Document Category: Health Benefits/NC Medicaid
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dma-3701-ia N.C. Health Choice Extended Coverage
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dma-3504 Notice of Approval of Service Request
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dma-3600 Tocolytic Prior Approval Request Form
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dma-3355 Prior Approval Form for Lower Extremity Prosthetic Component L5988
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dma-3400 Request for HCPCS Code Addition – Medicaid Home Health Fee Schedule
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dma-3352 Prior Approval Form for Lower Extremity Prosthetic Component L5968
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dma-3353 Prior Approval Form for Lower Extremity Prosthetic Component L5980
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dma-3354 Prior Approval Form for Lower Extremity Prosthetic Component L5987
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dma-3350 Prior Approval Form for Lower Extremity Prosthetic Component L5781 or L5782
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dma-3351 Prior Approval Form for Lower Extremity Prosthetic Component L5930