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

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12437 Results

Application of a modality to 1 or more areas; diathermy (eg, microwave)

Service Code
97024 (CPT) Application of a modality to 1 or more areas; diathermy (eg, microwave)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
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.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

Application of a modality to 1 or more areas; infrared

Service Code
97026 (CPT) Application of a modality to 1 or more areas; infrared
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
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.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

Application of a modality to 1 or more areas; ultraviolet

Service Code
97028 (CPT) Application of a modality to 1 or more areas; ultraviolet
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
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.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes

Service Code
97032 (CPT) Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
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.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

Application of a modality to 1 or more areas; iontophoresis, each 15 minutes

Service Code
97033 (CPT) Application of a modality to 1 or more areas; iontophoresis, each 15 minutes
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
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.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

Application of a modality to 1 or more areas; contrast baths, each 15 minutes

Service Code
97034 (CPT) Application of a modality to 1 or more areas; contrast baths, each 15 minutes
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
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.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

Application of a modality to 1 or more areas; ultrasound, each 15 minutes

Service Code
97035 (CPT) Application of a modality to 1 or more areas; ultrasound, each 15 minutes
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
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.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes

Service Code
97036 (CPT) Application of a modality to 1 or more areas; Hubbard tank, each 15 minutes
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
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.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

Unlisted modality (specify type and time if constant attendance)

Service Code
97039 (CPT) Unlisted modality (specify type and time if constant attendance)
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.

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

Service Code
97110 (CPT) Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
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.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility

Service Code
97110 (CPT) Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities

Service Code
97112 (CPT) Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
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.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities

Service Code
97112 (CPT) Therapeutic procedure, 1 or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises

Service Code
97113 (CPT) Therapeutic procedure, 1 or more areas, each 15 minutes; aquatic therapy with therapeutic exercises
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

Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)

Service Code
97116 (CPT) Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
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.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)

Service Code
97116 (CPT) Therapeutic procedure, 1 or more areas, each 15 minutes; gait training (includes stair climbing)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
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.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)

Service Code
97124 (CPT) Therapeutic procedure, 1 or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Age Group
All
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.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

Therapuetic interventions that focus on cognitive functions and compensatory strategies to manage the performance of activity, direct patient contact, initial 15 minutes

Service Code
97129 (CPT) Therapuetic interventions that focus on cognitive functions and compensatory strategies to manage the performance of activity, direct patient contact, initial 15 minutes
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.

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Therapuetic interventions that focus on cognitive functions and compensatory strategies to manage the performance of activity, direct patient contact, each additional 15 minutes. Add On.

Service Code
97130 (CPT) Therapuetic interventions that focus on cognitive functions and compensatory strategies to manage the performance of activity, direct patient contact, each additional 15 minutes. Add On.
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.

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Unlisted therapeutic procedure (specify)

Service Code
97139 (CPT) Unlisted therapeutic procedure (specify)
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.

Reauthorization Guidelines

See Evolent site for specific requirements

How to Submit

Please submit your request to Evolent