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December 2016 Texas Medicaid Provider Procedures Manual

Section 5: Fee‑for‑Service Prior Authorizations : 5.1 General Information About Prior Authorization : 5.1.8 Prior Authorization for Nonemergency Ambulance Transport : 5.1.8.2 Prior Authorization Types, Definitions

5.1.8.2
One-Time, Nonrepeating
One-time, nonrepeating requests are reserved for those clients who require a one-time transport. The request must be signed and dated by a physician, physician assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS), registered nurse (RN), or discharge planner with knowledge of the client’s condition. Without a signature and date, the form is considered incomplete.
Recurring
Recurring requests, up to 60 days, are reserved for those clients whose transportation needs are not anticipated to last longer than 60 days. The request must be signed and dated by a physician, PA, NP, or CNS. Without a signature and date, the form is considered incomplete. The request must include the approximate number of visits needed for the repetitive transport (e.g., dialysis, radiation therapy).
Refer to:

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.