CPT) Anesthesia for closed chest procedures; (including bronchoscopy) not otherwise specified
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0521 Rural health-Clinic

Service Code
0521 (Revenue) 0521 Rural health-Clinic
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for closed chest procedures; needle biopsy of pleura

Service Code
00522 (CPT) Anesthesia for closed chest procedures; needle biopsy of pleura
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0523 Family practice clinic

Service Code
0523 (Revenue) 0523 Family practice clinic
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for closed chest procedures; pneumocentesis

Service Code
00524 (CPT) Anesthesia for closed chest procedures; pneumocentesis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0526 Urgent care clinic

Service Code
0526 (Revenue) 0526 Urgent care clinic
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for closed chest procedures; mediastinoscopy and diagnostic thoracoscopy not utilizing 1 lung ventilation

Service Code
00528 (CPT) Anesthesia for closed chest procedures; mediastinoscopy and diagnostic thoracoscopy not utilizing 1 lung ventilation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for closed chest procedures; mediastinoscopy and diagnostic thoracoscopy utilizing 1 lung ventilation

Service Code
00529 (CPT) Anesthesia for closed chest procedures; mediastinoscopy and diagnostic thoracoscopy utilizing 1 lung ventilation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for permanent transvenous pacemaker insertion

Service Code
00530 (CPT) Anesthesia for permanent transvenous pacemaker insertion
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

0531 Osteopathic therapy

Service Code
0531 (Revenue) 0531 Osteopathic therapy
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for access to central venous circulation

Service Code
00532 (CPT) Anesthesia for access to central venous circulation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for transvenous insertion or replacement of pacing cardioverter-defibrillator

Service Code
00534 (CPT) Anesthesia for transvenous insertion or replacement of pacing cardioverter-defibrillator
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for cardiac electrophysiologic procedures including radiofrequency ablation

Service Code
00537 (CPT) Anesthesia for cardiac electrophysiologic procedures including radiofrequency ablation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Anesthesia for tracheobronchial reconstruction

Service Code
00539 (CPT) Anesthesia for tracheobronchial reconstruction
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Ambulance Services

Service Code
0540 (Revenue) AMBULANCE
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

Ambulance services provide medically necessary treatment for NC Medicaid Program beneficiaries. Transport is provided only if the beneficiary’s medical condition is such that the use of any other means of transportation is contraindicated. Ambulance services include emergency and non-emergency ambulance transport via ground and air medical ambulance for a Medicaid beneficiary.

Authorization Guidelines

Prior approval (PA) is required for non-emergency ambulance services for a Medicaid beneficiary by ground or air from North Carolina to another state, from one state to another, or from another state back to North Carolina.

The provider(s) shall submit to the Department of Health and Human Services (DHHS) Utilization Review Contractor the following:

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

the specific criteria in this policy.

  • c. Each trip requires a separate PA process and PA number.
  • d. For non-emergency medically necessary ambulance transport, PA shall be

obtained before service is rendered for a Medicaid beneficiary.

  • e. The PA is active for 30 calendar days.

Unit Value

The time of pick-up, in the range of 00–23 hours, is required on the claim form.

Limits

Ground ambulance loaded mileage is reimbursable only for out-of-county transport; in-county loaded ground mileage is not reimbursable.

Ambulance transports are covered only to specified destinations, including hospital, critical access hospital, skilled nursing facility, adult care home, ICF-IID, beneficiary's primary private residence, dialysis facility for ESRD when condition requires ambulance services, transfer site, and physician's office under stated criteria.

Air medical ambulance transport is covered only to an acute-care hospital.

The provider shall bill only one ambulance procedure code for the same date of service, the same hour or time of pick-up, and the same or a different provider.

The provider shall not bill a round-trip ambulance transport and a one-way-trip ambulance transport on the same date of service unless submitting an adjustment with documentation substantiating both.

Each trip requires a separate PA process and PA number; PA is active for 30 calendar days.

Exclusions

Air medical ambulance transport to a facility that is not an acute-care hospital is not covered. Ambulance transport of a deceased beneficiary is not covered if the beneficiary is pronounced dead before the ambulance is called. Loaded mileage to a facility that is not the nearest appropriate facility is not reimbursed. Other non-covered ambulance services include: an ambulance is called and no treatment is needed; false alarm calls; beneficiary refuses all medical services; transport for a medical service that is not Medicaid covered; commercial airline tickets; airstrip fees; taxes; separate additional charges for nursing personnel who are employees of a facility or ambulance service; waiting fees; and separate charges for oxygen and other items and supplies because these are included in the base rate. Services other than those listed in Subsection 3.2 are not covered. Routine pregnancy transport is not covered. Beneficiaries with Medicaid coverage through Family Planning are not covered to receive ambulance services.

Place of Service

Ambulance

Additional Service Specifics

Institutional providers must report one of the following condition codes: AK, AL, AM. Providers must report an origin and destination modifier for each ambulance trip provided. Providers must report QL modifier if the time of death pronouncement is made after dispatch but before the beneficiary is loaded onboard the ambulance.

Other Information

When multiple units respond to a call for services, the provider that transports the beneficiary is the only provider that may bill for the service. If both ground and air medical ambulances areinvolved, then each submits its own claim and each claim is processed and reimbursed independently of the other.

How to Submit

Please submit your request to Trillium Health Resources

Resources