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

Chronic pain management and treatment, monthly bundle including, diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and/or maintenance of a person-centered care plan th

Service Code
G3002 (HCPCS) Chronic pain management and treatment, monthly bundle including, diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and/or maintenance of a person-centered care plan th
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 all providers unless performed on the same day as surgery.

How to Submit

If applicable, please submit your request to Trillium.

Each additional 15 minutes of chronic pain management and treatment by a physician or other qualified health care professional, per calendar month. (List separately in addition to code for G3002. When using G3003, 15 minutes must be met or exceeded)

Service Code
G3003 (HCPCS) Each additional 15 minutes of chronic pain management and treatment by a physician or other qualified health care professional, per calendar month. (List separately in addition to code for G3002. When using G3003, 15 minutes must be met or exceeded)
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

G6038 Assay of salicylate

Service Code
G6038 (HCPCS) G6038 Assay of salicylate
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

G6039 Assay of acetaminophen

Service Code
G6039 (HCPCS) G6039 Assay of acetaminophen
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

G6040 Assay of alcohol (ethanol); any specimen except breath

Service Code
G6040 (HCPCS) G6040 Assay of alcohol (ethanol); any specimen except breath
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

G8950 PRE-HYPERTENSIVE OR HYPERTENSIVE BLOOD PRESSURE READING DOCUMENTED, INDICATED

Service Code
G8950 (HCPCS) G8950 PRE-HYPERTENSIVE OR HYPERTENSIVE BLOOD PRESSURE READING DOCUMENTED, INDICATED
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

G8952 PRE-HYPERTENSIVE OR HYPERTENSIVE BLOOD PRESSURE READING DOCUMENTED, INDICATED

Service Code
G8952 (HCPCS) G8952 PRE-HYPERTENSIVE OR HYPERTENSIVE BLOOD PRESSURE READING DOCUMENTED, INDICATED
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

Coordinated care fee, home monitoring

Service Code
G9006 (HCPCS) Coordinated care fee, home monitoring
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

Clinical Coverage Policy No: 12B

Service Code
G9012 (HCPCS) Other specified case management service not elsewhere classified
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
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.

Unit Value

1 unit =15 min

How to Submit

N/A - No authorization is required

Resources

Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s)

Service Code
G9143 (HCPCS) Warfarin responsiveness testing by genetic technique using any method, any number of specimen(s)
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.

How to Submit

Please submit your request to EviCore

Bundled payments for care improvement initiative home visit for patient assessment performed by a qualified health care professional for individuals not considered homebound including, but not limited to, assessment of safety, falls, clinical status, flui

Service Code
G9187 (HCPCS) Bundled payments for care improvement initiative home visit for patient assessment performed by a qualified health care professional for individuals not considered homebound including, but not limited to, assessment of safety, falls, clinical status, flui
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

Admission to Medicare Care Choice Model Program (MCCM)

Service Code
G9480 (HCPCS) Admission to Medicare Care Choice Model Program (MCCM)
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

Remote in-home visit for the evaluation and management of a new patient for use only in a Medicare-approved CMS Innovation Center Demonstration Project, which requires these three key components: a problem focused history; a problem focused examination; s

Service Code
G9481 (HCPCS) Remote in-home visit for the evaluation and management of a new patient for use only in a Medicare-approved CMS Innovation Center Demonstration Project, which requires these three key components: a problem focused history; a problem focused examination; s
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

Remote in-home visit for the evaluation and management of a new patient for use only in a Medicare-approved CMS Innovation Center Demonstration Project, which requires these three key components: an expanded problem focused history; an expanded problem fo

Service Code
G9482 (HCPCS) Remote in-home visit for the evaluation and management of a new patient for use only in a Medicare-approved CMS Innovation Center Demonstration Project, which requires these three key components: an expanded problem focused history; an expanded problem fo
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

Remote in-home visit for the evaluation and management of a new patient for use only in a Medicare-approved CMS Innovation Center Demonstration Project, which requires these three key components: a detailed history; a detailed examination; medical decisio

Service Code
G9483 (HCPCS) Remote in-home visit for the evaluation and management of a new patient for use only in a Medicare-approved CMS Innovation Center Demonstration Project, which requires these three key components: a detailed history; a detailed examination; medical decisio
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

Remote in-home visit for the evaluation and management of a new patient for use only in a Medicare-approved CMS Innovation Center Demonstration Project, which requires these three key components: a comprehensive history; a comprehensive examination; medic

Service Code
G9484 (HCPCS) Remote in-home visit for the evaluation and management of a new patient for use only in a Medicare-approved CMS Innovation Center Demonstration Project, which requires these three key components: a comprehensive history; a comprehensive examination; medic
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

Remote in-home visit for the evaluation and management of a new patient for use only in a Medicare-approved CMS Innovation Center Demonstration Project, which requires these three key components: a comprehensive history; a comprehensive examination; medic

Service Code
G9485 (HCPCS) Remote in-home visit for the evaluation and management of a new patient for use only in a Medicare-approved CMS Innovation Center Demonstration Project, which requires these three key components: a comprehensive history; a comprehensive examination; medic
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

Remote in-home visit for the evaluation and management of an established patient for use only in a Medicare-approved CMS Innovation Center Demonstration Project, which requires at least two of the following three key components: a problem focused history;

Service Code
G9486 (HCPCS) Remote in-home visit for the evaluation and management of an established patient for use only in a Medicare-approved CMS Innovation Center Demonstration Project, which requires at least two of the following three key components: a problem focused history;
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

Remote in-home visit for the evaluation and management of an established patient for use only in a Medicare-approved CMS Innovation Center Demonstration Project, which requires at least two of the following three key components: an expanded problem focuse

Service Code
G9487 (HCPCS) Remote in-home visit for the evaluation and management of an established patient for use only in a Medicare-approved CMS Innovation Center Demonstration Project, which requires at least two of the following three key components: an expanded problem focuse
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

Remote in-home visit for the evaluation and management of an established patient for use only in a Medicare-approved CMS Innovation Center Demonstration Project, which requires at least two of the following three key components: a detailed history; a deta

Service Code
G9488 (HCPCS) Remote in-home visit for the evaluation and management of an established patient for use only in a Medicare-approved CMS Innovation Center Demonstration Project, which requires at least two of the following three key components: a detailed history; a deta
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