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
Metyrapone panel This panel must include the following: Cortisol (82533 x 2) 11 deoxycortisol (82634 x 2)
How to Submit
N/A - No authorization is required
Thyrotropin releasing hormone (TRH) stimulation panel; 1 hour This panel must include the following: Thyroid stimulating hormone (TSH) (84443 x 3)
How to Submit
N/A - No authorization is required
Thyrotropin releasing hormone (TRH) stimulation panel; 2 hour This panel must include the following: Thyroid stimulating hormone (TSH) (84443 x 4)
How to Submit
N/A - No authorization is required
1E-7 Family Planning Services
Family Planning Medicaid services are provided to an eligible Medicaid beneficiary of childbearing age to temporarily or permanently prevent or delay pregnancy. Medicaid Family Planning is designed to reduce unintended pregnancies and improve the well-being of children and families in North Carolina.
Limits
Limited to one urinalysis procedure code per 365 calendar days. Urinalysis is allowed only in conjunction with an annual assessment or comprehensive preventive medicine evaluation.
Claims for laboratory procedures, except pregnancy tests, must include the Annual Assessment Date or Comprehensive Preventive Medicine Evaluation Date on the claim.
Exclusions
Urinalysis is not covered when it is for a medical condition unrelated to family planning or family planning-related services for FP Medicaid beneficiaries. FP Medicaid beneficiaries are only eligible for services described in THE Clinical Coverage Policy (Subsection 3.2.1), and unrelated conditions must be referred to primary care or a safety net provider. In addition, hospital emergency room or emergency department services are not covered for FP Medicaid beneficiaries, and hospital setting costs are the beneficiary's responsibility except for limited exceptions that do not include urinalysis.
Place of Service
Non-Telehealth Claims: a. Inpatient hospitals (not applicable for a FP Medicaid beneficiary) b. Outpatient hospital: For a FP Medicaid beneficiary, the only surgical procedure or service allowed requiring outpatient beneficiary registration is sterilization, IUD removal or ultrasound for IUD related complications including missing strings. c. Office: utilizing offices within places of service 11 (Office), 19 (Off Campus Outpatient) or 22 (On Campus Outpatient) d. Ambulatory Surgical Centers (applicable for a FP Medicaid beneficiary for a sterilization. Numeric POS code(s): 02-Telehealth Provided Other than in Patient's Home.
Additional Service Specifics
FP. GT applies only when the service is telehealth billable and delivered by interactive audio-video.
How to Submit
N/A - No authorization is required
Resources
Dialysis Service
Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.
Limits
Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.
For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.
Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.
Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.
If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.
Hemodialysis training is reimbursed in sessions that can last up to five hours per day.
Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.
CAPD and CCPD are covered per date of service, not per treatment.
Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.
Dialysis training is typically completed within two weeks of initiating self-care.
CAPD training sessions can last up to eight hours per day.
CCPD training sessions can last up to eight hours per day.
Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.
Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.
Little or no professional assistance is provided except in an emergency.
Dialysis training is typically completed within two weeks of initiating self-care.
Hemodialysis training sessions can last up to 5 hours per day.
Reimbursement for the completed course is allowed once per beneficiary's lifetime.
Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.
Training and retraining sessions are reimbursed at the same rate.
Exclusions
Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.
For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.
Medicaid shall not cover the following Dialysis Services:
- a. office visits, home visits, consults and care plan oversight included in the
monthly capitation;
- b. access maintenance performed by the staff in the ESRD facility;
- c. take home drugs and supplies;
- d. specimen collection fees;
- e. transportation: The beneficiary is encouraged to contact their local county
Department of Social Services for assistance;
- f. medical supply charges, including syringes and their administration;
- g. costs associated with a private caregiver, outside of allowed training paid to
the training facility; and
- h. capitation payment for the month in which the training code is billed.
Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.
Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.
Place of Service
Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.
How to Submit
N/A - No authorization is required
Resources
1E-7 Family Planning Services
Family Planning Medicaid services are provided to an eligible Medicaid beneficiary of childbearing age to temporarily or permanently prevent or delay pregnancy. Medicaid Family Planning is designed to reduce unintended pregnancies and improve the well-being of children and families in North Carolina.
Limits
Limited to one urinalysis procedure code per 365 calendar days. Urinalysis is allowed only in conjunction with an annual assessment or comprehensive preventive medicine evaluation.
Claims for laboratory procedures, except pregnancy tests, must include the Annual Assessment Date or Comprehensive Preventive Medicine Evaluation Date on the claim.
Exclusions
Urinalysis is not covered when it is for a medical condition unrelated to family planning or family planning-related services for FP Medicaid beneficiaries. FP Medicaid beneficiaries are only eligible for services described in THE Clinical Coverage Policy (Subsection 3.2.1), and unrelated conditions must be referred to primary care or a safety net provider. In addition, hospital emergency room or emergency department services are not covered for FP Medicaid beneficiaries, and hospital setting costs are the beneficiary's responsibility except for limited exceptions that do not include urinalysis.
Place of Service
Non-Telehealth Claims: a. Inpatient hospitals (not applicable for a FP Medicaid beneficiary) b. Outpatient hospital: For a FP Medicaid beneficiary, the only surgical procedure or service allowed requiring outpatient beneficiary registration is sterilization, IUD removal or ultrasound for IUD related complications including missing strings. c. Office: utilizing offices within places of service 11 (Office), 19 (Off Campus Outpatient) or 22 (On Campus Outpatient) d. Ambulatory Surgical Centers (applicable for a FP Medicaid beneficiary for a sterilization. Numeric POS code(s): 02-Telehealth Provided Other than in Patient's Home.
Additional Service Specifics
FP. GT applies only when the service is telehealth billable and delivered by interactive audio-video.
How to Submit
N/A - No authorization is required
Resources
1E-7 Family Planning Services
Family Planning Medicaid services are provided to an eligible Medicaid beneficiary of childbearing age to temporarily or permanently prevent or delay pregnancy. Medicaid Family Planning is designed to reduce unintended pregnancies and improve the well-being of children and families in North Carolina.
Limits
Limited to one urinalysis procedure code per 365 calendar days. Urinalysis is allowed only in conjunction with an annual assessment or comprehensive preventive medicine evaluation.
Claims for laboratory procedures, except pregnancy tests, must include the Annual Assessment Date or Comprehensive Preventive Medicine Evaluation Date on the claim.
Exclusions
Urinalysis is not covered when it is for a medical condition unrelated to family planning or family planning-related services for FP Medicaid beneficiaries. FP Medicaid beneficiaries are only eligible for services described in THE Clinical Coverage Policy (Subsection 3.2.1), and unrelated conditions must be referred to primary care or a safety net provider. In addition, hospital emergency room or emergency department services are not covered for FP Medicaid beneficiaries, and hospital setting costs are the beneficiary's responsibility except for limited exceptions that do not include urinalysis.
Place of Service
Non-Telehealth Claims: a. Inpatient hospitals (not applicable for a FP Medicaid beneficiary) b. Outpatient hospital: For a FP Medicaid beneficiary, the only surgical procedure or service allowed requiring outpatient beneficiary registration is sterilization, IUD removal or ultrasound for IUD related complications including missing strings. c. Office: utilizing offices within places of service 11 (Office), 19 (Off Campus Outpatient) or 22 (On Campus Outpatient) d. Ambulatory Surgical Centers (applicable for a FP Medicaid beneficiary for a sterilization. Numeric POS code(s): 02-Telehealth Provided Other than in Patient's Home.
Additional Service Specifics
FP. GT applies only when the service is telehealth billable and delivered by interactive audio-video.
How to Submit
N/A - No authorization is required
Resources
Dialysis Service
Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.
Limits
Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.
For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.
Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.
Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.
If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.
Hemodialysis training is reimbursed in sessions that can last up to five hours per day.
Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.
CAPD and CCPD are covered per date of service, not per treatment.
Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.
Dialysis training is typically completed within two weeks of initiating self-care.
CAPD training sessions can last up to eight hours per day.
CCPD training sessions can last up to eight hours per day.
Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.
Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.
Little or no professional assistance is provided except in an emergency.
Dialysis training is typically completed within two weeks of initiating self-care.
Hemodialysis training sessions can last up to 5 hours per day.
Reimbursement for the completed course is allowed once per beneficiary's lifetime.
Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.
Training and retraining sessions are reimbursed at the same rate.
Exclusions
Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.
For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.
Medicaid shall not cover the following Dialysis Services:
- a. office visits, home visits, consults and care plan oversight included in the
monthly capitation;
- b. access maintenance performed by the staff in the ESRD facility;
- c. take home drugs and supplies;
- d. specimen collection fees;
- e. transportation: The beneficiary is encouraged to contact their local county
Department of Social Services for assistance;
- f. medical supply charges, including syringes and their administration;
- g. costs associated with a private caregiver, outside of allowed training paid to
the training facility; and
- h. capitation payment for the month in which the training code is billed.
Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.
Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.
Place of Service
Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.
How to Submit
N/A - No authorization is required
Resources
1E-7 Family Planning Services
Family Planning Medicaid services are provided to an eligible Medicaid beneficiary of childbearing age to temporarily or permanently prevent or delay pregnancy. Medicaid Family Planning is designed to reduce unintended pregnancies and improve the well-being of children and families in North Carolina.
Limits
Limited to one urinalysis procedure code per 365 calendar days. Urinalysis is allowed only in conjunction with an annual assessment or comprehensive preventive medicine evaluation.
Claims for laboratory procedures, except pregnancy tests, must include the Annual Assessment Date or Comprehensive Preventive Medicine Evaluation Date on the claim.
Exclusions
Urinalysis is not covered when it is for a medical condition unrelated to family planning or family planning-related services for FP Medicaid beneficiaries. FP Medicaid beneficiaries are only eligible for services described in THE Clinical Coverage Policy (Subsection 3.2.1), and unrelated conditions must be referred to primary care or a safety net provider. In addition, hospital emergency room or emergency department services are not covered for FP Medicaid beneficiaries, and hospital setting costs are the beneficiary's responsibility except for limited exceptions that do not include urinalysis.
Place of Service
Non-Telehealth Claims: a. Inpatient hospitals (not applicable for a FP Medicaid beneficiary) b. Outpatient hospital: For a FP Medicaid beneficiary, the only surgical procedure or service allowed requiring outpatient beneficiary registration is sterilization, IUD removal or ultrasound for IUD related complications including missing strings. c. Office: utilizing offices within places of service 11 (Office), 19 (Off Campus Outpatient) or 22 (On Campus Outpatient) d. Ambulatory Surgical Centers (applicable for a FP Medicaid beneficiary for a sterilization. Numeric POS code(s): 02-Telehealth Provided Other than in Patient's Home.
Additional Service Specifics
FP. GT applies only when the service is telehealth billable and delivered by interactive audio-video.
How to Submit
N/A - No authorization is required
Resources
Dialysis Service
Dialysis Services are procedures and services for beneficiaries with chronic renal disease or acute kidney injury designed to replace the functioning of the kidney and maintain the function of related organs. Progressive chronic renal failure typically requires on going dialysis due to End Stage Renal Disease (ESRD), as a result of permanent loss of normal kidney tissues and function. Hemodialysis, peritoneal dialysis, and self-dialysis support services are covered, as outlined in this clinical policy, when they are provided by a Medicaid & Medicare certified ESRD hospital based renal dialysis center or free-standing ESRD facility for beneficiaries requiring dialysis services.
Limits
Hemodyalisis: Covered without documentation of medical necessity up to three times weekly. Cannot exceed more than one hemodialysis treatment per date of service.
For AKI dialysis treatments during the monthly billing cycle, only one payment for one treatment per day across settings is allowed; additional payment may be allowed for an uncompleted or partial treatment.
Providers shall document the first date of the ongoing dialysis treatment on each claim submitted.
Providers shall bill dialysis-related services once per calendar month using the last day of the month as the date of service.
If the beneficiary dies before month-end, use the date of death or the last date seen instead of the last day of the month.
Hemodialysis training is reimbursed in sessions that can last up to five hours per day.
Peritoneal Dialysis: Covered when provided by a Medicaid & Medicare certified ESRD hospital-based renal dialysis center or free-standing ESRD facility.
CAPD and CCPD are covered per date of service, not per treatment.
Providers shall bill dialysis-related services once per calendar month, using the last day of the month as the date of service.
Dialysis training is typically completed within two weeks of initiating self-care.
CAPD training sessions can last up to eight hours per day.
CCPD training sessions can last up to eight hours per day.
Home dialysis is performed at home by an ESRD beneficiary or private caregiver who has completed appropriate training.
Self Dialysis: Self-dialysis may be performed only in CMS-compliant centers or in the ESRD beneficiary's private primary residence.
Little or no professional assistance is provided except in an emergency.
Dialysis training is typically completed within two weeks of initiating self-care.
Hemodialysis training sessions can last up to 5 hours per day.
Reimbursement for the completed course is allowed once per beneficiary's lifetime.
Dialysis training sessions are limited to 25 sessions per beneficiary's lifetime.
Training and retraining sessions are reimbursed at the same rate.
Exclusions
Home dialysis is not covered for beneficiaries diagnosed with acute kidney injury because they require close medical supervision.
For undocumented aliens, dialysis is covered only as an emergency service in a facility with licensed professional monitoring during each episode of care; once the beneficiary is stable enough for in-home hemodialysis without immediate medical attention, the treatment is no longer an emergency service.
Medicaid shall not cover the following Dialysis Services:
- a. office visits, home visits, consults and care plan oversight included in the
monthly capitation;
- b. access maintenance performed by the staff in the ESRD facility;
- c. take home drugs and supplies;
- d. specimen collection fees;
- e. transportation: The beneficiary is encouraged to contact their local county
Department of Social Services for assistance;
- f. medical supply charges, including syringes and their administration;
- g. costs associated with a private caregiver, outside of allowed training paid to
the training facility; and
- h. capitation payment for the month in which the training code is billed.
Note: When a beneficiary becomes eligible for Medicare or another third-party payer, Medicaid cannot be billed as the primary payer.
Federal Qualified Health Centers and Rural Health Clinics may not provide dialysis services or any dialysis related services.
Place of Service
Home, ESRD facilities, and independent laboratories. Telehealth claims should be filed with the provider's usual place of services code(s). Co-payments Monthly co-payments are required for Dialysis Services.
How to Submit
N/A - No authorization is required
Resources
1E-7 Family Planning Services
Family Planning Medicaid services are provided to an eligible Medicaid beneficiary of childbearing age to temporarily or permanently prevent or delay pregnancy. Medicaid Family Planning is designed to reduce unintended pregnancies and improve the well-being of children and families in North Carolina.
Limits
Limited to one urinalysis procedure code per 365 calendar days. Urinalysis is allowed only in conjunction with an annual assessment or comprehensive preventive medicine evaluation.
Claims for laboratory procedures, except pregnancy tests, must include the Annual Assessment Date or Comprehensive Preventive Medicine Evaluation Date on the claim.
Exclusions
Urinalysis is not covered when it is for a medical condition unrelated to family planning or family planning-related services for FP Medicaid beneficiaries. FP Medicaid beneficiaries are only eligible for services described in THE Clinical Coverage Policy (Subsection 3.2.1), and unrelated conditions must be referred to primary care or a safety net provider. In addition, hospital emergency room or emergency department services are not covered for FP Medicaid beneficiaries, and hospital setting costs are the beneficiary's responsibility except for limited exceptions that do not include urinalysis.
Place of Service
Non-Telehealth Claims: a. Inpatient hospitals (not applicable for a FP Medicaid beneficiary) b. Outpatient hospital: For a FP Medicaid beneficiary, the only surgical procedure or service allowed requiring outpatient beneficiary registration is sterilization, IUD removal or ultrasound for IUD related complications including missing strings. c. Office: utilizing offices within places of service 11 (Office), 19 (Off Campus Outpatient) or 22 (On Campus Outpatient) d. Ambulatory Surgical Centers (applicable for a FP Medicaid beneficiary for a sterilization. Numeric POS code(s): 02-Telehealth Provided Other than in Patient's Home.
Additional Service Specifics
FP. GT applies only when the service is telehealth billable and delivered by interactive audio-video.
How to Submit
N/A - No authorization is required
Resources
1E-7 Family Planning Services
Family Planning Medicaid services are provided to an eligible Medicaid beneficiary of childbearing age to temporarily or permanently prevent or delay pregnancy. Medicaid Family Planning is designed to reduce unintended pregnancies and improve the well-being of children and families in North Carolina.
Limits
Limited to one urinalysis procedure code per 365 calendar days. Urinalysis is allowed only in conjunction with an annual assessment or comprehensive preventive medicine evaluation.
Claims for laboratory procedures, except pregnancy tests, must include the Annual Assessment Date or Comprehensive Preventive Medicine Evaluation Date on the claim.
Exclusions
Urinalysis is not covered when it is for a medical condition unrelated to family planning or family planning-related services for FP Medicaid beneficiaries. FP Medicaid beneficiaries are only eligible for services described in THE Clinical Coverage Policy (Subsection 3.2.1), and unrelated conditions must be referred to primary care or a safety net provider. In addition, hospital emergency room or emergency department services are not covered for FP Medicaid beneficiaries, and hospital setting costs are the beneficiary's responsibility except for limited exceptions that do not include urinalysis.
Place of Service
Non-Telehealth Claims: a. Inpatient hospitals (not applicable for a FP Medicaid beneficiary) b. Outpatient hospital: For a FP Medicaid beneficiary, the only surgical procedure or service allowed requiring outpatient beneficiary registration is sterilization, IUD removal or ultrasound for IUD related complications including missing strings. c. Office: utilizing offices within places of service 11 (Office), 19 (Off Campus Outpatient) or 22 (On Campus Outpatient) d. Ambulatory Surgical Centers (applicable for a FP Medicaid beneficiary for a sterilization. Numeric POS code(s): 02-Telehealth Provided Other than in Patient's Home.
Additional Service Specifics
FP. GT applies only when the service is telehealth billable and delivered by interactive audio-video.
How to Submit
N/A - No authorization is required
Resources
1E-7 Family Planning Services
Family Planning Medicaid services are provided to an eligible Medicaid beneficiary of childbearing age to temporarily or permanently prevent or delay pregnancy. Medicaid Family Planning is designed to reduce unintended pregnancies and improve the well-being of children and families in North Carolina.
Limits
Limited to one urinalysis procedure code per 365 calendar days. Urinalysis is allowed only in conjunction with an annual assessment or comprehensive preventive medicine evaluation.
Claims for laboratory procedures, except pregnancy tests, must include the Annual Assessment Date or Comprehensive Preventive Medicine Evaluation Date on the claim.
Exclusions
Urinalysis is not covered when it is for a medical condition unrelated to family planning or family planning-related services for FP Medicaid beneficiaries. FP Medicaid beneficiaries are only eligible for services described in THE Clinical Coverage Policy (Subsection 3.2.1), and unrelated conditions must be referred to primary care or a safety net provider. In addition, hospital emergency room or emergency department services are not covered for FP Medicaid beneficiaries, and hospital setting costs are the beneficiary's responsibility except for limited exceptions that do not include urinalysis.
Place of Service
Non-Telehealth Claims: a. Inpatient hospitals (not applicable for a FP Medicaid beneficiary) b. Outpatient hospital: For a FP Medicaid beneficiary, the only surgical procedure or service allowed requiring outpatient beneficiary registration is sterilization, IUD removal or ultrasound for IUD related complications including missing strings. c. Office: utilizing offices within places of service 11 (Office), 19 (Off Campus Outpatient) or 22 (On Campus Outpatient) d. Ambulatory Surgical Centers (applicable for a FP Medicaid beneficiary for a sterilization. Numeric POS code(s): 02-Telehealth Provided Other than in Patient's Home.
Additional Service Specifics
FP. GT applies only when the service is telehealth billable and delivered by interactive audio-video.
How to Submit
N/A - No authorization is required
Resources
Urinalysis; 2 or 3 glass test
How to Submit
N/A - No authorization is required
1E-7 Family Planning Services
Family Planning Medicaid services are provided to an eligible Medicaid beneficiary of childbearing age to temporarily or permanently prevent or delay pregnancy. Medicaid Family Planning is designed to reduce unintended pregnancies and improve the well-being of children and families in North Carolina.
Limits
Pregnancy tests may be performed only during an annual assessment, comprehensive preventive medicine evaluation, or any of the six inter-periodic visits allowed under the FP Medicaid program.
Pregnancy tests are exempt from the requirement to document the Annual Assessment Date (AAD) or Comprehensive Preventive Medicine Evaluation Date (AED) on claims.
Exclusions
For FP Medicaid beneficiaries, services are not covered if the beneficiary has no need for family planning services, and MAFDN beneficiaries are only eligible for services described in Subsection 3.2.1. The policy also states that no claim is filed if, before any service is rendered, the beneficiary confirms they have been sterilized, are post-menopausal, or are otherwise incapable of conceiving or fathering a child; the visit is to stop and the beneficiary is referred elsewhere.
Place of Service
Non-Telehealth Claims: a. Inpatient hospitals (not applicable for a FP Medicaid beneficiary) b. Outpatient hospital: For a FP Medicaid beneficiary, the only surgical procedure or service allowed requiring outpatient beneficiary registration is sterilization, IUD removal or ultrasound for IUD related complications including missing strings. c. Office: utilizing offices within places of service 11 (Office), 19 (Off Campus Outpatient) or 22 (On Campus Outpatient) d. Ambulatory Surgical Centers (applicable for a FP Medicaid beneficiary for a sterilization. Numeric POS code(s): 02-Telehealth Provided Other than in Patient's Home.
Additional Service Specifics
FP. GT applies only when the service is telehealth billable and delivered by interactive audio-video.
How to Submit
N/A - No authorization is required
Resources
Volume measurement for timed collection, each
How to Submit
N/A - No authorization is required
Unlisted urinalysis procedure
Authorization Guidelines
Please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.
How to Submit
Please submit your request to Trillium Health Resources
Genetic Testing for Diagnosis and Treatment
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
See Evicore site for specific requirements
Reauthorization Guidelines
See Evicore site for specific requirements
Limits
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
Resources
Genetic Testing for Diagnosis and Treatment
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
See Evicore site for specific requirements
Reauthorization Guidelines
See Evicore site for specific requirements
Limits
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
Resources
Genetic Testing for Diagnosis and Treatment
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
Authorization Guidelines
See Evicore site for specific requirements
Reauthorization Guidelines
See Evicore site for specific requirements
Limits
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
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.