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
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 10-19 minutes
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
Resources
Evaluation & Management
Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.
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
One CPT code = 1 unit of service.
Limits
- 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
- 2. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
- 3. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
- 4. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
- 5. The provider will communicate and coordinate care with other professionals providing care to the recipient.
- 6. Telehealth, Virtual Communication, and Hybrid Telehealth services must follow the guidelines and requirements detailed in the State-Funded Telehealth and Virtual Services service definition.
Other Information
Modifier(s):
GT: Telehealth
How to Submit
N/A - No authorization is required
Resources
Evaluation & Management
Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.
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
One service code = 1 unit of service
Limits
- 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
- 2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD. MCD is the payor of last resort.
- 3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
- 4. The provider will communicate and coordinate care with other professionals providing care to the member.
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
Limited to one annual assessment evaluation or one comprehensive preventive medicine evaluation per 365 calendar days for FP Medicaid beneficiaries.
An annual office visit assessment is required before any other family planning or family planning-related services are rendered, unless the beneficiary has had an annual assessment, a comprehensive preventive medicine evaluation, or a postpartum exam within the previous 365 days.
Only one annual focused assessment may be billed in a 365-day rolling calendar period.
Annual focused assessments are billed using office or other outpatient evaluation and management visit definitions for new or established patients.
If performed in lieu of a comprehensive preventive medicine evaluation, the annual assessment visit must be billed with the SC modifier.
The Annual Assessment Date is required to be documented on claims for the annual assessment.
Exclusions
FP Medicaid does not cover treatment for acute or chronic conditions discovered during screening. FP Medicaid also does not cover medical conditions unrelated to family planning or family planning-related services; beneficiaries needing non-family planning services must be referred to primary care or a safety net provider. General policy exclusions also apply when the service duplicates another provider's service or is experimental, investigational, or part of a clinical trial. A separate inter-periodic office visit cannot be billed with CPT procedure codes 58300, 58301, 57170, 11981, 11982, or 11983 because the office visit component is already included in reimbursement for those procedures. No claim is filed if, before any service is rendered, the beneficiary confirms they have been sterilized, are post-menopausal, or are otherwise incapable of conceiving or fathering a child; the provider must stop the visit, inform the beneficiary they are not eligible for Family Planning Medicaid services, and refer them to local safety net programs. FP Medicaid does not cover services for beneficiaries who have been sterilized or no longer have a need for family planning services. Hospital emergency room or emergency department services are not covered for FP Medicaid, and after-office-hours codes are not allowed when the service is provided in a hospital emergency room or emergency department.
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
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of
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
Resources
Evaluation & Management
Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.
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
One CPT code = 1 unit of service.
Limits
- 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
- 2. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
- 3. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
- 4. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
- 5. The provider will communicate and coordinate care with other professionals providing care to the recipient.
- 6. Telehealth, Virtual Communication, and Hybrid Telehealth services must follow the guidelines and requirements detailed in the State-Funded Telehealth and Virtual Services service definition.
Other Information
Modifier(s):
GT: Telehealth
How to Submit
N/A - No authorization is required
Resources
Evaluation & Management
Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.
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
One service code = 1 unit of service
Limits
- 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
- 2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD. MCD is the payor of last resort.
- 3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
- 4. The provider will communicate and coordinate care with other professionals providing care to the member.
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
Limited to one annual assessment evaluation or one comprehensive preventive medicine evaluation per 365 calendar days for FP Medicaid beneficiaries.
An annual office visit assessment is required before any other family planning or family planning-related services are rendered, unless the beneficiary has had an annual assessment, a comprehensive preventive medicine evaluation, or a postpartum exam within the previous 365 days.
Only one annual focused assessment may be billed in a 365-day rolling calendar period.
Annual focused assessments are billed using office or other outpatient evaluation and management visit definitions for new or established patients.
If performed in lieu of a comprehensive preventive medicine evaluation, the annual assessment visit must be billed with the SC modifier.
The Annual Assessment Date is required to be documented on claims for the annual assessment.
Exclusions
FP Medicaid does not cover treatment for acute or chronic conditions discovered during screening. FP Medicaid also does not cover medical conditions unrelated to family planning or family planning-related services; beneficiaries needing non-family planning services must be referred to primary care or a safety net provider. General policy exclusions also apply when the service duplicates another provider's service or is experimental, investigational, or part of a clinical trial. A separate inter-periodic office visit cannot be billed with CPT procedure codes 58300, 58301, 57170, 11981, 11982, or 11983 because the office visit component is already included in reimbursement for those procedures. No claim is filed if, before any service is rendered, the beneficiary confirms they have been sterilized, are post-menopausal, or are otherwise incapable of conceiving or fathering a child; the provider must stop the visit, inform the beneficiary they are not eligible for Family Planning Medicaid services, and refer them to local safety net programs. FP Medicaid does not cover services for beneficiaries who have been sterilized or no longer have a need for family planning services. Hospital emergency room or emergency department services are not covered for FP Medicaid, and after-office-hours codes are not allowed when the service is provided in a hospital emergency room or emergency department.
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
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minute
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
Resources
Evaluation & Management
Evaluation and Management services provided by a Psychiatrist / MD or a Psych NP/PA.
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
One CPT code = 1 unit of service.
Limits
- 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
- 2. State funds will not cover the same services provided by the same or different attending provider on the same day for the same individual
- 3. Only 1 psychiatric CPT code from the State-Funded Outpatient Behavioral Health Services policy is allowed per individual per day of service from the same attending provider. Only 2 psychiatric CPT codes from this policy are allowed per individual per date of service.
- 4. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
- 5. The provider will communicate and coordinate care with other professionals providing care to the recipient.
- 6. Telehealth, Virtual Communication, and Hybrid Telehealth services must follow the guidelines and requirements detailed in the State-Funded Telehealth and Virtual Services service definition.
Other Information
Modifier(s):
GT: Telehealth
How to Submit
N/A - No authorization is required
Resources
Evaluation & Management
Evaluation and Management provided by a Psychiatrist / MD/ DO or a Psych NP/PA.
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
One service code = 1 unit of service
Limits
- 1. Outpatient BH does not cover: a) sleep therapy for psychiatric disorders; b) medical, cognitive, intellectual or development issue that would not benefit from outpatient treatment services, OR; c) when the focus of treatment does not address the symptoms of the diagnosis.
- 2. Members w/ both MCD and Medicare, the provider shall bill Medicare as primary before submitting a claim to MCD. For members having both MCD and any other insurance coverage, the other insurance shall be billed prior to billing MCD. MCD is the payor of last resort.
- 3. Physicians billing E/M codes with psychotherapy add-on codes must have documentation supporting that the E/M service was separate and distinct from the psychotherapy service.
- 4. The provider will communicate and coordinate care with other professionals providing care to the member.
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
Limited to one annual assessment evaluation or one comprehensive preventive medicine evaluation per 365 calendar days for FP Medicaid beneficiaries.
An annual office visit assessment is required before any other family planning or family planning-related services are rendered, unless the beneficiary has had an annual assessment, a comprehensive preventive medicine evaluation, or a postpartum exam within the previous 365 days.
Only one annual focused assessment may be billed in a 365-day rolling calendar period.
Annual focused assessments are billed using office or other outpatient evaluation and management visit definitions for new or established patients.
If performed in lieu of a comprehensive preventive medicine evaluation, the annual assessment visit must be billed with the SC modifier.
The Annual Assessment Date is required to be documented on claims for the annual assessment.
Exclusions
FP Medicaid does not cover treatment for acute or chronic conditions discovered during screening. FP Medicaid also does not cover medical conditions unrelated to family planning or family planning-related services; beneficiaries needing non-family planning services must be referred to primary care or a safety net provider. General policy exclusions also apply when the service duplicates another provider's service or is experimental, investigational, or part of a clinical trial. A separate inter-periodic office visit cannot be billed with CPT procedure codes 58300, 58301, 57170, 11981, 11982, or 11983 because the office visit component is already included in reimbursement for those procedures. No claim is filed if, before any service is rendered, the beneficiary confirms they have been sterilized, are post-menopausal, or are otherwise incapable of conceiving or fathering a child; the provider must stop the visit, inform the beneficiary they are not eligible for Family Planning Medicaid services, and refer them to local safety net programs. FP Medicaid does not cover services for beneficiaries who have been sterilized or no longer have a need for family planning services. Hospital emergency room or emergency department services are not covered for FP Medicaid, and after-office-hours codes are not allowed when the service is provided in a hospital emergency room or emergency department.
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
Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of
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
Resources
99221 25 Initial Hospital Care low severity SEPARATELY IDENTIFIABLE E/M SERVICE BY THE SAME PROVIDER SAME DAY OF 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
N/A - No authorization is required
99222 25 Initial Hospital Care Moderate severity SEPARATELY IDENTIFIABLE E/M SERVICE BY THE SAME PROVIDER SAME DAY OF 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
N/A - No authorization is required
99223 25 Initial hospital care, per day, for the evaluation and management of a patient. Initial and Subsequent;separately identifiable E/M service by the same provider same day of 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
N/A - No authorization is required
99231 25 Subsequent hospital care, per day, for the evaluation and management of a patient. Physician time approximate 15 minutes SEPARATELY IDENTIFIABLE E/M SERVICE BY THE SAME PROVIDER SAME DAY OF 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
N/A - No authorization is required
99232 25 GTSubsequent hospital care, per day, for the evaluation and management of a patient. Physician time approximate 25 minutes;Separate Identifiable service by same provider same date of service;Telehealth
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
99233 25 Significant separate identifiable evaluation of management of service by the same physician on the same day of the procedure or other service
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
99234 25 Observation or inpatient hospital care, for the evaluation and management of a patient. Admitted/Discharged SEPARATELY IDENTIFIABLE E/M SERVICE BY THE SAME PROVIDER SAME DAY OF 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
N/A - No authorization is required
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