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
State Plan Personal Care Services (PCS)
State Plan Personal Care Services (PCS) in In-home setting provides Personal Care Services in the Medicaid beneficiary’s living arrangement by paraprofessional aides employed by licensed home care agencies.
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
Unit Value
1 unit of service = 15 minutes
Limits
Must be provided in the beneficiary's primary private residence; beneficiaries under 21 approved under EPSDT may receive services in the home, school, or other approved community settings.
Covered PCS needs must occur at minimum once per week.
Monthly limit: under age 21, up to 60 hours per month.
Monthly limit: age 18 and older, up to 80 hours per month.
Certain beneficiaries age 18 and older may qualify for up to 50 additional hours per month if all stated criteria are met.
Standard reassessment/reauthorization interval is no later than 365 calendar days from approval, unless a shorter period is set.
Expedited provisional approval must not exceed 60 calendar days without NC Medicaid approval.
Expedited or fast-track approval may authorize up to 60 hours during the provisional period. Time may be authorized only for medication assistance services allowed by state law.
Exclusions
Services are not covered when the service is not documented as completed in accordance with policy; when it exceeds the amount approved by the CIAE; when it is billed for a date it was not completed; when provided outside the authorized service period; when provided by a person living in the same primary private residence as the beneficiary; when provided by a legally responsible person or specified relatives; when family members or other informal caregivers are willing, able, and regularly available to meet the need; when independent medical information does not validate the assessment; or when rendered concurrently with another substantially equivalent federal or state funded service such as home health aide, CAP in-home aide services, or private duty nursing. PCS is not covered when the initial independent assessment has not been completed; services are not documented as completed per policy; a reassessment was not completed within 30 calendar days of the end of the previous prior authorization period because the beneficiary refused, could not be reached, or did not attend. Medicaid does not cover skilled nursing by an LPN or RN, services by other licensed health care professionals, respite care, care of non-service-related pets and animals, yard or home maintenance work, IADLs without associated ADLs, transportation, financial management, errands, companion sitting or leisure activities, ongoing supervision or monitoring except when approved under EPSDT, personal care or home management tasks for other household residents, tasks not identified in the independent assessment and service plan, or room and board.
PCS is not covered when rendered concurrently with another substantially equivalent federal or state funded service, including home health aide services and in-home aide services in CAP programs, and Private Duty Nursing. The policy also states PCS is not intended as a substitute for childcare, daycare, or afterschool care and is not covered for infants or children when needs do not meet medical necessity criteria, are parental responsibility, or are age-appropriate needs.
Place of Service
In-Home PCS is provided in the beneficiary’s primary private residence. Beneficiaries under 21 years of age approved for PCS under EPSDT may receive services in the home, school, or other approved community settings.
Additional Service Specifics
Any beneficiary Under 21 Years regardless of setting use the modifier HA; In-Home Care Agencies, Beneficiary 21 Years and Older use modifier HB
How to Submit
Please submit your request to Carolina Complete Health through Availity
Resources
State Plan Personal Care Services (PCS) Clinical Coverage Policy No: 3L-1 Provided in Congregate Settings
State Plan Personal Care Services (PCS) is provided in a congregate setting for a Medicaid beneficiary by paraprofessional aides employed by licensed home care agencies, licensed Adult Care Homes, or home staff in licensed supervised living homes.
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
Unit Value
1 unit of service = 15 minutes
Limits
Service must be provided in a congregate setting: a North Carolina licensed Adult Care Home, combination home, or qualifying supervised living/group home.
PCS must occur at minimum once per week.
PCS is not covered if provided at a location other than the beneficiary's primary congregate living setting.
Beneficiaries age 18 and older may receive up to 80 hours per month.
Beneficiaries age 18 and older meeting all additional criteria may receive up to 50 additional hours per month, up to the State Plan maximum.
Authorized hours are for a specified number of PCS hours per month based on independent assessment and service plan.
Exclusions
PCS is not covered when the initial independent assessment has not been completed; when PCS is not documented as completed according to policy; when reassessment was not completed within 30 calendar days of the previous prior authorization end date because the beneficiary refused, could not be reached, or did not attend; when PCS is provided at a location other than the beneficiary's primary congregate living setting; when PCS exceeds the amount approved by the CIAE; when PCS is not completed on the billed date of service; when PCS is provided before the effective date or after the end date of the prior authorized period; or when PCS is performed by the beneficiary's legally responsible person, spouse, child, parent, sibling, grandparent, grandchild, or equivalent step or in-law relation. PCS is also not covered when family or other informal caregivers are willing, able, and available on a regular basis adequate to meet the need, or when independent medical information does not validate the assessment. In licensed congregate facilities, PCS is not covered for beneficiaries who are ventilator dependent, require continuous licensed nursing care, whose physician certifies placement is no longer appropriate, whose needs cannot be met in that residence, or whose medical and functional needs cannot be properly met in a licensed care home. Medicaid does not cover under PCS skilled nursing by an LPN or RN, services by other licensed health care professionals, respite care, care of non-service-related pets and animals, yard or home maintenance, IADLs without associated ADLs, transportation, financial management, errands, companion sitting or leisure activities, ongoing supervision and monitoring, tasks not identified in the independent assessment and service plan, or room and board. PCS is not covered when rendered concurrently with another substantially equivalent federal or state funded service, including home health aide services, CAP in-home aide services, or Private Duty Nursing.
Place of Service
PCS is provided in the beneficiary’s congregate facility licensed by the State of North Carolina as an Adult Care Home, a family care home, a combination home, or a supervised living facility for adults with intellectual disabilities, developmental disabilities, or mental illness.
Additional Service Specifics
Provider(s) shall follow applicable modifier guidelines: Adult Care Homes HC; Combination Homes TT; Special Care Units SC; Family Care Homes HQ; Supervised living Facilities for adults with MI/SA HH; Supervised living Facilities for adults with I/DD HI
How to Submit
Please submit your request to Carolina Complete Health through Availity
Resources
Home visit for individual, family, or marriage counseling
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 fecal impaction management and enema administration
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 hemodialysis
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 home visit service or 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.
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 infusion/specialty drug administration, per visit (up to 2 hours);
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
Home infusion/specialty drug administration, per visit (up to 2 hours); each additional hour (List separately in addition to code for primary 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
Genetic Testing for Diagnosis and Treatment
Genetic testing is used to identify changes or abnormalities in chromosomes, genes, or proteins to confirm or rule out suspected genetic conditions. Testing samples include blood, amniotic fluid, or bodily tissues. A genetic test involves an analysis of human chromosomes, deoxyribonucleic acid (DNA), ribonucleic acid (RNA), or gene products to establish a diagnosis of a genetic condition. In general, three categories of genetic testing—cytogenetic, biochemical, and molecular—are available to detect abnormalities in chromosome structure, protein function, and DNA sequence, respectively.
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 Evicore site for specific requirements
Limits
once in a lifetime
Place of Service
Inpatient, Outpatient, Office, Laboratory
How to Submit
Please submit your request to EviCore
Resources
Liver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported as quantitative scores for fibrosis, ste
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
Liver disease, ten biochemical assays (ALT, A2-macroglobulin, apolipoprotein A-1, total bilirubin, GGT, haptoglobin, AST, glucose, total cholesterol and triglycerides) utilizing serum, prognostic algorithm reported as quantitative scores for fibrosis, ste
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
Scoliosis, DNA analysis of 53 single nucleotide polymorphisms (SNPs), using saliva, prognostic algorithm reported as a risk score
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 EviCore
Oncology (prostate) gene expression profile by real-time RT-PCR of 3 genes (ERG, PCA3, and SPDEF), urine, algorithm reported as risk score
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 EviCore
Oncology (hepatic), mRNA expression levels of 161 genes, utilizing fresh hepatocellular carcinoma tumor tissue, with alpha-fetoprotein level, algorithm reported as a risk classifier
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 EviCore
Oncology (gastrointestinal neuroendocrine tumors), real-time PCR expression analysis of 51 genes, utilizing whole peripheral blood, algorithm reported as a nomogram of tumor disease index
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 EviCore
Drug test(s), presumptive, with definitive confirmation of positive results, any number of drug classes, urine, includes specimen verification including DNA authentication in comparison to buccal DNA, per date of 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
Helicobacter pylori detection and antibiotic resistance, DNA, 16S and 23S rRNA, gyrA, pbp1, rdxA and rpoB, next-generation sequencing, formalin-fixed paraffin-embedded or fresh tissue or fecal sample, predictive, reported as positive or negative for resis
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 EviCore
Oncology, prostate cancer, mRNA expression assay of 12 genes (10 content and 2 housekeeping), RT-PCR test utilizing blood plasma and urine, algorithms to predict high-grade prostate cancer risk
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 EviCore
Prescription drug monitoring, evaluation of drugs present by LC-MS/MS, using oral fluid, reported as a comparison to an estimated steady-state range, per date of service including all drug compounds and metabolites
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
Oncology (urothelial), mRNA, gene expression profiling by real-time quantitative PCR of five genes (MDK, HOXA13, CDC2 [CDK1], IGFBP5, and CXCR2), utilizing urine, algorithm reported as a risk score for having urothelial carcinoma
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 EviCore
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