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Member and Recipient Service Line: 1-877-685-2415

Provider Support Service Line: 1-855-250-1539

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Home Modifications

Service Code
S5165 (HCPCS) Home modifications; per service
Prior Authorization Required
Yes
Benefit Plan
Innovations Waiver Medicaid
Diagnosis Group
Intellectual/ Developmental Disability

Home Modifications are physical modifications to a private residence that are necessary to ensure the health, welfare, and safety of the member or to enhance the individual’s level of independence. Home Modifications are intended to increase the member’s ability to access his/her environment and are of direct or remedial benefit to the member or in some way related to the member’s disability. This service covers purchases, installation, maintenance, and as necessary, the repair of home modifications required to enable individuals to increase, maintain or improve their functional capacity to perform daily life tasks that would not be possible otherwise.

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

  • 1. A private residence is a home owned by the individual or his/her family (natural, adoptive, or foster family).
  • 2. All Home Mods requiring a building permit must meet county code to pass inspection.
  • 3. All services must be provided in accordance with applicable State or local building codes and other regulations.
  • 4. All items must meet applicable standards of manufacture, design, and installation.
  • 5. When an assessment is completed by another professional recommending the MN of specific items, then an MD/ DO, PA, or NP must write a letter of MN OR sign off on the letter of MN prepared by professional AND write a prescription.

Exclusions

  • • The service is limited to expenditures of $50,000 of supports (ATES, Home Modifications) over the duration of the waiver.
  • • A member who receives Residential Supports may not receive this service.
  • • Adaptations that add to the total square footage of the home are excluded from this benefit except when necessary to complete an adaptation.
  • • Central air conditioning; general plumbing; swimming pools; Jacuzzis; fences; service and maintenance contracts and extended warranties are not covered.
  • • Locks that are used to restrict an individual’s rights are not a covered modification.
  • • Equipment or supplies purchased for exclusive use at the school/home school are not covered.
  • • Waiver funding will not be used to replace equipment that has not been reasonably cared for and maintained.
  • • Home Modifications do not cover new construction, costs associated with building a new home, financing of a new home, and/or down payment of a new home.
  • • Items that would normally be available to any child, and are ordinarily provided by the family, are not covered.• Home Modifications exclude adaptations, improvements or repairs to the residence which are of general utility and are not of direct or remedial benefit to the individual or in some way related to the individual’s disability.
  • • Items that are portable may be purchased for use by a member who lives in a residence rented by the member or his/her family.
  • • Items that are not of direct or remedial benefit to the member are excluded from this service.
  • • Repair of equipment is covered for items purchased through the waiver or purchased prior to waiver participation, as long as the item is identified within this service definition and the cost of the repair does not exceed the cost of purchasing a replacement piece of equipment. The member or his/her family must own any equipment that is repaired.
  • • If an approved Modification is in the process of being completed, and additional issues are discovered that would prevent the approved Modification from being completed in a safe manner or from passing inspection; a plan revision must be submitted to request the necessary materials and labor to complete the modification in a safe manner.
  • • Incidental issues that are discovered during the home modification process, that do not impact safety; and are not necessary for the approved home modification to be able to be completed; and do not impact the modification passing inspection, are the responsibility of the homeowner.
  • • 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 Carolina Complete Health through Availity

Resources

Home Delivered Prepared Meals

Service Code
S5170 (HCPCS) Home delivered meals, including preparation; per meal
Prior Authorization Required
No
Benefit Plan
Innovations Waiver Medicaid
Diagnosis Group
Intellectual/ Developmental Disability

Home Delivered Prepared Meals

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

Up to seven home delivered meals per week.

Exclusions

  • • Up to seven meals per week/one per day
  • • Not available to individuals receiving a per diem residential service.
  • • 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

N/A - No authorization is required

Resources

Home health respiratory therapy, initial evaluation

Service Code
S5180 (HCPCS) Home health respiratory therapy, initial evaluation
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

Home health respiratory therapy, NOS, per diem

Service Code
S5181 (HCPCS) Home health respiratory therapy, NOS, per diem
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

Home infusion therapy, catheter care/maintenance, not otherwise classified; includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Service Code
S5497 (HCPCS) Home infusion therapy, catheter care/maintenance, not otherwise classified; includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
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

Home infusion therapy, catheter care/maintenance, simple (single lumen), includes administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment, (drugs and nursing visits coded separately), per diem

Service Code
S5498 (HCPCS) Home infusion therapy, catheter care/maintenance, simple (single lumen), includes administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment, (drugs and nursing visits coded separately), per diem
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

Home infusion therapy, catheter care/maintenance, complex (more than one lumen), includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per

Service Code
S5501 (HCPCS) Home infusion therapy, catheter care/maintenance, complex (more than one lumen), includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per
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

Insulin delivery device, reusable pen; 1.5 ml size

Service Code
S5560 (HCPCS) Insulin delivery device, reusable pen; 1.5 ml size
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

Insulin delivery device, reusable pen; 3 ml size

Service Code
S5561 (HCPCS) Insulin delivery device, reusable pen; 3 ml size
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

Magnetic resonance cholangiopancreatography (MRCP)

Service Code
S8037 (HCPCS) Magnetic resonance cholangiopancreatography (MRCP)
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.

Magnetic resonance imaging (MRI), low-field

Service Code
S8042 (HCPCS) Magnetic resonance imaging (MRI), low-field
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.

Fluorine-18 fluorodeoxyglucose (F-18 FDG) imaging using dual-head coincidence detection system (nondedicated PET scan)

Service Code
S8085 (HCPCS) Fluorine-18 fluorodeoxyglucose (F-18 FDG) imaging using dual-head coincidence detection system (nondedicated PET scan)
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

Electron beam computed tomography (also known as ultrafast CT, cine CT)

Service Code
S8092 (HCPCS) Electron beam computed tomography (also known as ultrafast CT, cine CT)
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.

Oxygen contents, gaseous, 1 unit equals 1 cubic foot

Service Code
S8120 (HCPCS) Oxygen contents, gaseous, 1 unit equals 1 cubic foot
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

Oxygen contents, liquid, 1 unit equals 1 pound

Service Code
S8121 (HCPCS) Oxygen contents, liquid, 1 unit equals 1 pound
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

Flutter device

Service Code
S8185 (HCPCS) Flutter device
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

Tracheostomy supply, not otherwise classified

Service Code
S8189 (HCPCS) Tracheostomy supply, not otherwise classified
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

Haberman feeder for cleft lip/palate

Service Code
S8265 (HCPCS) Haberman feeder for cleft lip/palate
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

Supplies for home delivery of infant

Service Code
S8415 (HCPCS) Supplies for home delivery of infant
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

Insulin syringes (100 syringes, any size)

Service Code
S8490 (HCPCS) Insulin syringes (100 syringes, any size)
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