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
Moderate (45 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)
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.
Comprehensive (60 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)
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.
Extensive (75 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)
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.
Brief (20 minutes) care management home visit for an existing 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)
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.
Limited (30 minutes) care management home visit for an existing 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)
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.
Moderate (45 minutes) care management home visit for an existing 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)
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.
Comprehensive (60 minutes) care management home visit for an existing 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)
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.
Extensive (75 minutes) care management home visit for an existing 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)
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.
Limited (30 minutes) care management home care plan oversight. 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)
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.
Comprehensive (60 minutes) care management home care plan oversight. 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)
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.
Prostate cancer screening; prostate specific antigen test (PSA)
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
Diabetes Outpatient Self-Management Education
Diabetes outpatient self-management education (DSME) is an interactive, ongoing process of teaching the knowledge, skills and abilities needed for diabetes self-care. The process combines the needs, goals, and life experiences of the diabetic beneficiary and certified diabetes educator(s) and is guided by evidence-based standards. This process includes: a. Assessment of the individual’s specific education needs; b. Identification of the individual’s specific diabetes self-management goals; c. Education and behavioral intervention directed toward helping the individual achieve identified self-management goals; d. Evaluation of the individual’s attainment of identified self-management goals.
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.
Unit Value
1 unit = 30min
Limits
Physician certification is required. A physician referral will meet this qualification. A prescription signed by the referring physician will suffice as certification. Initially, up to 10 hours of DSME is covered within a continuous 12-month period (not necessarily within the same calendar year). DSME may be offered in any combination of individual or group counseling. For follow-up training, a maximum of 2 hours of training is covered each year, starting with the calendar year in which the beneficiary receives the initial training, in any combination of individual or group counseling.
Benefits are provided for diet therapy or dietary counseling when the services are included in the fee for the overall program.
Exclusions
Specific Criteria Not Covered by Medicaid DSME is not covered if the beneficiary does not have a diagnosis of diabetes. If the program does not meet the requirements for staff qualifications as recognized providers by the American Diabetes Association, or the Diabetes Education Accredited Programs DSME is not covered. Diet therapy or dietary counseling as a separate charge is not covered. Meals provided during an Outpatient Diabetes Self-Care Program are not covered.
Place of Service
Physician’s office, outpatient hospital department, physician diagnostic clinic, local health department, rural health clinic, federally qualified health center.
How to Submit
N/A - No authorization is required
Resources
Diabetes Outpatient Self-Management Education
Diabetes outpatient self-management education (DSME) is an interactive, ongoing process of teaching the knowledge, skills and abilities needed for diabetes self-care. The process combines the needs, goals, and life experiences of the diabetic beneficiary and certified diabetes educator(s) and is guided by evidence-based standards. This process includes: a. Assessment of the individual’s specific education needs; b. Identification of the individual’s specific diabetes self-management goals; c. Education and behavioral intervention directed toward helping the individual achieve identified self-management goals; d. Evaluation of the individual’s attainment of identified self-management goals.
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.
Unit Value
1 unit = 30min
Limits
Physician certification is required. A physician referral will meet this qualification. A prescription signed by the referring physician will suffice as certification. Initially, up to 10 hours of DSME is covered within a continuous 12-month period (not necessarily within the same calendar year). DSME may be offered in any combination of individual or group counseling. For follow-up training, a maximum of 2 hours of training is covered each year, starting with the calendar year in which the beneficiary receives the initial training, in any combination of individual or group counseling.
Benefits are provided for diet therapy or dietary counseling when the services are included in the fee for the overall program.
Exclusions
Specific Criteria Not Covered by Medicaid DSME is not covered if the beneficiary does not have a diagnosis of diabetes. If the program does not meet the requirements for staff qualifications as recognized providers by the American Diabetes Association, or the Diabetes Education Accredited Programs DSME is not covered. Diet therapy or dietary counseling as a separate charge is not covered. Meals provided during an Outpatient Diabetes Self-Care Program are not covered.
Place of Service
Physician’s office, outpatient hospital department, physician diagnostic clinic, local health department, rural health clinic, federally qualified health center.
How to Submit
N/A - No authorization is required
Resources
Medically Necessary Routine Foot Care
Medically necessary routine foot care is the cutting or removal of corns and calluses; trimming, cutting, clipping, or debriding of nails; and other hygienic care due to a physical or clinical finding that is consistent with a metabolic, neurological, and/or peripheral vascular disease diagnosis and indicative of severe peripheral involvement.
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.
Place of Service
Inpatient, Outpatient, Office.
Other Information
Modifiers: Q7, Q8, Q9
How to Submit
N/A - No authorization is required
Resources
Occupational therapy services requiring the skills of a qualified occupational therapist, furnished as a component of a partial hospitalization treatment program, per session (45 minutes or more)
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 Evolent site for specific requirements
How to Submit
Please submit your request to Evolent
Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes
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
Conditional Requirements
Pre-authorization required for all providers unless rendered on same day as evaluation.
How to Submit
If applicable, please submit your request to Carolina Complete Health.
Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes
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
Conditional Requirements
Pre-authorization required for all providers unless rendered on same day as evaluation.
How to Submit
If applicable, please submit your request to Carolina Complete Health.
Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes
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
Conditional Requirements
Pre-authorization required for all providers unless rendered on same day as evaluation.
How to Submit
If applicable, please submit your request to Carolina Complete Health.
Hospice Services
The NC Medicaid (Medicaid) hospice benefit is a comprehensive set of services, identified and coordinated by a hospice interdisciplinary group (IDG). The IDG delivers medical, nursing, social, psychological, emotional, and spiritual services to enable physical and emotional comfort and support using a holistic approach to maintain the best quality of life for a terminally ill beneficiary, their family, and caregivers. The priority of hospice services is to meet the needs and goals of the hospice beneficiary, family, and caregivers with daily activities and to help the terminally ill beneficiary with minimal disruption to normal activities, in the environment that best meets the care and comfort needs of the beneficiary and unit of care.
The hospice IDG achieves this by organizing and managing a comprehensive care plan focused on coordinating care, services and resources to the beneficiary, caregivers, and family necessary for the palliation and management of the terminal illness and related conditions.
Only Medicare-certified and North Carolina licensed hospice agencies are eligible to participate as Medicaid hospice providers through the NC Division of Health Service Regulation (www.ncdhhs.gov). Each site providing hospice services must be separately licensed. The North Carolina Medical Care Commission has rulemaking authority for hospice. The statutes that apply to hospice agencies are General Statute 131E-200 through 207 and the licensure rules are under Title 10A of the North Carolina Administrative Code (10A NCAC 13K); (G.S. 131E, Article 9, 175-190) and administrative rules (10A NCAC Subchapter 14C).
A Hospice provider must have a contract with a nursing home or hospital if services are provided within those facilities.
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.
Unit Value
units of service = 15-minute increments up to 4 hours total per day
Limits
First and second benefit periods are each 90 calendar days.
Third and each subsequent benefit period are 60 calendar days.
First-benefit-period PA request and election statement must be uploaded within six calendar days of the effective date of hospice election.
PA for third and subsequent benefit periods must be submitted at least ten calendar days before the end of the current benefit period.
Written certifications may be completed no more than 15 calendar days prior to the effective date of election.
Recertifications may be completed no more than 15 calendar days prior to the start of a subsequent benefit period. Face-to-face encounter must occur prior to, but no more than 30 calendar days prior to, the third benefit period recertification and every recertification thereafter.
Initial assessment must be completed within 48 hours after election of hospice care.
Comprehensive assessment must be completed no later than five calendar days after election of hospice care.
Medicaid room and board coverage in SNF/NF/ICF-IID applies when the Medicare hospice benefit is elected.
Exclusions
Medicaid shall not cover additional respite care services over and above the per diem amount contracted for hospice services. Attending and consulting physician services are not considered a hospice service and are instead covered under the Medicaid Physician Services program policies. A beneficiary who elects the hospice benefit waives rights to Medicaid coverage of other services that replicate hospice-covered services. Specifically, home health, durable medical equipment, and home infusion therapy are not allowed when they pertain to treatment of the terminal illness or related conditions, and drugs and biologicals pertaining to the terminal diagnosis are reimbursed to the hospice as part of the hospice per diem rather than separately, although Medicaid may reimburse the pharmacy directly for drugs used to treat conditions unrelated to the terminal illness. For beneficiaries under 21 years old, the waiver of curative services is not applicable, and concurrent care is available without requiring waiver of rights to cure- or treatment-related services for the terminal condition.
Diagnosis Requirements
The beneficiary must be terminally ill, meaning the beneficiary has a medical prognosis that life expectancy is 6 months or less if the illness runs its normal course.
Place of Service
The beneficiary’s primary private residence. An adult care home under a written agreement with the hospice provider. A hospice residential care facility or hospice inpatient unit. A hospital, nursing facility, or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) under a written agreement with the hospice provider
How to Submit
Please submit your request to Carolina Complete Health through Availity
Resources
Services of home health/hospice aide in home health or hospice settings, each 15 minutes
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
Conditional Requirements
Pre-authorization required for all providers unless rendered on same day as evaluation.
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.