Prior Authorization Guidance and Reminders
Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. This page provides reminders and guidance on proper documentation for successful Prior Authorization submission.
Review all clinical policies online for complete guidance and coverage criteria.
Reminders for Non-covered Codes and Requests Beyond Benefit Limit
Prior authorization (PA) requirements for:
- Non-covered services, procedures, or products
- Instances where members require services/products beyond benefit limits outlined in NC Medicaid Clinical Coverage Policies
A prior authorization is required when:
- A provider determines a member needs services not included in NC Medicaid covered services/procedures or products
- A provider determines a member needs services, procedures, or products beyond the identified benefit limits.
Prior authorization requirements:
- When submitting an authorization for the above, providers should fax their authorization requests and note the reason for the request.
- “PA request due to a need beyond the benefit limit”
- “PA review needed due to code not being found on the NC Medicaid Managed Care Covered Code list”
- All PA requests should include documentation to support medical necessity of the service/procedure/product being requested. If clinical documentation is not submitted, a request may be denied due to insufficient information to determine medical necessity.
| Code/Description | Pre-Auth Check Tool | Benefit Limit per Policy | PA Requirement Beyond Limit/Not Covered |
|---|---|---|---|
| A6258 – Transparent film, sterile, >16 sq. in. but ≤48 sq. in., each dressing | No PA required for all providers | 16 per month | PA required if member needs >16/month |
| T4544 – Adult-sized disposable incontinence product, protective underwear/pull-on, above extra large, each | No PA required for all providers | 200 per month | PA required if member needs >200/month |
| A7035 – Headgear used with positive airway pressure device | No PA required for all providers | 2 per year | PA required if member needs >2/year |
| S9480 – Mental Health Intensive Outpatient Program | PA required for non-par providers | Not an NC Medicaid covered code | PA required |
PA Documentation Tips
By submitting proper documentation with your prior authorization (PA) requests, PAs can be reviewed more expeditiously leading to efficient turnaround times for reviews and notifications. This supports getting members connected to needed services promptly.
Outpatient Specialized Therapies Clinical Coverage Policy No: 10A
Required Documentation:
- Signed MD Order within the last 6 months
- Evaluation/progress notes from the past 3 months Plan
of Care - For continuations: new order (if previous is signed & dated longer than 6 months ago) and an updated plan of care stating frequency and duration of therapy.
Required Documentation:
- HH Therapy: Physician Order/Signed Plan of Care (CMS-485 form), Face to face encounter within 90 days prior or within 30 days after starting care, Therapy Evaluation and Plan of Care. Therapy evaluation must be completed prior and submitted with the Prior Authorization request.
- HH Skilled Nursing: Physician Order/Signed Plan of Care (CMS-485 form), Face to face encounter within 90 days prior or within 30 days after starting care.
Physical Rehabilitation Equipment and Supplies, 5A-1
Respiratory Equipment and Supplies, 5A-2
Nursing Equipment and Supplies, 5A-3
Orthotics and Prosthetics, 5B
Reminders:
- A PA is required for anything over the benefit limit outlined in the Clinical Coverage Policy.
- Carolina Complete Health is committed to supporting postpartum breastfeeding mothers by covering breast pumps, regardless of specific medical necessity criteria outlined in policy 5A-3. No prior authorization is required, and claims should be submitted through the usual process.
Providers do not need to request authorizations or re-authorizations for Personal Care Services. For guidance on initial PCS request and re-assessments, see our Personal Care Services and Home Health provider resource page.