PA Lookup

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

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.

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
• Records Management and Documentation Manual

How to Submit

N/A - No authorization is required

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

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

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.

STI and other screening services under FP Medicaid are available only after an annual assessment or comprehensive preventive medicine evaluation has been performed. Telehealth is allowed only for select services in the policy; telehealth-eligible CPT visit codes are listed separately in Attachment A rather than as STI laboratory codes.

Exclusions

Family Planning Medicaid does not cover treatment for acute or chronic conditions discovered during screening when those conditions are unrelated to family planning or family planning-related services. Medical treatment for HIV, Hepatitis B, and Hepatitis C is not covered by Family Planning Medicaid. Hospital emergency room or emergency department services and inpatient hospital services are not covered for FP Medicaid beneficiaries. In addition, outpatient hospital services for FP Medicaid are generally not covered except for sterilization, medically necessary removal of contraceptive devices, or ultrasound for IUD-related complications.

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
• Records Management and Documentation Manual

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, Trichomonas Vaginalis screening/diagnostic testing may be performed only during an annual assessment, comprehensive preventive medicine evaluation, or one of the six allowed inter-periodic visits.

FP Medicaid beneficiaries are limited to six inter-periodic visits per 365 calendar days; each in-person or telehealth encounter counts toward that six-visit allotment.

For MAFDN/FP Medicaid claims, the Annual Assessment Date or Comprehensive Preventive Medicine Evaluation Date must be included on claims for laboratory procedures, except pregnancy tests.

Exclusions

For FP Medicaid beneficiaries, hospital emergency room or emergency department services and inpatient hospital services are not covered. FP Medicaid also does not cover medical conditions unrelated to family planning or family planning-related services, and treatment for acute or chronic conditions discovered during screening is 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, QW. 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
• Records Management and Documentation Manual

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, Trichomonas Vaginalis screening/diagnostic testing may be performed only during an annual assessment, comprehensive preventive medicine evaluation, or one of the six allowed inter-periodic visits.

FP Medicaid beneficiaries are limited to six inter-periodic visits per 365 calendar days; each in-person or telehealth encounter counts toward that six-visit allotment.

For MAFDN/FP Medicaid claims, the Annual Assessment Date or Comprehensive Preventive Medicine Evaluation Date must be included on claims for laboratory procedures, except pregnancy tests.

Exclusions

For FP Medicaid beneficiaries, hospital emergency room or emergency department services and inpatient hospital services are not covered. FP Medicaid also does not cover medical conditions unrelated to family planning or family planning-related services, and treatment for acute or chronic conditions discovered during screening is 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, QW. 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
• Records Management and Documentation Manual

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, Bacterial Vaginosis testing is allowed during the annual assessment, comprehensive preventive medicine evaluation, or any of the six inter-periodic visits allowed under the program.

FP Medicaid beneficiaries are limited to six inter-periodic visits per 365 calendar days.

Family Planning Medicaid claims must have a primary diagnosis of contraception.

The annual assessment date or annual evaluation date must be included on claims for laboratory procedures, except pregnancy tests.

Exclusions

FP Medicaid does not cover treatment for acute or chronic conditions discovered during screening. FP Medicaid also does not cover medical conditions unrelated to family planning or family planning-related services; beneficiaries needing non-family planning services must be referred to primary care or a safety net provider. General policy exclusions also apply when the service duplicates another provider's service or is experimental, investigational, or part of a clinical trial.

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
• Records Management and Documentation Manual

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

Scabies testing is allowed during the annual assessment, comprehensive preventive medicine evaluation, or any of the six inter-periodic visits allowed under FP Medicaid.

For FP Medicaid beneficiaries, services are limited to one comprehensive preventive medicine evaluation or one annual assessment per 365 calendar days.

For FP Medicaid beneficiaries, no more than six inter-periodic visits are allowed per 365 calendar days.

Exclusions

Scabies services are not covered when the beneficiary does not meet eligibility requirements or does not meet coverage criteria under the policy. FP Medicaid does not cover medical conditions unrelated to family planning or family planning-related services

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
• Records Management and Documentation Manual

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

Human Immunodeficiency Virus (HIV) is a ribonucleic acid (RNA) virus characterized by a high replication rate throughout all stages of infection. There are four types of HIV: HIV-1, HIV-2, Human T-cell Lymphotropic Virus (HTLV) type 1, and HTLV type 2. In HIV-1, the reverse transcription enzyme required for replication is error prone, resulting in a high rate of mutations. Viral replication continues in the presence of selective drug(s). This is called drug resistance, and it is one of the most common reasons for failure of HIV therapy. HIV drug resistance testing assesses the HIV strain(s) infecting an individual to determine each strain’s resistance to specific antiretroviral drugs. Two methods are available for testing resistant HIV strains: genotypic and phenotypic. Both isolate the virus from the beneficiary. Genotype tests detect specific mutations in the genome of a beneficiary’s viral isolate that are associated with antiretroviral resistance. Phenotype tests assess how well the beneficiary’s virus grows in the presence of different concentrations of antiretroviral drugs and compares these concentrations with a viral strain used as a control.

Limits

Genotype and phenotype testing for HIV drug resistance is not covered in the following circumstances.

• a. The viral load is less than 1,000 copies/ml.
• b. Combined genotype and phenotype testing for HIV drug resistance is considered investigational but could be considered medically necessary in a complex case where the physician believes both types of testing might provide additional useful information, not provided by one or the other. This will be determined on a case-by-case basis, and with medical documentation supporting why both tests are necessary.The test must be ordered by a treating physician or other qualified treating non-physician practitioner within the scope of their license and in compliance with Medicaid requirements.Coverage is limited to no more than two HIV-1 drug-resistant tissue tests in a 12-month period. If additional testing is needed within a 12-month period, an exception may be requested and must include medical necessity documentation.

The service may be billed on professional or institutional claims.

Place of Service

Inpatient, Outpatient, Office

Additional Service Specifics

CPT 86701 or 86703 is performed initially. CPT 86702 is performed when the results of 86701 are negative and clinical suspicion of HIV-2 exists. CPT 86689 is performed only on samples that show repeated positive results by 86701, 86702, or 86703. Note: The laboratory performing the test(s) shall bill for the service.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1S-1
• Records Management and Documentation Manual

Human Immunodeficiency Virus (HIV) is a ribonucleic acid (RNA) virus characterized by a high replication rate throughout all stages of infection. There are four types of HIV: HIV-1, HIV-2, Human T-cell Lymphotropic Virus (HTLV) type 1, and HTLV type 2. In HIV-1, the reverse transcription enzyme required for replication is error prone, resulting in a high rate of mutations. Viral replication continues in the presence of selective drug(s). This is called drug resistance, and it is one of the most common reasons for failure of HIV therapy. HIV drug resistance testing assesses the HIV strain(s) infecting an individual to determine each strain’s resistance to specific antiretroviral drugs. Two methods are available for testing resistant HIV strains: genotypic and phenotypic. Both isolate the virus from the beneficiary. Genotype tests detect specific mutations in the genome of a beneficiary’s viral isolate that are associated with antiretroviral resistance. Phenotype tests assess how well the beneficiary’s virus grows in the presence of different concentrations of antiretroviral drugs and compares these concentrations with a viral strain used as a control.

Limits

Genotype and phenotype testing for HIV drug resistance is not covered in the following circumstances.

• a. The viral load is less than 1,000 copies/ml.
• b. Combined genotype and phenotype testing for HIV drug resistance is considered investigational but could be considered medically necessary in a complex case where the physician believes both types of testing might provide additional useful information, not provided by one or the other. This will be determined on a case-by-case basis, and with medical documentation supporting why both tests are necessary.The test must be ordered by a treating physician or other qualified treating non-physician practitioner within the scope of their license and in compliance with Medicaid requirements.Coverage is limited to no more than two HIV-1 drug-resistant tissue tests in a 12-month period. If additional testing is needed within a 12-month period, an exception may be requested and must include medical necessity documentation.

The service may be billed on professional or institutional claims.

Place of Service

Inpatient, Outpatient, Office

Additional Service Specifics

CPT 86701 or 86703 is performed initially. CPT 86702 is performed when the results of 86701 are negative and clinical suspicion of HIV-2 exists. CPT 86689 is performed only on samples that show repeated positive results by 86701, 86702, or 86703. Note: The laboratory performing the test(s) shall bill for the service.

How to Submit

N/A - No authorization is required

Resources

• Clinical Coverage Policy No: 1S-1
• Records Management and Documentation Manual

How to Submit

N/A - No authorization is required

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 EviCore

• https://www.evicore.com/

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required

How to Submit

N/A - No authorization is required