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); Legionella pneumophila, quantification
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria species, direct probe technique
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria species, amplified probe technique
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria species, quantification
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, direct probe technique
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, amplified probe technique
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria tuberculosis, quantification
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, direct probe technique
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, amplified probe technique
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); Mycobacteria avium-intracellulare, quantification
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma genitalium, amplified probe technique
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, direct probe technique
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, amplified probe technique
How to Submit
N/A - No authorization is required
Infectious agent detection by nucleic acid (DNA or RNA); Mycoplasma pneumoniae, 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
For FP Medicaid beneficiaries, Hepatitis B, Hepatitis C, and STI screening may be performed only during the annual assessment, comprehensive preventive medicine evaluation, or one of the six inter-periodic visits allowed per 365 calendar days, after an annual assessment or comprehensive preventive medicine evaluation has been performed.
FP Medicaid beneficiaries are limited to one annual office visit assessment before other family planning or family planning-related services are rendered, unless they 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.
Each in-person or telehealth encounter counts as one of the six allotted inter-periodic visits per 365 days.
Exclusions
For FP Medicaid, medical treatment for HIV, Hepatitis B, and Hepatitis C is not covered. FP Medicaid also does not cover treatment for acute or chronic conditions discovered during screening when unrelated to covered family planning or family planning-related services. MAFDN beneficiaries are only eligible for services described in the CCP (Subsection 3.2.1); if a condition unrelated to family planning or family planning-related services occurs, the provider must refer the beneficiary to a primary care or safety net provider.
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
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, Hepatitis B, Hepatitis C, and STI screening may be performed only during the annual assessment, comprehensive preventive medicine evaluation, or one of the six inter-periodic visits allowed per 365 calendar days, after an annual assessment or comprehensive preventive medicine evaluation has been performed.
FP Medicaid beneficiaries are limited to one annual office visit assessment before other family planning or family planning-related services are rendered, unless they 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.
Each in-person or telehealth encounter counts as one of the six allotted inter-periodic visits per 365 days.
Exclusions
For FP Medicaid, medical treatment for HIV, Hepatitis B, and Hepatitis C is not covered. FP Medicaid also does not cover treatment for acute or chronic conditions discovered during screening when unrelated to covered family planning or family planning-related services. MAFDN beneficiaries are only eligible for services described in the CCP (Subsection 3.2.1); if a condition unrelated to family planning or family planning-related services occurs, the provider must refer the beneficiary to a primary care or safety net provider.
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
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, Hepatitis B, Hepatitis C, and STI screening may be performed only during the annual assessment, comprehensive preventive medicine evaluation, or one of the six inter-periodic visits allowed per 365 calendar days, after an annual assessment or comprehensive preventive medicine evaluation has been performed.
FP Medicaid beneficiaries are limited to one annual office visit assessment before other family planning or family planning-related services are rendered, unless they 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.
Each in-person or telehealth encounter counts as one of the six allotted inter-periodic visits per 365 days.
Exclusions
For FP Medicaid, medical treatment for HIV, Hepatitis B, and Hepatitis C is not covered. FP Medicaid also does not cover treatment for acute or chronic conditions discovered during screening when unrelated to covered family planning or family planning-related services. MAFDN beneficiaries are only eligible for services described in the CCP (Subsection 3.2.1); if a condition unrelated to family planning or family planning-related services occurs, the provider must refer the beneficiary to a primary care or safety net provider.
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
Infectious agent detection by nucleic acid (DNA or RNA); orthopoxvirus (eg, monkeypox virus, cowpox virus, vaccinia virus), amplified probe technique, each
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
HPV vaccine is allowed during an annual assessment or comprehensive preventive medicine evaluation.
Gardasil 9 may be administered to male and female beneficiaries through age 45 years.
For FP Medicaid, Papillomavirus laboratory testing is available during the annual assessment, comprehensive preventive medicine evaluation, or one of the six inter-periodic visits allowed under the program.
Exclusions
If an unrelated medical condition occurs or the beneficiary has no need for family planning services, the provider must refer the beneficiary to a primary care or safety net provider. In addition, hospital emergency room or emergency department services and inpatient hospital services are not covered for FP Medicaid beneficiaries.
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
HPV vaccine is allowed during an annual assessment or comprehensive preventive medicine evaluation.
Gardasil 9 may be administered to male and female beneficiaries through age 45 years.
For FP Medicaid, Papillomavirus laboratory testing is available during the annual assessment, comprehensive preventive medicine evaluation, or one of the six inter-periodic visits allowed under the program.
Exclusions
If an unrelated medical condition occurs or the beneficiary has no need for family planning services, the provider must refer the beneficiary to a primary care or safety net provider. In addition, hospital emergency room or emergency department services and inpatient hospital services are not covered for FP Medicaid beneficiaries.
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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