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2012 Texas Medicaid Provider Procedures Manual

Ambulance Services Handbook : 2. Ambulance Services : 2.2 Services/Benefits, Limitations, and Prior Authorization : 2.2.2 Nonemergency Ambulance Transport Services : 2.2.2.1 Nonemergency Ambulance Transport Prior Authorization

2.2.2.1
Facilities and other providers must request and obtain prior authorization before contacting the ambulance provider for nonemergency ambulance services. HRC states that a provider of nonemergency ambulance transport is 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 ambulance provider submits a copy of the claim for which payment was denied.
TMHP responds to nonemergency transport prior authorization requests within two business days of receipt of requests for 60 days or less and within 1 business day of receipt of requests for 61 to 180 days. 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 intended transport. If the client’s medical condition is not appropriate for transport by ambulance, nonemergency 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.
Medicaid providers who participate in one of the Medicaid Managed Care Health Maintenance Organization (HMO) plans must follow its requirements.
The TMHP Ambulance Unit reviews the prior authorization request to determine whether the client’s medical condition is appropriate for transport by ambulance. Incomplete information may cause the request to be suspended for additional medical information or 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 condition requiring transport by ambulance.
Prior authorization is required when an extra attendant is needed for any nonemergency transport. When a client’s condition changes, such as a need for oxygen or additional monitoring during transport, the prior authorization request must be updated.
Refer to:
2.2.2.1.1 Prior Authorization Types, Definitions
One-Time, Nonrepeating
One-time, nonrepeating requests (one day) for prior authorization must be submitted on the Nonemergency Ambulance Prior Authorization Request (2 Pages) form, which can be found in this handbook. The physician’s signature is not needed for one-time, nonrepeating requests.
Short Term
Short-term requests (two to 60 days) for prior authorization are reserved for those clients whose transportation needs are short-term and are not anticipated to last longer than 60 days. Short-term requests must be submitted on the Nonemergency Ambulance Prior Authorization Request (2 Pages) form, which can be found in this handbook. The request must include the physician’s original signature and date signed. The signature must be current, unaltered, original, and handwritten. Computerized or stamped signatures will not be accepted. Without a signature and date, the form is considered incomplete.
Long Term
Long-term requests (61 to 180 days) are reserved for those clients whose transportation needs extend beyond 60 days. Long-term requests must be submitted on the Nonemergency Ambulance Prior Authorization Request (2 Pages) form, which can be found in this handbook. The request must include the physician’s original signature and date signed. The signature must be current, unaltered, original, and handwritten. Computerized or stamped signatures will not be accepted. Without a signature and date, the form is considered incomplete.

Texas Medicaid & Healthcare Partnership
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