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
Perforated continuous infusion catheter set (e.g., InfiltraLong), including all components, non-opioid medical device (must be a qualifying Medicare non-opioid medical device for post-surgical pain relief in accordance with Section 4135 of the CAA, 2023)
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
Continuous anesthesia echogenic conduction catheter set (e.g., SonoLong), non-opioid medical device (must be a qualifying Medicare non-opioid medical device for post-surgical pain relief in accordance with Section 4135 of the CAA, 2023)
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
Linear peristaltic pain management infusion pump (e.g., CADD-Solis ambulatory infusion pump), and all disposable system components, non-opioid medical device (must be a qualifying Medicare non-opioid medical device for post-surgical pain relief in accorda
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
Rotary peristaltic infusion pump (e.g., reusable ambIT pump) including all disposable system components, reusable non-opioid medical device (must be a qualifying Medicare non-opioid medical device for post-surgical pain relief in accordance with Section 4
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
Electronic cryo-pneumatic compression, pain management system (e.g., Game Ready GRPro 2.1 system), including control unit, anatomically correct wrap(s), and other system component(s), non-opioid medical device (must be a qualifying Medicare non-opioid med
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
Suzetrigine, oral, 1 mg
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
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
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.
Limits
*The first periodic oral evaluation must be at least six calendar months after the comprehensive oral evaluation (D0150) or at least six calendar months after an oral evaluation for a beneficiary under three years of age (D0145) for the same provider
- * Allowed once per six calendar month period for the same provider
Exclusions
Claims for clinical oral evaluation services that fall outside the applicable service limitations are denied unless special approval is granted for medically necessary services for a Medicaid beneficiary under 21 years of age.
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
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.
Limits
- * Use as the emergency exam for the first visit for a specific problem; followup evaluations for the same problem must be coded as D0170 * Document in the beneficiary’s chart the nature of the emergency and the treatment provided
Exclusions
Claims for clinical oral evaluation services that fall outside the applicable service limitations are denied unless special approval is granted for medically necessary services for a Medicaid beneficiary under 21 years of age.
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
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.
Limits
- * Evaluation includes recording the oral and physical health history,
evaluation of caries susceptibility, development of an appropriate preventive oral health regimen, and communication with and counseling the child’s parent, legal guardian, or primary caregiver
- * The first oral evaluation for a patient under three years of age must be at
least six calendar months after the comprehensive oral evaluation (D0150) or at least six calendar months after a periodic oral evaluation (D0120) for the same provider
- * Allowed once per six calendar month period for the same provider (for
example, a patient seen for an oral evaluation for a patient under three years of age on any date in January would be eligible for the next oral evaluation for a beneficiary under three years of age on any date in July)
- * Allowed on beneficiaries under three years of age
- * Service must be provided in conjunction with topical fluoride varnish
(D1206)
- * Procedure code D1206 must be billed on the detail line before D0145
Exclusions
Claims for clinical oral evaluation services that fall outside the applicable service limitations are denied unless special approval is granted for medically necessary services for a Medicaid beneficiary under 21 years of age.
How to Submit
N/A - No authorization is required
Resources
Physician Fluoride Varnish Services
Physician fluoride varnish services are defined as preventive procedures provided by or under the supervision of a physician. This includes caries screening, recording of notable findings in the oral cavity, preventive oral health and dietary counseling, and administration of topical fluoride varnish. Such services shall maintain a high standard of quality and shall be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations hereinafter specified. Only the procedure codes listed in this policy are covered under the N.C. Medicaid Physician Fluoride Varnish Program.
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.
Limits
Must be billed in conjunction with D0145.
Limited to beneficiaries under 3½ years of age.
Allowed once every 60 calendar days.
Limited to six times before the beneficiary reaches 3½ years of age.
D1206 must be billed on the detail line before D0145.
Reimbursement is allowed only when teeth are present and fluoride varnish is applied to the teeth.
Topical fluoride must be applied to all teeth erupted on the date of service.
The oral screening package may be provided at well-child checkups, during a sick visit, or at a separately scheduled visit.
Exclusions
Medicaid will not reimburse this procedure when teeth are not present or when fluoride varnish is not applied to the teeth.
Place of Service
The oral screening package is allowed in the physician’s office, health department clinics, Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHC), and the beneficiary’s residence.
Additional Service Specifics
D1206 - Topical application of fluoride varnish * replaced procedure code D1203 effective January 1, 2007 * must be billed in conjunction with D0145 * limited to beneficiaries under 3½ years of age * allowed once every 60 calendar days * limited to six times prior to the beneficiary reaching 3½ years of age * procedure code D1206 must be billed on the detail line before D0145
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
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.
Limits
- * Use as the initial exam for a beneficiary * Allowed as an initial exam once per provider per beneficiary
Exclusions
Claims for clinical oral evaluation services that fall outside the applicable service limitations are denied unless special approval is granted for medically necessary services for a Medicaid beneficiary under 21 years of age.
How to Submit
N/A - No authorization is required
Resources
Orthodontic Services
Orthodontics is defined as a corrective procedure for functionally impairing occlusal conditions (including craniofacial abnormalities and traumatic or pathologic anatomical deviations) that cause pain or suffering, physical deformity, significant malfunction, aggravates a condition, or results in further injury or infirmity. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
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.
Limits
- * Use as the initial exam for a beneficiary
- * Allowed as an initial exam once per billing provider per beneficiary
Exclusions
Not covered:
- a. Interceptive or Phase I treatment cases of the primary and transitional
dentition except for cases involving functionally impairing malocclusions caused by cleft lip and palate or other severe craniofacial developmental anomalies or severe traumatic injuries;
- b. Minor tooth movement cases requiring a relatively short treatment period
(less than 12 months);
- c. Cuspid impactions with a poor prognosis of being brought down into
occlusion in the presence of no other significant problems;
- d. Bilateral or unilateral posterior crossbites of moderate severity without a
significant mandibular shift or history of temporomandibular dysfunction and a lack of other significant problems;
- e. Class I malocclusions with moderate crowding, no crossbites, overbite and
overjet within normal limits;
- f. Simple space closure of mild to moderate anterior spacing;
- g. Simple one arch treatment;
- h. Localized tooth alignment problems requiring a relatively short period of
treatment (such as simple anterior or posterior crossbites, diastema closure, rotations);
- i. Orthodontic treatment begun prior to the patient becoming eligible for
Medicaid;
- j. Habit appliance therapy;
- k. Occlusal guard (including splint therapy for the treatment of
temporomandibular dysfunction); and
- l. Orthodontic treatment started as a private pay arrangement before Medicaid
approval is requested.
Additional Service Specifics
Pregnant Medicaid eligible beneficiaries covered under the Medicaid for Pregnant Women program class “MPW” and beneficiaries covered under the Family Planning Waiver program class “MAFD” are not eligible for orthodontic services as described in this policy. Beneficiaries covered under the Medicare Qualified Beneficiaries program class “MQB” do not receive a Medicaid card and the only benefit that the beneficiary receives from Medicaid is the payment of the Medicare premium. The beneficiary is not eligible for any orthodontic services as described in this policy. Beneficiaries enrolled with the Program of All-Inclusive Care for the Elderly (PACE) are not covered for orthodontic services as described in this policy.
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
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.
Limits
- * Entails extensive diagnostic and cognitive modalities based on the findings
of a comprehensive oral evaluation
- * Requires integration of extensive diagnostic modalities to develop a
treatment plan for a specific problem
- * The condition requiring this type of evaluation must be described and
documented
- * Examples include dentofacial anomalies, complicated perio-prosthetic
conditions, complex temporomandibular dysfunction, facial pain of unknown origin, and systemic diseases requiring multidisciplinary consultation
- * Not allowed as a routine office visit or for orthodontic records
Exclusions
Claims for clinical oral evaluation services that fall outside the applicable service limitations are denied unless special approval is granted for medically necessary services for a Medicaid beneficiary under 21 years of age.
How to Submit
N/A - No authorization is required
Resources
Orthodontic Services
Orthodontics is defined as a corrective procedure for functionally impairing occlusal conditions (including craniofacial abnormalities and traumatic or pathologic anatomical deviations) that cause pain or suffering, physical deformity, significant malfunction, aggravates a condition, or results in further injury or infirmity. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
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.
Limits
- * Allowed for the initial consultation visit for combined comprehensive orthodontic treatment and orthognathic surgery
Exclusions
Not covered:
- a. Interceptive or Phase I treatment cases of the primary and transitional
dentition except for cases involving functionally impairing malocclusions caused by cleft lip and palate or other severe craniofacial developmental anomalies or severe traumatic injuries;
- b. Minor tooth movement cases requiring a relatively short treatment period
(less than 12 months);
- c. Cuspid impactions with a poor prognosis of being brought down into
occlusion in the presence of no other significant problems;
- d. Bilateral or unilateral posterior crossbites of moderate severity without a
significant mandibular shift or history of temporomandibular dysfunction and a lack of other significant problems;
- e. Class I malocclusions with moderate crowding, no crossbites, overbite and
overjet within normal limits;
- f. Simple space closure of mild to moderate anterior spacing;
- g. Simple one arch treatment;
- h. Localized tooth alignment problems requiring a relatively short period of
treatment (such as simple anterior or posterior crossbites, diastema closure, rotations);
- i. Orthodontic treatment begun prior to the patient becoming eligible for
Medicaid;
- j. Habit appliance therapy;
- k. Occlusal guard (including splint therapy for the treatment of
temporomandibular dysfunction); and
- l. Orthodontic treatment started as a private pay arrangement before Medicaid
approval is requested.
Additional Service Specifics
Pregnant Medicaid eligible beneficiaries covered under the Medicaid for Pregnant Women program class “MPW” and beneficiaries covered under the Family Planning Waiver program class “MAFD” are not eligible for orthodontic services as described in this policy. Beneficiaries covered under the Medicare Qualified Beneficiaries program class “MQB” do not receive a Medicaid card and the only benefit that the beneficiary receives from Medicaid is the payment of the Medicare premium. The beneficiary is not eligible for any orthodontic services as described in this policy. Beneficiaries enrolled with the Program of All-Inclusive Care for the Elderly (PACE) are not covered for orthodontic services as described in this policy.
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
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.
Limits
- * Use as a follow-up exam for a specific problem that has been evaluated previously such as monitoring of a traumatic injury, evaluation of a soft tissue lesion, or evaluation of undiagnosed continuing pain * Document in the beneficiary’s chart the nature of the emergency and the treatment provided
Exclusions
Claims for clinical oral evaluation services that fall outside the applicable service limitations are denied unless special approval is granted for medically necessary services for a Medicaid beneficiary under 21 years of age.
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
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.
Limits
- * Limited to beneficiaries age six and older except in the hospital or
ambulatory surgical center setting
- * Allowed one time in five years
- * Not allowed on the same date of service as D0330
- * Any combination of D0220, D0230, D0270, D0272, D0273, or D0274
taken on the same date of service that exceeds the maximum allowed fee for D0210 is reimbursed at the same fee as D0210
- * Panoramic radiographic image and bitewing radiographic images taken on
the same date of service shall not be billed as a D0210
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
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.
Limits
- * Only one allowed per date of service per beneficiary per provider
- * Any combination of D0220, D0230, D0270, D0272, D0273, or D0274
taken on the same date of service that exceeds the maximum allowed fee for D0210 is reimbursed at the same fee as D0210
- * Not allowed on the same date of service as D0210 *Panoramic radiographic image and bitewing radiographic images taken on the same date of service shall not be billed as D0210.
How to Submit
N/A - No authorization is required
Resources
Orthodontic Services
Orthodontics is defined as a corrective procedure for functionally impairing occlusal conditions (including craniofacial abnormalities and traumatic or pathologic anatomical deviations) that cause pain or suffering, physical deformity, significant malfunction, aggravates a condition, or results in further injury or infirmity. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
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.
Limits
- * These images include, but are not limited to: Lateral Skull; PosteriorAnterior Skull; Submentovertex; Waters; Reverse Tomes; Oblique Mandibular Body; Lateral Ramus
Exclusions
Not covered:
- a. Interceptive or Phase I treatment cases of the primary and transitional
dentition except for cases involving functionally impairing malocclusions caused by cleft lip and palate or other severe craniofacial developmental anomalies or severe traumatic injuries;
- b. Minor tooth movement cases requiring a relatively short treatment period
(less than 12 months);
- c. Cuspid impactions with a poor prognosis of being brought down into
occlusion in the presence of no other significant problems;
- d. Bilateral or unilateral posterior crossbites of moderate severity without a
significant mandibular shift or history of temporomandibular dysfunction and a lack of other significant problems;
- e. Class I malocclusions with moderate crowding, no crossbites, overbite and
overjet within normal limits;
- f. Simple space closure of mild to moderate anterior spacing;
- g. Simple one arch treatment;
- h. Localized tooth alignment problems requiring a relatively short period of
treatment (such as simple anterior or posterior crossbites, diastema closure, rotations);
- i. Orthodontic treatment begun prior to the patient becoming eligible for
Medicaid;
- j. Habit appliance therapy;
- k. Occlusal guard (including splint therapy for the treatment of
temporomandibular dysfunction); and
- l. Orthodontic treatment started as a private pay arrangement before Medicaid
approval is requested.
Additional Service Specifics
Pregnant Medicaid eligible beneficiaries covered under the Medicaid for Pregnant Women program class “MPW” and beneficiaries covered under the Family Planning Waiver program class “MAFD” are not eligible for orthodontic services as described in this policy. Beneficiaries covered under the Medicare Qualified Beneficiaries program class “MQB” do not receive a Medicaid card and the only benefit that the beneficiary receives from Medicaid is the payment of the Medicare premium. The beneficiary is not eligible for any orthodontic services as described in this policy. Beneficiaries enrolled with the Program of All-Inclusive Care for the Elderly (PACE) are not covered for orthodontic services as described in this policy.
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
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.
Limits
- * Allowed one time in a 12-calendar month period (for example, a beneficiary
receiving bitewings on any date in January would be eligible for additional bitewings on any date the following January)
- * Any combination of D0220, D0230, D0270, D0272, D0273, or D0274
taken on the same date of service that exceeds the maximum allowed fee for D0210 is reimbursed at the same fee as D0210
- * Not allowed on same date of service as D0270, D0273, or D0274
- * Not allowed within the same 12-calendar month period as D0210, D0270,
D0273, or D0274
How to Submit
N/A - No authorization is required
Resources
Dental Services
Dental services are defined as diagnostic, preventive, or corrective procedures provided by or under the supervision of a dentist. This includes services to treat disease, maintain oral health, and treat injuries or impairments that may affect a beneficiary’s oral or general health. Such services must maintain a high standard of quality and must be within the reasonable limits of services customarily available and provided to most persons in the community with the limitations and exclusions specified in this policy. Only the procedure codes listed in this policy are covered under the North Carolina (NC) Medicaid (Title XIX) Dental Program.
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.
Limits
- * Allowed one time in a 12-calendar month period (for example, a beneficiary
receiving bitewings on any date in January would be eligible for additional bitewings on any date the following January)
- * Any combination of D0220, D0230, D0270, D0272, D0273, or D0274
taken on the same date of service that exceeds the maximum allowed fee for D0210 is reimbursed at the same fee as D0210
- * Not allowed on same date of service as D0270, D0273, or D0274
- * Not allowed within the same 12-calendar month period as D0210, D0270,
D0273, or D0274
How to Submit
N/A - No authorization is required
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.