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

Positioning wheelchair back cushion, planar back with lateral supports, width 22 in or greater, any height, including any type mounting hardware

Service Code
E2621 (HCPCS) Positioning wheelchair back cushion, planar back with lateral supports, width 22 in or greater, any height, including any type mounting hardware
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

Skin protection wheelchair seat cushion, adjustable, width less than 22 in, any depth

Service Code
E2622 (HCPCS) Skin protection wheelchair seat cushion, adjustable, width less than 22 in, any depth
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

Skin protection wheelchair seat cushion, adjustable, width 22 in or greater, any depth

Service Code
E2623 (HCPCS) Skin protection wheelchair seat cushion, adjustable, width 22 in or greater, any depth
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

Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 in, any depth

Service Code
E2624 (HCPCS) Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 in, any depth
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

Skin protection and positioning wheelchair seat cushion, adjustable, width 22 in or greater, any depth

Service Code
E2625 (HCPCS) Skin protection and positioning wheelchair seat cushion, adjustable, width 22 in or greater, any depth
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, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable

Service Code
E2626 (HCPCS) Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable
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, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable Rancho type

Service Code
E2627 (HCPCS) Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable Rancho 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, shoulder elbow, mobile arm support attached to wheelchair, balanced, reclining

Service Code
E2628 (HCPCS) Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, reclining
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, shoulder elbow, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints)

Service Code
E2629 (HCPCS) Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints)
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, shoulder elbow, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type suspension support

Service Code
E2630 (HCPCS) Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type suspension support
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, addition to mobile arm support, elevating proximal arm

Service Code
E2631 (HCPCS) Wheelchair accessory, addition to mobile arm support, elevating proximal arm
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, addition to mobile arm support, offset or lateral rocker arm with elastic balance control

Service Code
E2632 (HCPCS) Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with elastic balance control
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, addition to mobile arm support, supinator

Service Code
E2633 (HCPCS) Wheelchair accessory, addition to mobile arm support, supinator
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

Gait modulation system, rhythmic auditory stimulation, including restricted therapy software, all components and accessories, prescription only

Service Code
E3200 (HCPCS) Gait modulation system, rhythmic auditory stimulation, including restricted therapy software, all components and accessories, prescription only
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

Gait trainer, pediatric size, posterior support, includes all accessories and components

Service Code
E8000 (HCPCS) Gait trainer, pediatric size, posterior support, includes all accessories and components
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

Gait trainer, pediatric size, upright support, includes all accessories and components

Service Code
E8001 (HCPCS) Gait trainer, pediatric size, upright support, includes all accessories and components
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

Gait trainer, pediatric size, anterior support, includes all accessories and components

Service Code
E8002 (HCPCS) Gait trainer, pediatric size, anterior support, includes all accessories and components
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

Professional services for the administration of intravenous chemotherapy or other intravenous highly complex drug or biological infusion for each infusion drug administration calendar day in the individual's home, each 15 min

Service Code
G0070 (HCPCS) Professional services for the administration of intravenous chemotherapy or other intravenous highly complex drug or biological infusion for each infusion drug administration calendar day in the individual's home, each 15 min
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

Brief (20 minutes) care management home visit for a new patient. For use only in a Medicare-approved CMMI model (services must be furnished within a beneficiary's home, domiciliary, rest home, assisted living and/or nursing facility)

Service Code
G0076 (HCPCS) Brief (20 minutes) care management home visit for a new patient. For use only in a Medicare-approved CMMI model (services must be furnished within a beneficiary's home, domiciliary, rest home, assisted living and/or nursing facility)
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

Limited (30 minutes) care management home visit for a new patient. For use only in a Medicare-approved CMMI model (services must be furnished within a beneficiary's home, domiciliary, rest home, assisted living and/or nursing facility)

Service Code
G0077 (HCPCS) Limited (30 minutes) care management home visit for a new patient. For use only in a Medicare-approved CMMI model (services must be furnished within a beneficiary's home, domiciliary, rest home, assisted living and/or nursing facility)
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.

Conditional Requirements

Pre-authorization is required for members under 21 via EPSDT.

How to Submit

If applicable, please submit your request to Trillium.