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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 : 2.2.2.3 Nonemergency Prior Authorization and Retroactive Eligibility

2.2.2.3
Nonemergency Prior Authorization and Retroactive Eligibility
Retroactive eligibility occurs when the effective date of a client’s Medicaid coverage is before the eligibility “add date.” The date the client’s Medicaid eligibility is added to TMHP’s eligibility file is called the “add date.”
For clients with retroactive eligibility, prior authorization requests must be submitted after the client’s add date and before a claim is submitted to TMHP.
For services provided to fee-for-service Medicaid clients during the client’s retroactive eligibility period (i.e., the period from the effective date to the add date), prior authorization must be obtained within 95 days of the client’s add date and before a claim for those services is submitted to TMHP. For services provided on or after the client’s add date, the provider must obtain prior authorization within 3 business days of the date of service.
The provider is responsible for verifying eligibility. The provider is strongly encouraged to access the Automated Inquiry System (AIS) or TMHP Electronic Data Interchange (EDI) frequently while providing services to the client. If services are discontinued before the client’s add date, the provider must still obtain prior authorization within 95 days of the add date to be able to submit claims.
If a client’s Medicaid eligibility is pending, a PAN must be requested before a nonemergency transport. Initially this request will be denied for Medicaid eligibility. When Medicaid eligibility is established, the requestor has 95 days from the date on which the eligibility was added to TMHP’s files to contact the TMHP Ambulance Unit and request that authorization be considered.
To inquire about Medicaid eligibility, providers can contact AIS at 1-800-925-9126.

Texas Medicaid & Healthcare Partnership
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