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

Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes

Service Code
S8948 (HCPCS) Application of a modality (requiring constant provider attendance) to one or more areas; low-level laser; each 15 minutes
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

Complex lymphedema therapy, each 15 minutes

Service Code
S8950 (HCPCS) Complex lymphedema therapy, each 15 minutes
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 uterine monitor with or without associated nursing services

Service Code
S9001 (HCPCS) Home uterine monitor with or without associated nursing services
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 administration of aerosolized drug therapy (e.g., Pentamidine); administrative services, professional pharmacy services, care coordination, all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Service Code
S9061 (HCPCS) Home administration of aerosolized drug therapy (e.g., Pentamidine); administrative services, professional pharmacy services, care coordination, 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

Global fee urgent care centers

Service Code
S9083 (HCPCS) Global fee urgent care centers
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

Services provided in an urgent care center (list in addition to code for service)

Service Code
S9088 (HCPCS) Services provided in an urgent care center (list in addition to code for service)
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

Vertebral axial decompression, per session

Service Code
S9090 (HCPCS) Vertebral axial decompression, per session
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

Home visit for wound care

Service Code
S9097 (HCPCS) Home visit for wound care
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 visit, phototherapy services (e.g., Bili-lite), including equipment rental, nursing services, blood draw, supplies, and other services, per diem

Service Code
S9098 (HCPCS) Home visit, phototherapy services (e.g., Bili-lite), including equipment rental, nursing services, blood draw, supplies, and other services, 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

Telemonitoring of patient in their home, including all necessary equipment; computer system, connections, and software; maintenance; patient education and support; per month

Service Code
S9110 (HCPCS) Telemonitoring of patient in their home, including all necessary equipment; computer system, connections, and software; maintenance; patient education and support; per month
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

Private Duty Nursing for Beneficiaries under age 21

Service Code
S9123 (HCPCS) Nursing care, in the home; by registered nurse, per hour (use for general nursing care only, not to be used when CPT codes 99500-99602 can be used)
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Private Duty Nursing (PDN) is a substantial, complex, and continuous skilled nursing care that is considered supplemental to the care provided to a beneficiary by the beneficiary’s family, foster parents, and delegated caregivers, as applicable Private Duty Nursing services is defined by 42CFR 440.80. Private Duty Nursing services are for a beneficiary who may require more individual and continuous care than is available from a visiting nurse or routinely provided by the nursing staff of the hospital or skilled nursing facility.

PDN care must be medically appropriate and medically necessary for the beneficiary to be covered by NC Medicaid. PDN services are provided:

  • a. Only in the beneficiary’s private primary residence;
  • b. Under the direction of a written individualized plan of care;
  • c. Authorized by the beneficiary’s primary physician; and
  • d. PDN services must be rendered by a registered nurse (RN) or licensed practical nurse (LPN) who is licensed

by the North Carolina Board of Nursing (NCBON) and employed by a state licensed and accredited home care agency.

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

Unit Value

PDN services are billed in 15-minute units

Limits

Services are provided only in the beneficiary's private primary residence; approved hours may be used outside that setting only when normal life activities temporarily take the beneficiary outside the residence.

Normal life activities include supported or sheltered work settings, licensed childcare, school and school-related activities, and religious services and activities.

PDN hours may not be used when the beneficiary is receiving care in an inpatient facility, outpatient facility, hospital, or residential-type medical setting.PDN services are billed in 15-minute units.

Billing shall not exceed the NC Medicaid authorized number of PDN units per week. Congregate care is limited to a maximum ratio of 1 private duty nurse to 2 individuals receiving nursing services.

Total PDN services must not exceed 112 hours per week or 16 hours per day. Unused hours cannot be banked or rolled over to another week.

Exclusions

PDN is not covered when there is no trained primary informal caregiver available to provide direct care during planned and unplanned absences of PDN staff; if no caregiver is available to assume this role, PDN cannot be approved. Observation in case an intervention is required is not considered complex skilled nursing and is not covered by Medicaid as medically necessary PDN services. Skilled nursing does not include tasks that can be delegated to unlicensed personnel according to NC Board of Nursing scope-of-practice rules and in-home aide rules. For beneficiaries under 21 years of age, EPSDT does not require coverage of any service, product, or procedure that is unsafe, ineffective, experimental or investigational, not medical in nature, or not generally recognized as an accepted method of medical practice or treatment.

Diagnosis Requirements

The beneficiary must be medically fragile and require skilled nursing care that is reasonable, necessary, appropriate, and based on evidence-based clinical standards of care.

Place of Service

PDN services are provided in the beneficiary's private primary residence.

Additional Service Specifics

PDN services shall not exceed the NC Medicaid authorized number of PDN units per week. The qualifications of the nurse shall be specified.

How to Submit

Please submit your request to Carolina Complete Health through Availity

Resources

Private Duty Nursing for Beneficiaries under age 21

Service Code
S9124 (HCPCS) Nursing care, in the home; by licensed practical nurse, per hour
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Private Duty Nursing (PDN) is a substantial, complex, and continuous skilled nursing care that is considered supplemental to the care provided to a beneficiary by the beneficiary’s family, foster parents, and delegated caregivers, as applicable Private Duty Nursing services is defined by 42CFR 440.80. Private Duty Nursing services are for a beneficiary who may require more individual and continuous care than is available from a visiting nurse or routinely provided by the nursing staff of the hospital or skilled nursing facility.

PDN care must be medically appropriate and medically necessary for the beneficiary to be covered by NC Medicaid. PDN services are provided:

  • a. Only in the beneficiary’s private primary residence;
  • b. Under the direction of a written individualized plan of care;
  • c. Authorized by the beneficiary’s primary physician; and
  • d. PDN services must be rendered by a registered nurse (RN) or licensed practical nurse (LPN) who is licensed

by the North Carolina Board of Nursing (NCBON) and employed by a state licensed and accredited home care agency.

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

Unit Value

PDN services are billed in 15-minute units

Limits

Services are provided only in the beneficiary's private primary residence; approved hours may be used outside that setting only when normal life activities temporarily take the beneficiary outside the residence.

Normal life activities include supported or sheltered work settings, licensed childcare, school and school-related activities, and religious services and activities.

PDN hours may not be used when the beneficiary is receiving care in an inpatient facility, outpatient facility, hospital, or residential-type medical setting.PDN services are billed in 15-minute units.

Billing shall not exceed the NC Medicaid authorized number of PDN units per week. Congregate care is limited to a maximum ratio of 1 private duty nurse to 2 individuals receiving nursing services.

Total PDN services must not exceed 112 hours per week or 16 hours per day. Unused hours cannot be banked or rolled over to another week.

Exclusions

PDN is not covered when there is no trained primary informal caregiver available to provide direct care during planned and unplanned absences of PDN staff; if no caregiver is available to assume this role, PDN cannot be approved. Observation in case an intervention is required is not considered complex skilled nursing and is not covered by Medicaid as medically necessary PDN services. Skilled nursing does not include tasks that can be delegated to unlicensed personnel according to NC Board of Nursing scope-of-practice rules and in-home aide rules. For beneficiaries under 21 years of age, EPSDT does not require coverage of any service, product, or procedure that is unsafe, ineffective, experimental or investigational, not medical in nature, or not generally recognized as an accepted method of medical practice or treatment.

Diagnosis Requirements

The beneficiary must be medically fragile and require skilled nursing care that is reasonable, necessary, appropriate, and based on evidence-based clinical standards of care.

Place of Service

PDN services are provided in the beneficiary's private primary residence.

Additional Service Specifics

PDN services shall not exceed the NC Medicaid authorized number of PDN units per week. The qualifications of the nurse shall be specified.

How to Submit

Please submit your request to Carolina Complete Health through Availity

Resources

Respite care, in the home, per diem

Service Code
S9125 (HCPCS) Respite care, in the home, 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.

Conditional Requirements

Pre-authorization is required for members under 21 via EPSDT.

How to Submit

If applicable, please submit your request to Trillium.

Social work visit, in the home, per diem

Service Code
S9127 (HCPCS) Social work visit, in the home, 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.

How to Submit

Please submit your request to Trillium Health Resources

Speech therapy, in the home, per diem

Service Code
S9128 (HCPCS) Speech therapy, in the home, 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.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

Occupational therapy, in the home, per diem

Service Code
S9129 (HCPCS) Occupational therapy, in the home, 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.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

Physical therapy; in the home, per diem

Service Code
S9131 (HCPCS) Physical therapy; in the home, 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.

Conditional Requirements

Pre-authorization required for all providers unless rendered on same day as evaluation.

How to Submit

If applicable, please submit your request to Trillium.

Speech therapy, re-evaluation

Service Code
S9152 (HCPCS) Speech therapy, re-evaluation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Home management of preterm labor, including administrative services, professional pharmacy services, care coordination, and all necessary supplies or equipment (drugs and nursing visits coded separately), per diem (do not use this code with any home infus

Service Code
S9208 (HCPCS) Home management of preterm labor, including administrative services, professional pharmacy services, care coordination, and all necessary supplies or equipment (drugs and nursing visits coded separately), per diem (do not use this code with any home infus
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

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 management of preterm premature rupture of membranes (PPROM), including administrative services, professional pharmacy services, care coordination, and all necessary supplies or equipment (drugs and nursing visits coded separately), per diem (do not

Service Code
S9209 (HCPCS) Home management of preterm premature rupture of membranes (PPROM), including administrative services, professional pharmacy services, care coordination, and all necessary supplies or equipment (drugs and nursing visits coded separately), per diem (do not
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

How to Submit

Please submit your request to Carolina Complete Health through Availity