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

Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for headrest, cushioned, any type

Service Code
E1033 (HCPCS) Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for headrest, cushioned, any type
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

Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for lateral trunk or hip support, any type

Service Code
E1034 (HCPCS) Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for lateral trunk or hip support, any type
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

Transport chair, pediatric size

Service Code
E1037 (HCPCS) Transport chair, pediatric size
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

Transport chair, adult size, patient weight capacity up to and including 300 pounds

Service Code
E1038 (HCPCS) Transport chair, adult size, patient weight capacity up to and including 300 pounds
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

Transport chair, adult size, heavy-duty, patient weight capacity greater than 300 pounds

Service Code
E1039 (HCPCS) Transport chair, adult size, heavy-duty, patient weight capacity greater than 300 pounds
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

Manual adult size wheelchair, includes tilt in space

Service Code
E1161 (HCPCS) Manual adult size wheelchair, includes tilt in space
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

Wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each

Service Code
E1226 (HCPCS) Wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), 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

Wheelchair, pediatric size, not otherwise specified

Service Code
E1229 (HCPCS) Wheelchair, pediatric size, not otherwise specified
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

Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system

Service Code
E1231 (HCPCS) Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system
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

Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system

Service Code
E1232 (HCPCS) Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system
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

Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system

Service Code
E1233 (HCPCS) Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system
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

Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system

Service Code
E1234 (HCPCS) Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system
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

Wheelchair, pediatric size, rigid, adjustable, with seating system

Service Code
E1235 (HCPCS) Wheelchair, pediatric size, rigid, adjustable, with seating system
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

Wheelchair, pediatric size, folding, adjustable, with seating system

Service Code
E1236 (HCPCS) Wheelchair, pediatric size, folding, adjustable, with seating system
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

Wheelchair, pediatric size, rigid, adjustable, without seating system

Service Code
E1237 (HCPCS) Wheelchair, pediatric size, rigid, adjustable, without seating system
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

Wheelchair, pediatric size, folding, adjustable, without seating system

Service Code
E1238 (HCPCS) Wheelchair, pediatric size, folding, adjustable, without seating system
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

Power wheelchair, pediatric size, not otherwise specified

Service Code
E1239 (HCPCS) Power wheelchair, pediatric size, not otherwise specified
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

Whirlpool, portable (overtub type)

Service Code
E1300 (HCPCS) Whirlpool, portable (overtub type)
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

Oxygen accessory, wheeled cart for portable cylinder or portable concentrator, any type, replacement only, each

Service Code
E1354 (HCPCS) Oxygen accessory, wheeled cart for portable cylinder or portable concentrator, any type, replacement only, 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

Stand/rack

Service Code
E1355 (HCPCS) Stand/rack
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