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2012 Texas Medicaid Provider Procedures Manual

Ambulance Services Handbook : 2. Ambulance Services : 2.2 Services/Benefits, Limitations, and Prior Authorization : 2.2.5 Types of Transport : 2.2.5.6 Not Medically Necessary Transports

2.2.5.6
Not Medically Necessary Transports
Providers must use the GY modifier to submit claims for instances when the provider is aware no medical necessity existed. When billing for this type of transportation, ambulance providers must maintain a signed Client Acknowledgment Statement indicating that the client was aware, prior to service rendered, that the transport was not medically necessary. The Client Acknowledgment Statement is subject to retrospective review.
Refer to:
Subsection 1.5.9.1, “Client Acknowledgment Statement” in Section 1, “Provider Enrollment and Responsibilities” (Vol. 1, General Information).

Texas Medicaid & Healthcare Partnership
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