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

Foot, arch support, removable, premolded, metatarsal, each

Service Code
L3050 (HCPCS) Foot, arch support, removable, premolded, metatarsal, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Foot, arch support, removable, premolded, longitudinal/metatarsal, each

Service Code
L3060 (HCPCS) Foot, arch support, removable, premolded, longitudinal/metatarsal, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Foot, arch support, nonremovable, attached to shoe, longitudinal, each

Service Code
L3070 (HCPCS) Foot, arch support, nonremovable, attached to shoe, longitudinal, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Foot, arch support, nonremovable, attached to shoe, metatarsal, each

Service Code
L3080 (HCPCS) Foot, arch support, nonremovable, attached to shoe, metatarsal, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Foot, arch support, nonremovable, attached to shoe, longitudinal/metatarsal, each

Service Code
L3090 (HCPCS) Foot, arch support, nonremovable, attached to shoe, longitudinal/metatarsal, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Hallus-valgus night dynamic splint, prefabricated, off-the-shelf

Service Code
L3100 (HCPCS) Hallus-valgus night dynamic splint, prefabricated, off-the-shelf
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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Foot, abduction rotation bar, including shoes

Service Code
L3140 (HCPCS) Foot, abduction rotation bar, including shoes
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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Foot, abduction rotation bar, without shoes

Service Code
L3150 (HCPCS) Foot, abduction rotation bar, without shoes
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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Foot, adjustable shoe-styled positioning device

Service Code
L3160 (HCPCS) Foot, adjustable shoe-styled positioning device
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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Orthopedic footwear, ladies shoe, Oxford, each

Service Code
L3215 (HCPCS) Orthopedic footwear, ladies shoe, Oxford, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Orthopedic footwear, ladies shoe, depth inlay, each

Service Code
L3216 (HCPCS) Orthopedic footwear, ladies shoe, depth inlay, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Orthopedic footwear, ladies shoe, hightop, depth inlay, each

Service Code
L3217 (HCPCS) Orthopedic footwear, ladies shoe, hightop, depth inlay, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Orthopedic footwear, mens shoe, Oxford, each

Service Code
L3219 (HCPCS) Orthopedic footwear, mens shoe, Oxford, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Orthopedic footwear, mens shoe, depth inlay, each

Service Code
L3221 (HCPCS) Orthopedic footwear, mens shoe, depth inlay, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Orthopedic footwear, mens shoe, hightop, depth inlay, each

Service Code
L3222 (HCPCS) Orthopedic footwear, mens shoe, hightop, depth inlay, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Orthopedic footwear, woman's shoe, Oxford, used as an integral part of a brace (orthosis)

Service Code
L3224 (HCPCS) Orthopedic footwear, woman's shoe, Oxford, used as an integral part of a brace (orthosis)
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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Orthopedic footwear, man's shoe, Oxford, used as an integral part of a brace (orthosis)

Service Code
L3225 (HCPCS) Orthopedic footwear, man's shoe, Oxford, used as an integral part of a brace (orthosis)
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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each

Service Code
L3250 (HCPCS) Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Foot, shoe molded to patient model, silicone shoe, each

Service Code
L3251 (HCPCS) Foot, shoe molded to patient model, silicone shoe, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.

Foot, shoe molded to patient model, Plastazote (or similar), custom fabricated, each

Service Code
L3252 (HCPCS) Foot, shoe molded to patient model, Plastazote (or similar), custom fabricated, 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

Conditional Requirements

Pre-authorization is required for members 21 and older for all providers. For all other members, authorization is required for non-participating providers only.

How to Submit

If applicable, please submit your request to Carolina Complete Health.