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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

Injection, follitropin beta, 75 IU

Service Code
S0128 (HCPCS) Injection, follitropin beta, 75 IU
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

Injection, ganirelix acetate, 250 mcg

Service Code
S0132 (HCPCS) Injection, ganirelix acetate, 250 mcg
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

Physician management of patient home care, standard monthly case rate (per 30 days)

Service Code
S0270 (HCPCS) Physician management of patient home care, standard monthly case rate (per 30 days)
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

Physician visit at member's home, outside of a capitation arrangement

Service Code
S0273 (HCPCS) Physician visit at member's home, outside of a capitation arrangement
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

1E-6 Pregnancy Management Program

Service Code
S0280 (HCPCS) Medical home program, comprehensive care coordination and planning, initial plan
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

The Pregnancy Management Program (PMP) (formerly Pregnancy Medical Home - PMH) is a care program with a set of mandatory standards and clinical initiatives aimed at improving the quality of pregnancy care, improving maternal and infant outcomes, and reducing health care costs. The PMP encourages adoption of the best prenatal, pregnancy, and perinatal care for Medicaid beneficiaries. Unlike the PMH program, there is no enrollment requirement for the PMP. All providers eligible to bill NC Medicaid (Medicaid) for obstetric services are considered participating PMP providers. A key feature of the PMP is the continued use of the standardized screening form to identify and refer women at risk for an adverse birth outcome to the Care Management for High-Risk Pregnancies (CMHRP) program, a more intense set of care management services that is coordinated and provided by Local Health Departments (LHDs). Together, these two programs work to improve the overall health of women and newborns across the state. All PMP providers shall be required to ensure appropriate coordination with LHD care managers for the sub-set of their practice population who receive CMHRP services. To allow the PMP to stay abreast of PMP beneficiary medical needs, LHD care managers shall provide the PMP alerts, including: emergency department (ED) visits, visits to a specialist, and missed appointments.

Authorization Guidelines

If your request is for outpatient Durable Medical Equipment, Personal Care Service, or Private Duty Nursing, see the Carolina Complete Health site for specific requirements. If your request is NOT for outpatient Durable Medical Equipment, Personal Care Service, or Private Duty Nursing, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for outpatient Durable Medical Equipment, Personal Care Service, or Private Duty Nursing, please submit request to Carolina Complete Health. If your request is NOT for outpatient Durable Medical Equipment, Personal Care Service, or Private Duty Nursing, please submit request to Trillium.

Age Group Details

PMP providers are not required to obtain prior approval for any obstetrical ultrasound.

Place of Service

Inpatient hospital, Outpatient hospital, Office.

Additional Service Specifics

Telehealth Claims: Modifier GT must be appended to the CPT or HCPCS code to indicate that a service has been provided via interactive audio-visual communication. This modifier is not appropriate for virtual patient communications or remote patient monitoring.

How to Submit

If your request is for outpatient Durable Medical Equipment, Personal Care Service, or Private Duty Nursing, please submit request to Carolina Complete Health. If your request is NOT for outpatient Durable Medical Equipment, Personal Care Service, or Private Duty Nursing, please submit request to Trillium.

Resources

1E-6 Pregnancy Management Program

Service Code
S0281 (HCPCS) Medical home program, comprehensive care coordination and planning, maintenance of plan
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

The Pregnancy Management Program (PMP) (formerly Pregnancy Medical Home - PMH) is a care program with a set of mandatory standards and clinical initiatives aimed at improving the quality of pregnancy care, improving maternal and infant outcomes, and reducing health care costs. The PMP encourages adoption of the best prenatal, pregnancy, and perinatal care for Medicaid beneficiaries. Unlike the PMH program, there is no enrollment requirement for the PMP. All providers eligible to bill NC Medicaid (Medicaid) for obstetric services are considered participating PMP providers. A key feature of the PMP is the continued use of the standardized screening form to identify and refer women at risk for an adverse birth outcome to the Care Management for High-Risk Pregnancies (CMHRP) program, a more intense set of care management services that is coordinated and provided by Local Health Departments (LHDs). Together, these two programs work to improve the overall health of women and newborns across the state. All PMP providers shall be required to ensure appropriate coordination with LHD care managers for the sub-set of their practice population who receive CMHRP services. To allow the PMP to stay abreast of PMP beneficiary medical needs, LHD care managers shall provide the PMP alerts, including: emergency department (ED) visits, visits to a specialist, and missed appointments.

Authorization Guidelines

If your request is for outpatient Durable Medical Equipment, Personal Care Service, or Private Duty Nursing, see the Carolina Complete Health site for specific requirements. If your request is NOT for outpatient Durable Medical Equipment, Personal Care Service, or Private Duty Nursing, please submit any records and any other information that you believe support the member has met the applicable medical necessity criteria to Trillium.

Conditional Requirements

If your request is for outpatient Durable Medical Equipment, Personal Care Service, or Private Duty Nursing, please submit request to Carolina Complete Health. If your request is NOT for outpatient Durable Medical Equipment, Personal Care Service, or Private Duty Nursing, please submit request to Trillium.

Age Group Details

PMP providers are not required to obtain prior approval for any obstetrical ultrasound.

Place of Service

Inpatient hospital, Outpatient hospital, Office.

Additional Service Specifics

Telehealth Claims: Modifier GT must be appended to the CPT or HCPCS code to indicate that a service has been provided via interactive audio-visual communication. This modifier is not appropriate for virtual patient communications or remote patient monitoring.

How to Submit

If your request is for outpatient Durable Medical Equipment, Personal Care Service, or Private Duty Nursing, please submit request to Carolina Complete Health. If your request is NOT for outpatient Durable Medical Equipment, Personal Care Service, or Private Duty Nursing, please submit request to Trillium.

Resources

Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline

Service Code
S2083 (HCPCS) Adjustment of gastric band diameter via subcutaneous port by injection or aspiration of saline
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

Metal-on-metal total hip resurfacing, including acetabular and femoral components

Service Code
S2118 (HCPCS) Metal-on-metal total hip resurfacing, including acetabular and femoral components
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 Evolent site for specific requirements

How to Submit

Please submit your request to Evolent

Low density lipoprotein (LDL) apheresis using heparin-induced extracorporeal LDL precipitation

Service Code
S2120 (HCPCS) Low density lipoprotein (LDL) apheresis using heparin-induced extracorporeal LDL precipitation
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

Cord blood harvesting for transplantation, allogeneic

Service Code
S2140 (HCPCS) Cord blood harvesting for transplantation, allogeneic
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

MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING MINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION; USING ARTERIAL GRAFT(S), SINGLE CORONARY ARTERIAL GRAFT

Service Code
S2205 (HCPCS) MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING MINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION; USING ARTERIAL GRAFT(S), SINGLE CORONARY ARTERIAL GRAFT
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 Turning Point site for specific requirements

How to Submit

Please submit your request to Turning Point

MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING MINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION; USING ARTERIAL GRAFT(S), TWO CORONARY ARTERIAL GRAFTS

Service Code
S2206 (HCPCS) MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING MINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION; USING ARTERIAL GRAFT(S), TWO CORONARY ARTERIAL GRAFTS
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 Turning Point site for specific requirements

How to Submit

Please submit your request to Turning Point

MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING MINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION; USING TWO ARTERIAL GRAFTS AND SINGLE VENOUS GRAFT

Service Code
S2207 (HCPCS) MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING MINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION; USING TWO ARTERIAL GRAFTS AND SINGLE VENOUS GRAFT
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 Turning Point site for specific requirements

How to Submit

Please submit your request to Turning Point

MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING MINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION; USING SINGLE ARTERIAL AND VENOUS GRAFT(S), SINGLE VENOUS GRAFT

Service Code
S2208 (HCPCS) MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING MINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION; USING SINGLE ARTERIAL AND VENOUS GRAFT(S), SINGLE VENOUS GRAFT
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 Turning Point site for specific requirements

How to Submit

Please submit your request to Turning Point

MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING MINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION; USING TWO ARTERIAL GRAFTS AND SINGLE VENOUS GRAFT

Service Code
S2209 (HCPCS) MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS SURGERY INVOLVING MINI-THORACOTOMY OR MINI-STERNOTOMY SURGERY, PERFORMED UNDER DIRECT VISION; USING TWO ARTERIAL GRAFTS AND SINGLE VENOUS GRAFT
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 Turning Point site for specific requirements

How to Submit

Please submit your request to Turning Point

Cochlear and Auditory Brainstem Implants

Service Code
S2235 (CPT) (not found on description sheet)
Prior Authorization Required
No
Benefit Plan
Medicaid
Age Group
All
Diagnosis Group
Physical Health

A cochlear implant is an electronic medical device designed to restore some ability to perceive sounds and understand speech by individuals with severe to profound hearing loss. A cochlear implant bypasses damaged hair cells in the cochlea and stimulates the remaining nerve fibers directly through the application of electrical current. Cochlear implants have external parts and internal (surgically implanted) parts that work together to allow the user to perceive sound.

An auditory brainstem implant (ABI) is a modification of the cochlear implant in which the stimulating electrode is placed directly into the brain.

After surgery, these two devices require activation, fitting of essential external components, programming, and rehabilitation for proper function and benefit.

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.

Limits

Postoperative activation, evaluation, and programming are covered as separate procedures only for beneficiaries ages 12 years through 20 years. Contralateral cochlear implant is considered only after successful placement of the original implant and on a case-by-case basis with documentation of medical necessity.

Simultaneous bilateral cochlear implants are covered only in the limited circumstances stated in policy.

Postoperative activation, evaluation, and programming are covered after the postoperative period for beneficiaries ages 12 months and older.

Exclusions

Aural rehabilitation for physicians is billed under Clinical Coverage Policy 10A, Outpatient Specialized Therapies.Billing unit limit: procedure codes in Section C are billed with 1 unit, except CPT 92640, which is billed as 1 unit = 1 hour.

Age Group Details

Auditory Brainstem Implants- 12 through 20 years of age, Cochlear Implants/Aural Rehabilitation/Contralateral Cochlear Implant-12 months of age and older,

Place of Service

Inpatient, Outpatient.

Additional Service Specifics

Simultaneous bilateral cochlear implants are billed with 69930 and modifier 50.

Resources

Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; lumbar, single interspace

Service Code
S2350 (HCPCS) Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; lumbar, single interspace
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.

Conditional Requirements

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

How to Submit

If your request is for OUTPATIENT services, please submit the request to Evolent. If your request is for INPATIENT services, please submit the request to Trillium.

STAT laboratory request (situations other than S3601)

Service Code
S3600 (HCPCS) STAT laboratory request (situations other than S3601)
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

Emergency STAT laboratory charge for patient who is homebound or residing in a nursing facility

Service Code
S3601 (HCPCS) Emergency STAT laboratory charge for patient who is homebound or residing in a nursing facility
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

Newborn metabolic screening panel, includes test kit, postage and the laboratory tests specified by the state for inclusion in this panel (e.g., galactose; hemoglobin, electrophoresis; hydroxyprogesterone, 17-d; phenylalanine (PKU); and thyroxine, total)

Service Code
S3620 (HCPCS) Newborn metabolic screening panel, includes test kit, postage and the laboratory tests specified by the state for inclusion in this panel (e.g., galactose; hemoglobin, electrophoresis; hydroxyprogesterone, 17-d; phenylalanine (PKU); and thyroxine, total)
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