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

Summit AC, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4398 (HCPCS) Summit AC, per sq cm (add-on, list separately in addition to primary procedure)
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

Summit FX, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4399 (HCPCS) Summit FX, per sq cm (add-on, list separately in addition to primary procedure)
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

Polygon3 Membrane, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4400 (HCPCS) Polygon3 Membrane, per sq cm (add-on, list separately in addition to primary procedure)
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

Absolv3 Membrane, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4401 (HCPCS) Absolv3 Membrane, per sq cm (add-on, list separately in addition to primary procedure)
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 2.0, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4402 (HCPCS) XWRAP 2.0, per sq cm (add-on, list separately in addition to primary procedure)
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 Plus, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4403 (HCPCS) XWRAP Dual Plus, per sq cm (add-on, list separately in addition to primary procedure)
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 Hydro Plus, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4404 (HCPCS) XWRAP Hydro Plus, per sq cm (add-on, list separately in addition to primary procedure)
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 Fenestra Plus, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4405 (HCPCS) XWRAP Fenestra Plus, per sq cm (add-on, list separately in addition to primary procedure)
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 Fenestra, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4406 (HCPCS) XWRAP Fenestra, per sq cm (add-on, list separately in addition to primary procedure)
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 Tribus, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4407 (HCPCS) XWRAP Tribus, per sq cm (add-on, list separately in addition to primary procedure)
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 Hydro, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4408 (HCPCS) XWRAP Hydro, per sq cm (add-on, list separately in addition to primary procedure)
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

AmniomatrixF3X, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4409 (HCPCS) AmniomatrixF3X, per sq cm (add-on, list separately in addition to primary procedure)
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

AmchoMatrixDL, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4410 (HCPCS) AmchoMatrixDL, per sq cm (add-on, list separately in addition to primary procedure)
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

AmniomatrixF4X, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4411 (HCPCS) AmniomatrixF4X, per sq cm (add-on, list separately in addition to primary procedure)
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

CHORIOFIX, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4412 (HCPCS) CHORIOFIX, per sq cm (add-on, list separately in addition to primary procedure)
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

Cygnus Solo, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4413 (HCPCS) Cygnus Solo, per sq cm (add-on, list separately in addition to primary procedure)
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

SimpliChor, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4414 (HCPCS) SimpliChor, per sq cm (add-on, list separately in addition to primary procedure)
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

AlexiGuard SL-T, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4415 (HCPCS) AlexiGuard SL-T, per sq cm (add-on, list separately in addition to primary procedure)
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

AlexiGuard TL-T, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4416 (HCPCS) AlexiGuard TL-T, per sq cm (add-on, list separately in addition to primary procedure)
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

AlexiGuard DL-T, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4417 (HCPCS) AlexiGuard DL-T, per sq cm (add-on, list separately in addition to primary procedure)
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