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
Submucosal cryolysis therapy; soft palate only
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
Submucosal cryolysis therapy; base of tongue and lingual tonsil only
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
Transcatheter implantation of wireless inferior vena cava sensor for long-term hemodynamic monitoring, including deployment of the sensor, radiological supervision and interpretation, right heart catheterization, and inferior vena cava venography, when pe
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
Remote monitoring of implantable inferior vena cava pressure sensor, physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial set-up and patient education on use of equipment
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
Remote monitoring of an implanted inferior vena cava sensor for up to 30 days, including at least weekly downloads of inferior vena cava area recordings, interpretation(s), trend analysis, and report(s) by a physician or other qualified health care profes
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
Intravascular imaging of extracranial cerebral vessels using optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention, including all associated radiological supervision, interpretation, and report; initial vessel (Li
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
Intravascular imaging of extracranial cerebral vessels using optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention, including all associated radiological supervision, interpretation, and report; each additional ve
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
Intravascular imaging of intracranial cerebral vessels using optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention, including all associated radiological supervision, interpretation, and report; initial vessel (Li
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
Intravascular imaging of intracranial cerebral vessels using optical coherence tomography (OCT) during diagnostic evaluation and/or therapeutic intervention, including all associated radiological supervision, interpretation, and report; each additional ve
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
INTERNAL MAMMARY ARTERY GRAFT PERFORMED FOR PRIMARY, ISOLATED CORONARY ARTERY BYPASS GRAFT PROCEDURE (CABG)
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 Turning Point site for specific requirements
How to Submit
Please submit your request to Turning Point
Ambulance Services
Ambulance services provide medically necessary treatment for NC Medicaid Program beneficiaries. Transport is provided only if the beneficiary’s medical condition is such that the use of any other means of transportation is contraindicated. Ambulance services include emergency and non-emergency ambulance transport via ground and air medical ambulance for a Medicaid 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
The time of pick-up, in the range of 00–23 hours, is required on the claim form.
Limits
Ground ambulance loaded mileage is reimbursable only for out-of-county transport; in-county loaded ground mileage is not reimbursable.
Ambulance transports are covered only to specified destinations, including hospital, critical access hospital, skilled nursing facility, adult care home, ICF-IID, beneficiary's primary private residence, dialysis facility for ESRD when condition requires ambulance services, transfer site, and physician's office under stated criteria.
Air medical ambulance transport is covered only to an acute-care hospital.
The provider shall bill only one ambulance procedure code for the same date of service, the same hour or time of pick-up, and the same or a different provider.
The provider shall not bill a round-trip ambulance transport and a one-way-trip ambulance transport on the same date of service unless submitting an adjustment with documentation substantiating both.
Each trip requires a separate PA process and PA number; PA is active for 30 calendar days.
Exclusions
Air medical ambulance transport to a facility that is not an acute-care hospital is not covered. Ambulance transport of a deceased beneficiary is not covered if the beneficiary is pronounced dead before the ambulance is called. Loaded mileage to a facility that is not the nearest appropriate facility is not reimbursed. Other non-covered ambulance services include: an ambulance is called and no treatment is needed; false alarm calls; beneficiary refuses all medical services; transport for a medical service that is not Medicaid covered; commercial airline tickets; airstrip fees; taxes; separate additional charges for nursing personnel who are employees of a facility or ambulance service; waiting fees; and separate charges for oxygen and other items and supplies because these are included in the base rate. Services other than those listed in Subsection 3.2 are not covered. Routine pregnancy transport is not covered. Beneficiaries with Medicaid coverage through Family Planning are not covered to receive ambulance services.
Place of Service
Ambulance
Additional Service Specifics
Institutional providers must report one of the following condition codes: AK, AL, AM. Providers must report an origin and destination modifier for each ambulance trip provided. Providers must report QL modifier if the time of death pronouncement is made after dispatch but before the beneficiary is loaded onboard the ambulance.
Other Information
When multiple units respond to a call for services, the provider that transports the beneficiary is the only provider that may bill for the service. If both ground and air medical ambulances areinvolved, then each submits its own claim and each claim is processed and reimbursed independently of the other.
How to Submit
Please submit your request to Trillium Health Resources
Resources
Ambulance Services
Ambulance services provide medically necessary treatment for NC Medicaid Program beneficiaries. Transport is provided only if the beneficiary’s medical condition is such that the use of any other means of transportation is contraindicated. Ambulance services include emergency and non-emergency ambulance transport via ground and air medical ambulance for a Medicaid 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
The time of pick-up, in the range of 00–23 hours, is required on the claim form.
Limits
Ground ambulance loaded mileage is reimbursable only for out-of-county transport; in-county loaded ground mileage is not reimbursable.
Ambulance transports are covered only to specified destinations, including hospital, critical access hospital, skilled nursing facility, adult care home, ICF-IID, beneficiary's primary private residence, dialysis facility for ESRD when condition requires ambulance services, transfer site, and physician's office under stated criteria.
Air medical ambulance transport is covered only to an acute-care hospital.
The provider shall bill only one ambulance procedure code for the same date of service, the same hour or time of pick-up, and the same or a different provider.
The provider shall not bill a round-trip ambulance transport and a one-way-trip ambulance transport on the same date of service unless submitting an adjustment with documentation substantiating both.
Each trip requires a separate PA process and PA number; PA is active for 30 calendar days.
Exclusions
Air medical ambulance transport to a facility that is not an acute-care hospital is not covered. Ambulance transport of a deceased beneficiary is not covered if the beneficiary is pronounced dead before the ambulance is called. Loaded mileage to a facility that is not the nearest appropriate facility is not reimbursed. Other non-covered ambulance services include: an ambulance is called and no treatment is needed; false alarm calls; beneficiary refuses all medical services; transport for a medical service that is not Medicaid covered; commercial airline tickets; airstrip fees; taxes; separate additional charges for nursing personnel who are employees of a facility or ambulance service; waiting fees; and separate charges for oxygen and other items and supplies because these are included in the base rate. Services other than those listed in Subsection 3.2 are not covered. Routine pregnancy transport is not covered. Beneficiaries with Medicaid coverage through Family Planning are not covered to receive ambulance services.
Place of Service
Ambulance
Additional Service Specifics
Institutional providers must report one of the following condition codes: AK, AL, AM. Providers must report an origin and destination modifier for each ambulance trip provided. Providers must report QL modifier if the time of death pronouncement is made after dispatch but before the beneficiary is loaded onboard the ambulance.
Other Information
When multiple units respond to a call for services, the provider that transports the beneficiary is the only provider that may bill for the service. If both ground and air medical ambulances areinvolved, then each submits its own claim and each claim is processed and reimbursed independently of the other.
How to Submit
Please submit your request to Trillium Health Resources
Resources
Ambulance Services
Ambulance services provide medically necessary treatment for NC Medicaid Program beneficiaries. Transport is provided only if the beneficiary’s medical condition is such that the use of any other means of transportation is contraindicated. Ambulance services include emergency and non-emergency ambulance transport via ground and air medical ambulance for a Medicaid 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
The time of pick-up, in the range of 00–23 hours, is required on the claim form.
Limits
Ground ambulance loaded mileage is reimbursable only for out-of-county transport; in-county loaded ground mileage is not reimbursable.
Ambulance transports are covered only to specified destinations, including hospital, critical access hospital, skilled nursing facility, adult care home, ICF-IID, beneficiary's primary private residence, dialysis facility for ESRD when condition requires ambulance services, transfer site, and physician's office under stated criteria.
Air medical ambulance transport is covered only to an acute-care hospital.
The provider shall bill only one ambulance procedure code for the same date of service, the same hour or time of pick-up, and the same or a different provider.
The provider shall not bill a round-trip ambulance transport and a one-way-trip ambulance transport on the same date of service unless submitting an adjustment with documentation substantiating both.
Each trip requires a separate PA process and PA number; PA is active for 30 calendar days.
Exclusions
Air medical ambulance transport to a facility that is not an acute-care hospital is not covered. Ambulance transport of a deceased beneficiary is not covered if the beneficiary is pronounced dead before the ambulance is called. Loaded mileage to a facility that is not the nearest appropriate facility is not reimbursed. Other non-covered ambulance services include: an ambulance is called and no treatment is needed; false alarm calls; beneficiary refuses all medical services; transport for a medical service that is not Medicaid covered; commercial airline tickets; airstrip fees; taxes; separate additional charges for nursing personnel who are employees of a facility or ambulance service; waiting fees; and separate charges for oxygen and other items and supplies because these are included in the base rate. Services other than those listed in Subsection 3.2 are not covered. Routine pregnancy transport is not covered. Beneficiaries with Medicaid coverage through Family Planning are not covered to receive ambulance services.
Place of Service
Ambulance
Additional Service Specifics
Institutional providers must report one of the following condition codes: AK, AL, AM. Providers must report an origin and destination modifier for each ambulance trip provided. Providers must report QL modifier if the time of death pronouncement is made after dispatch but before the beneficiary is loaded onboard the ambulance.
Other Information
When multiple units respond to a call for services, the provider that transports the beneficiary is the only provider that may bill for the service. If both ground and air medical ambulances areinvolved, then each submits its own claim and each claim is processed and reimbursed independently of the other.
How to Submit
Please submit your request to Trillium Health Resources
Resources
Ambulance Services
Ambulance services provide medically necessary treatment for NC Medicaid Program beneficiaries. Transport is provided only if the beneficiary’s medical condition is such that the use of any other means of transportation is contraindicated. Ambulance services include emergency and non-emergency ambulance transport via ground and air medical ambulance for a Medicaid 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
The time of pick-up, in the range of 00–23 hours, is required on the claim form.
Limits
Ground ambulance loaded mileage is reimbursable only for out-of-county transport; in-county loaded ground mileage is not reimbursable.
Ambulance transports are covered only to specified destinations, including hospital, critical access hospital, skilled nursing facility, adult care home, ICF-IID, beneficiary's primary private residence, dialysis facility for ESRD when condition requires ambulance services, transfer site, and physician's office under stated criteria.
Air medical ambulance transport is covered only to an acute-care hospital.
The provider shall bill only one ambulance procedure code for the same date of service, the same hour or time of pick-up, and the same or a different provider.
The provider shall not bill a round-trip ambulance transport and a one-way-trip ambulance transport on the same date of service unless submitting an adjustment with documentation substantiating both.
Each trip requires a separate PA process and PA number; PA is active for 30 calendar days.
Exclusions
Air medical ambulance transport to a facility that is not an acute-care hospital is not covered. Ambulance transport of a deceased beneficiary is not covered if the beneficiary is pronounced dead before the ambulance is called. Loaded mileage to a facility that is not the nearest appropriate facility is not reimbursed. Other non-covered ambulance services include: an ambulance is called and no treatment is needed; false alarm calls; beneficiary refuses all medical services; transport for a medical service that is not Medicaid covered; commercial airline tickets; airstrip fees; taxes; separate additional charges for nursing personnel who are employees of a facility or ambulance service; waiting fees; and separate charges for oxygen and other items and supplies because these are included in the base rate. Services other than those listed in Subsection 3.2 are not covered. Routine pregnancy transport is not covered. Beneficiaries with Medicaid coverage through Family Planning are not covered to receive ambulance services.
Place of Service
Ambulance
Additional Service Specifics
Institutional providers must report one of the following condition codes: AK, AL, AM. Providers must report an origin and destination modifier for each ambulance trip provided. Providers must report QL modifier if the time of death pronouncement is made after dispatch but before the beneficiary is loaded onboard the ambulance.
Other Information
When multiple units respond to a call for services, the provider that transports the beneficiary is the only provider that may bill for the service. If both ground and air medical ambulances areinvolved, then each submits its own claim and each claim is processed and reimbursed independently of the other.
How to Submit
Please submit your request to Trillium Health Resources
Resources
Ambulance Services
Ambulance services provide medically necessary treatment for NC Medicaid Program beneficiaries. Transport is provided only if the beneficiary’s medical condition is such that the use of any other means of transportation is contraindicated. Ambulance services include emergency and non-emergency ambulance transport via ground and air medical ambulance for a Medicaid 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
The time of pick-up, in the range of 00–23 hours, is required on the claim form.
Limits
Ground ambulance loaded mileage is reimbursable only for out-of-county transport; in-county loaded ground mileage is not reimbursable.
Ambulance transports are covered only to specified destinations, including hospital, critical access hospital, skilled nursing facility, adult care home, ICF-IID, beneficiary's primary private residence, dialysis facility for ESRD when condition requires ambulance services, transfer site, and physician's office under stated criteria.
Air medical ambulance transport is covered only to an acute-care hospital.
The provider shall bill only one ambulance procedure code for the same date of service, the same hour or time of pick-up, and the same or a different provider.
The provider shall not bill a round-trip ambulance transport and a one-way-trip ambulance transport on the same date of service unless submitting an adjustment with documentation substantiating both.
Each trip requires a separate PA process and PA number; PA is active for 30 calendar days.
Exclusions
Air medical ambulance transport to a facility that is not an acute-care hospital is not covered. Ambulance transport of a deceased beneficiary is not covered if the beneficiary is pronounced dead before the ambulance is called. Loaded mileage to a facility that is not the nearest appropriate facility is not reimbursed. Other non-covered ambulance services include: an ambulance is called and no treatment is needed; false alarm calls; beneficiary refuses all medical services; transport for a medical service that is not Medicaid covered; commercial airline tickets; airstrip fees; taxes; separate additional charges for nursing personnel who are employees of a facility or ambulance service; waiting fees; and separate charges for oxygen and other items and supplies because these are included in the base rate. Services other than those listed in Subsection 3.2 are not covered. Routine pregnancy transport is not covered. Beneficiaries with Medicaid coverage through Family Planning are not covered to receive ambulance services.
Place of Service
Ambulance
Additional Service Specifics
Institutional providers must report one of the following condition codes: AK, AL, AM. Providers must report an origin and destination modifier for each ambulance trip provided. Providers must report QL modifier if the time of death pronouncement is made after dispatch but before the beneficiary is loaded onboard the ambulance.
Other Information
When multiple units respond to a call for services, the provider that transports the beneficiary is the only provider that may bill for the service. If both ground and air medical ambulances areinvolved, then each submits its own claim and each claim is processed and reimbursed independently of the other.
How to Submit
Please submit your request to Trillium Health Resources
Resources
Ambulance Services
Ambulance services provide medically necessary treatment for NC Medicaid Program beneficiaries. Transport is provided only if the beneficiary’s medical condition is such that the use of any other means of transportation is contraindicated. Ambulance services include emergency and non-emergency ambulance transport via ground and air medical ambulance for a Medicaid 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
The time of pick-up, in the range of 00–23 hours, is required on the claim form.
Limits
Ground ambulance loaded mileage is reimbursable only for out-of-county transport; in-county loaded ground mileage is not reimbursable.
Ambulance transports are covered only to specified destinations, including hospital, critical access hospital, skilled nursing facility, adult care home, ICF-IID, beneficiary's primary private residence, dialysis facility for ESRD when condition requires ambulance services, transfer site, and physician's office under stated criteria.
Air medical ambulance transport is covered only to an acute-care hospital.
The provider shall bill only one ambulance procedure code for the same date of service, the same hour or time of pick-up, and the same or a different provider.
The provider shall not bill a round-trip ambulance transport and a one-way-trip ambulance transport on the same date of service unless submitting an adjustment with documentation substantiating both.
Each trip requires a separate PA process and PA number; PA is active for 30 calendar days.
Exclusions
Air medical ambulance transport to a facility that is not an acute-care hospital is not covered. Ambulance transport of a deceased beneficiary is not covered if the beneficiary is pronounced dead before the ambulance is called. Loaded mileage to a facility that is not the nearest appropriate facility is not reimbursed. Other non-covered ambulance services include: an ambulance is called and no treatment is needed; false alarm calls; beneficiary refuses all medical services; transport for a medical service that is not Medicaid covered; commercial airline tickets; airstrip fees; taxes; separate additional charges for nursing personnel who are employees of a facility or ambulance service; waiting fees; and separate charges for oxygen and other items and supplies because these are included in the base rate. Services other than those listed in Subsection 3.2 are not covered. Routine pregnancy transport is not covered. Beneficiaries with Medicaid coverage through Family Planning are not covered to receive ambulance services.
Place of Service
Ambulance
Additional Service Specifics
Institutional providers must report one of the following condition codes: AK, AL, AM. Providers must report an origin and destination modifier for each ambulance trip provided. Providers must report QL modifier if the time of death pronouncement is made after dispatch but before the beneficiary is loaded onboard the ambulance.
Other Information
When multiple units respond to a call for services, the provider that transports the beneficiary is the only provider that may bill for the service. If both ground and air medical ambulances areinvolved, then each submits its own claim and each claim is processed and reimbursed independently of the other.
How to Submit
Please submit your request to Trillium Health Resources
Resources
Ambulance Services
Ambulance services provide medically necessary treatment for NC Medicaid Program beneficiaries. Transport is provided only if the beneficiary’s medical condition is such that the use of any other means of transportation is contraindicated. Ambulance services include emergency and non-emergency ambulance transport via ground and air medical ambulance for a Medicaid 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
The time of pick-up, in the range of 00–23 hours, is required on the claim form.
Limits
Ground ambulance loaded mileage is reimbursable only for out-of-county transport; in-county loaded ground mileage is not reimbursable.
Ambulance transports are covered only to specified destinations, including hospital, critical access hospital, skilled nursing facility, adult care home, ICF-IID, beneficiary's primary private residence, dialysis facility for ESRD when condition requires ambulance services, transfer site, and physician's office under stated criteria.
Air medical ambulance transport is covered only to an acute-care hospital.
The provider shall bill only one ambulance procedure code for the same date of service, the same hour or time of pick-up, and the same or a different provider.
The provider shall not bill a round-trip ambulance transport and a one-way-trip ambulance transport on the same date of service unless submitting an adjustment with documentation substantiating both.
Each trip requires a separate PA process and PA number; PA is active for 30 calendar days.
Exclusions
Air medical ambulance transport to a facility that is not an acute-care hospital is not covered. Ambulance transport of a deceased beneficiary is not covered if the beneficiary is pronounced dead before the ambulance is called. Loaded mileage to a facility that is not the nearest appropriate facility is not reimbursed. Other non-covered ambulance services include: an ambulance is called and no treatment is needed; false alarm calls; beneficiary refuses all medical services; transport for a medical service that is not Medicaid covered; commercial airline tickets; airstrip fees; taxes; separate additional charges for nursing personnel who are employees of a facility or ambulance service; waiting fees; and separate charges for oxygen and other items and supplies because these are included in the base rate. Services other than those listed in Subsection 3.2 are not covered. Routine pregnancy transport is not covered. Beneficiaries with Medicaid coverage through Family Planning are not covered to receive ambulance services.
Place of Service
Ambulance
Additional Service Specifics
Institutional providers must report one of the following condition codes: AK, AL, AM. Providers must report an origin and destination modifier for each ambulance trip provided. Providers must report QL modifier if the time of death pronouncement is made after dispatch but before the beneficiary is loaded onboard the ambulance.
Other Information
When multiple units respond to a call for services, the provider that transports the beneficiary is the only provider that may bill for the service. If both ground and air medical ambulances areinvolved, then each submits its own claim and each claim is processed and reimbursed independently of the other.
How to Submit
Please submit your request to Trillium Health Resources
Resources
Ambulance Services
Ambulance services provide medically necessary treatment for NC Medicaid Program beneficiaries. Transport is provided only if the beneficiary’s medical condition is such that the use of any other means of transportation is contraindicated. Ambulance services include emergency and non-emergency ambulance transport via ground and air medical ambulance for a Medicaid 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
The time of pick-up, in the range of 00–23 hours, is required on the claim form.
Limits
Ground ambulance loaded mileage is reimbursable only for out-of-county transport; in-county loaded ground mileage is not reimbursable.
Ambulance transports are covered only to specified destinations, including hospital, critical access hospital, skilled nursing facility, adult care home, ICF-IID, beneficiary's primary private residence, dialysis facility for ESRD when condition requires ambulance services, transfer site, and physician's office under stated criteria.
Air medical ambulance transport is covered only to an acute-care hospital.
The provider shall bill only one ambulance procedure code for the same date of service, the same hour or time of pick-up, and the same or a different provider.
The provider shall not bill a round-trip ambulance transport and a one-way-trip ambulance transport on the same date of service unless submitting an adjustment with documentation substantiating both.
Each trip requires a separate PA process and PA number; PA is active for 30 calendar days.
Exclusions
Air medical ambulance transport to a facility that is not an acute-care hospital is not covered. Ambulance transport of a deceased beneficiary is not covered if the beneficiary is pronounced dead before the ambulance is called. Loaded mileage to a facility that is not the nearest appropriate facility is not reimbursed. Other non-covered ambulance services include: an ambulance is called and no treatment is needed; false alarm calls; beneficiary refuses all medical services; transport for a medical service that is not Medicaid covered; commercial airline tickets; airstrip fees; taxes; separate additional charges for nursing personnel who are employees of a facility or ambulance service; waiting fees; and separate charges for oxygen and other items and supplies because these are included in the base rate. Services other than those listed in Subsection 3.2 are not covered. Routine pregnancy transport is not covered. Beneficiaries with Medicaid coverage through Family Planning are not covered to receive ambulance services.
Place of Service
Ambulance
Additional Service Specifics
Institutional providers must report one of the following condition codes: AK, AL, AM. Providers must report an origin and destination modifier for each ambulance trip provided. Providers must report QL modifier if the time of death pronouncement is made after dispatch but before the beneficiary is loaded onboard the ambulance.
Other Information
When multiple units respond to a call for services, the provider that transports the beneficiary is the only provider that may bill for the service. If both ground and air medical ambulances areinvolved, then each submits its own claim and each claim is processed and reimbursed independently of the other.
How to Submit
Please submit your request to Trillium Health Resources
Resources
Ambulance Services
Ambulance services provide medically necessary treatment for NC Medicaid Program beneficiaries. Transport is provided only if the beneficiary’s medical condition is such that the use of any other means of transportation is contraindicated. Ambulance services include emergency and non-emergency ambulance transport via ground and air medical ambulance for a Medicaid 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
The time of pick-up, in the range of 00–23 hours, is required on the claim form.
Limits
Ground ambulance loaded mileage is reimbursable only for out-of-county transport; in-county loaded ground mileage is not reimbursable.
Ambulance transports are covered only to specified destinations, including hospital, critical access hospital, skilled nursing facility, adult care home, ICF-IID, beneficiary's primary private residence, dialysis facility for ESRD when condition requires ambulance services, transfer site, and physician's office under stated criteria.
Air medical ambulance transport is covered only to an acute-care hospital.
The provider shall bill only one ambulance procedure code for the same date of service, the same hour or time of pick-up, and the same or a different provider.
The provider shall not bill a round-trip ambulance transport and a one-way-trip ambulance transport on the same date of service unless submitting an adjustment with documentation substantiating both.
Each trip requires a separate PA process and PA number; PA is active for 30 calendar days.
Exclusions
Air medical ambulance transport to a facility that is not an acute-care hospital is not covered. Ambulance transport of a deceased beneficiary is not covered if the beneficiary is pronounced dead before the ambulance is called. Loaded mileage to a facility that is not the nearest appropriate facility is not reimbursed. Other non-covered ambulance services include: an ambulance is called and no treatment is needed; false alarm calls; beneficiary refuses all medical services; transport for a medical service that is not Medicaid covered; commercial airline tickets; airstrip fees; taxes; separate additional charges for nursing personnel who are employees of a facility or ambulance service; waiting fees; and separate charges for oxygen and other items and supplies because these are included in the base rate. Services other than those listed in Subsection 3.2 are not covered. Routine pregnancy transport is not covered. Beneficiaries with Medicaid coverage through Family Planning are not covered to receive ambulance services.
Place of Service
Ambulance
Additional Service Specifics
Institutional providers must report one of the following condition codes: AK, AL, AM. Providers must report an origin and destination modifier for each ambulance trip provided. Providers must report QL modifier if the time of death pronouncement is made after dispatch but before the beneficiary is loaded onboard the ambulance.
Other Information
When multiple units respond to a call for services, the provider that transports the beneficiary is the only provider that may bill for the service. If both ground and air medical ambulances areinvolved, then each submits its own claim and each claim is processed and reimbursed independently of the other.
How to Submit
Please submit your request to Trillium Health Resources
Resources
Ambulance Services
Ambulance services provide medically necessary treatment for NC Medicaid Program beneficiaries. Transport is provided only if the beneficiary’s medical condition is such that the use of any other means of transportation is contraindicated. Ambulance services include emergency and non-emergency ambulance transport via ground and air medical ambulance for a Medicaid 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
The time of pick-up, in the range of 00–23 hours, is required on the claim form.
Limits
Ground ambulance loaded mileage is reimbursable only for out-of-county transport; in-county loaded ground mileage is not reimbursable.
Ambulance transports are covered only to specified destinations, including hospital, critical access hospital, skilled nursing facility, adult care home, ICF-IID, beneficiary's primary private residence, dialysis facility for ESRD when condition requires ambulance services, transfer site, and physician's office under stated criteria.
Air medical ambulance transport is covered only to an acute-care hospital.
The provider shall bill only one ambulance procedure code for the same date of service, the same hour or time of pick-up, and the same or a different provider.
The provider shall not bill a round-trip ambulance transport and a one-way-trip ambulance transport on the same date of service unless submitting an adjustment with documentation substantiating both.
Each trip requires a separate PA process and PA number; PA is active for 30 calendar days.
Exclusions
Air medical ambulance transport to a facility that is not an acute-care hospital is not covered. Ambulance transport of a deceased beneficiary is not covered if the beneficiary is pronounced dead before the ambulance is called. Loaded mileage to a facility that is not the nearest appropriate facility is not reimbursed. Other non-covered ambulance services include: an ambulance is called and no treatment is needed; false alarm calls; beneficiary refuses all medical services; transport for a medical service that is not Medicaid covered; commercial airline tickets; airstrip fees; taxes; separate additional charges for nursing personnel who are employees of a facility or ambulance service; waiting fees; and separate charges for oxygen and other items and supplies because these are included in the base rate. Services other than those listed in Subsection 3.2 are not covered. Routine pregnancy transport is not covered. Beneficiaries with Medicaid coverage through Family Planning are not covered to receive ambulance services.
Place of Service
Ambulance
Additional Service Specifics
Institutional providers must report one of the following condition codes: AK, AL, AM. Providers must report an origin and destination modifier for each ambulance trip provided. Providers must report QL modifier if the time of death pronouncement is made after dispatch but before the beneficiary is loaded onboard the ambulance.
Other Information
When multiple units respond to a call for services, the provider that transports the beneficiary is the only provider that may bill for the service. If both ground and air medical ambulances areinvolved, then each submits its own claim and each claim is processed and reimbursed independently of the other.
How to Submit
Please submit your request to Trillium Health Resources
Resources
If you find any wrong or out of date information on our pages, we want to know. Please email info@TrilliumNC.org with any corrections.