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
Services performed by a qualified physical therapist assistant 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 assistant 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 physical therapist, in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, 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
How to Submit
Please submit your request to Carolina Complete Health through Availity
Services performed by a qualified occupational therapist, in the home health setting, in the establishment or delivery of a safe and effective occupational therapy maintenance program, 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
How to Submit
Please submit your request to Carolina Complete Health through Availity
Services performed by a qualified speech-language pathologist, in the home health setting, in the establishment or delivery of a safe and effective speech-language pathology maintenance program, 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
How to Submit
Please submit your request to Carolina Complete Health through Availity
Skilled services by a registered nurse (RN) for management and evaluation of the plan of care; each 15 minutes (the patient's underlying condition or complication requires an RN to ensure that essential nonskilled care achieves its purpose in the home hea
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
Physician supervision of a patient under a Medicare-approved hospice (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patie
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
Quantitative software measurements of cardiac volume, cardiac chambers volumes and left ventricular wall mass derived from CT scan(s) data of the chest/heart (with or without contrast)
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
G0237 THERAPEUTIC PROCEDURES TO INCREASE STRENGTH OR ENDURANCE OF RESPIRATORY MUSCLES, FACE TO FACE, Non Covered Medicaid Service
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
Please submit your request to Trillium Health Resources
Demonstration, prior to initiation of home INR monitoring, for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face-t
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
Physician review, interpretation, and patient management of home INR testing for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; testing not occurring more frequen
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
Injection procedure for sacroiliac joint; provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography
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 Evolent site for specific requirements
Conditional Requirements
Pre-authorization is required for all providers unless performed on the same day as surgery.
How to Submit
If applicable, please submit your request to Evolent.
Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to 77065 or 77066)
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
Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care
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 required for all providers unless rendered on same day as evaluation.
How to Submit
If applicable, please submit your request to Trillium.
Reconstruction, computed tomographic angiography of aorta for surgical planning for vascular surgery
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
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
How to Submit
If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.
Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee
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
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
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
Preoperative pulmonary surgery services for preparation for LVRS, complete course of services, to include a minimum of 16 days of services
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
Complete CBC, automated (HgB, HCT, RBC, WBC, without platelet count) and automated WBC differential count
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
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