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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12437 Results

Neonatal and Pediatric Critical and Intensive Care Services

Service Code
99472 (CPT) Subsequent 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

Neonatal and Pediatric Critical and Intensive Care Services

Service Code
99475 (CPT) Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years 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

Neonatal and Pediatric Critical and Intensive Care Services

Service Code
99476 (CPT) Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years 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

Neonatal and Pediatric Critical and Intensive Care Services

Service Code
99477 (CPT) Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or younger, who requires intensive observation, frequent interventions, and other intensive care services
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
99478 (CPT) Subsequent intensive care, per day, for the evaluation and management of the recovering very low birth weight infant (present body weight less than 1500 grams)
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
99479 (CPT) Subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight of 1500-2500 grams)
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
99480 (CPT) Subsequent intensive care, per day, for the evaluation and management of the recovering infant (present body weight of 2501-5000 grams)
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

99483-ASSESSMENT OF AND CARE PLANNING FOR PATIENT WITH IMPAIRED THOUGHT PROCESSING, TYPICALLY 60 MINUTES

Service Code
99483 (CPT) 99483-ASSESSMENT OF AND CARE PLANNING FOR PATIENT WITH IMPAIRED THOUGHT PROCESSING, TYPICALLY 60 MINUTES
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

99492-INITIAL PSYCHIATRIC COLLABORATIVE CARE MANAGEMENT, FIRST CALENDAR MONTH, FIRST 70 MINUTES

Service Code
99492 (CPT) 99492-INITIAL PSYCHIATRIC COLLABORATIVE CARE MANAGEMENT, FIRST CALENDAR MONTH, FIRST 70 MINUTES
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

99493-FOLLOW-UP PSYCHIATRIC COLLABORATIVE CARE MANAGEMENT, SUBSEQUENT CALENDAR MONTH, FIRST 60 MINUTES

Service Code
99493 (CPT) 99493-FOLLOW-UP PSYCHIATRIC COLLABORATIVE CARE MANAGEMENT, SUBSEQUENT CALENDAR MONTH, FIRST 60 MINUTES
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

99494-PSYCHIATRIC COLLABORATIVE CARE MANAGEMENT PER CALENDAR MONTH, EACH ADDITIONAL 30 MINUTES

Service Code
99494 (CPT) 99494-PSYCHIATRIC COLLABORATIVE CARE MANAGEMENT PER CALENDAR MONTH, EACH ADDITIONAL 30 MINUTES
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

Child Medical Evaluation and Medical Team Conference for Child Maltreatment

Service Code
99499 (CPT) Unlisted evaluation and management service
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring

Service Code
99500 (CPT) Home visit for prenatal monitoring and assessment to include fetal heart rate, non-stress test, uterine monitoring, and gestational diabetes monitoring
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 the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

1M-5 Home Visit for Postnatal Assessment and Follow-up Care

Service Code
99501 (CPT) Home visit for postnatal assessment and follow-up care
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

A home visit for postnatal assessment and follow-up care is designed to deliver health, social support, and/or educational services directly to families in their homes. A home visit for postnatal assessment and follow-up care is a means to follow up on the mother’s health; to counsel on family planning and infant care; and to arrange for additional appointments for the infant and mother.

The goals of the home visit for postnatal assessment and follow-up care are:

  • a. to provide a key mechanism for reaching families early with preventive and anticipatory

services;

  • b. to provide opportunities for timely referral of problems;
  • c. to promote spacing of subsequent pregnancies; and
  • d. to provide a link with women’s preventive health 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.

Unit Value

One visit per pregnancy

Limits

Covered within two to three weeks following the client's discharge from the hospital, but no later than 60 days after delivery.

Must be a one-to-one, face-to-face visit conducted in the client's home.

Reimbursed once per client per pregnancy.

Must be billed per date of service.

Exclusions

Coordination of care strategies must be identified by all caregivers to avoid duplication of services.

Diagnosis Requirements

The beneficiary must be a postpartum woman who receives Medicaid.

Place of Service

Beneficiary's home

How to Submit

N/A - No authorization is required

Resources

1M-4 Home visit for Newborn Care and Assessment

Service Code
99502 (CPT) Home visit for newborn care and assessment
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

A home visit for newborn care and assessment delivers health, social support, and/or educational services directly to families in their homes. A home visit for newborn care and assessment is a means to follow up on the infant’s health; to counsel on infant care; to follow up on newborn screening; and to arrange for additional appointments for the infant.

The goals of the home visit for newborn care and assessment are:

  • a. to provide a key mechanism for reaching families early with preventive and anticipatory

services;

  • b. to provide opportunities for timely referral of problems; and
  • c. to provide a link with children’s preventive health 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.

Unit Value

One visit – once per lifetime of newborn beneficiary

Limits

A home visit for newborn care and assessment is covered within two or three weeks following discharge from the hospital, but no later than 60 days after delivery.Eligible only for infants from birth through 60 days of age.

Covered within two or three weeks following discharge from the hospital, and no later than 60 days after delivery.

Must be a one-on-one, face-to-face visit conducted in the client's home.

Billing unit is one visit, once per lifetime of the newborn beneficiary.

Reimbursed once per lifetime.

Must be billed per date of service.

Exclusions

A home visit for newborn care and assessment must be a one-on-one, face-to-face visit conducted in the client’s home. This includes, but is not limited to, assessment, counseling, teaching, and referral to other service providers for additional services. A home visit for newborn care and assessment must follow the curriculum requirements outlined on the Newborn Home Visit form. In addition, an infant cannot receive both the home visit for newborn care and assessment and the EPSDT home visit for newborn care and assessment.

Place of Service

Beneficiary's home

How to Submit

N/A - No authorization is required

Resources

Home visit for respiratory therapy care (eg, bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation)

Service Code
99503 (CPT) Home visit for respiratory therapy care (eg, bronchodilator, oxygen therapy, respiratory assessment, apnea evaluation)
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.

How to Submit

Please submit your request to Carolina Complete Health through Availity

Home visit for mechanical ventilation care

Service Code
99504 (CPT) Home visit for mechanical ventilation care
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.

How to Submit

Please submit your request to Carolina Complete Health through Availity

Home visit for stoma care and maintenance including colostomy and cystostomy

Service Code
99505 (CPT) Home visit for stoma care and maintenance including colostomy and cystostomy
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 the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Home visit for intramuscular injections

Service Code
99506 (CPT) Home visit for intramuscular injections
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 the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

Home visit for care and maintenance of catheter(s) (eg, urinary, drainage, and enteral)

Service Code
99507 (CPT) Home visit for care and maintenance of catheter(s) (eg, urinary, drainage, and enteral)
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 the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity