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
Monitoring and storage of cryopreserved embryos, per 30 days
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
Management of ovulation induction (interpretation of diagnostic tests and studies, nonface-to-face medical management of the patient), per cycle
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
Contraceptive pills for birth control
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
Home infusion therapy, routine service of infusion device (e.g., pump maintenance)
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 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.
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.
Home infusion therapy, repair of infusion device (e.g., pump repair)
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 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.
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.
Home care training to home care client, per session
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
Natural Supports Education
Natural Supports Education provides training to families and the members’ natural support network in order to enhance the decision-making capacity of the natural support network, provide orientation regarding the nature and impact of the intellectual and other developmental disabilities upon the member, provide education and training on intervention and strategies, and provide education and training in the use of specialized equipment and supplies. The requested education and training must have outcomes directly related to the needs of the member or the natural support network’s ability to provide care and support to the member. The expected outcome of this training is to develop and support greater access to the community by the member by strengthening his or her natural support network.
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
- • Reimbursement for conference and class attendance will be limited to $1,000 per year.
- • The cost of transportation, lodging, and meals are not included in this service.
- • Natural Supports Education excludes training furnished to family members through Specialized Consultation Services.
- • Training and education, including reimbursement for conferences, are excluded for family members and natural support networks when those members are employed to provide supervision and care to the member.
- • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
- • See the CCP for all applicable exclusions, limitations & exceptions.
Length of Stay
Services are expected to begin within 45 calendar days following approval of the initial ISP
Additional Service Specifics
In addition to individualized natural support education, reimbursement will be made for enrollment fees and materials related to attendance at conferences and classes by the primary caregiver.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Natural Supports Education
Natural Supports Education provides training to families and the members’ natural support network in order to enhance the decision-making capacity of the natural support network, provide orientation regarding the nature and impact of the intellectual and other developmental disabilities upon the member, provide education and training on intervention and strategies, and provide education and training in the use of specialized equipment and supplies. The requested education and training must have outcomes directly related to the needs of the member or the natural support network’s ability to provide care and support to the member. The expected outcome of this training is to develop and support greater access to the community by the member by strengthening his or her natural support network.
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
- • Reimbursement for conference and class attendance will be limited to $1,000 per year.
- • The cost of transportation, lodging, and meals are not included in this service.
- • Natural Supports Education excludes training furnished to family members through Specialized Consultation Services.
- • Training and education, including reimbursement for conferences, are excluded for family members and natural support networks when those members are employed to provide supervision and care to the member.
- • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
- • See the CCP for all applicable exclusions, limitations & exceptions.
Length of Stay
Services are expected to begin within 45 calendar days following approval of the initial ISP
Additional Service Specifics
In addition to individualized natural support education, reimbursement will be made for enrollment fees and materials related to attendance at conferences and classes by the primary caregiver.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Natural Supports Education
Natural Supports Education provides training to families and the members’ natural support network in order to enhance the decision-making capacity of the natural support network, provide orientation regarding the nature and impact of the intellectual and other developmental disabilities upon the member, provide education and training on intervention and strategies, and provide education and training in the use of specialized equipment and supplies. The requested education and training must have outcomes directly related to the needs of the member or the natural support network’s ability to provide care and support to the member. The expected outcome of this training is to develop and support greater access to the community by the member by strengthening his or her natural support network.
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
- • Reimbursement for conference and class attendance will be limited to $1,000 per year.
- • The cost of transportation, lodging, and meals are not included in this service.
- • Natural Supports Education excludes training furnished to family members through Specialized Consultation Services.
- • Training and education, including reimbursement for conferences, are excluded for family members and natural support networks when those members are employed to provide supervision and care to the member.
- • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
- • See the CCP for all applicable exclusions, limitations & exceptions.
Length of Stay
Services are expected to begin within 45 calendar days following approval of the initial ISP
Additional Service Specifics
In addition to individualized natural support education, reimbursement will be made for enrollment fees and materials related to attendance at conferences and classes by the primary caregiver.
How to Submit
N/A - No authorization is required
Resources
Natural Supports Education
Natural Supports Education provides training to families and the members’ natural support network in order to enhance the decision-making capacity of the natural support network, provide orientation regarding the nature and impact of the intellectual and other developmental disabilities upon the member, provide education and training on intervention and strategies, and provide education and training in the use of specialized equipment and supplies. The requested education and training must have outcomes directly related to the needs of the member or the natural support network’s ability to provide care and support to the member. The expected outcome of this training is to develop and support greater access to the community by the member by strengthening his or her natural support network.
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
- • Reimbursement for conference and class attendance will be limited to $1,000 per year.
- • The cost of transportation, lodging, and meals are not included in this service.
- • Natural Supports Education excludes training furnished to family members through Specialized Consultation Services.
- • Training and education, including reimbursement for conferences, are excluded for family members and natural support networks when those members are employed to provide supervision and care to the member.
- • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
- • See the CCP for all applicable exclusions, limitations & exceptions.
Length of Stay
Services are expected to begin within 45 calendar days following approval of the initial ISP
Additional Service Specifics
In addition to individualized natural support education, reimbursement will be made for enrollment fees and materials related to attendance at conferences and classes by the primary caregiver.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Home care training, nonfamily; per 15 minutes
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
Home care training, nonfamily; per session
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
Clinical Coverage Policy No: 10C
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
Resources
Homemaker service, NOS; per 15 minutes
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
Homemaker service, NOS; per diem
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
Residential Treatment Services: Level II/ Family/ Program Type
Residential treatment provides a structured, therapeutic, and supervised environment to improve the level of functioning for beneficiaries. There are four levels of residential treatment. Residential Treatment Level II Service provides a moderate to highly structured and supervised environment in a family or program setting.
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
- 1. TAR: prior authorization required
- 2. Complete PCP: recently reviewed detailing the member’s progress with the service. Should include progress towards each of the goals and involvement in therapy, to include family therapy if reunification is the goal. If family therapy is not occurring in this case, please explain.
- 3. CCA: Re-assessment is required when new behavioral concerns are identified, there are changed/ unmet service or tx needs, and/or as part of the annual review of the service plan. Assessment must include an ASAM Score supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
- 4. Submission of applicable records that support the member has met the medical necessity criteria.
Unit Value
One unit = 1 day
Limits
MCD will not cover this service when the service duplicates another procedure, product, or service.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Respite Services
Respite services provide periodic or scheduled support and relief to the primary caregiver(s) from the responsibility and stress of caring for the member. This service also enables the individual to receive periodic support and relief from the primary caregiver(s) at his/her choice. NC Innovations respite may also be used to provide temporary relief to a member who resides in Licensed or Unlicensed AFL, but it may not be billed on the same day as Residential Supports unless it is for a member to access a summer camp or support group. This service enables the primary caregiver to meet or participate in planned or emergency events, and to have planned time for him/her and/or family members. Respite may be utilized during school hours for sickness, injury, or when a student is suspended or expelled.
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
Respite may include in and out-of-home services, inclusive of overnight, weekend care, or emergency care (family emergency based, not to include out of home crisis).
Exclusions
- • This service may not be used as a regularly scheduled daily service for individual support.
- • This service is not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Employment or one of the State Plan Medicaid Services that works directly with the person such as Private Duty Nursing.
- • Residential Support AFL cannot be billed on the same day as Per Diem Respite for the same member.
- • This service is not available to members who reside in licensed facilities that are licensed as 5600B or 5600C.
- • Staff sleep time is not reimbursable.
- • Respite services are only provided for the member; other family members, such as siblings of the member, may not receive care from the provider while Respite Care is being provided/billed.
- • Respite Care is not provided by any person who resides in the member’s primary place of residence.
- • For a member who is eligible for educational services under Individual’s With Disability Educational Act, Respite does not include transportation to and from school settings. This includes transportation to and from the member’s home, provider home where the member is receiving services before/after school or any community location where the member may be receiving services before or after school.
- • Respite may not be used for a member who is living alone or with a roommate.
- • The primary caregiver(s) is the person principally responsible for the care and supervision of the member and must maintain his/her primary residence at the same address as the member.
- • Services provided in the private home of the direct service employee are subject to the checklist and monthly monitoring by the qualified professional.Cost of 24 hours of respite care cannot exceed the per diem rate for the average community ICF-IID facility.• For services provided in the home of a direct service employee, the Provider Agency, Employer of Record or Agency With Choice is required to complete the Health and Safety Checklist and Justification for Services form prior to the delivery of service in that home and every six months afterwards, as long as the service continues to be provided in that location. The member or legally responsible person must sign this checklist.
- • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
- • See the CCP for all applicable exclusions, limitations & exceptions.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Respite Services
Respite services provide periodic or scheduled support and relief to the primary caregiver(s) from the responsibility and stress of caring for the member. This service also enables the individual to receive periodic support and relief from the primary caregiver(s) at his/her choice. NC Innovations respite may also be used to provide temporary relief to a member who resides in Licensed or Unlicensed AFL, but it may not be billed on the same day as Residential Supports unless it is for a member to access a summer camp or support group. This service enables the primary caregiver to meet or participate in planned or emergency events, and to have planned time for him/her and/or family members. Respite may be utilized during school hours for sickness, injury, or when a student is suspended or expelled.
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
Respite may include in and out-of-home services, inclusive of overnight, weekend care, or emergency care (family emergency based, not to include out of home crisis).
Exclusions
- • This service may not be used as a regularly scheduled daily service for individual support.
- • This service is not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Employment or one of the State Plan Medicaid Services that works directly with the person such as Private Duty Nursing.
- • Residential Support AFL cannot be billed on the same day as Per Diem Respite for the same member.
- • This service is not available to members who reside in licensed facilities that are licensed as 5600B or 5600C.
- • Staff sleep time is not reimbursable.
- • Respite services are only provided for the member; other family members, such as siblings of the member, may not receive care from the provider while Respite Care is being provided/billed.
- • Respite Care is not provided by any person who resides in the member’s primary place of residence.
- • For a member who is eligible for educational services under Individual’s With Disability Educational Act, Respite does not include transportation to and from school settings. This includes transportation to and from the member’s home, provider home where the member is receiving services before/after school or any community location where the member may be receiving services before or after school.
- • Respite may not be used for a member who is living alone or with a roommate.
- • The primary caregiver(s) is the person principally responsible for the care and supervision of the member and must maintain his/her primary residence at the same address as the member.
- • Services provided in the private home of the direct service employee are subject to the checklist and monthly monitoring by the qualified professional.Cost of 24 hours of respite care cannot exceed the per diem rate for the average community ICF-IID facility.• For services provided in the home of a direct service employee, the Provider Agency, Employer of Record or Agency With Choice is required to complete the Health and Safety Checklist and Justification for Services form prior to the delivery of service in that home and every six months afterwards, as long as the service continues to be provided in that location. The member or legally responsible person must sign this checklist.
- • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
- • See the CCP for all applicable exclusions, limitations & exceptions.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Respite Services
Respite services provide periodic or scheduled support and relief to the primary caregiver(s) from the responsibility and stress of caring for the member. This service also enables the individual to receive periodic support and relief from the primary caregiver(s) at his/her choice. NC Innovations respite may also be used to provide temporary relief to a member who resides in Licensed or Unlicensed AFL, but it may not be billed on the same day as Residential Supports unless it is for a member to access a summer camp or support group. This service enables the primary caregiver to meet or participate in planned or emergency events, and to have planned time for him/her and/or family members. Respite may be utilized during school hours for sickness, injury, or when a student is suspended or expelled.
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
Respite may include in and out-of-home services, inclusive of overnight, weekend care, or emergency care (family emergency based, not to include out of home crisis).
Exclusions
- • This service may not be used as a regularly scheduled daily service for individual support.
- • This service is not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Employment or one of the State Plan Medicaid Services that works directly with the person such as Private Duty Nursing.
- • Residential Support AFL cannot be billed on the same day as Per Diem Respite for the same member.
- • This service is not available to members who reside in licensed facilities that are licensed as 5600B or 5600C.
- • Staff sleep time is not reimbursable.
- • Respite services are only provided for the member; other family members, such as siblings of the member, may not receive care from the provider while Respite Care is being provided/billed.
- • Respite Care is not provided by any person who resides in the member’s primary place of residence.
- • For a member who is eligible for educational services under Individual’s With Disability Educational Act, Respite does not include transportation to and from school settings. This includes transportation to and from the member’s home, provider home where the member is receiving services before/after school or any community location where the member may be receiving services before or after school.
- • Respite may not be used for a member who is living alone or with a roommate.
- • The primary caregiver(s) is the person principally responsible for the care and supervision of the member and must maintain his/her primary residence at the same address as the member.
- • Services provided in the private home of the direct service employee are subject to the checklist and monthly monitoring by the qualified professional.Cost of 24 hours of respite care cannot exceed the per diem rate for the average community ICF-IID facility.• For services provided in the home of a direct service employee, the Provider Agency, Employer of Record or Agency With Choice is required to complete the Health and Safety Checklist and Justification for Services form prior to the delivery of service in that home and every six months afterwards, as long as the service continues to be provided in that location. The member or legally responsible person must sign this checklist.
- • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
- • See the CCP for all applicable exclusions, limitations & exceptions.
How to Submit
Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)
Resources
Unskilled respite care, not hospice; per diem
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
If you find any wrong or out of date information on our pages, we want to know. Please email info@TrilliumNC.org with any corrections.