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

CYGNUS Disk, per sq cm

Service Code
Q4362 (HCPCS) CYGNUS Disk, 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

Amnio Burgeon Membrane and Hydromembrane, per sq cm

Service Code
Q4363 (HCPCS) Amnio Burgeon Membrane and 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

Amnio Burgeon Xplus Membrane and Xplus Hydromembrane, per sq cm

Service Code
Q4364 (HCPCS) Amnio Burgeon Xplus Membrane and 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

Amnio Burgeon Dual-Layer Membrane, per sq cm

Service Code
Q4365 (HCPCS) Amnio Burgeon 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

Dual Layer Amnio Burgeon X-Membrane, per sq cm

Service Code
Q4366 (HCPCS) Dual Layer Amnio Burgeon X-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

AmnioCore SL, per sq cm

Service Code
Q4367 (HCPCS) AmnioCore SL, 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

AmchoThick, per sq cm

Service Code
Q4368 (HCPCS) AmchoThick, 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

AmnioPlast 3, per sq cm

Service Code
Q4369 (HCPCS) AmnioPlast 3, 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

AeroGuard, per sq cm

Service Code
Q4370 (HCPCS) AeroGuard, 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

NeoGuard, per sq cm

Service Code
Q4371 (HCPCS) NeoGuard, 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 EXCEL, per sq cm

Service Code
Q4372 (HCPCS) AmchoPlast EXCEL, 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

Membrane Wrap-Lite, per sq cm

Service Code
Q4373 (HCPCS) Membrane Wrap-Lite, 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

duoGRAFT AC, per sq cm

Service Code
Q4375 (HCPCS) duoGRAFT AC, 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

Duograft AA, per sq cm

Service Code
Q4376 (HCPCS) Duograft AA, 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

triGRAFT FT, per sq cm

Service Code
Q4377 (HCPCS) triGRAFT FT, 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

Renew FT Matrix, per sq cm

Service Code
Q4378 (HCPCS) Renew FT 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

AmnioDefend FT Matrix, per sq cm

Service Code
Q4379 (HCPCS) AmnioDefend FT 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

AdvoGraft One, per sq cm

Service Code
Q4380 (HCPCS) AdvoGraft One, 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
Q4381 (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

AdvoGraft Dual, per sq cm

Service Code
Q4382 (HCPCS) AdvoGraft 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