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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

99407 EP SMOKING AND TOBACCO USE CESSATION COUNSEL SERVICE PROVIDED UNDER MEDICAID EPSDT

Service Code
99407 (CPT) 99407 EP SMOKING AND TOBACCO USE CESSATION COUNSEL SERVICE PROVIDED UNDER MEDICAID EPSDT
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

99408 59 Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes; DISTINCT PROCEDURAL SERVICE

Service Code
99408 (CPT) 99408 59 Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes; DISTINCT PROCEDURAL SERVICE
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

99409 59 - alcohol and/or substance (other than tobacco) abuse structured screening (eg. audit, dast) and brief intervention (sbi) services; greater than 30 minutes; Distinct Procedural Service

Service Code
99409 (CPT) 99409 59 - alcohol and/or substance (other than tobacco) abuse structured screening (eg. audit, dast) and brief intervention (sbi) services; greater than 30 minutes; Distinct Procedural Service
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

99417-PROLONGED OFFICE OR OTHER OUTPATIENT SERVICE BY CLINICAL STAFF, EACH 15 MINUTES OF TOTAL TIME

Service Code
99417 (CPT) 99417-PROLONGED OFFICE OR OTHER OUTPATIENT SERVICE BY CLINICAL STAFF, EACH 15 MINUTES OF TOTAL TIME
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

99418-PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT SERVICE(S) TIME WITH OR WITHOUT DIRECT PATIENT CONTACT BEYOND THE REQUIRED TIME OF THE PRIMARY SERVICE

Service Code
99418 (CPT) 99418-PROLONGED INPATIENT OR OBSERVATION EVALUATION AND MANAGEMENT SERVICE(S) TIME WITH OR WITHOUT DIRECT PATIENT CONTACT BEYOND THE REQUIRED TIME OF THE PRIMARY SERVICE
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

99421-Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes

Service Code
99421 (CPT) 99421-Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
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

99422-Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes

Service Code
99422 (CPT) 99422-Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
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

99423-Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes

Service Code
99423 (CPT) 99423-Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes
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

Unlisted preventive medicine service

Service Code
99429 (CPT) Unlisted preventive medicine service
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

Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate); device(s) supply with daily recording(s) or programmed alert(s) transmission, 2-15 days in a 30-day period

Service Code
99445 (CPT) Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate); device(s) supply with daily recording(s) or programmed alert(s) transmission, 2-15 days in a 30-day period
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

Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care profe

Service Code
99446 (CPT) Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care profe
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

Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care profe

Service Code
99447 (CPT) Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care profe
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

Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care profe

Service Code
99448 (CPT) Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care profe
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

Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care profe

Service Code
99449 (CPT) Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient's treating/requesting physician or other qualified health care profe
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

99454- Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days

Service Code
99454 (CPT) 99454- Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days
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

Pelvic examination (List separately in addition to code for primary procedure)

Service Code
99459 (CPT) Pelvic examination (List separately in addition to code for primary procedure)
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

Neonatal and Pediatric Critical and Intensive Care Services

Service Code
99468 (CPT) Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Neonatal and pediatric critical and intensive care services are evaluation and management services provided to other than normal newborns, infants and children from birth through 5 years of age. The level of care is based on the intensity of service and status of the beneficiary.

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 by only one physician.

Limits

Limited to once per day.

Exclusions

Neonatal and pediatric critical and intensive care services are not covered when CCP (Section 3.2) criteria are not met, including admission to a critical or intensive care unit because no other hospital beds are available or because hospital rules require certain treatments to be administered in the unit.

Age Group Details

Service is for neonates or infants.

Place of Service

Inpatient.

How to Submit

N/A - No authorization is required

Resources

Neonatal and Pediatric Critical and Intensive Care Services

Service Code
99469 (CPT) Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Neonatal and pediatric critical and intensive care services are evaluation and management services provided to other than normal newborns, infants and children from birth through 5 years of age. The level of care is based on the intensity of service and status of the beneficiary.

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 by only one physician.

Limits

Limited to once per day.

Exclusions

Neonatal and pediatric critical and intensive care services are not covered when CCP (Section 3.2) criteria are not met, including admission to a critical or intensive care unit because no other hospital beds are available or because hospital rules require certain treatments to be administered in the unit.

Age Group Details

Service is for neonates or infants.

Place of Service

Inpatient.

How to Submit

N/A - No authorization is required

Resources

Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring 1 real-time interactive communication with the patient/caregiver during the calendar month; f

Service Code
99470 (CPT) Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring 1 real-time interactive communication with the patient/caregiver during the calendar month; f
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

Neonatal and Pediatric Critical and Intensive Care Services

Service Code
99471 (CPT) Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Neonatal and pediatric critical and intensive care services are evaluation and management services provided to other than normal newborns, infants and children from birth through 5 years of age. The level of care is based on the intensity of service and status of the beneficiary.

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 by only one physician.

Limits

Limited to once per day.

Exclusions

Neonatal and pediatric critical and intensive care services are not covered when CCP (Section 3.2) criteria are not met, including admission to a critical or intensive care unit because no other hospital beds are available or because hospital rules require certain treatments to be administered in the unit.

Age Group Details

Service is for neonates or infants.

Place of Service

Inpatient.

How to Submit

N/A - No authorization is required

Resources