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Member and Recipient Service Line: 1-877-685-2415

Provider Support Service Line: 1-855-250-1539

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12437 Results

Leukocyte transfusion

Service Code
86950 (CPT) Leukocyte transfusion
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Volume reduction of blood or blood product (eg, red blood cells or platelets), each unit

Service Code
86960 (CPT) Volume reduction of blood or blood product (eg, red blood cells or platelets), each unit
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Pooling of platelets or other blood products

Service Code
86965 (CPT) Pooling of platelets or other blood products
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Pretreatment of RBCs for use in RBC antibody detection, identification, and/or compatibility testing; incubation with chemical agents or drugs, each

Service Code
86970 (CPT) Pretreatment of RBCs for use in RBC antibody detection, identification, and/or compatibility testing; incubation with chemical agents or drugs, each
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Pretreatment of RBCs for use in RBC antibody detection, identification, and/or compatibility testing; incubation with enzymes, each

Service Code
86971 (CPT) Pretreatment of RBCs for use in RBC antibody detection, identification, and/or compatibility testing; incubation with enzymes, each
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Pretreatment of RBCs for use in RBC antibody detection, identification, and/or compatibility testing; by density gradient separation

Service Code
86972 (CPT) Pretreatment of RBCs for use in RBC antibody detection, identification, and/or compatibility testing; by density gradient separation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Pretreatment of serum for use in RBC antibody identification; incubation with drugs, each

Service Code
86975 (CPT) Pretreatment of serum for use in RBC antibody identification; incubation with drugs, each
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Pretreatment of serum for use in RBC antibody identification; by dilution

Service Code
86976 (CPT) Pretreatment of serum for use in RBC antibody identification; by dilution
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Pretreatment of serum for use in RBC antibody identification; incubation with inhibitors, each

Service Code
86977 (CPT) Pretreatment of serum for use in RBC antibody identification; incubation with inhibitors, each
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Pretreatment of serum for use in RBC antibody identification; by differential red cell absorption using patient RBCs or RBCs of known phenotype, each absorption

Service Code
86978 (CPT) Pretreatment of serum for use in RBC antibody identification; by differential red cell absorption using patient RBCs or RBCs of known phenotype, each absorption
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Splitting of blood or blood products, each unit

Service Code
86985 (CPT) Splitting of blood or blood products, each unit
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Unlisted transfusion medicine procedure

Service Code
86999 (CPT) Unlisted transfusion medicine procedure
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

Animal inoculation, small animal, with observation and dissection

Service Code
87003 (CPT) Animal inoculation, small animal, with observation and dissection
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Concentration (any type), for infectious agents

Service Code
87015 (CPT) Concentration (any type), for infectious agents
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate)

Service Code
87040 (CPT) Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Culture, bacterial; stool, aerobic, with isolation and preliminary examination (eg, KIA, LIA), Salmonella and Shigella species

Service Code
87045 (CPT) Culture, bacterial; stool, aerobic, with isolation and preliminary examination (eg, KIA, LIA), Salmonella and Shigella species
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Culture, bacterial; stool, aerobic, additional pathogens, isolation and presumptive identification of isolates, each plate

Service Code
87046 (CPT) Culture, bacterial; stool, aerobic, additional pathogens, isolation and presumptive identification of isolates, each plate
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
87070 (CPT) Culture, bacterial; any other source except urine, blood or stool, aerobic, with isolation and presumptive identification of isolates
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

  • • For FP Medicaid beneficiaries, these services are limited to services described in the policy's covered family planning service set.
  • • Outpatient hospital registration is limited for FP Medicaid; the only allowed outpatient registered surgical procedure or service is sterilization, IUD removal, or ultrasound for IUD-related complications including missing strings.
  • • Ultrasound for IUD placement issues may be performed only during an annual assessment, comprehensive preventive medicine evaluation, or inter-periodic visit.
  • • Telehealth claims, when allowed under the policy, must be filed with the provider's usual place of service and not place of service 02.

Exclusions

Ultrasound is not covered to verify IUD placement at the time of insertion. Ultrasounds are not intended for routine checking of placement after IUD insertion. FP Medicaid does not cover medical conditions unrelated to family planning or family planning-related services. For FP Medicaid, surgical procedures or hospital services requiring outpatient beneficiary registration are not covered other than medically necessary contraceptive device removal or sterilizations; the policy note also identifies ultrasound for an IUD complication or removal of an IUD as exceptions to hospital cost responsibility. Hospital emergency room or emergency department services, inpatient hospital services, and treatment for acute or chronic conditions discovered during screening are not covered under FP Medicaid.

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

Service Code
87071 (CPT) Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool
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

  • • For FP Medicaid beneficiaries, these services are limited to services described in the policy's covered family planning service set.
  • • Outpatient hospital registration is limited for FP Medicaid; the only allowed outpatient registered surgical procedure or service is sterilization, IUD removal, or ultrasound for IUD-related complications including missing strings.
  • • Ultrasound for IUD placement issues may be performed only during an annual assessment, comprehensive preventive medicine evaluation, or inter-periodic visit.
  • • Telehealth claims, when allowed under the policy, must be filed with the provider's usual place of service and not place of service 02.

Exclusions

Ultrasound is not covered to verify IUD placement at the time of insertion. Ultrasounds are not intended for routine checking of placement after IUD insertion. FP Medicaid does not cover medical conditions unrelated to family planning or family planning-related services. For FP Medicaid, surgical procedures or hospital services requiring outpatient beneficiary registration are not covered other than medically necessary contraceptive device removal or sterilizations; the policy note also identifies ultrasound for an IUD complication or removal of an IUD as exceptions to hospital cost responsibility. Hospital emergency room or emergency department services, inpatient hospital services, and treatment for acute or chronic conditions discovered during screening are not covered under FP Medicaid.

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

Culture, bacterial; quantitative, anaerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool

Service Code
87073 (CPT) Culture, bacterial; quantitative, anaerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required