Issued: April 8, 2026
Partners Health Management is issuing this provider alert to Physical Health providers as a reminder of updated prior authorization (PA) requirements for definitive drug testing services. These changes are intended to ensure appropriate utilization of testing services and alignment with NC Medicaid and health plan clinical coverage policies.
Providers are encouraged to review the information below to understand which procedure codes are impacted, when authorization is required, and how these changes will be applied.
These updates apply to services rendered on or after Feb. 1, 2026.
What is happening?
Definitive drug testing for 15 or more drugs or drug classes billed under G0482–G0483 have required prior authorization since Aug. 1, 2024.
Effective Feb. 1, 2026, prior authorization requirements expand to include:
- G0481 (tests assessing 8–14 drugs or drug classes); and
- G0480 (tests assessing 1–7 drugs or drug classes) after more than 12 tests are performed for a member within a calendar year.
| Procedure code (Number of drugs/classes tested in one encounter) | Previous Authorization Requirements | Current Authorization Requirements
(Effective Feb 2026) |
| G0480 (1-7) | PA not required | PA required after 12 tests |
| G0481 (8-14) | PA not required | PA required |
| G0482 (15-21) | PA required | PA required |
| G0483 (22+) | PA required | PA required |
What do providers need to do?
- Providers should review the updated requirements outlined in this communication and in the table above.
- Providers should continue to verify authorization needs prior to rendering services.
- Utilize the pre‑authorization check tool to confirm whether authorization is required prior to rendering services.
- Review applicable clinical coverage policies issued by NC Medicaid and Carolina Complete Health to ensure documentation and medical necessity requirements are met.
- Ensure claims are submitted accurately and align with approved prior authorizations to avoid denials.
What do providers need to know?
- Authorization determinations are based on procedure codes, clinical criteria and benefit coverage. These requirements are reflected in the pre‑authorization check tool.
- Please review associated clinical coverage policies from our partners NC Medicaid and Carolina Complete Health for more detail:
Drug Testing for Opioid Treatment and Controlled Substance Monitoring (1S‑8)
Drugs of Abuse: Definitive Testing (NC.CP.MP.50).
Who can providers contact if they have questions?
- Physical Health Utilization Management: PHUMQuestions@PartnersBHM.org.
- Claims: ClaimsDepartment@PartnersBHM.org.
- Provider Network Relations: PNRelations@PartnersBHM.org or call the Provider Services Line at 1-877-398-4145 for questions other than rates or claims.