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

Filter, nondisposable, used with positive airway pressure device

Service Code
A7039 (HCPCS) Filter, nondisposable, used with positive airway pressure device
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

Water chamber for humidifier, used with positive airway pressure device, replacement, each

Service Code
A7046 (HCPCS) Water chamber for humidifier, used with positive airway pressure device, replacement, each
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

Vacuum drainage collection unit and tubing kit, including all supplies needed for collection unit change, for use with implanted catheter, each

Service Code
A7048 (HCPCS) Vacuum drainage collection unit and tubing kit, including all supplies needed for collection unit change, for use with implanted catheter, each
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

Expiratory positive airway pressure intranasal resistance valve

Service Code
A7049 (HCPCS) Expiratory positive airway pressure intranasal resistance valve
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

Tracheostoma valve, including diaphragm, each

Service Code
A7501 (HCPCS) Tracheostoma valve, including diaphragm, each
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

Replacement diaphragm/faceplate for tracheostoma valve, each

Service Code
A7502 (HCPCS) Replacement diaphragm/faceplate for tracheostoma valve, each
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

Filter holder or filter cap, reusable, for use in a tracheostoma heat and moisture exchange system, each

Service Code
A7503 (HCPCS) Filter holder or filter cap, reusable, for use in a tracheostoma heat and moisture exchange system, each
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

Filter for use in a tracheostoma heat and moisture exchange system, each

Service Code
A7504 (HCPCS) Filter for use in a tracheostoma heat and moisture exchange system, each
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

Housing, reusable without adhesive, for use in a heat and moisture exchange system and/or with a tracheostoma valve, each

Service Code
A7505 (HCPCS) Housing, reusable without adhesive, for use in a heat and moisture exchange system and/or with a tracheostoma valve, each
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

Adhesive disc for use in a heat and moisture exchange system and/or with tracheostoma valve, any type each

Service Code
A7506 (HCPCS) Adhesive disc for use in a heat and moisture exchange system and/or with tracheostoma valve, any type each
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

Filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system, each

Service Code
A7507 (HCPCS) Filter holder and integrated filter without adhesive, for use in a tracheostoma heat and moisture exchange system, each
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

Housing and integrated adhesive, for use in a tracheostoma heat and moisture exchange system and/or with a tracheostoma valve, each

Service Code
A7508 (HCPCS) Housing and integrated adhesive, for use in a tracheostoma heat and moisture exchange system and/or with a tracheostoma valve, each
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

Filter holder and integrated filter housing, and adhesive, for use as a tracheostoma heat and moisture exchange system, each

Service Code
A7509 (HCPCS) Filter holder and integrated filter housing, and adhesive, for use as a tracheostoma heat and moisture exchange system, each
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

Tracheostomy/laryngectomy tube, noncuffed, polyvinyl chloride (PVC), silicone or equal, each

Service Code
A7520 (HCPCS) Tracheostomy/laryngectomy tube, noncuffed, polyvinyl chloride (PVC), silicone or equal, each
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

Tracheostomy/laryngectomy tube, cuffed, polyvinyl chloride (PVC), silicone or equal, each

Service Code
A7521 (HCPCS) Tracheostomy/laryngectomy tube, cuffed, polyvinyl chloride (PVC), silicone or equal, each
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

Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable and reusable), each

Service Code
A7522 (HCPCS) Tracheostomy/laryngectomy tube, stainless steel or equal (sterilizable and reusable), each
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

Tracheostoma stent/stud/button, each

Service Code
A7524 (HCPCS) Tracheostoma stent/stud/button, each
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

Tracheostomy mask, each

Service Code
A7525 (HCPCS) Tracheostomy mask, each
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

Tracheostomy tube collar/holder, each

Service Code
A7526 (HCPCS) Tracheostomy tube collar/holder, each
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

Helmet, protective, soft, custom fabricated, includes all components and accessories

Service Code
A8002 (HCPCS) Helmet, protective, soft, custom fabricated, includes all components and accessories
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