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
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
Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, direct probe technique
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, amplified probe technique
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); hepatitis G, 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.
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.
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.
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); Herpes virus-6, direct probe technique
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, amplified probe technique
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); Herpes virus-6, 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
HIV screening may be performed only during an annual assessment, a 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 this six-visit limit.
HIV and other STI screenings may be performed during those visit types after an annual assessment or comprehensive preventive medicine evaluation has been performed. For FP Medicaid claims, the Annual Assessment Date or Comprehensive Preventive Medicine Evaluation Date must be included on claims for laboratory procedures.
Exclusions
Medical treatment for HIV is not covered by Family Planning Medicaid. In addition, FP Medicaid 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.
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
Genotyping and Phenotyping Clinical Coverage Policy No.:1S-1 For HIV Drug Resistance Testing
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
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
HIV screening may be performed only during an annual assessment, a 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 this six-visit limit.
HIV and other STI screenings may be performed during those visit types after an annual assessment or comprehensive preventive medicine evaluation has been performed. For FP Medicaid claims, the Annual Assessment Date or Comprehensive Preventive Medicine Evaluation Date must be included on claims for laboratory procedures.
Exclusions
Medical treatment for HIV is not covered by Family Planning Medicaid. In addition, FP Medicaid 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.
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
Genotyping and Phenotyping Clinical Coverage Policy No.:1S-1 For HIV Drug Resistance Testing
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
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
HIV screening may be performed only during an annual assessment, a 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 this six-visit limit.
HIV and other STI screenings may be performed during those visit types after an annual assessment or comprehensive preventive medicine evaluation has been performed. For FP Medicaid claims, the Annual Assessment Date or Comprehensive Preventive Medicine Evaluation Date must be included on claims for laboratory procedures.
Exclusions
Medical treatment for HIV is not covered by Family Planning Medicaid. In addition, FP Medicaid 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.
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
Genotyping and Phenotyping Clinical Coverage Policy No.:1S-1 For HIV Drug Resistance Testing
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
Infectious agent detection by nucleic acid (DNA or RNA); HIV-2, amplified probe technique, includes reverse transcription when performed
How to Submit
N/A - No authorization is required
Genotyping and Phenotyping Clinical Coverage Policy No.:1S-1 For HIV Drug Resistance Testing
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
Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, direct probe technique
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); Legionella pneumophila, amplified probe technique
How to Submit
N/A - No authorization is required
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