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2012 Texas Medicaid Provider Procedures Manual

Ambulance Services Handbook

Ambulance Services Handbook
Table of Contents
1. General Information AM-5
2. Ambulance Services AM-5
2.1 Enrollment AM-5
2.1.1 Subscription Plans AM-5
2.2 Services/Benefits, Limitations, and Prior Authorization AM-6
2.2.1 Emergency Ambulance Transport Services AM-6
2.2.1.1 Prior Authorization for Emergency Out-of-State Transport AM-7
2.2.2 Nonemergency Ambulance Transport Services AM-7
2.2.2.1 Nonemergency Ambulance Transport Prior Authorization AM-7
2.2.2.1.1 Prior Authorization Types, Definitions AM-8
2.2.2.2 Nonemergency Prior Authorization Process AM-8
2.2.2.3 Nonemergency Prior Authorization and Retroactive Eligibility AM-9
2.2.3 Levels of Service AM-10
2.2.4 Oxygen AM-10
2.2.5 Types of Transport AM-10
2.2.5.1 Multiple Client Transports AM-10
2.2.5.2 Air or Specialized Vehicle Transports AM-10
2.2.5.3 Specialty Care Transport (SCT) AM-11
2.2.5.4 Transports for Pregnancies AM-11
2.2.5.5 Transports to or from State Institutions AM-11
2.2.5.6 Not Medically Necessary Transports AM-11
2.2.5.7 Transports for Nursing Facility Residents AM-11
2.2.5.8 Emergency Transports Involving a Hospital AM-12
2.2.5.9 No Transport AM-12
2.3 Documentation Requirements AM-13
2.4 Claims Filing and Reimbursement AM-13
2.4.1 Claims Information AM-13
2.4.2 Reimbursement AM-13
2.4.2.1 Ambulance Disposable Supplies AM-14
2.4.3 Medicare and Medicaid Coverage AM-14
2.4.3.1 Medicare Services Paid AM-14
2.4.3.2 Medicare Services Denied AM-14
2.4.4 Ambulance Claims Coding AM-14
2.4.4.1 Place of Service Codes AM-15
2.4.4.2 Origin and Destination Codes AM-15
2.4.5 Air or Specialized Vehicle Transports AM-16
2.4.6 Emergency Transport Billing AM-16
2.4.7 Nonemergency Transport Billing AM-23
2.4.8 Extra Attendant AM-23
2.4.8.1 Emergency Transports AM-24
2.4.8.2 Nonemergency Transports AM-24
2.4.9 Night Call AM-24
2.4.10 Waiting Time AM-24
2.4.11 Appeals AM-24
2.4.12 Relation of Service to Time of Death AM-25
2.5 Claims Resources AM-25
2.6 Contact TMHP AM-25
3. Forms AM-25
AM. 1 Nonemergency Ambulance Prior Authorization Request (2 Pages) AM-26
4. Claim Form Examples AM-28
AM. 2 Ambulance 1 AM-29
AM. 3 Ambulance 2 AM-30
AM. 4 Ambulance 3 AM-31
Index AM-32

Texas Medicaid & Healthcare Partnership
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