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
Necropsy (autopsy), limited, gross and/or microscopic; single organ
How to Submit
N/A - No authorization is required
Necropsy (autopsy); forensic examination
How to Submit
N/A - No authorization is required
Necropsy (autopsy); coroner's call
How to Submit
N/A - No authorization is required
Unlisted necropsy (autopsy) procedure
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
Cytopathology, fluids, washings or brushings, except cervical or vaginal; smears with interpretation
How to Submit
N/A - No authorization is required
Cytopathology, fluids, washings or brushings, except cervical or vaginal; simple filter method with interpretation
How to Submit
N/A - No authorization is required
Cytopathology, concentration technique, smears and interpretation (eg, Saccomanno technique)
How to Submit
N/A - No authorization is required
Cytopathology, selective cellular enhancement technique with interpretation (eg, liquid based slide preparation method), except cervical or vaginal
How to Submit
N/A - No authorization is required
Cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual
How to Submit
N/A - No authorization is required
Cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; using computer-assisted technology
How to Submit
N/A - No authorization is required
Cytopathology, forensic (eg, sperm)
How to Submit
N/A - No authorization is required
Sex chromatin identification; Barr bodies
How to Submit
N/A - No authorization is required
Sex chromatin identification; peripheral blood smear, polymorphonuclear drumsticks
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
Limited to one pap test procedure per 365 calendar days.
The pap test may be billed only during an annual assessment, comprehensive preventive medicine evaluation, or any of the six allowed inter-periodic visits under FP Medicaid.
One repeat pap test is allowed only when the initial specimen has insufficient cells.
Any allowed repeat pap test must be performed within 180 calendar days of the first pap test.
Pap tests are billed by CLIA-certified laboratories. For FP Medicaid laboratory procedures, the claim must include the Annual Assessment Date or Comprehensive Preventive Medicine Evaluation Date.
Exclusions
Pap tests are not separately listed as excluded. However, Medicaid does not cover services when the beneficiary does not meet eligibility or coverage criteria, when the service duplicates another provider's service, or when the service is experimental, investigational, or part of a clinical trial. FP Medicaid also 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
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
Limited to one pap test procedure per 365 calendar days.
The pap test may be billed only during an annual assessment, comprehensive preventive medicine evaluation, or any of the six allowed inter-periodic visits under FP Medicaid.
One repeat pap test is allowed only when the initial specimen has insufficient cells.
Any allowed repeat pap test must be performed within 180 calendar days of the first pap test.
Pap tests are billed by CLIA-certified laboratories. For FP Medicaid laboratory procedures, the claim must include the Annual Assessment Date or Comprehensive Preventive Medicine Evaluation Date.
Exclusions
Pap tests are not separately listed as excluded. However, Medicaid does not cover services when the beneficiary does not meet eligibility or coverage criteria, when the service duplicates another provider's service, or when the service is experimental, investigational, or part of a clinical trial. FP Medicaid also 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
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
Limited to one pap test procedure per 365 calendar days.
The pap test may be billed only during an annual assessment, comprehensive preventive medicine evaluation, or any of the six allowed inter-periodic visits under FP Medicaid.
One repeat pap test is allowed only when the initial specimen has insufficient cells.
Any allowed repeat pap test must be performed within 180 calendar days of the first pap test.
Pap tests are billed by CLIA-certified laboratories. For FP Medicaid laboratory procedures, the claim must include the Annual Assessment Date or Comprehensive Preventive Medicine Evaluation Date.
Exclusions
Pap tests are not separately listed as excluded. However, Medicaid does not cover services when the beneficiary does not meet eligibility or coverage criteria, when the service duplicates another provider's service, or when the service is experimental, investigational, or part of a clinical trial. FP Medicaid also 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
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
Limited to one pap test procedure per 365 calendar days.
The pap test may be billed only during an annual assessment, comprehensive preventive medicine evaluation, or any of the six allowed inter-periodic visits under FP Medicaid.
One repeat pap test is allowed only when the initial specimen has insufficient cells.
Any allowed repeat pap test must be performed within 180 calendar days of the first pap test.
Pap tests are billed by CLIA-certified laboratories. For FP Medicaid laboratory procedures, the claim must include the Annual Assessment Date or Comprehensive Preventive Medicine Evaluation Date.
Exclusions
Pap tests are not separately listed as excluded. However, Medicaid does not cover services when the beneficiary does not meet eligibility or coverage criteria, when the service duplicates another provider's service, or when the service is experimental, investigational, or part of a clinical trial. FP Medicaid also 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
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
Limited to one pap test procedure per 365 calendar days.
The pap test may be billed only during an annual assessment, comprehensive preventive medicine evaluation, or any of the six allowed inter-periodic visits under FP Medicaid.
One repeat pap test is allowed only when the initial specimen has insufficient cells.
Any allowed repeat pap test must be performed within 180 calendar days of the first pap test.
Pap tests are billed by CLIA-certified laboratories. For FP Medicaid laboratory procedures, the claim must include the Annual Assessment Date or Comprehensive Preventive Medicine Evaluation Date.
Exclusions
Pap tests are not separately listed as excluded. However, Medicaid does not cover services when the beneficiary does not meet eligibility or coverage criteria, when the service duplicates another provider's service, or when the service is experimental, investigational, or part of a clinical trial. FP Medicaid also 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
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
Limited to one pap test procedure per 365 calendar days.
The pap test may be billed only during an annual assessment, comprehensive preventive medicine evaluation, or any of the six allowed inter-periodic visits under FP Medicaid.
One repeat pap test is allowed only when the initial specimen has insufficient cells.
Any allowed repeat pap test must be performed within 180 calendar days of the first pap test.
Pap tests are billed by CLIA-certified laboratories. For FP Medicaid laboratory procedures, the claim must include the Annual Assessment Date or Comprehensive Preventive Medicine Evaluation Date.
Exclusions
Pap tests are not separately listed as excluded. However, Medicaid does not cover services when the beneficiary does not meet eligibility or coverage criteria, when the service duplicates another provider's service, or when the service is experimental, investigational, or part of a clinical trial. FP Medicaid also 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
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
Limited to one pap test procedure per 365 calendar days.
The pap test may be billed only during an annual assessment, comprehensive preventive medicine evaluation, or any of the six allowed inter-periodic visits under FP Medicaid.
One repeat pap test is allowed only when the initial specimen has insufficient cells.
Any allowed repeat pap test must be performed within 180 calendar days of the first pap test.
Pap tests are billed by CLIA-certified laboratories. For FP Medicaid laboratory procedures, the claim must include the Annual Assessment Date or Comprehensive Preventive Medicine Evaluation Date.
Exclusions
Pap tests are not separately listed as excluded. However, Medicaid does not cover services when the beneficiary does not meet eligibility or coverage criteria, when the service duplicates another provider's service, or when the service is experimental, investigational, or part of a clinical trial. FP Medicaid also 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
If you find any wrong or out of date information on our pages, we want to know. Please email info@TrilliumNC.org with any corrections.