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
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 only in an office setting
- * Allowed up to a total of six hours of anesthesia time
Exclusions
Medicaid does not cover acupuncture, hypnosis, or other non-pharmacologic methods. The policy also states that non-intravenous conscious sedation is not covered. Local anesthesia is not separately reimbursable because it is considered part of the underlying procedure.
Additional Service Specifics
In ambulatory surgical centers, anesthesia services are billed based on total anesthesia time; time begins when the anesthesiology provider prepares the beneficiary for induction and ends when the beneficiary can be placed under postoperative supervision and the provider is no longer in personal attendance.
How to Submit
N/A - No authorization is required
Resources
Moderate (Conscious) Sedation Clinical Coverage Policy No: 1L-2 AKA Procedural Sedation and Analgesia (PSA)
Moderate (conscious) sedation/Procedural sedation and analgesia (PSA) is the use of medication to depress the level of consciousness in a patient while allowing the patient to continually and independently maintain a patent airway and respond appropriately to verbal commands or gentle stimulation.
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
Intraservice time begins with administration of the sedation agent(s), requires continuous face-to-face attendance, and ends when personal contact by the physician or dentist providing the sedation concludes.
Exclusions
Medicaid will not reimburse moderate sedation codes 99155 through 99157 when billed with codes in Appendix G in the nonfacility setting. Codes 99151 through 99157 are not billable with anesthesia codes 00100 through 01999 or pulse oximetry codes 94760 through 94762.
Place of Service
Office, Hospital, Outpatient hospital, Ambulatory surgical center, Nursing facility.
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
- * Reimbursement includes monitoring and management
Exclusions
Medicaid does not cover acupuncture, hypnosis, or other non-pharmacologic methods. The policy also states that non-intravenous conscious sedation is not covered. Local anesthesia is not separately reimbursable because it is considered part of the underlying procedure.
Additional Service Specifics
In ambulatory surgical centers, anesthesia services are billed based on total anesthesia time; time begins when the anesthesiology provider prepares the beneficiary for induction and ends when the beneficiary can be placed under postoperative supervision and the provider is no longer in personal attendance.
How to Submit
N/A - No authorization is required
Resources
Moderate (Conscious) Sedation Clinical Coverage Policy No: 1L-2 AKA Procedural Sedation and Analgesia (PSA)
Moderate (conscious) sedation/Procedural sedation and analgesia (PSA) is the use of medication to depress the level of consciousness in a patient while allowing the patient to continually and independently maintain a patent airway and respond appropriately to verbal commands or gentle stimulation.
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
Intraservice time begins with administration of the sedation agent(s), requires continuous face-to-face attendance, and ends when personal contact by the physician or dentist providing the sedation concludes.
Exclusions
Medicaid will not reimburse moderate sedation codes 99155 through 99157 when billed with codes in Appendix G in the nonfacility setting. Codes 99151 through 99157 are not billable with anesthesia codes 00100 through 01999 or pulse oximetry codes 94760 through 94762.
Place of Service
Office, Hospital, Outpatient hospital, Ambulatory surgical center, Nursing facility.
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 once per date of service
- * Allowed only in an office setting
- * Intravenous conscious sedation performed in the dental office must include documentation in the record of pharmacologic agents, IV site, monitoring of vital signs, and complete anesthesia time
- * Reimbursement includes all drugs or medicaments necessary for adequate anesthesia
- * Reimbursement includes monitoring and management
Exclusions
Medicaid does not cover acupuncture, hypnosis, or other non-pharmacologic methods. The policy also states that non-intravenous conscious sedation is not covered. Local anesthesia is not separately reimbursable because it is considered part of the underlying procedure.
Additional Service Specifics
In ambulatory surgical centers, anesthesia services are billed based on total anesthesia time; time begins when the anesthesiology provider prepares the beneficiary for induction and ends when the beneficiary can be placed under postoperative supervision and the provider is no longer in personal attendance.
How to Submit
N/A - No authorization is required
Resources
Moderate (Conscious) Sedation Clinical Coverage Policy No: 1L-2 AKA Procedural Sedation and Analgesia (PSA)
Moderate (conscious) sedation/Procedural sedation and analgesia (PSA) is the use of medication to depress the level of consciousness in a patient while allowing the patient to continually and independently maintain a patent airway and respond appropriately to verbal commands or gentle stimulation.
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
Intraservice time begins with administration of the sedation agent(s), requires continuous face-to-face attendance, and ends when personal contact by the physician or dentist providing the sedation concludes.
Exclusions
Medicaid will not reimburse moderate sedation codes 99155 through 99157 when billed with codes in Appendix G in the nonfacility setting. Codes 99151 through 99157 are not billable with anesthesia codes 00100 through 01999 or pulse oximetry codes 94760 through 94762.
Place of Service
Office, Hospital, Outpatient hospital, Ambulatory surgical center, Nursing facility.
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 only in an office setting
- * Allowed up to a total of six hours of anesthesia time
Additional Service Specifics
In ambulatory surgical centers, anesthesia services are billed based on total anesthesia time; time begins when the anesthesiology provider prepares the beneficiary for induction and ends when the beneficiary can be placed under postoperative supervision and the provider is no longer in personal attendance.
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
- * Includes visits to nursing facilities, long-term care facilities, adult care
homes, hospice sites, institutions, etc.
- * A dentist can be reimbursed for one facility call per date of service for each
beneficiary treated in the facility
- * Must be billed with other definitive treatment (other CDT codes) rendered
on that date of service
- * Procedure codes for treatment must be billed on the detail lines before
D9410 on the dental claim
- * Not allowed for post-surgical follow-up care or initial six months postdelivery care for appliances when other definitive treatment is not being
rendered
Additional Service Specifics
In ambulatory surgical centers, anesthesia services are billed based on total anesthesia time; time begins when the anesthesiology provider prepares the beneficiary for induction and ends when the beneficiary can be placed under postoperative supervision and the provider is no longer in personal attendance.
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
- * One visit per surgery
- * Necessity of hospitalization shall be documented on paper claims or in the record if billing electronically
- * Submit operative notes with the paper claim or maintain in the record if billing electronically
- * Hospitalization does not require admission pre-certification
- * A Community Care of North Carolina (Carolina ACCESS) beneficiary requires referral from his or her primary care physician for hospital admission
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.
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 for a single administration of antibiotics, steroids, antiinflammatory drugs, or other therapeutic medications
- * Not allowed for the administration of sedatives, anesthetic, reversal agents, medications available in over-the-counter formulations, and prescription medications that can be self-administered by the beneficiary prior to treatment * Identify drug, dosage, and rationale in the beneficiary’s dental record and on the claim form if filed as a paper claim * Not allowed on the same date of service as D9612
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 for the administration of antibiotics, steroids, anti-inflammatory drugs, or other therapeutic medications when two or more different medications are necessary * Not allowed for the administration of sedatives, anesthetic, reversal agents, medications available in over-the-counter formulations, and prescription medications that can be self-administered by the beneficiary prior to treatment * Identify drug, dosage, and rationale in the beneficiary’s dental record and on the claim form if filed as a paper claim * Not allowed on the same date of service as D9610
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
The provider(s) shall submit to the following:
- a. the prior approval request; and
- b. all health records and any other records that support the beneficiary has met
the specific criteria in Subsection 3.2 of this policy.
As indicated in Subsection 5.3, the provider shall submit a request for prior approval before rendering certain dental services. Prior approval applies only to procedures, not to reimbursement amounts and does not guarantee payment. The beneficiary’s eligibility for the date of service must be verified before rendering treatment. Failure to obtain required prior approval before rendering a service shall result in denial of payment for that service. The Medicaid program has the right to require prior approval for any services by providers who have been or are under investigation by NC Medicaid.
A prior approval request consists of the following:
- a. Electronic entry into the NCTracks Prior Approval Portal or a completed
2019 American Dental Association (ADA) Dental Claim Form submitted by mail;
- b. Properly arranged radiographic images that are clearly labeled with the date
taken, the provider’s name, and the beneficiary’s name;
- c. Documentation as specified in Subsection 5.3 Limitations or
Requirements; and
- d. Any additional information to clarify unusual circumstances or explain the
complexity of the treatment plan such as a pre-treatment narrative, periodontal charting, photographic images, and etc.
When radiographic images cannot be obtained, the provider shall include a written explanation and shall complete the tooth chart in field 33 on the ADA Dental Claim Form. Panoramic radiographic images must be labeled clearly to indicate the beneficiary’s left and right. All radiographic images must be of diagnostic quality suitable for interpretation and must be retained in the beneficiary’s record for a minimum of six years for the purpose of Medicaid post-payment review (minimum of 10 years per NC State Dental Board of Examiners rules). Prior approval requests must be entered in the NCTracks Prior Approval Portal or mailed to the address listed below.
Limits
- * Infiltration of a sustained release pharmacologic agent for long acting surgical site pain control
- * Not for local anesthesia purposes
- * Allowed per quadrant
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
- * Medicaid enrolled dentists may render provider to provider teledentistry services via synchronous, live audio and video transmission * Dentist in the distant site must have enough information and evidence to make a diagnosis * Must be billed with oral evaluation codes D0140 or D0170 * Reported in addition to other procedures delivered on the same date of service * Dental treatment rendered through teledentistry must be documented in the beneficiary record including the date/time/duration of encounter, reasons for the encounter, technology used, records reviewed, diagnosis, and treatment recommendations * Limited to four teledentistry services (D9995 or D9996) in a six-month period * The originating site is the facility in which the beneficiary is located * The distant site is the facility from which the provider furnishes the teledentistry service * All services sites/providers must be Medicaid enrolled * Consultation must take place by an encrypted two-way real-time interactive audio and video telecommunications system * Enter “02” (Telehealth) as the place of treatment for teledentistry claims
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
- * Medicaid enrolled dentists may render provider to provider teledentistry services via asynchronous, store and forward or eConsults
- * Dentist in the distant site must have enough information and evidence to make a diagnosis
- * Must be billed with oral evaluation codes D0140 or D0170
- * Reported in addition to other procedures delivered on the same date of service
- * Dental treatment rendered through teledentistry must be documented in the beneficiary record including the date/time/duration of encounter, reasons for the encounter, technology used, records reviewed, diagnosis, and treatment recommendations
- * Limited to once per recipient, per provider for a one-week period
- * Limited to four teledentistry services (D9995 or D9996) in a six-month period
- * The originating site is the facility in which the beneficiary is located
- * The distant site is the facility from which the provider furnishes the teledentistry service
- * All services sites/providers must be Medicaid enrolled
- * Consultation must take place by an encrypted telecommunications system
- * Enter “02” (Telehealth) as the place of treatment for teledentistry claims
How to Submit
N/A - No authorization is required
Resources
Cane, includes canes of all materials, adjustable or fixed, with tip
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
Cane, quad or three-prong, includes canes of all materials, adjustable or fixed, with tips
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
Crutches, forearm, includes crutches of various materials, adjustable or fixed, pair, complete with tips and handgrips
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
Crutch, forearm, includes crutches of various materials, adjustable or fixed, each, with tip and handgrips
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
Crutches, underarm, wood, adjustable or fixed, pair, with pads, tips, and handgrips
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
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.