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

Granulocytes, pheresis, each unit

Service Code
P9050 (HCPCS) Granulocytes, pheresis, each unit
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

Whole blood or red blood cells, leukocytes reduced, CMV-negative, each unit

Service Code
P9051 (HCPCS) Whole blood or red blood cells, leukocytes reduced, CMV-negative, each unit
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

Platelets, HLA-matched leukocytes reduced, apheresis/pheresis, each unit

Service Code
P9052 (HCPCS) Platelets, HLA-matched leukocytes reduced, apheresis/pheresis, each unit
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

Platelets, pheresis, leukocytes reduced, CMV-negative, irradiated, each unit

Service Code
P9053 (HCPCS) Platelets, pheresis, leukocytes reduced, CMV-negative, irradiated, each unit
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

Whole blood or red blood cells, leukocytes reduced, frozen, deglycerol, washed, each unit

Service Code
P9054 (HCPCS) Whole blood or red blood cells, leukocytes reduced, frozen, deglycerol, washed, each unit
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

Platelets, leukocytes reduced, CMV-negative, apheresis/pheresis, each unit

Service Code
P9055 (HCPCS) Platelets, leukocytes reduced, CMV-negative, apheresis/pheresis, each unit
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

Whole blood, leukocytes reduced, irradiated, each unit

Service Code
P9056 (HCPCS) Whole blood, leukocytes reduced, irradiated, each unit
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

Red blood cells, frozen/deglycerolized/washed, leukocytes reduced, irradiated, each unit

Service Code
P9057 (HCPCS) Red blood cells, frozen/deglycerolized/washed, leukocytes reduced, irradiated, each unit
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

Red blood cells, leukocytes reduced, CMV-negative, irradiated, each unit

Service Code
P9058 (HCPCS) Red blood cells, leukocytes reduced, CMV-negative, irradiated, each unit
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

Fresh frozen plasma between 8-24 hours of collection, each unit

Service Code
P9059 (HCPCS) Fresh frozen plasma between 8-24 hours of collection, each unit
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

Fresh frozen plasma, donor retested, each unit

Service Code
P9060 (HCPCS) Fresh frozen plasma, donor retested, each unit
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

Plasma, pooled multiple donor, pathogen reduced, frozen, each unit

Service Code
P9070 (HCPCS) Plasma, pooled multiple donor, pathogen reduced, frozen, each unit
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

Plasma (single donor), pathogen reduced, frozen, each unit

Service Code
P9071 (HCPCS) Plasma (single donor), pathogen reduced, frozen, each unit
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

Platelets, pheresis, pathogen-reduced, each unit

Service Code
P9073 (HCPCS) Platelets, pheresis, pathogen-reduced, each unit
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

Blood component or product not otherwise classified

Service Code
P9099 (HCPCS) Blood component or product not otherwise classified
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

Pathogen(s) test for platelets

Service Code
P9100 (HCPCS) Pathogen(s) test for platelets
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

Travel allowance, one way in connection with medically necessary laboratory specimen collection drawn from homebound or nursing homebound patient; prorated miles actually travelled

Service Code
P9603 (HCPCS) Travel allowance, one way in connection with medically necessary laboratory specimen collection drawn from homebound or nursing homebound patient; prorated miles actually travelled
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

Travel allowance, one way in connection with medically necessary laboratory specimen collection drawn from homebound or nursing homebound patient; prorated trip charge

Service Code
P9604 (HCPCS) Travel allowance, one way in connection with medically necessary laboratory specimen collection drawn from homebound or nursing homebound patient; prorated trip charge
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

P9612-CATHETERIZATION FOR COLLECTION OF SPECIMEN, SINGLE PATIENT

Service Code
P9612 (HCPCS) P9612-CATHETERIZATION FOR COLLECTION OF SPECIMEN, SINGLE PATIENT
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

Catheterization for collection of specimen(s) (multiple patients)

Service Code
P9615 (HCPCS) Catheterization for collection of specimen(s) (multiple patients)
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