Prior Authorization

Carolina Complete Health Standard Plan Pre-Auth Tool

To check on a specific service or procedure for Carolina Complete Health members, use the Pre-Auth Tool. Providers should also review the Clinical Coverage Policy for specific details on services and procedures.

Trillium Health Resources Physical Health Pre-Auth Tool

To check on a specific physical health service or procedure for Trillium Tailored Plan members, use the Pre-Auth Tool. Providers should also review the Clinical Coverage Policy for specific details on services and procedures.

Partners Health
Management Pre-Auth Tool

Partners’ Service Pre-Authorization Lookup Tool provides authorization requirements by service code. You may also refer to the Partners Benefit Grids and enter an authorization into Pro-Auth if an authorization is indicated.

All services are subject to benefit coverage, limitations, and exclusions as described in applicable plan coverage guidelines. For details, view the Clinical Coverage Policies. All medical services performed, even if a Prior Authorization is not required, must be medically necessary and may not be experimental in nature.

Medical necessity is defined for Carolina Complete Health beneficiaries as healthcare services, supplies or equipment provided by a licensed healthcare professional that are:

Appropriate and consistent with the diagnosis or treatment of the patient’s condition, illness, or injury;
In accordance with the standards of good medical practice consistent with evidence based and clinical practice guidelines;
Not primarily for the personal comfort or convenience of the beneficiary, family, or provider;
The most appropriate services, supplies, equipment, or level of care that can be safely and efficiently provided to the beneficiary;
Furnished in a setting appropriate to the patient’s medical need and condition and, when supplied to the care of an inpatient, further mean that the beneficiary’s medical symptoms or conditions require that the services cannot be safely provided to the beneficiary as an outpatient service;
Not experimental or investigational or for research or education.
For information on the medical necessity “EPSDT Guarantee” please see the “Early Periodic Screen, Diagnostic and Treatment Services” section

Experimental studies and related guidance is found in the following:

See Provider Manual for additional details.

All medical services performed must be medically necessary and may not be experimental in nature. Experimental is defined as medical care that is investigatory or an unproven procedure or treatment regimen that does not meet generally accepted standards of medical practice in North Carolina.

In evaluating whether a particular service is or is not experimental the agency will consider safety, effectiveness and common acceptance as verified through:

Scientifically validated clinical studies
Medical literature research and
Qualified medical experts.

Experimental studies and related guidance is found in the following:

See Provider Manual for additional details.