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

Supplies for external noninsulin drug infusion pump, syringe type cartridge, sterile, each

Service Code
K0552 (HCPCS) Supplies for external noninsulin drug infusion pump, syringe type cartridge, sterile, 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

Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each

Service Code
K0601 (HCPCS) Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, 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

Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each

Service Code
K0602 (HCPCS) Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, 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

Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each

Service Code
K0603 (HCPCS) Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, 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

Replacement battery for external infusion pump owned by patient, lithium, 3.6 volt, each

Service Code
K0604 (HCPCS) Replacement battery for external infusion pump owned by patient, lithium, 3.6 volt, 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

Replacement battery for external infusion pump owned by patient, lithium, 4.5 volt, each

Service Code
K0605 (HCPCS) Replacement battery for external infusion pump owned by patient, lithium, 4.5 volt, 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

Automatic external defibrillator, with integrated electrocardiogram analysis, garment type

Service Code
K0606 (HCPCS) Automatic external defibrillator, with integrated electrocardiogram analysis, garment 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 Turning Point site for specific requirements

How to Submit

Please submit your request to Turning Point

Power wheelchair accessory, 12 to 24 amp hour sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)

Service Code
K0733 (HCPCS) Power wheelchair accessory, 12 to 24 amp hour sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)
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

Portable gaseous oxygen system, rental; home compressor used to fill portable oxygen cylinders; includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and tubing

Service Code
K0738 (HCPCS) Portable gaseous oxygen system, rental; home compressor used to fill portable oxygen cylinders; includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and tubing
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

Repair or nonroutine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes

Service Code
K0739 (HCPCS) Repair or nonroutine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes
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

Suction pump, home model, portable, for use on wounds

Service Code
K0743 (HCPCS) Suction pump, home model, portable, for use on wounds
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

Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds

Service Code
K0813 (HCPCS) Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds
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, group 1 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds

Service Code
K0814 (HCPCS) Power wheelchair, group 1 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds
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, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds

Service Code
K0815 (HCPCS) Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds
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, group 1 standard, captain's chair, patient weight capacity up to and including 300 pounds

Service Code
K0816 (HCPCS) Power wheelchair, group 1 standard, captain's chair, patient weight capacity up to and including 300 pounds
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, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds

Service Code
K0820 (HCPCS) Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds
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, group 2 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds

Service Code
K0821 (HCPCS) Power wheelchair, group 2 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds
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, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds

Service Code
K0822 (HCPCS) Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds
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, group 2 standard, captain's chair, patient weight capacity up to and including 300 pounds

Service Code
K0823 (HCPCS) Power wheelchair, group 2 standard, captain's chair, patient weight capacity up to and including 300 pounds
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, group 2 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds

Service Code
K0824 (HCPCS) Power wheelchair, group 2 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds
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