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

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

Service Code
Q4418 (HCPCS) BioLab Membrane Wrap Flow, 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.

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

BioLab Membrane Wrap Lite Flow, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4419 (HCPCS) BioLab Membrane Wrap Lite Flow, 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.

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

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

Service Code
Q4420 (HCPCS) NuForm, 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

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

Service Code
Q4421 (HCPCS) BioLab Membrane Wrap 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

A/C Wrap, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4422 (HCPCS) A/C Wrap, 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

BioLab Tri-Membrane Wrap Flow, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4423 (HCPCS) BioLab Tri-Membrane Wrap Flow, 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

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

Service Code
Q4424 (HCPCS) Revive FT, 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

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

Service Code
Q4425 (HCPCS) Revive TL, 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.

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity

DermaBind TL + or DermaBind TL X, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4426 (HCPCS) DermaBind TL + or DermaBind TL X, 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

DermaBind DL N, DermaBind DL +, or DermaBind DL X, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4427 (HCPCS) DermaBind DL N, DermaBind DL +, or DermaBind DL X, 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

DermaBind SL N, DermaBind SL +, or DermaBind SL X, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4428 (HCPCS) DermaBind SL N, DermaBind SL +, or DermaBind SL X, per sq cm (add-on, list separately in addition to primary procedure)
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

DermaBind CH N or DermaBind CH X, per sq cm (add-on, list separately in addition to primary procedure)

Service Code
Q4429 (HCPCS) DermaBind CH N or DermaBind CH X, 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

PMA skin substitute product, not otherwise specified (list in addition to primary procedure)

Service Code
Q4431 (HCPCS) PMA skin substitute product, not otherwise specified (list 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

510(k) skin substitute product, not otherwise specified (list in addition to primary procedure)

Service Code
Q4432 (HCPCS) 510(k) skin substitute product, not otherwise specified (list 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

361 HCT/P skin substitute product, not otherwise specified (list in addition to primary procedure)

Service Code
Q4433 (HCPCS) 361 HCT/P skin substitute product, not otherwise specified (list 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

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

Service Code
Q4435 (HCPCS) Renati 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

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

Service Code
Q4436 (HCPCS) Renati AC Membrane, per sq cm (add-on, list separately in addition to primary procedure)
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

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

Service Code
Q4437 (HCPCS) Revival 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

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

Service Code
Q4438 (HCPCS) Pretect, per sq cm (add-on, list separately in addition to primary procedure)
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

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

Service Code
Q4439 (HCPCS) InstaGraft, 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