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
Infectious agent detection by nucleic acid (DNA or RNA); Clostridium difficile, toxin gene(s), amplified probe technique
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); Chlamydia trachomatis and Neisseria gonorrhoeae, multiplex amplified probe technique
Authorization Guidelines
Authorization is required for non-participating independent labs. For all other providers, no auth is required.
Conditional Requirements
Authorization is required for non-participating independent labs. For all other providers, no auth is required.
How to Submit
If applicable, please submit your request to Trillium.
Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, direct probe technique
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, amplified probe technique
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); cytomegalovirus, quantification
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); enterovirus, amplified probe technique, includes reverse transcription when performed
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); vancomycin resistance (eg, enterococcus species van A, van B), amplified probe technique
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, includes reverse transcription, when performed, and amplified probe technique, each type or subtype
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, first 2 types or sub-types
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); influenza virus, for multiple types or sub-types, includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, each additional influenza virus type or sub-type
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe tech
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe tech
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe tech
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
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
Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, amplified probe technique
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); Gardnerella vaginalis, quantification
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
FP Medicaid allows Hepatitis B screening only during an annual assessment, a comprehensive preventive medicine evaluation, or one of the six inter-periodic visits allowed under the FP Medicaid program.
HIV, Hepatitis B, Hepatitis C, and other STI screenings can be performed during those visit types only after an annual assessment or comprehensive preventive medicine evaluation has been performed.
FP Medicaid beneficiaries are limited to one comprehensive preventive medicine evaluation or one annual assessment per 365 calendar 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
Family Planning Medicaid does not cover medical treatment for Hepatitis B discovered through screening. FP Medicaid also does not cover treatment for acute or chronic conditions discovered during screening, and does not cover medical conditions unrelated to family planning or family planning-related services; beneficiaries must be referred to primary care or a safety net provider for non-covered care.
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
FP Medicaid allows Hepatitis B screening only during an annual assessment, a comprehensive preventive medicine evaluation, or one of the six inter-periodic visits allowed under the FP Medicaid program.
HIV, Hepatitis B, Hepatitis C, and other STI screenings can be performed during those visit types only after an annual assessment or comprehensive preventive medicine evaluation has been performed.
FP Medicaid beneficiaries are limited to one comprehensive preventive medicine evaluation or one annual assessment per 365 calendar 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
Family Planning Medicaid does not cover medical treatment for Hepatitis B discovered through screening. FP Medicaid also does not cover treatment for acute or chronic conditions discovered during screening, and does not cover medical conditions unrelated to family planning or family planning-related services; beneficiaries must be referred to primary care or a safety net provider for non-covered care.
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
Covered for FP Medicaid during either the annual assessment, a comprehensive preventive medicine evaluation, or one of the six inter-periodic visits allowed under the FP Medicaid program.
HIV, Hepatitis B, Hepatitis C, and other STI screenings may be performed only after an annual assessment or comprehensive preventive medicine evaluation has been performed.
Each in-person or telehealth inter-periodic encounter counts toward the beneficiary's limit of six inter-periodic visits per 365 calendar days.
Claims for laboratory procedures must include the Annual Evaluation Date or Annual Assessment Date.
Exclusions
Medical treatment for Hepatitis C is not covered by Family Planning Medicaid; only screening is covered.
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
Covered for FP Medicaid during either the annual assessment, a comprehensive preventive medicine evaluation, or one of the six inter-periodic visits allowed under the FP Medicaid program.
HIV, Hepatitis B, Hepatitis C, and other STI screenings may be performed only after an annual assessment or comprehensive preventive medicine evaluation has been performed.
Each in-person or telehealth inter-periodic encounter counts toward the beneficiary's limit of six inter-periodic visits per 365 calendar days.
Claims for laboratory procedures must include the Annual Evaluation Date or Annual Assessment Date.
Exclusions
Medical treatment for Hepatitis C is not covered by Family Planning Medicaid; only screening is covered.
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
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