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

TheraMend, per sq cm

Service Code
Q4342 (HCPCS) TheraMend, per sq cm
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 Trillium Health Resources

Dermacyte AC Matrix Amniotic Membrane Allograft, per sq cm

Service Code
Q4343 (HCPCS) Dermacyte AC Matrix Amniotic Membrane Allograft, per sq cm
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 Trillium Health Resources

Tri-Membrane Wrap, per sq cm

Service Code
Q4344 (HCPCS) Tri-Membrane Wrap, per sq cm
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 Trillium Health Resources

Matrix HD Allograft Dermis, per sq cm

Service Code
Q4345 (HCPCS) Matrix HD Allograft Dermis, per sq cm
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 Trillium Health Resources

Shelter DM Matrix, per sq cm

Service Code
Q4346 (HCPCS) Shelter DM Matrix, per sq cm
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 Trillium Health Resources

Rampart DL Matrix, per sq cm

Service Code
Q4347 (HCPCS) Rampart DL Matrix, per sq cm
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 Trillium Health Resources

Sentry SL Matrix, per sq cm

Service Code
Q4348 (HCPCS) Sentry SL Matrix, per sq cm
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 Trillium Health Resources

Mantle DL Matrix, per sq cm

Service Code
Q4349 (HCPCS) Mantle DL Matrix, per sq cm
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 Trillium Health Resources

Palisade DM Matrix, per sq cm

Service Code
Q4350 (HCPCS) Palisade DM Matrix, per sq cm
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 Trillium Health Resources

Enclose TL Matrix, per sq cm

Service Code
Q4351 (HCPCS) Enclose TL Matrix, per sq cm
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 Trillium Health Resources

Overlay SL Matrix, per sq cm

Service Code
Q4352 (HCPCS) Overlay SL Matrix, per sq cm
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 Trillium Health Resources

Xceed TL Matrix, per sq cm

Service Code
Q4353 (HCPCS) Xceed TL Matrix, per sq cm
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 Trillium Health Resources

PalinGen Dual-Layer Membrane, per sq cm

Service Code
Q4354 (HCPCS) PalinGen Dual-Layer Membrane, per sq cm
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 Trillium Health Resources

Abiomend Xplus Membrane and Abiomend Xplus Hydromembrane, per sq cm

Service Code
Q4355 (HCPCS) Abiomend Xplus Membrane and Abiomend Xplus Hydromembrane, per sq cm
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 Trillium Health Resources

Abiomend Membrane and Abiomend Hydromembrane, per sq cm

Service Code
Q4356 (HCPCS) Abiomend Membrane and Abiomend Hydromembrane, per sq cm
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 Trillium Health Resources

XWRAP Plus, per sq cm

Service Code
Q4357 (HCPCS) XWRAP Plus, per sq cm
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 Trillium Health Resources

XWRAP Dual, per sq cm

Service Code
Q4358 (HCPCS) XWRAP Dual, per sq cm
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 Trillium Health Resources

ChoriPly, per sq cm

Service Code
Q4359 (HCPCS) ChoriPly, per sq cm
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 Trillium Health Resources

AmchoPlast FD, per sq cm

Service Code
Q4360 (HCPCS) AmchoPlast FD, per sq cm
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 Trillium Health Resources

EPIXPRESS, per sq cm

Service Code
Q4361 (HCPCS) EPIXPRESS, per sq cm
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 Trillium Health Resources