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

Filter By:
Clear Filters
12437 Results

Gastric suction pump, home model, portable or stationary, electric

Service Code
E2000 (HCPCS) Gastric suction pump, home model, portable or stationary, electric
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

Blood glucose monitor with integrated voice synthesizer

Service Code
E2100 (HCPCS) Blood glucose monitor with integrated voice synthesizer
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

Adjunctive, nonimplanted continuous glucose monitor (CGM) or receiver

Service Code
E2102 (HCPCS) Adjunctive, nonimplanted continuous glucose monitor (CGM) or receiver
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

Home blood glucose monitor for use with integrated lancing/blood sample testing cartridge

Service Code
E2104 (HCPCS) Home blood glucose monitor for use with integrated lancing/blood sample testing cartridge
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 wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 in and less than 24 in

Service Code
E2201 (HCPCS) Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 in and less than 24 in
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 wheelchair accessory, nonstandard seat frame width, 24-27 in

Service Code
E2202 (HCPCS) Manual wheelchair accessory, nonstandard seat frame width, 24-27 in
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 wheelchair accessory, nonstandard seat frame depth, 20 to less than 22 in

Service Code
E2203 (HCPCS) Manual wheelchair accessory, nonstandard seat frame depth, 20 to less than 22 in
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 wheelchair accessory, nonstandard seat frame depth, 22 to 25 in

Service Code
E2204 (HCPCS) Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 in
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 wheelchair accessory, handrim without projections (includes ergonomic or contoured), any type, replacement only, each

Service Code
E2205 (HCPCS) Manual wheelchair accessory, handrim without projections (includes ergonomic or contoured), 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

Manual wheelchair accessory, wheel lock assembly, complete, replacement only, each

Service Code
E2206 (HCPCS) Manual wheelchair accessory, wheel lock assembly, complete, 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

Wheelchair accessory, crutch and cane holder, each

Service Code
E2207 (HCPCS) Wheelchair accessory, crutch and cane 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

Wheelchair accessory, cylinder tank carrier, each

Service Code
E2208 (HCPCS) Wheelchair accessory, cylinder tank carrier, 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

Accessory, arm trough, with or without hand support, each

Service Code
E2209 (HCPCS) Accessory, arm trough, with or without hand support, 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 accessory, bearings, any type, replacement only, each

Service Code
E2210 (HCPCS) Wheelchair accessory, bearings, 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

Manual wheelchair accessory, pneumatic propulsion tire, any size, each

Service Code
E2211 (HCPCS) Manual wheelchair accessory, pneumatic propulsion tire, any size, 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

Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each

Service Code
E2212 (HCPCS) Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, 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

Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any size, each

Service Code
E2213 (HCPCS) Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any size, 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

Manual wheelchair accessory, pneumatic caster tire, any size, each

Service Code
E2214 (HCPCS) Manual wheelchair accessory, pneumatic caster tire, any size, 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

Manual wheelchair accessory, tube for pneumatic caster tire, any size, each

Service Code
E2215 (HCPCS) Manual wheelchair accessory, tube for pneumatic caster tire, any size, 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

Manual wheelchair accessory, foam filled propulsion tire, any size, each

Service Code
E2216 (HCPCS) Manual wheelchair accessory, foam filled propulsion tire, any size, 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