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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12437 Results

Stem cells (ie, CD34), total count

Service Code
86367 (CPT) Stem cells (ie, CD34), total count
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Microsomal antibodies (eg, thyroid or liver-kidney), each

Service Code
86376 (CPT) Microsomal antibodies (eg, thyroid or liver-kidney), each
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Neutralization test, viral

Service Code
86382 (CPT) Neutralization test, viral
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Nitroblue tetrazolium dye test (NTD)

Service Code
86384 (CPT) Nitroblue tetrazolium dye test (NTD)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Nuclear Matrix Protein 22 (NMP22), qualitative

Service Code
86386 (CPT) Nuclear Matrix Protein 22 (NMP22), qualitative
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Particle agglutination; screen, each antibody

Service Code
86403 (CPT) Particle agglutination; screen, each antibody
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Particle agglutination; titer, each antibody

Service Code
86406 (CPT) Particle agglutination; titer, each antibody
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); screen

Service Code
86408 (CPT) Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); screen
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); titer

Service Code
86409 (CPT) Neutralizing antibody, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]); titer
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative

Service Code
86413 (CPT) Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) antibody, quantitative
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Rheumatoid factor; qualitative

Service Code
86430 (CPT) Rheumatoid factor; qualitative
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Rheumatoid factor; quantitative

Service Code
86431 (CPT) Rheumatoid factor; quantitative
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Tuberculosis test, cell mediated immunity antigen response measurement; gamma interferon

Service Code
86480 (CPT) Tuberculosis test, cell mediated immunity antigen response measurement; gamma interferon
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Tuberculosis test, cell mediated immunity antigen response measurement; enumeration of gamma interferon-producing T-cells in cell suspension

Service Code
86481 (CPT) Tuberculosis test, cell mediated immunity antigen response measurement; enumeration of gamma interferon-producing T-cells in cell suspension
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Skin test; candida

Service Code
86485 (CPT) Skin test; candida
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Skin test; unlisted antigen, each

Service Code
86486 (CPT) Skin test; unlisted antigen, each
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

Skin test; histoplasmosis

Service Code
86510 (CPT) Skin test; histoplasmosis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Skin test; tuberculosis, intradermal

Service Code
86580 (CPT) Skin test; tuberculosis, intradermal
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Streptokinase, antibody

Service Code
86590 (CPT) Streptokinase, antibody
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

1E-7 Family Planning Services

Service Code
86592 (CPT) Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

Syphilis screening may be performed only during an annual assessment, comprehensive preventive medicine evaluation, or one of the six inter-periodic visits allowed under FP Medicaid.

FP Medicaid allows a total of six courses of STI antibiotic treatments from the approved list per 365 calendar days; this applies to syphilis treatment medications on the approved STI medication list.

For FP Medicaid beneficiaries, an annual office visit assessment is required before rendering family planning or family planning-related services unless the beneficiary already had an annual assessment, comprehensive preventive medicine evaluation, or postpartum exam in the previous 365 days.

FP Medicaid beneficiaries are limited to six inter-periodic visits per 365 calendar days in addition to the annual assessment or comprehensive preventive medicine evaluation.

Exclusions

FP Medicaid does not cover treatment for acute or chronic conditions discovered during screening when unrelated to covered family planning or family planning-related services. Medical treatment for HIV, Hepatitis B, and Hepatitis C is specifically not covered, and beneficiaries with medical conditions unrelated to family planning must be referred to primary care or a safety net provider. Hospital emergency room or emergency department services, inpatient hospital services, and most outpatient hospital services are also not covered for FP Medicaid, except limited specified family planning services not specific to syphilis.

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