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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

In vitro fertilization; including but not limited to identification and incubation of mature oocytes, fertilization with sperm, incubation of embryo(s), and subsequent visualization for determination of development

Service Code
S4011 (HCPCS) In vitro fertilization; including but not limited to identification and incubation of mature oocytes, fertilization with sperm, incubation of embryo(s), and subsequent visualization for determination of development
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

Complete cycle, gamete intrafallopian transfer (GIFT), case rate

Service Code
S4013 (HCPCS) Complete cycle, gamete intrafallopian transfer (GIFT), case rate
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

Complete cycle, zygote intrafallopian transfer (ZIFT), case rate

Service Code
S4014 (HCPCS) Complete cycle, zygote intrafallopian transfer (ZIFT), case rate
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

Complete in vitro fertilization cycle, not otherwise specified, case rate

Service Code
S4015 (HCPCS) Complete in vitro fertilization cycle, not otherwise specified, case rate
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

Frozen in vitro fertilization cycle, case rate

Service Code
S4016 (HCPCS) Frozen in vitro fertilization cycle, case rate
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

Incomplete cycle, treatment cancelled prior to stimulation, case rate

Service Code
S4017 (HCPCS) Incomplete cycle, treatment cancelled prior to stimulation, case rate
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

Frozen embryo transfer procedure cancelled before transfer, case rate

Service Code
S4018 (HCPCS) Frozen embryo transfer procedure cancelled before transfer, case rate
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

In vitro fertilization procedure cancelled before aspiration, case rate

Service Code
S4020 (HCPCS) In vitro fertilization procedure cancelled before aspiration, case rate
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

In vitro fertilization procedure cancelled after aspiration, case rate

Service Code
S4021 (HCPCS) In vitro fertilization procedure cancelled after aspiration, case rate
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

Assisted oocyte fertilization, case rate

Service Code
S4022 (HCPCS) Assisted oocyte fertilization, case rate
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

Donor egg cycle, incomplete, case rate

Service Code
S4023 (HCPCS) Donor egg cycle, incomplete, case rate
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

Air polymer-type A intrauterine foam, per study dose

Service Code
S4024 (HCPCS) Air polymer-type A intrauterine foam, per study dose
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

Donor services for in vitro fertilization (sperm or embryo), case rate

Service Code
S4025 (HCPCS) Donor services for in vitro fertilization (sperm or embryo), case rate
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

Procurement of donor sperm from sperm bank

Service Code
S4026 (HCPCS) Procurement of donor sperm from sperm bank
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

Storage of previously frozen embryos

Service Code
S4027 (HCPCS) Storage of previously frozen embryos
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

Microsurgical epididymal sperm aspiration (MESA)

Service Code
S4028 (HCPCS) Microsurgical epididymal sperm aspiration (MESA)
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

Sperm procurement and cryopreservation services; initial visit

Service Code
S4030 (HCPCS) Sperm procurement and cryopreservation services; initial visit
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

Sperm procurement and cryopreservation services; subsequent visit

Service Code
S4031 (HCPCS) Sperm procurement and cryopreservation services; subsequent visit
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

Stimulated intrauterine insemination (IUI), case rate

Service Code
S4035 (HCPCS) Stimulated intrauterine insemination (IUI), case rate
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

Cryopreserved embryo transfer, case rate

Service Code
S4037 (HCPCS) Cryopreserved embryo transfer, case rate
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