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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 : 2.2.2.2 Nonemergency Prior Authorization Process

2.2.2.2
Nonemergency Prior Authorization Process
Prior authorization is required for all nonemergency ambulance transport. The special evening and weekend hours for submitting prior authorization requests by telephone ended on September 1, 2009. Providers may submit prior authorization requests on the TMHP website at www. tmhp.com or may fax the new Nonemergency Ambulance Prior Authorization Request (2 Pages) form, which can be found in this handbook, to the TMHP Ambulance Unit at (512) 514-4205.
Medicaid providers may request prior authorization using one of the following methods:
The client’s physician, nursing facility, intermediate care facility for persons with intellectual disabilities (ICF-MR), health-care provider, or other responsible party completes the online prior authorization request on the TMHP website at www. tmhp.com.
Hospitals may call TMHP at 1-800-540-0694 to request prior authorization Monday through Friday, 7 a.m. to 7 p.m., Central Time. A request may be submitted up to 60 days before the date on which the nonemergency transport will occur. A request for a one-day transport may be submitted on the next business day following the transport in some circumstances; however, every attempt should be made to obtain prior authorization before the transport takes place.
Authorization requests for one day transports submitted beyond the next business day will be denied. A request for a recurring transport must be submitted before the client is transported by ambulance.
Clients requiring hospital-to-hospital and hospital-to-outpatient medical facility transports are issued a PAN for that transport only.
Refer to:
Subsection 4.2.1, “Prior Authorization Requirements” in the Inpatient and Outpatient Hospital Services Handbook (Vol. 2, Provider Handbooks) for more information on nonemergency prior authorization for hospitals.
TMHP reviews all of the documentation it receives. An online prior authorization request submitted on the TMHP website at www.tmhp.com is responded to with an online approval or denial. Alternately, a letter of approval or denial is faxed to the requesting provider. The client is notified by mail if the authorization request is denied or downgraded. Reasons for denial include documentation that does not meet the criteria of a medical condition that is appropriate for transport by ambulance, or the client is not Medicaid eligible for the dates of services requested. Clients may appeal prior authorization request denials by contacting TMHP Client Notification at 1-800-414-3406. Providers may not appeal prior authorization request denials.
The requesting provider must contact the transporting ambulance provider with the PAN and the dates of service that were approved.
Refer to:
Subsection 5.5.1, “Prior Authorization Requests Through the TMHP Website” in Section 5, “Prior Authorization” (Vol. 1, General Information) for additional information, including mandatory documentation requirements and retention.
Providers are not required to fax medical documentation to TMHP; however, in certain circumstances, TMHP may request that the hospital fax the supporting documentation.
Incomplete online or faxed request forms are not considered a valid authorization request and are denied.
A nonemergency transport will be denied when a claim is submitted with a Nonemergency Ambulance Prior Authorization Request (2 Pages) form completed and signed after the service is rendered. In addition, a Nonemergency Ambulance Prior Authorization Request (2 Pages) form completed and signed after the service is rendered will not be accepted on appeal of the denial.
Emergency transports that use an extra attendant do not require prior authorization. Modifier ET must be billed with the extra attendant procedure code A0424.
The hospital must maintain documentation of medical necessity, including a copy of the authorization from TMHP in the client’s medical record for any item or service that requires prior authorization. The services provided must be clearly documented in the medical record with all pertinent information regarding the client’s condition to substantiate the need and medical necessity for the services.
Refer to:
Subsection 4.2.1, “Prior Authorization Requirements” in the Inpatient and Outpatient Hospital Services Handbook (Vol. 2, Provider Handbooks).

Texas Medicaid & Healthcare Partnership
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