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

Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each

Service Code
E2384 (HCPCS) Power wheelchair accessory, pneumatic caster tire, any size, 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

Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each

Service Code
E2385 (HCPCS) Power wheelchair accessory, tube for pneumatic caster tire, any size, 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

Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each

Service Code
E2386 (HCPCS) Power wheelchair accessory, foam filled drive wheel tire, any size, 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

Power wheelchair accessory, foam filled caster tire, any size, replacement only, each

Service Code
E2387 (HCPCS) Power wheelchair accessory, foam filled caster tire, any size, 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

Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each

Service Code
E2388 (HCPCS) Power wheelchair accessory, foam drive wheel tire, any size, 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

Power wheelchair accessory, foam caster tire, any size, replacement only, each

Service Code
E2389 (HCPCS) Power wheelchair accessory, foam caster tire, any size, 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

Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size, replacement only, each

Service Code
E2390 (HCPCS) Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size, 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

Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each

Service Code
E2391 (HCPCS) Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, 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

Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each

Service Code
E2392 (HCPCS) Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, 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

Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each

Service Code
E2394 (HCPCS) Power wheelchair accessory, drive wheel excludes tire, any size, 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

Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each

Service Code
E2395 (HCPCS) Power wheelchair accessory, caster wheel excludes tire, any size, 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

Power wheelchair accessory, caster fork, any size, replacement only, each

Service Code
E2396 (HCPCS) Power wheelchair accessory, caster fork, any size, 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

Negative pressure wound therapy electrical pump, stationary or portable

Service Code
E2402 (HCPCS) Negative pressure wound therapy electrical pump, stationary or portable
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

Speech generating device, digitized speech, using prerecorded messages, less than or equal to eight minutes recording time

Service Code
E2500 (HCPCS) Speech generating device, digitized speech, using prerecorded messages, less than or equal to eight minutes recording time
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

Speech generating device, digitized speech, using prerecorded messages, greater than eight minutes but less than or equal to 20 minutes recording time

Service Code
E2502 (HCPCS) Speech generating device, digitized speech, using prerecorded messages, greater than eight minutes but less than or equal to 20 minutes recording time
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

Speech generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time

Service Code
E2504 (HCPCS) Speech generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time
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

Speech generating device, digitized speech, using prerecorded messages, greater than 40 minutes recording time

Service Code
E2506 (HCPCS) Speech generating device, digitized speech, using prerecorded messages, greater than 40 minutes recording time
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

Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device

Service Code
E2508 (HCPCS) Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the 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

Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access

Service Code
E2510 (HCPCS) Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access
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

Speech generating software program, for personal computer or personal digital assistant

Service Code
E2511 (HCPCS) Speech generating software program, for personal computer or personal digital assistant
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