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
Computed tomographic angiography, abdominal aorta and bilateral iliofemoral lower extremity runoff, with contrast material(s), including noncontrast images, if performed, and image postprocessing
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
3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent works
How to Submit
N/A - No authorization is required
3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstati
How to Submit
N/A - No authorization is required
Computed tomography, limited or localized follow-up study
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.
Magnetic resonance spectroscopy
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
Unlisted computed tomography procedure (eg, diagnostic, interventional)
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
Unlisted magnetic resonance procedure (eg, diagnostic, interventional)
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
1E-4 Fetal Surveillance
Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.
Authorization Guidelines
The provider(s) shall submit 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 Subsection 3.2 of this policy.
- c. If the Medicaid recipient is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
Conditional Requirements
Prior authorization is required if provider is not part of the Pregnancy Medical Home program, except if done in emergency department or inpatient.
Limits
One combination of primary and add-on ultrasound codes is allowed per day for multiple-fetus billing.
CPT 76815 includes one or more fetuses and can only be reimbursed for one unit of service.
For multiple fetuses, 76816 is billed with one unit for the first fetus; additional fetuses are billed on a separate line with units equal to the number of additional fetuses.
One unit of 76817 is covered on the same date of service in addition to transabdominal ultrasounds if medically necessary.
For multiple gestation pregnancies, there is no limit to the number of ultrasounds during the pregnancy when billed according to the policy instructions, but excessive billing is subject to post-payment review.
Exclusions
Ultrasound is not covered when:
-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:
-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:
-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP
Age Group Details
Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria
Place of Service
Inpatient, Outpatient, Physician’s Office.
How to Submit
Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable
Resources
1E-4 Fetal Surveillance
Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.
Authorization Guidelines
The provider(s) shall submit 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 Subsection 3.2 of this policy.
- c. If the Medicaid recipient is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
Conditional Requirements
Prior authorization is required if provider is not part of the Pregnancy Medical Home program, except if done in emergency department or inpatient.
Limits
One combination of primary and add-on ultrasound codes is allowed per day for multiple-fetus billing.
CPT 76815 includes one or more fetuses and can only be reimbursed for one unit of service.
For multiple fetuses, 76816 is billed with one unit for the first fetus; additional fetuses are billed on a separate line with units equal to the number of additional fetuses.
One unit of 76817 is covered on the same date of service in addition to transabdominal ultrasounds if medically necessary.
For multiple gestation pregnancies, there is no limit to the number of ultrasounds during the pregnancy when billed according to the policy instructions, but excessive billing is subject to post-payment review.
Exclusions
Ultrasound is not covered when:
-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:
-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:
-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP
Age Group Details
Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria
Place of Service
Inpatient, Outpatient, Physician’s Office.
How to Submit
Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable
Resources
1E-4 Fetal Surveillance
Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.
Authorization Guidelines
The provider(s) shall submit 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 Subsection 3.2 of this policy.
- c. If the Medicaid recipient is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
Conditional Requirements
Prior authorization is required if provider is not part of the Pregnancy Medical Home program, except if done in emergency department or inpatient.
Limits
One combination of primary and add-on ultrasound codes is allowed per day for multiple-fetus billing.
CPT 76815 includes one or more fetuses and can only be reimbursed for one unit of service.
For multiple fetuses, 76816 is billed with one unit for the first fetus; additional fetuses are billed on a separate line with units equal to the number of additional fetuses.
One unit of 76817 is covered on the same date of service in addition to transabdominal ultrasounds if medically necessary.
For multiple gestation pregnancies, there is no limit to the number of ultrasounds during the pregnancy when billed according to the policy instructions, but excessive billing is subject to post-payment review.
Exclusions
Ultrasound is not covered when:
-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:
-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:
-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP
Age Group Details
Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria
Place of Service
Inpatient, Outpatient, Physician’s Office.
How to Submit
Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable
Resources
1E-4 Fetal Surveillance
Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.
Authorization Guidelines
The provider(s) shall submit 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 Subsection 3.2 of this policy.
- c. If the Medicaid recipient is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
Conditional Requirements
Prior authorization is required if provider is not part of the Pregnancy Medical Home program, except if done in emergency department or inpatient.
Limits
One combination of primary and add-on ultrasound codes is allowed per day for multiple-fetus billing.
CPT 76815 includes one or more fetuses and can only be reimbursed for one unit of service.
For multiple fetuses, 76816 is billed with one unit for the first fetus; additional fetuses are billed on a separate line with units equal to the number of additional fetuses.
One unit of 76817 is covered on the same date of service in addition to transabdominal ultrasounds if medically necessary.
For multiple gestation pregnancies, there is no limit to the number of ultrasounds during the pregnancy when billed according to the policy instructions, but excessive billing is subject to post-payment review.
Exclusions
Ultrasound is not covered when:
-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:
-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:
-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP
Age Group Details
Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria
Place of Service
Inpatient, Outpatient, Physician’s Office.
How to Submit
Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable
Resources
1E-4 Fetal Surveillance
Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.
Authorization Guidelines
The provider(s) shall submit 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 Subsection 3.2 of this policy.
- c. If the Medicaid recipient is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
Conditional Requirements
Prior authorization is required if provider is not part of the Pregnancy Medical Home program, except if done in emergency department or inpatient.
Limits
One combination of primary and add-on ultrasound codes is allowed per day for multiple-fetus billing.
CPT 76815 includes one or more fetuses and can only be reimbursed for one unit of service.
For multiple fetuses, 76816 is billed with one unit for the first fetus; additional fetuses are billed on a separate line with units equal to the number of additional fetuses.
One unit of 76817 is covered on the same date of service in addition to transabdominal ultrasounds if medically necessary.
For multiple gestation pregnancies, there is no limit to the number of ultrasounds during the pregnancy when billed according to the policy instructions, but excessive billing is subject to post-payment review.
Exclusions
Ultrasound is not covered when:
-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:
-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:
-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP
Age Group Details
Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria
Place of Service
Inpatient, Outpatient, Physician’s Office.
How to Submit
Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable
Resources
1E-4 Fetal Surveillance
Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.
Authorization Guidelines
The provider(s) shall submit 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 Subsection 3.2 of this policy.
- c. If the Medicaid recipient is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
Conditional Requirements
Prior authorization is required if provider is not part of the Pregnancy Medical Home program, except if done in emergency department or inpatient.
Limits
One combination of primary and add-on ultrasound codes is allowed per day for multiple-fetus billing.
CPT 76815 includes one or more fetuses and can only be reimbursed for one unit of service.
For multiple fetuses, 76816 is billed with one unit for the first fetus; additional fetuses are billed on a separate line with units equal to the number of additional fetuses.
One unit of 76817 is covered on the same date of service in addition to transabdominal ultrasounds if medically necessary.
For multiple gestation pregnancies, there is no limit to the number of ultrasounds during the pregnancy when billed according to the policy instructions, but excessive billing is subject to post-payment review.
Exclusions
Ultrasound is not covered when:
-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:
-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:
-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP
Age Group Details
Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria
Place of Service
Inpatient, Outpatient, Physician’s Office.
How to Submit
Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable
Resources
1E-4 Fetal Surveillance
Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.
Authorization Guidelines
The provider(s) shall submit 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 Subsection 3.2 of this policy.
- c. If the Medicaid recipient is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
Conditional Requirements
Prior authorization is required if provider is not part of the Pregnancy Medical Home program, except if done in emergency department or inpatient.
Limits
One combination of primary and add-on ultrasound codes is allowed per day for multiple-fetus billing.
CPT 76815 includes one or more fetuses and can only be reimbursed for one unit of service.
For multiple fetuses, 76816 is billed with one unit for the first fetus; additional fetuses are billed on a separate line with units equal to the number of additional fetuses.
One unit of 76817 is covered on the same date of service in addition to transabdominal ultrasounds if medically necessary.
For multiple gestation pregnancies, there is no limit to the number of ultrasounds during the pregnancy when billed according to the policy instructions, but excessive billing is subject to post-payment review.
Exclusions
Ultrasound is not covered when:
-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:
-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:
-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP
Age Group Details
Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria
Place of Service
Inpatient, Outpatient, Physician’s Office.
How to Submit
Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable
Resources
1E-4 Fetal Surveillance
Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.
Authorization Guidelines
The provider(s) shall submit 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 Subsection 3.2 of this policy.
- c. If the Medicaid recipient is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
Conditional Requirements
Prior authorization is required if provider is not part of the Pregnancy Medical Home program, except if done in emergency department or inpatient.
Limits
One combination of primary and add-on ultrasound codes is allowed per day for multiple-fetus billing.
CPT 76815 includes one or more fetuses and can only be reimbursed for one unit of service.
For multiple fetuses, 76816 is billed with one unit for the first fetus; additional fetuses are billed on a separate line with units equal to the number of additional fetuses.
One unit of 76817 is covered on the same date of service in addition to transabdominal ultrasounds if medically necessary.
For multiple gestation pregnancies, there is no limit to the number of ultrasounds during the pregnancy when billed according to the policy instructions, but excessive billing is subject to post-payment review.
Exclusions
Ultrasound is not covered when:
-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:
-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:
-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP
Age Group Details
Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria
Place of Service
Inpatient, Outpatient, Physician’s Office.
How to Submit
Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable
Resources
1E-4 Fetal Surveillance
Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.
Authorization Guidelines
The provider(s) shall submit 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 Subsection 3.2 of this policy.
- c. If the Medicaid recipient is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
Conditional Requirements
Prior authorization is required if provider is not part of the Pregnancy Medical Home program, except if done in emergency department or inpatient.
Limits
One combination of primary and add-on ultrasound codes is allowed per day for multiple-fetus billing.
CPT 76815 includes one or more fetuses and can only be reimbursed for one unit of service.
For multiple fetuses, 76816 is billed with one unit for the first fetus; additional fetuses are billed on a separate line with units equal to the number of additional fetuses.
One unit of 76817 is covered on the same date of service in addition to transabdominal ultrasounds if medically necessary.
For multiple gestation pregnancies, there is no limit to the number of ultrasounds during the pregnancy when billed according to the policy instructions, but excessive billing is subject to post-payment review.
Exclusions
Ultrasound is not covered when:
-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:
-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:
-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP
Age Group Details
Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria
Place of Service
Inpatient, Outpatient, Physician’s Office.
How to Submit
Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable
Resources
1E-4 Fetal Surveillance
Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.
Authorization Guidelines
The provider(s) shall submit 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 Subsection 3.2 of this policy.
- c. If the Medicaid recipient is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
Conditional Requirements
Prior authorization is required if provider is not part of the Pregnancy Medical Home program, except if done in emergency department or inpatient.
Limits
One combination of primary and add-on ultrasound codes is allowed per day for multiple-fetus billing.
CPT 76815 includes one or more fetuses and can only be reimbursed for one unit of service.
For multiple fetuses, 76816 is billed with one unit for the first fetus; additional fetuses are billed on a separate line with units equal to the number of additional fetuses.
One unit of 76817 is covered on the same date of service in addition to transabdominal ultrasounds if medically necessary.
For multiple gestation pregnancies, there is no limit to the number of ultrasounds during the pregnancy when billed according to the policy instructions, but excessive billing is subject to post-payment review.
Exclusions
Ultrasound is not covered when:
-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:
-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:
-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP
Age Group Details
Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria
Place of Service
Inpatient, Outpatient, Physician’s Office.
How to Submit
Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable
Resources
1E-4 Fetal Surveillance
Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.
Authorization Guidelines
The provider(s) shall submit 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 Subsection 3.2 of this policy.
- c. If the Medicaid recipient is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
Conditional Requirements
Prior authorization is required if provider is not part of the Pregnancy Medical Home program, except if done in emergency department or inpatient.
Limits
One combination of primary and add-on ultrasound codes is allowed per day for multiple-fetus billing.
CPT 76815 includes one or more fetuses and can only be reimbursed for one unit of service.
For multiple fetuses, 76816 is billed with one unit for the first fetus; additional fetuses are billed on a separate line with units equal to the number of additional fetuses.
One unit of 76817 is covered on the same date of service in addition to transabdominal ultrasounds if medically necessary.
For multiple gestation pregnancies, there is no limit to the number of ultrasounds during the pregnancy when billed according to the policy instructions, but excessive billing is subject to post-payment review.
Exclusions
Ultrasound is not covered when:
-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:
-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:
-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP
Age Group Details
Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria
Place of Service
Inpatient, Outpatient, Physician’s Office.
How to Submit
Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable
Resources
1E-4 Fetal Surveillance
Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.
Authorization Guidelines
The provider(s) shall submit 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 Subsection 3.2 of this policy.
- c. If the Medicaid recipient is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
Conditional Requirements
Prior authorization is required if provider is not part of the Pregnancy Medical Home program, except if done in emergency department or inpatient.
Limits
Fetal BPPs may be performed on each fetus.
The diagnosis must support the number of units billed; for example, two units may be billed when a BPP is performed on twins.
The number of fetal biophysical profiles billed must match the diagnosis billed; for twin pregnancy diagnoses listed in billing guidance, the number billed cannot exceed two.
For multiple fetuses, the first fetus profile is billed on one detail with no modifier and one unit; additional fetus profiles are billed on the next detail with modifier 59 and units equal to the number of additional fetuses.
Claims for fetal biophysical profiles with more than one unit and without the appropriate diagnosis code will be denied.
A fetal biophysical profile must not be billed for a fetus that is deceased.
Exclusions
Ultrasound is not covered when:
-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:
-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:
-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP
Age Group Details
Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria
Place of Service
Inpatient, Outpatient, Physician’s Office.
Additional Service Specifics
In billing, a fetal non-stress test cannot be billed with fetal biophysical profile 76818. Claims for fetal biophysical profiles submitted with more than one unit and without the appropriate diagnosis code will be denied and must be corrected and resubmitted. A fetal biophysical profile must not be billed for a fetus that is deceased.
How to Submit
Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable
Resources
1E-4 Fetal Surveillance
Fetal surveillance testing may be necessary to ensure that the fetus is developing normally. The predominant goal of antepartum fetal testing is to lower perinatal morbidity and mortality rates. Fetal testing should not begin until interventions can be undertaken.
Authorization Guidelines
The provider(s) shall submit 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 Subsection 3.2 of this policy.
- c. If the Medicaid recipient is under 21 years of age, information supporting
that all EPSDT criteria are met and evidence-based literature supporting the request, if available.
Conditional Requirements
Prior authorization is required if provider is not part of the Pregnancy Medical Home program, except if done in emergency department or inpatient.
Limits
Fetal BPPs may be performed on each fetus.
The diagnosis must support the number of units billed; for example, two units may be billed when a BPP is performed on twins.
The number of fetal biophysical profiles billed must match the diagnosis billed; for twin pregnancy diagnoses listed in billing guidance, the number billed cannot exceed two.
For multiple fetuses, the first fetus profile is billed on one detail with no modifier and one unit; additional fetus profiles are billed on the next detail with modifier 59 and units equal to the number of additional fetuses.
Claims for fetal biophysical profiles with more than one unit and without the appropriate diagnosis code will be denied.
A fetal biophysical profile must not be billed for a fetus that is deceased.
Exclusions
Ultrasound is not covered when:
-it is a screening test used in the absence of medical indications or predisposing factors; or -it is used solely to determine the sex of the fetus.Fetal echocardiography is not covered when:
-it is used for routine screening for congenital heart disease in the absence of risk factors listed in the CCP (Subsection 3.6); or -the pregnancy is low risk and there are normal anatomic findings on ultrasound examination; or -premature contractions are occasional and without sustained tachycardia or signs of dysfunction or distress; or -a non-cardiovascular system abnormality is present, but evaluation of the cardiovascular system will not alter either obstetrical decision making or fetal outcome. Amniocentesis is not covered when it is performed for the following reasons:
-sex determination, in the absence of a documented risk of an X-linked disorder, or -routine screening, in the absence of risk factors noted in the CCP
Age Group Details
Medicaid beneficiaries from ages 9 through 60 are eligible for the procedure when they meet the medical necessity criteria
Place of Service
Inpatient, Outpatient, Physician’s Office.
Additional Service Specifics
In billing, a fetal non-stress test cannot be billed with fetal biophysical profile 76818. Claims for fetal biophysical profiles submitted with more than one unit and without the appropriate diagnosis code will be denied and must be corrected and resubmitted. A fetal biophysical profile must not be billed for a fetus that is deceased.
How to Submit
Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable
Resources
If you find any wrong or out of date information on our pages, we want to know. Please email info@TrilliumNC.org with any corrections.