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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 : Nonemergency Ambulance Exception Request
Clients whose physician has documented a debilitating condition and who require recurring trips that will extend longer than 60 days may qualify for an exception to the 60-day prior authorization request.
To request an exception, providers must submit all of the following documentation:
A completed Nonemergency Ambulance Exception form that is signed and dated by a physician. Without a physician’s signature and date, the form is considered incomplete.

Texas Medicaid & Healthcare Partnership
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