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8.3.2.1 Nonemergency Ambulance Transport Prior Authorization
Facilities and other requesting providers must request and obtain prior authorization before contacting the ambulance provider for the transport of a Medicaid client whose medical condition is such that the use of an ambulance is the only appropriate means of transport, e.g., alternate means of transport are medically contraindicated. In addition, the HRC states that a provider who is denied payment for non-emergency ambulance transport may be entitled to payment from the nursing facility, health-care provider, or other responsible party that requested the service if payment under the Medical Assistance Program is denied because of lack of prior authorization and the provider submits a copy of the bill for which payment was denied.
TMHP responds to nonemergency transport prior authorization requests within 48 hours of receipt of the request. It is recommended that all requests for a prior authorization number (PAN) be submitted in sufficient time to allow TMHP to issue the PAN before the date of the requested transport. If the client's medical condition is not appropriate for transport by ambulance, non-emergency ambulance services are not a benefit. Prior authorization is a condition for reimbursement but is not a guarantee of payment. The client and provider must meet all of the Medicaid requirements, such as client eligibility and claim filing deadlines.
These prior authorization requirements also apply to Medicaid providers who participate in PCCM. Medicaid providers who participate in one of the Medicaid Managed Care HMO plans must follow the requirements of their plan.
The TMHP Ambulance Unit reviews the prior authorization requests to determine whether the client's medical condition is appropriate for transport by ambulance. Incomplete information may cause the request to be denied.
The following information assists TMHP in determining the appropriateness of the transport:
• An explanation of the client's physical condition that establishes the medical necessity for transport. The explanation must clearly state the client's conditions requiring transport by ambulance.
•The necessary equipment, treatment, or personnel used during the transport.
•The origination and destination points of the client's transport.
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