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
98010-Synchronous audio-only visit for the evaluation and management of a new patient. 45min+
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
98011-Synchronous audio-only visit for the evaluation and management of a new patient. 60 + min
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
98012-Synchronous audio-only visit for the evaluation and management of an established patient. 10 ,min +
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
98013-Synchronous audio-only visit for the evaluation and management of an established patient. 20 min+
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
98014-Synchronous audio-only visit for the evaluation and management of an established patient. 30 min
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
98015-Synchronous audio-only visit for the evaluation and management of an established patient. 40 min
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
98016-Brief communication technology-based service (eg, virtual check-in) by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient 5-10minutes
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
Chiropractic Services
Chiropractic Services is the science of adjusting the cause of disease by realigning the spine, releasing pressure on nerves radiating from the spine to all parts of the body, and allowing the nerves to carry their full quota of health current (nerve energy) from the brain to all parts of the body.
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.
Unit Value
Manipulation of the spine may be billed only once per date of service
Limits
Combined optional-service limit: chiropractic visits, together with podiatry and optometry, are limited to 8 visits per beneficiary per State fiscal year (July 1 through June 30).
Manipulation of the spine may be billed only once per date of service.
Exclusions
Medicaid shall not cover Chiropractic Services for the following: maintenance, supportive and wellness care; preventative care. Continued treatment is not allowed if no improvement is documented after 30 calendar days of modified chiropractic treatment, and further chiropractic care is not allowed once maximum therapeutic benefit has been achieved.
Age Group Details
Not covered for beneficiaries aged 11 years and under.
Place of Service
Office.
How to Submit
N/A - No authorization is required
Resources
Chiropractic Services
Chiropractic Services is the science of adjusting the cause of disease by realigning the spine, releasing pressure on nerves radiating from the spine to all parts of the body, and allowing the nerves to carry their full quota of health current (nerve energy) from the brain to all parts of the body.
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.
Unit Value
Manipulation of the spine may be billed only once per date of service
Limits
Combined optional-service limit: chiropractic visits, together with podiatry and optometry, are limited to 8 visits per beneficiary per State fiscal year (July 1 through June 30).
Manipulation of the spine may be billed only once per date of service.
Exclusions
Medicaid shall not cover Chiropractic Services for the following: maintenance, supportive and wellness care; preventative care. Continued treatment is not allowed if no improvement is documented after 30 calendar days of modified chiropractic treatment, and further chiropractic care is not allowed once maximum therapeutic benefit has been achieved.
Age Group Details
Not covered for beneficiaries aged 11 years and under.
Place of Service
Office.
How to Submit
N/A - No authorization is required
Resources
Chiropractic Services
Chiropractic Services is the science of adjusting the cause of disease by realigning the spine, releasing pressure on nerves radiating from the spine to all parts of the body, and allowing the nerves to carry their full quota of health current (nerve energy) from the brain to all parts of the body.
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.
Unit Value
Manipulation of the spine may be billed only once per date of service
Limits
Combined optional-service limit: chiropractic visits, together with podiatry and optometry, are limited to 8 visits per beneficiary per State fiscal year (July 1 through June 30).
Manipulation of the spine may be billed only once per date of service.
Exclusions
Medicaid shall not cover Chiropractic Services for the following: maintenance, supportive and wellness care; preventative care. Continued treatment is not allowed if no improvement is documented after 30 calendar days of modified chiropractic treatment, and further chiropractic care is not allowed once maximum therapeutic benefit has been achieved.
Age Group Details
Not covered for beneficiaries aged 11 years and under.
Place of Service
Office.
How to Submit
N/A - No authorization is required
Resources
Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least 1 real-time interactive communication with the patient or caregiver during the calendar month; f
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 is required for members under 21 via EPSDT.
How to Submit
If applicable, please submit your request to Trillium.
98980-REMOTE THERAPEUTIC MONITORING TREATMENT MANAGEMENT SERVICES BY PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL, FIRST 20 MINUTES PER CALENDAR MONTH
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
Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); device(s) supply for data access or data transmissions to support monitoring of respiratory system, 2-15 days in a 30-day period
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
Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); device(s) supply for data access or data transmissions to support monitoring of musculoskeletal system, 2-15 days in a 30-day period
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
Remote therapeutic monitoring (eg, therapy adherence, therapy response, digital therapeutic intervention); device(s) supply for data access or data transmissions to support monitoring of cognitive behavioral therapy, 2-15 days in a 30-day period
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
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.
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
After-hours billing requires reporting an office visit CPT code together with an after-office-hours CPT code; the example given is 99211 plus 99050 equals one visit.
For FP Medicaid beneficiaries, after-hours office visits are subject to the policy's inter-periodic visit structure, with six inter-periodic visits allowed per 365 calendar days, and each in-person or telehealth encounter counts as one of the six.
Exclusions
After-office-hours codes are not allowed when the service is provided in a hospital emergency room or emergency department.
FP Medicaid does not cover hospital emergency room or emergency department 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
Special Services: After Hours
Special service (or miscellaneous office services) CPT codes represent urgent or emergent services that are provided under special circumstances. Special service CPT codes are adjunct services to outpatient evaluation and management services.
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
- a. Documentation in the medical record must substantiate that the service was provided
in accordance with this policy.
- b. Special services cannot be billed when a scheduled appointment begins during posted
office hours and ends after posted office hours are over.
- c. One special service is billable per beneficiary per date of service.a. Special services codes are not covered when routine medically necessary
services or health maintenance services are provided to beneficiaries.
Examples of some routine medical services and health maintenance services are:
- 1. Scheduled appointments for medically necessary non-emergent and
non-urgent medical care.
- 2. Appointments scheduled outside of posted office hours for the
convenience of the provider.
- b. Special Services CPT codes are not covered when the service is provided in
a hospital emergency department by physicians assigned to cover the emergency department.
- c. Special Services CPT codes are not covered when the service is provided in
the inpatient setting
Exclusions
Special services codes are not covered when routine medically necessary services or health maintenance services are provided to beneficiaries. Examples of some routine medical services and health maintenance services are: a. Adult preventive medicine health assessments for Medicaid beneficiaries 21 years of age and older. b. Health Check screenings for Medicaid beneficiaries up to 21 years of age.
- 1. Dental services shall be provided on a restricted basis in accordance with criteria adopted by the Department to implement this subsection.”
Place of Service
Outpatient, Office
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.
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
After-hours billing requires reporting an office visit CPT code together with an after-office-hours CPT code; the example given is 99211 plus 99050 equals one visit.
For FP Medicaid beneficiaries, after-hours office visits are subject to the policy's inter-periodic visit structure, with six inter-periodic visits allowed per 365 calendar days, and each in-person or telehealth encounter counts as one of the six.
Exclusions
After-office-hours codes are not allowed when the service is provided in a hospital emergency room or emergency department.
FP Medicaid does not cover hospital emergency room or emergency department 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
Special Services: After Hours
Special service (or miscellaneous office services) CPT codes represent urgent or emergent services that are provided under special circumstances. Special service CPT codes are adjunct services to outpatient evaluation and management services.
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
- a. Documentation in the medical record must substantiate that the service was provided
in accordance with this policy.
- b. Special services cannot be billed when a scheduled appointment begins during posted
office hours and ends after posted office hours are over.
- c. One special service is billable per beneficiary per date of service.a. Special services codes are not covered when routine medically necessary
services or health maintenance services are provided to beneficiaries.
Examples of some routine medical services and health maintenance services are:
- 1. Scheduled appointments for medically necessary non-emergent and
non-urgent medical care.
- 2. Appointments scheduled outside of posted office hours for the
convenience of the provider.
- b. Special Services CPT codes are not covered when the service is provided in
a hospital emergency department by physicians assigned to cover the emergency department.
- c. Special Services CPT codes are not covered when the service is provided in
the inpatient setting
Exclusions
Special services codes are not covered when routine medically necessary services or health maintenance services are provided to beneficiaries. Examples of some routine medical services and health maintenance services are: a. Adult preventive medicine health assessments for Medicaid beneficiaries 21 years of age and older. b. Health Check screenings for Medicaid beneficiaries up to 21 years of age.
- 1. Dental services shall be provided on a restricted basis in accordance with criteria adopted by the Department to implement this subsection.”
Place of Service
Outpatient, Office
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.
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
After-hours billing requires reporting an office visit CPT code together with an after-office-hours CPT code; the example given is 99211 plus 99050 equals one visit.
For FP Medicaid beneficiaries, after-hours office visits are subject to the policy's inter-periodic visit structure, with six inter-periodic visits allowed per 365 calendar days, and each in-person or telehealth encounter counts as one of the six.
Exclusions
After-office-hours codes are not allowed when the service is provided in a hospital emergency room or emergency department.
FP Medicaid does not cover hospital emergency room or emergency department 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
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