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
Home management of gestational hypertension, includes administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately); per diem (do not use this code with any
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 postpartum hypertension, includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem (do not use this code with any
How to Submit
N/A - No authorization is required
Home management of preeclampsia, includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing services coded separately); per diem (do not use this code with any home infu
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 gestational diabetes, includes administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately); per diem (do not use this code with any hom
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 Infusion Therapy
The Home Infusion Therapy (HIT) program covers self-administered infusion therapy and enteral supplies provided to a NC Medicaid (Medicaid) beneficiary residing in a private residence or to a Medicaid beneficiary residing in an adult care home. Covered services include the following: a. Total parenteral nutrition (TPN); b. Enteral nutrition (EN); c. Intravenous chemotherapy; d. Intravenous antibiotic therapy; and e. Pain management therapy, including subcutaneous, epidural, intrathecal, and intravenous pain management therapy.
Authorization Guidelines
The provider(s) shall submit (DHHS) Utilization Review Personnel the following:
- a. the prior approval request; and
- b. all health records and any other records that support the beneficiary has met the
specific criteria in this policy.
A medical provider shall refer a potential beneficiary to a PDN service provider to initiate the initial referral review process. The PDN service provider shall complete a comprehensive assessment within 48 hours of the start of care (SOC) date and enter a request for PA by submitting documents (as listed in Subsection 5.2.2.2) for initial referral provisional review.
Initial provisional approval may be granted for 30-calendar days only, pending receipt of additional documentation (refer to Subsection 5.2.2.3). NC Medicaid shall complete a clinical review for PDN services upon receipt of the following required documents dated within the last sixty (60) days:
- a. DMA-3508 (PDN Referral Form) signed by the attending physician AND
- b. Recent history and physical (H&P).
- 1. If the beneficiary is being discharged from the hospital, submit current
hospital progress notes or a hospital discharge summary;
- 2. If the beneficiary is being referred from the community, submit clinic notes
from the last two office visits pertaining to the referring diagnosis;
- 3. Private health insurance coverage or denial documentation for current
approval period, if applicable.
PDN service providers shall indicate in their submitted documents all caregivers available to supplement care and the status of training provided.
Note: Once all required documentation is received, NC Medicaid shall conduct a clinical review for initial referral provisional PDN services.
Incomplete or omitted documentation or a request for additional information not received within the specified timeframe, is handled as an incomplete request and may result in denial of the PA request.
If the initial referral request is received after the start of care date, NC Medicaid shall only consider approval of PA from the date of request submission.
Reauthorization Guidelines
Continuation approval is granted for the remainder of the 180-day PA period. The PDN service provider shall submit the following documentation by PA day 30 to include:
- a. Attending physician-signed CMS-485 (Home Health Certification and Plan of
Care Form);
- b. Employment verification documentation to include one of the following:
- 1. A statement on company letterhead signed by a supervisor or representative
from the employer’s Human Resources Department detailing the employee’s current status of employment (such as active or on family medical leave), typical work schedule, and employer’s contact information; or
- 2. Pay stubs for the last two (2) months of employment; or
- 3. If a caregiver is self-employed, a Federal Schedule C (Form 1040), or the
Profit or Loss from Business (Sole Proprietorship) form from the most recent tax return may be used; and
- c. PDN service provider’s consent to treat document.
Additional documentation shall be required throughout the first 180-day authorization period to validate the initial request for PDN. The DMA-3509 (PDN Medical Update Form) and attending physician-signed CMS-485 shall be uploaded every 60 days.
A verbal order and date signed by RN if CMS-485 (Locator 23) if not signed by the attending physician in advance of the certification period is acceptable. All attending physician signed 485’s for the 180-day certification period shall be uploaded before the PA expiration date.
- a. By PA day 60: DMA-3509 (PDN Medical Update Form) and attending
physician-signed CMS-485 (Home Health Certification and Plan of Care Form) shall be submitted.
- b. By PA day 120: DMA-3509 (PDN Medical Update Form) and attending
physician-signed CMS-485 (Home Health Certification and Plan of Care Form) shall be submitted.
If the beneficiary experiences a significant change of condition, NC Medicaid shall re-evaluate services at that time (Refer to Subsection 5.2.2.7).
Note: Once all required documentation is received, NC Medicaid shall complete the clinical review for initial referral continuation of PDN services. Incomplete or omitted documentation or a request for additional information not received within the specified timeframe, is handled as an incomplete request and may result in denial of the PA request.
If the required documentation for initial continuation is received after the provisional approval timeframe has ended, NC Medicaid shall only consider extending continuation approval of PA from the date of request submission.
Unit Value
Per Diem
Place of Service
Outpatient
How to Submit
Please submit your request to Trillium Health Resources
Resources
Home Infusion Therapy
The Home Infusion Therapy (HIT) program covers self-administered infusion therapy and enteral supplies provided to a NC Medicaid (Medicaid) beneficiary residing in a private residence or to a Medicaid beneficiary residing in an adult care home. Covered services include the following: a. Total parenteral nutrition (TPN); b. Enteral nutrition (EN); c. Intravenous chemotherapy; d. Intravenous antibiotic therapy; and e. Pain management therapy, including subcutaneous, epidural, intrathecal, and intravenous pain management therapy.
Authorization Guidelines
The provider(s) shall submit (DHHS) Utilization Review Personnel the following:
- a. the prior approval request; and
- b. all health records and any other records that support the beneficiary has met the
specific criteria in this policy.
A medical provider shall refer a potential beneficiary to a PDN service provider to initiate the initial referral review process. The PDN service provider shall complete a comprehensive assessment within 48 hours of the start of care (SOC) date and enter a request for PA by submitting documents (as listed in Subsection 5.2.2.2) for initial referral provisional review.
Initial provisional approval may be granted for 30-calendar days only, pending receipt of additional documentation (refer to Subsection 5.2.2.3). NC Medicaid shall complete a clinical review for PDN services upon receipt of the following required documents dated within the last sixty (60) days:
- a. DMA-3508 (PDN Referral Form) signed by the attending physician AND
- b. Recent history and physical (H&P).
- 1. If the beneficiary is being discharged from the hospital, submit current
hospital progress notes or a hospital discharge summary;
- 2. If the beneficiary is being referred from the community, submit clinic notes
from the last two office visits pertaining to the referring diagnosis;
- 3. Private health insurance coverage or denial documentation for current
approval period, if applicable.
PDN service providers shall indicate in their submitted documents all caregivers available to supplement care and the status of training provided.
Note: Once all required documentation is received, NC Medicaid shall conduct a clinical review for initial referral provisional PDN services.
Incomplete or omitted documentation or a request for additional information not received within the specified timeframe, is handled as an incomplete request and may result in denial of the PA request.
If the initial referral request is received after the start of care date, NC Medicaid shall only consider approval of PA from the date of request submission.
Reauthorization Guidelines
Continuation approval is granted for the remainder of the 180-day PA period. The PDN service provider shall submit the following documentation by PA day 30 to include:
- a. Attending physician-signed CMS-485 (Home Health Certification and Plan of
Care Form);
- b. Employment verification documentation to include one of the following:
- 1. A statement on company letterhead signed by a supervisor or representative
from the employer’s Human Resources Department detailing the employee’s current status of employment (such as active or on family medical leave), typical work schedule, and employer’s contact information; or
- 2. Pay stubs for the last two (2) months of employment; or
- 3. If a caregiver is self-employed, a Federal Schedule C (Form 1040), or the
Profit or Loss from Business (Sole Proprietorship) form from the most recent tax return may be used; and
- c. PDN service provider’s consent to treat document.
Additional documentation shall be required throughout the first 180-day authorization period to validate the initial request for PDN. The DMA-3509 (PDN Medical Update Form) and attending physician-signed CMS-485 shall be uploaded every 60 days.
A verbal order and date signed by RN if CMS-485 (Locator 23) if not signed by the attending physician in advance of the certification period is acceptable. All attending physician signed 485’s for the 180-day certification period shall be uploaded before the PA expiration date.
- a. By PA day 60: DMA-3509 (PDN Medical Update Form) and attending
physician-signed CMS-485 (Home Health Certification and Plan of Care Form) shall be submitted.
- b. By PA day 120: DMA-3509 (PDN Medical Update Form) and attending
physician-signed CMS-485 (Home Health Certification and Plan of Care Form) shall be submitted.
If the beneficiary experiences a significant change of condition, NC Medicaid shall re-evaluate services at that time (Refer to Subsection 5.2.2.7).
Note: Once all required documentation is received, NC Medicaid shall complete the clinical review for initial referral continuation of PDN services. Incomplete or omitted documentation or a request for additional information not received within the specified timeframe, is handled as an incomplete request and may result in denial of the PA request.
If the required documentation for initial continuation is received after the provisional approval timeframe has ended, NC Medicaid shall only consider extending continuation approval of PA from the date of request submission.
Unit Value
Per Diem
Place of Service
Outpatient
How to Submit
Please submit your request to Trillium Health Resources
Resources
Home infusion therapy, continuous anticoagulant infusion therapy (e.g., Heparin), administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
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 infusion therapy, immunotherapy, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
How to Submit
N/A - No authorization is required
Home therapy; peritoneal dialysis, administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
How to Submit
N/A - No authorization is required
Home therapy; enteral nutrition; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (enteral formula and nursing visits coded separately), per diem
How to Submit
N/A - No authorization is required
Home infusion therapy, tocolytic infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
How to Submit
N/A - No authorization is required
Home infusion therapy, continuous insulin infusion therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
How to Submit
N/A - No authorization is required
Home infusion therapy, chelation therapy; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
How to Submit
N/A - No authorization is required
Home Infusion Therapy
The Home Infusion Therapy (HIT) program covers self-administered infusion therapy and enteral supplies provided to a NC Medicaid (Medicaid) beneficiary residing in a private residence or to a Medicaid beneficiary residing in an adult care home. Covered services include the following: a. Total parenteral nutrition (TPN); b. Enteral nutrition (EN); c. Intravenous chemotherapy; d. Intravenous antibiotic therapy; and e. Pain management therapy, including subcutaneous, epidural, intrathecal, and intravenous pain management therapy.
Unit Value
Per Diem
Place of Service
Outpatient
How to Submit
N/A - No authorization is required
Resources
Delivery or service to high risk areas requiring escort or extra protection, per visit
How to Submit
N/A - No authorization is required
1M-2, Childbirth Education
Childbirth education is a series of classes designed to help pregnant women and their support person to understand the changes experienced during pregnancy, to prepare for the labor and delivery experience, and to understand the postpartum period, including, but not limited to, the importance of proper postpartum care for the mother and the child.
Limits
Covered only during pregnancy. Eligible beneficiaries are pregnant women who receive Medicaid.
Classes meet for 1 or 2 hours per session, for a total of 10 hours of instruction.
Classes are reimbursed per class; each class can be either one hour or two hours.
Only classes actually attended by the beneficiary may be billed.
Maximum 4 hours of instruction may be provided per day.
Maximum 10 hours of instruction may be billed per pregnancy.
A complete childbirth education series consists of 10 hours of instruction.
Must be billed per date of service.
Maximum beneficiaries in group classes, excluding partners, is 10.
How to Submit
N/A - No authorization is required
Resources
Professional Treatment Services in Facility-Based Crisis Program
This service provides an alternative to hospitalization for adults who have a MH or SU disorder. The objectives of the service include assessment and evaluation of the condition(s) that have resulted in acute psychiatric symptoms, disruptive or dangerous behaviors, or intoxication from alcohol or drugs; to implement intensive tx, behavioral management interventions, or detox protocols; to stabilize the immediate problems that have resulted in the need for crisis intervention or detox; to ensure the safety of the individual receiving the service by closely monitoring their medical condition and response to the tx protocol; and to arrange for linkage to services that will provide further tx or rehabilitation upon discharge from the service.
Authorization Guidelines
- 1. TAR: prior authorization required. The initially submitted request following the pass-through shall not exceed 8 days (192 units).
- 2. Assessment: Completed by a licensed professional, not a QP. If applicable, the ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions (if applicable).
- 3. Service Order: Required and must be ordered by a primary care physician, psychiatrist, or a licensed psychologist.
- 4. Service Plan: Required and must be completed at the time the recipient is admitted to a service.
- 5. Submission of all records that support the recipient has met the medical necessity criteria.
Reauthorization Guidelines
- 1. TAR: prior approval required.
- 2. Service Plan: recently reviewed detailing the recipient’s progress with the service OR Progress Notes documenting the continued stay criteria.
- 3. CCA: required prior to discharge in order to document MN.
- 4. Submission of all records that support the recipient has met the medical necessity criteria.
Conditional Requirements
Prior authorization required following the pass thorugh period ( first 7 days/112 units).
Unit Value
One unit = 1 hour
Limits
One unit = 1 hour, up to 16 hours in a 24-hour period.
Length of Stay
- 1. The initial request following the pass-through shall not exceed 8 days (128 units).
- 2. This is a short-term service that cannot be provided for more than 45 days in a 12-month period.
Exclusions
Services related to this policy are not covered when the service duplicates another provider’s service.
Diagnosis Requirements
Mental Health & Substance Use
Additional Service Specifics
No prior authorization required for the first 7 days (112 units).
How to Submit
Authorization Conditionally Required – See the conditional prior authorization requirements before continuing to the Trillium request form (iTransact for TP Medicaid members and Provider Direct for MCD Direct members), if applicable
Resources
Facility-Based Crisis Service for Children and Adolescents
This is a service that provides an alternative to hospitalization for an eligible member who presents with escalated behavior due to a mental health, intellectual or development disability or substance use disorder and requires treatment in a 24-hour residential facility. Under the direction of a psychiatrist, this service provides assessment and short-term therapeutic interventions designed to prevent hospitalization by de-escalating and stabilizing acute responses to crisis situations.
Authorization Guidelines
Maintained in the Record (not all inclusive):
- 1. Service Order: Required, signed by an MD/ DO, PA, NP, or licensed psychologist.
- 2. Pre-Admission Nurse Screening: Required, conducted by an RN or LPN under the supervision of an RN to determine medical appropriateness for this LOC and to rule out acute or severe chronic comorbidities that could require complex medical intervention in a higher LOC
- 3. Clinical Assessment: A full CCA must be completed prior to DC.
- 4. Nursing Assessment: Required within 24 hours of admission
- 5. Psychiatric Evaluation: Required within 24 hours of admission
- 6. Tx plan: Required to direct tx and interventions during the stay. Must include the goal(s), objectives, tx interventions and the individual responsible for carrying out the intervention.
- 7. Care Coordination Referral: If not already linked with a care coordinator, a referral should be made for care coordination within 24 hours of admission.
- 8. Discharge/ Aftercare Plan: to include: a) the date, time and location of first follow up appointment; b) the behavioral health services to be provided; c) living and educational or vocational arrangements; d) the members current treatment and care coordination needs; and. e) diagnosis and discharge medications
- 9. Crisis Plan: to includes interventions to prevent readmission into a crisis setting
- 10. Submission of applicable records that support the member has met the medical necessity criteria.
All services are subject to post-payment review.
Unit Value
One unit = 1 hour
Limits
- 1. Within 24-hrs of admission, provider must contact the MCO to determine if the member is enrolled with another service provider or if the member is receiving care coordination. If the member is not already linked with a care coordinator, a referral must be made.
- 2. MCD will not cover Facility-Based Crisis Service delivered to a child or adolescent stepping down from an inpatient level of care.
- 3. IDD Exclusion Rules apply [see NCGS 122C-261(f), 122C-262(d), and 122C 263(d)(2)]
Age Group Details
Children (ages 6-17). Members 18 to 21 are eligible for FBC Services for Adults.
Level of Care
If SU applies, ASAM Level 3.7
Place of Service
Licensed crisis settings
How to Submit
N/A - No authorization is required
Resources
Home Infusion Therapy
The Home Infusion Therapy (HIT) program covers self-administered infusion therapy and enteral supplies provided to a NC Medicaid (Medicaid) beneficiary residing in a private residence or to a Medicaid beneficiary residing in an adult care home. Covered services include the following: a. Total parenteral nutrition (TPN); b. Enteral nutrition (EN); c. Intravenous chemotherapy; d. Intravenous antibiotic therapy; and e. Pain management therapy, including subcutaneous, epidural, intrathecal, and intravenous pain management therapy.
Authorization Guidelines
The provider(s) shall submit (DHHS) Utilization Review Personnel the following:
- a. the prior approval request; and
- b. all health records and any other records that support the beneficiary has met the
specific criteria in this policy.
A medical provider shall refer a potential beneficiary to a PDN service provider to initiate the initial referral review process. The PDN service provider shall complete a comprehensive assessment within 48 hours of the start of care (SOC) date and enter a request for PA by submitting documents (as listed in Subsection 5.2.2.2) for initial referral provisional review.
Initial provisional approval may be granted for 30-calendar days only, pending receipt of additional documentation (refer to Subsection 5.2.2.3). NC Medicaid shall complete a clinical review for PDN services upon receipt of the following required documents dated within the last sixty (60) days:
- a. DMA-3508 (PDN Referral Form) signed by the attending physician AND
- b. Recent history and physical (H&P).
- 1. If the beneficiary is being discharged from the hospital, submit current
hospital progress notes or a hospital discharge summary;
- 2. If the beneficiary is being referred from the community, submit clinic notes
from the last two office visits pertaining to the referring diagnosis;
- 3. Private health insurance coverage or denial documentation for current
approval period, if applicable.
PDN service providers shall indicate in their submitted documents all caregivers available to supplement care and the status of training provided.
Note: Once all required documentation is received, NC Medicaid shall conduct a clinical review for initial referral provisional PDN services.
Incomplete or omitted documentation or a request for additional information not received within the specified timeframe, is handled as an incomplete request and may result in denial of the PA request.
If the initial referral request is received after the start of care date, NC Medicaid shall only consider approval of PA from the date of request submission.
Reauthorization Guidelines
Continuation approval is granted for the remainder of the 180-day PA period. The PDN service provider shall submit the following documentation by PA day 30 to include:
- a. Attending physician-signed CMS-485 (Home Health Certification and Plan of
Care Form);
- b. Employment verification documentation to include one of the following:
- 1. A statement on company letterhead signed by a supervisor or representative
from the employer’s Human Resources Department detailing the employee’s current status of employment (such as active or on family medical leave), typical work schedule, and employer’s contact information; or
- 2. Pay stubs for the last two (2) months of employment; or
- 3. If a caregiver is self-employed, a Federal Schedule C (Form 1040), or the
Profit or Loss from Business (Sole Proprietorship) form from the most recent tax return may be used; and
- c. PDN service provider’s consent to treat document.
Additional documentation shall be required throughout the first 180-day authorization period to validate the initial request for PDN. The DMA-3509 (PDN Medical Update Form) and attending physician-signed CMS-485 shall be uploaded every 60 days.
A verbal order and date signed by RN if CMS-485 (Locator 23) if not signed by the attending physician in advance of the certification period is acceptable. All attending physician signed 485’s for the 180-day certification period shall be uploaded before the PA expiration date.
- a. By PA day 60: DMA-3509 (PDN Medical Update Form) and attending
physician-signed CMS-485 (Home Health Certification and Plan of Care Form) shall be submitted.
- b. By PA day 120: DMA-3509 (PDN Medical Update Form) and attending
physician-signed CMS-485 (Home Health Certification and Plan of Care Form) shall be submitted.
If the beneficiary experiences a significant change of condition, NC Medicaid shall re-evaluate services at that time (Refer to Subsection 5.2.2.7).
Note: Once all required documentation is received, NC Medicaid shall complete the clinical review for initial referral continuation of PDN services. Incomplete or omitted documentation or a request for additional information not received within the specified timeframe, is handled as an incomplete request and may result in denial of the PA request.
If the required documentation for initial continuation is received after the provisional approval timeframe has ended, NC Medicaid shall only consider extending continuation approval of PA from the date of request submission.
Unit Value
Per Diem
Place of Service
Outpatient
How to Submit
Please submit your request to Trillium Health Resources
Resources
Routine venipuncture for collection of specimen(s), single homebound, nursing home, or skilled nursing facility patient
How to Submit
N/A - No authorization is required
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.