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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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12437 Results

Home therapy; hematopoietic hormone injection therapy (e.g., erythropoietin, G-CSF, GM-CSF); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately),

Service Code
S9537 (HCPCS) Home therapy; hematopoietic hormone injection therapy (e.g., erythropoietin, G-CSF, GM-CSF); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately),
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Home transfusion of blood product(s); administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (blood products, drugs, and nursing visits coded separately), per diem

Service Code
S9538 (HCPCS) Home transfusion of blood product(s); administrative services, professional pharmacy services, care coordination and all necessary supplies and equipment (blood products, drugs, and nursing visits coded separately), per diem
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Home injectable therapy, not otherwise classified, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Service Code
S9542 (HCPCS) Home injectable therapy, not otherwise classified, including 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

How to Submit

N/A - No authorization is required

Home injectable therapy; growth hormone, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Service Code
S9558 (HCPCS) Home injectable therapy; growth hormone, including 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

How to Submit

N/A - No authorization is required

Home injectable therapy, interferon, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Service Code
S9559 (HCPCS) Home injectable therapy, interferon, including 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

How to Submit

N/A - No authorization is required

Home injectable therapy; hormonal therapy (e.g., leuprolide, goserelin), including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Service Code
S9560 (HCPCS) Home injectable therapy; hormonal therapy (e.g., leuprolide, goserelin), including 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

How to Submit

N/A - No authorization is required

Home injectable therapy, palivizumab, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Service Code
S9562 (HCPCS) Home injectable therapy, palivizumab, including 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

How to Submit

N/A - No authorization is required

Home injectable therapy, immunotherapy, including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

Service Code
S9563 (HCPCS) Home injectable therapy, immunotherapy, including 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

How to Submit

N/A - No authorization is required

Home therapy, irrigation therapy (e.g., sterile irrigation of an organ or anatomical cavity); including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded se

Service Code
S9590 (HCPCS) Home therapy, irrigation therapy (e.g., sterile irrigation of an organ or anatomical cavity); including administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded se
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Home therapy; professional pharmacy services for provision of infusion, specialty drug administration, and/or disease state management, not otherwise classified, per hour (do not use this code with any per diem code)

Service Code
S9810 (HCPCS) Home therapy; professional pharmacy services for provision of infusion, specialty drug administration, and/or disease state management, not otherwise classified, per hour (do not use this code with any per diem code)
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Medical records copying fee, administrative

Service Code
S9981 (HCPCS) Medical records copying fee, administrative
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

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

Medical records copying fee, per page

Service Code
S9982 (HCPCS) Medical records copying fee, per page
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Authorization Guidelines

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

Services provided as part of a Phase I clinical trial

Service Code
S9988 (HCPCS) Services provided as part of a Phase I clinical trial
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

Services provided as part of a Phase II clinical trial

Service Code
S9990 (HCPCS) Services provided as part of a Phase II clinical trial
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

Services provided as part of a Phase III clinical trial

Service Code
S9991 (HCPCS) Services provided as part of a Phase III clinical trial
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

How to Submit

N/A - No authorization is required

Private Duty Nursing for Beneficiaries Age 21 and Older

Service Code
T1000 (HCPCS) Private duty/independent nursing service(s), licensed, up to 15 minutes
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

See the Carolina Complete Health site for specific requirements

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.

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.

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
T1000 (HCPCS) Private duty/independent nursing service(s), licensed, up to 15 minutes
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

See the Carolina Complete Health site for specific requirements

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

1M-6 Maternal Care Skilled Nurse Home Visit

Service Code
T1001 (CPT) Nursing assessment / evaluation
Prior Authorization Required
No
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

Maternal care skilled nurse home visits assess and treat pregnant women who have one or more of the high-risk medical conditions specified below.

Limits

Must be a one-on-one, face-to-face visit conducted in the client's home.

Reimbursed up to two visits per month.

Additional units may be reimbursed only through the adjustment process when coverage conditions are met and documentation supports medical necessity.

Must be billed per date of service.

Diagnosis Requirements

Service is for pregnant women and is covered when medically necessary.

Place of Service

Beneficiary’s home.

Resources

Home Infusion Therapy

Service Code
T1002 (HCPCS) RN services, up to 15 minutes
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

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

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

Unit Value

Per Diem

Place of Service

Outpatient

How to Submit

Please submit your request to Carolina Complete Health through Availity

Resources

Sexually Transmitted Disease Treatment Provided in Health Departments

Service Code
T1002 (HCPCS) RN services, up to 15 minutes
Prior Authorization Required
Yes
Benefit Plan
Medicaid
Diagnosis Group
Physical Health

This service refers specifically to the treatment of sexually transmitted diseases (STD) provided in the local health department setting. Service includes medical history, diagnostic examinations for sexually transmitted diseases, laboratory tests as medically indicated, treatment as indicated, and referral as appropriate.

Authorization Guidelines

See the Carolina Complete Health site for specific requirements

Reauthorization Guidelines

See the Carolina Complete Health site for specific requirements

Unit Value

Per Diem

Limits

4 units per day may be billed

Place of Service

Health Department

How to Submit

Please submit your request to Carolina Complete Health through Availity

Resources