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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Assistive technology assessment (eg, to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact, with written report, each 15 minutes

Service Code
97755 (CPT) Assistive technology assessment (eg, to restore, augment or compensate for existing function, optimize functional tasks and/or maximize environmental accessibility), direct one-on-one contact, with written report, each 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

Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes

Service Code
97760 (CPT) Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, 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.

Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes

Service Code
97760 (CPT) Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes
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.

Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes

Service Code
97761 (CPT) Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, 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.

Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes

Service Code
97761 (CPT) Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes
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.

Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes

Service Code
97763 (CPT) Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, 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.

Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes

Service Code
97763 (CPT) Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes
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.

Unlisted physical medicine/rehabilitation service or procedure

Service Code
97799 (CPT) Unlisted physical medicine/rehabilitation service or procedure
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

Dietary Evaluation and Counseling Clinical Coverage Policy No: 1-I and Medical Lactation Services

Service Code
97802 (CPT) Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes
Prior Authorization Required
No
Telehealth Billable
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
Diagnosis Group
Physical Health

Dietary Evaluation and Counseling offers direction and guidance for specific nutrient needs related to a beneficiary’s diagnosis and treatment. Individualized care plans provide for diseaserelated dietary evaluation and counseling. Medical lactation services provide support and counseling, or behavioral interventions to improve breastfeeding outcomes.

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.

Limits

The initial assessment and intervention for a Medicaid beneficiary is limited to four units of service per date of service and cannot exceed four units per 270 calendar-days by the same or a different provider.The re-assessment and intervention is limited to four units of service per date of service and cannot exceed 20 units per 365 calendar days by the same or a different provider.The service must be provided as an individual, face-to-face encounter with the beneficiary or the beneficiary's caretaker.

Diagnosis Requirements

For beneficiaries under 21 years of age, there must be a chronic, episodic, or acute condition for which nutrition therapy is a critical component of medical management

Age Group Details

Children through 20 years of age are eligible for dietary evaluation and counseling when they meet the medical necessity

Place of Service

The service is provided in hospital outpatient clinics; public agencies such as health departments, federally qualified health centers, and rural health clinics; private agencies; physician or medical diagnostic clinics; and physician offices.

How to Submit

N/A - No authorization is required

Resources

Dietary Evaluation and Counseling Clinical Coverage Policy No: 1-I and Medical Lactation Services

Service Code
97803 (CPT) Medical nutrition therapy; re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes
Prior Authorization Required
No
Telehealth Billable
Yes
Benefit Plan
Medicaid
Age Group
Medicaid Child (Age 0-20)
Diagnosis Group
Physical Health

Dietary Evaluation and Counseling offers direction and guidance for specific nutrient needs related to a beneficiary’s diagnosis and treatment. Individualized care plans provide for diseaserelated dietary evaluation and counseling. Medical lactation services provide support and counseling, or behavioral interventions to improve breastfeeding outcomes.

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.

Limits

The initial assessment and intervention for a Medicaid beneficiary is limited to four units of service per date of service and cannot exceed four units per 270 calendar-days by the same or a different provider.The re-assessment and intervention is limited to four units of service per date of service and cannot exceed 20 units per 365 calendar days by the same or a different provider.The service must be provided as an individual, face-to-face encounter with the beneficiary or the beneficiary's caretaker.

Diagnosis Requirements

For beneficiaries under 21 years of age, there must be a chronic, episodic, or acute condition for which nutrition therapy is a critical component of medical management

Age Group Details

Children through 20 years of age are eligible for dietary evaluation and counseling when they meet the medical necessity

Place of Service

The service is provided in hospital outpatient clinics; public agencies such as health departments, federally qualified health centers, and rural health clinics; private agencies; physician or medical diagnostic clinics; and physician offices.

How to Submit

N/A - No authorization is required

Resources

98000-Synchronous audio-video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. 15 + min

Service Code
98000 (CPT) 98000-Synchronous audio-video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. 15 + min
Prior Authorization Required
No
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.

How to Submit

N/A - No authorization is required

98001-Synchronous audio-video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low medical decision making. 30 min +

Service Code
98001 (CPT) 98001-Synchronous audio-video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low medical decision making. 30 min +
Prior Authorization Required
No
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.

How to Submit

N/A - No authorization is required

98002-Synchronous audio-video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate medical decision making. 45 min +

Service Code
98002 (CPT) 98002-Synchronous audio-video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate medical decision making. 45 min +
Prior Authorization Required
No
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.

How to Submit

N/A - No authorization is required

98003-Synchronous audio-video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. 60 + min

Service Code
98003 (CPT) 98003-Synchronous audio-video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. 60 + min
Prior Authorization Required
No
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.

How to Submit

N/A - No authorization is required

98004-Synchronous audio-video visit for the evaluation and management of established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. 10 + min

Service Code
98004 (CPT) 98004-Synchronous audio-video visit for the evaluation and management of established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. 10 + min
Prior Authorization Required
No
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.

How to Submit

N/A - No authorization is required

98005-Synchronous audio-video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. 20 + min

Service Code
98005 (CPT) 98005-Synchronous audio-video visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. 20 + min
Prior Authorization Required
No
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.

How to Submit

N/A - No authorization is required

98006-Synchronous audio-video visit for the evaluation and management of established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. 30+ min

Service Code
98006 (CPT) 98006-Synchronous audio-video visit for the evaluation and management of established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. 30+ min
Prior Authorization Required
No
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.

How to Submit

N/A - No authorization is required

98007-Synchronous audio-video visit for the evaluation and management of a established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. 40+ min

Service Code
98007 (CPT) 98007-Synchronous audio-video visit for the evaluation and management of a established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. 40+ min
Prior Authorization Required
No
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

N/A - No authorization is required

98008-Synchronous audio-only visit for the evaluation and management of a new patient 10 + min

Service Code
98008 (CPT) 98008-Synchronous audio-only visit for the evaluation and management of a new patient 10 + min
Prior Authorization Required
No
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.

How to Submit

N/A - No authorization is required

98009-Synchronous audio-only visit for the evaluation and management of a new patient. 30+ min

Service Code
98009 (CPT) 98009-Synchronous audio-only visit for the evaluation and management of a new patient. 30+ min
Prior Authorization Required
No
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.

How to Submit

N/A - No authorization is required