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
Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service; first hour (List separately in addition to code for outpatient Evaluation and Management or psychotherapy service, except with office or
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
Prolonged service(s) in the outpatient setting requiring direct patient contact beyond the time of the usual service; each additional 30 minutes (List separately in addition to code for prolonged 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
Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour (List separately in addition to code for inpatient or observation Evaluation and Management 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
Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; each additional 30 minutes (List separately in addition to code for prolonged 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
Standby service, requiring prolonged attendance, each 30 minutes (eg, operative standby, standby for frozen section, for cesarean/high risk delivery, for monitoring EEG)
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
Child Medical Evaluation and Medical Team Conference for Child Maltreatment
Child Medical Evaluation A Child Medical Evaluation (CME) is a medical evaluation where service is provided by a qualified physician, nurse practitioner (NP) or physician assistant (PA) rostered with the North Carolina Child Medical Evaluation Program (CMEP). A CME is provided at the request of child welfare services when they are completing an active assessment due to concerns for child maltreatment. Medical Team Conference A medical team conference for child maltreatment is a service provided by an interdisciplinary team of health care professionals, who work with health professionals or community agency representatives to coordinate care when there is suspected child maltreatment.
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 unit per day. One unit = one CME per occurrence. One unit per day. One unit = one medical team conference.
Limits
Limited to one CME per occurrence per day when child maltreatment is suspected.
Child maltreatment applies to children under 18 years of age.
Exclusions
CPT 99499 cannot be billed for an exam that is not referred by child welfare services.The service is billed on professional or institutional claims.
Place of Service
Inpatient hospital, Outpatient hospital, Office
Additional Service Specifics
Note: CPT code 99170-Anogenital exam, magnified, in childhood for suspected trauma, including image recording when performed, is included in the reimbursement for CPT code 99499, unless a colposcope is used.
Note: CPT code 99499 cannot be billed for an exam that is not referred by child welfare services.
Note: Physicians, nurse practitioners and physician assistants may only bill for a medical team conference when they are the provider that performed and billed for the child medical evaluation (99499) prior to the medical team conference.
How to Submit
N/A - No authorization is required
Resources
Supervision of a patient under care of home health agency (patient not present) in home, domiciliary or equivalent environment (eg, Alzheimer's facility) requiring complex and multidisciplinary care modalities involving regular development and/or revision
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 the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
Supervision of a patient under care of home health agency (patient not present) in home, domiciliary or equivalent environment (eg, Alzheimer's facility) requiring complex and multidisciplinary care modalities involving regular development and/or revision
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 the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
Supervision of a hospice patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of relate
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 the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
Supervision of a hospice patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of relate
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 the Carolina Complete Health site for specific requirements
How to Submit
Please submit your request to Carolina Complete Health through Availity
Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics
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
Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics
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
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
FP Medicaid beneficiaries are limited to either one comprehensive preventive medicine evaluation or one annual assessment evaluation per 365 calendar days.
A comprehensive preventive medicine evaluation may be performed only if the beneficiary has not been seen in the previous 365 days.
If the beneficiary had an annual assessment, a comprehensive preventive medicine evaluation, or a postpartum exam in the previous 365 days, another comprehensive evaluation is not required before receiving Family Planning services.
FP Medicaid beneficiaries are limited to six inter-periodic visits per 365 calendar days in addition to the annual assessment or comprehensive preventive medicine evaluation.
One urinalysis and one blood count procedure code are allowed per 365 calendar days in conjunction with this service.
Exclusions
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 visit must stop and the beneficiary is informed they are not eligible for Family Planning Medicaid services. Nurse visits billed with CPT code 99211 cannot be submitted on the same date of service as a comprehensive preventive medicine evaluation by a physician or advanced practice practitioner; total time must be combined into one evaluation and management code. Hospital emergency room or emergency department services are not covered for FP Medicaid beneficiaries, and inpatient hospital services are not covered. FP Medicaid also does not cover treatment for acute or chronic conditions discovered during screening, or services for beneficiaries who have been sterilized or no longer have a need for family planning 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
Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics
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.
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
FP Medicaid beneficiaries are limited to either one comprehensive preventive medicine evaluation or one annual assessment evaluation per 365 calendar days.
A comprehensive preventive medicine evaluation may be performed only if the beneficiary has not been seen in the previous 365 days.
If the beneficiary had an annual assessment, a comprehensive preventive medicine evaluation, or a postpartum exam in the previous 365 days, another comprehensive evaluation is not required before receiving Family Planning services.
FP Medicaid beneficiaries are limited to six inter-periodic visits per 365 calendar days in addition to the annual assessment or comprehensive preventive medicine evaluation.
One urinalysis and one blood count procedure code are allowed per 365 calendar days in conjunction with this service.
Exclusions
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 visit must stop and the beneficiary is informed they are not eligible for Family Planning Medicaid services. Nurse visits billed with CPT code 99211 cannot be submitted on the same date of service as a comprehensive preventive medicine evaluation by a physician or advanced practice practitioner; total time must be combined into one evaluation and management code. Hospital emergency room or emergency department services are not covered for FP Medicaid beneficiaries, and inpatient hospital services are not covered. FP Medicaid also does not cover treatment for acute or chronic conditions discovered during screening, or services for beneficiaries who have been sterilized or no longer have a need for family planning 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
Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics
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.
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
FP Medicaid beneficiaries are limited to either one comprehensive preventive medicine evaluation or one annual assessment evaluation per 365 calendar days.
A comprehensive preventive medicine evaluation may be performed only if the beneficiary has not been seen in the previous 365 days.
If the beneficiary had an annual assessment, a comprehensive preventive medicine evaluation, or a postpartum exam in the previous 365 days, another comprehensive evaluation is not required before receiving Family Planning services.
FP Medicaid beneficiaries are limited to six inter-periodic visits per 365 calendar days in addition to the annual assessment or comprehensive preventive medicine evaluation.
One urinalysis and one blood count procedure code are allowed per 365 calendar days in conjunction with this service.
Exclusions
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 visit must stop and the beneficiary is informed they are not eligible for Family Planning Medicaid services. Nurse visits billed with CPT code 99211 cannot be submitted on the same date of service as a comprehensive preventive medicine evaluation by a physician or advanced practice practitioner; total time must be combined into one evaluation and management code. Hospital emergency room or emergency department services are not covered for FP Medicaid beneficiaries, and inpatient hospital services are not covered. FP Medicaid also does not cover treatment for acute or chronic conditions discovered during screening, or services for beneficiaries who have been sterilized or no longer have a need for family planning 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
Adult Preventive Medicine Clinical Coverage Policy No.: 1A-2 Annual Health Assessment
An adult preventive medicine health assessment consists of a comprehensive unclothed physical examination, comprehensive health history, anticipatory guidance/risk factor reduction interventions, and the ordering of gender- and age-appropriate laboratory and diagnostic procedures.
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
Medicaid beneficiaries 21 years of age and older may receive one annual health assessment per 365 days.
The annual health assessment is not included in the legislated 22-visit limit per year.
Injectable medications and ancillary studies for laboratory and radiology are the only CPT codes that are separately billable when an annual health assessment is billed.
An annual health assessment and an office visit cannot be billed on the same date of service.
Age Group Details
Covered for Medicaid beneficiaries 21 years of age and older
Place of Service
Outpatient, Clinic.
How to Submit
N/A - No authorization is required
Resources
Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics
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.
How to Submit
N/A - No authorization is required
Resources
Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics
An adult preventive medicine health assessment consists of a comprehensive unclothed physical examination, comprehensive health history, anticipatory guidance/risk factor reduction interventions, and the ordering of gender- and age-appropriate laboratory and diagnostic procedures.
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.
Age Group Details
Covered for Medicaid beneficiaries 21 years of age and older
How to Submit
N/A - No authorization is required
Resources
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