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
12437 Results
Hemoglobin, quantitative, transcutaneous, per day; carboxyhemoglobin
Service Code
88740 (CPT) Hemoglobin, quantitative, transcutaneous, per day; carboxyhemoglobin
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Hemoglobin, quantitative, transcutaneous, per day; methemoglobin
Service Code
88741 (CPT) Hemoglobin, quantitative, transcutaneous, per day; methemoglobin
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Unlisted in vivo (eg, transcutaneous) laboratory service
Service Code
88749 (CPT) Unlisted in vivo (eg, transcutaneous) laboratory service
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
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
Caffeine halothane contracture test (CHCT) for malignant hyperthermia susceptibility, including interpretation and report
Service Code
89049 (CPT) Caffeine halothane contracture test (CHCT) for malignant hyperthermia susceptibility, including interpretation and report
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood;
Service Code
89050 (CPT) Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood; with differential count
Service Code
89051 (CPT) Cell count, miscellaneous body fluids (eg, cerebrospinal fluid, joint fluid), except blood; with differential count
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Leukocyte assessment, fecal, qualitative or semiquantitative
Service Code
89055 (CPT) Leukocyte assessment, fecal, qualitative or semiquantitative
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Crystal identification by light microscopy with or without polarizing lens analysis, tissue or any body fluid (except urine)
Service Code
89060 (CPT) Crystal identification by light microscopy with or without polarizing lens analysis, tissue or any body fluid (except urine)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Fat stain, feces, urine, or respiratory secretions
Service Code
89125 (CPT) Fat stain, feces, urine, or respiratory secretions
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Meat fibers, feces
Service Code
89160 (CPT) Meat fibers, feces
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Nasal smear for eosinophils
Service Code
89190 (CPT) Nasal smear for eosinophils
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Sputum, obtaining specimen, aerosol induced technique (separate procedure)
Service Code
89220 (CPT) Sputum, obtaining specimen, aerosol induced technique (separate procedure)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Sweat collection by iontophoresis
Service Code
89230 (CPT) Sweat collection by iontophoresis
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Unlisted miscellaneous pathology test
Service Code
89240 (CPT) Unlisted miscellaneous pathology test
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
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
Culture of oocyte(s)/embryo(s), less than 4 days;
Service Code
89250 (CPT) Culture of oocyte(s)/embryo(s), less than 4 days;
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture of oocyte(s)/embryos
Service Code
89251 (CPT) Culture of oocyte(s)/embryo(s), less than 4 days; with co-culture of oocyte(s)/embryos
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Assisted embryo hatching, microtechniques (any method)
Service Code
89253 (CPT) Assisted embryo hatching, microtechniques (any method)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Oocyte identification from follicular fluid
Service Code
89254 (CPT) Oocyte identification from follicular fluid
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Preparation of embryo for transfer (any method)
Service Code
89255 (CPT) Preparation of embryo for transfer (any method)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
Sperm identification from aspiration (other than seminal fluid)
Service Code
89257 (CPT) Sperm identification from aspiration (other than seminal fluid)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health
How to Submit
N/A - No authorization is required
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