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

Orthopedic shoe addition, March bar

Service Code
L3595 (HCPCS) Orthopedic shoe addition, March bar
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.

Transfer of an orthosis from one shoe to another, caliper plate, existing

Service Code
L3600 (HCPCS) Transfer of an orthosis from one shoe to another, caliper plate, existing
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.

Transfer of an orthosis from one shoe to another, caliper plate, new

Service Code
L3610 (HCPCS) Transfer of an orthosis from one shoe to another, caliper plate, new
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.

Transfer of an orthosis from one shoe to another, solid stirrup, existing

Service Code
L3620 (HCPCS) Transfer of an orthosis from one shoe to another, solid stirrup, existing
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.

Transfer of an orthosis from one shoe to another, solid stirrup, new

Service Code
L3630 (HCPCS) Transfer of an orthosis from one shoe to another, solid stirrup, new
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 shoe, modification, addition or transfer, not otherwise specified

Service Code
L3649 (HCPCS) Orthopedic shoe, modification, addition or transfer, not otherwise specified
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

Shoulder orthosis (SO), shoulder joint design, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

Service Code
L3677 (HCPCS) Shoulder orthosis (SO), shoulder joint design, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
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

Elbow orthosis (EO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

Service Code
L3702 (HCPCS) Elbow orthosis (EO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
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

Elbow orthosis (EO), elastic with metal joints, prefabricated, off-the-shelf

Service Code
L3710 (HCPCS) Elbow orthosis (EO), elastic with metal joints, 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

How to Submit

Please submit your request to Carolina Complete Health through Availity

Elbow orthosis (EO), double upright with forearm/arm cuffs, free motion, custom fabricated

Service Code
L3720 (HCPCS) Elbow orthosis (EO), double upright with forearm/arm cuffs, free motion, custom fabricated
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

Elbow orthosis (EO), double upright with forearm/arm cuffs, extension/ flexion assist, custom fabricated

Service Code
L3730 (HCPCS) Elbow orthosis (EO), double upright with forearm/arm cuffs, extension/ flexion assist, custom fabricated
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

Elbow orthosis (EO), double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated

Service Code
L3740 (HCPCS) Elbow orthosis (EO), double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated
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

Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

Service Code
L3760 (HCPCS) Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
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

Elbow orthosis (EO), with adjustable position locking joint(s), prefabricated, off-the-shelf

Service Code
L3761 (HCPCS) Elbow orthosis (EO), with adjustable position locking joint(s), 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

How to Submit

Please submit your request to Carolina Complete Health through Availity

Elbow orthosis (EO), rigid, without joints, includes soft interface material, prefabricated, off-the-shelf

Service Code
L3762 (HCPCS) Elbow orthosis (EO), rigid, without joints, includes soft interface material, 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

How to Submit

Please submit your request to Carolina Complete Health through Availity

Elbow-wrist-hand orthosis (EWHO), rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

Service Code
L3763 (HCPCS) Elbow-wrist-hand orthosis (EWHO), rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
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

Elbow-wrist-hand orthosis (EWHO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

Service Code
L3764 (HCPCS) Elbow-wrist-hand orthosis (EWHO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment
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

Elbow-wrist-hand-finger orthosis (EWHFO), rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

Service Code
L3765 (HCPCS) Elbow-wrist-hand-finger orthosis (EWHFO), rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
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

Elbow-wrist-hand-finger orthosis (EWHFO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

Service Code
L3766 (HCPCS) Elbow-wrist-hand-finger orthosis (EWHFO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment
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

Wrist-hand-finger orthosis (WHFO), includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and adjustment

Service Code
L3806 (HCPCS) Wrist-hand-finger orthosis (WHFO), includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and adjustment
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