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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 : 5.1.8.5 Documentation of Medical Necessity and Run Sheets

5.1.8.5
5.1.8.5.1
Retrospective review may be performed to ensure documentation supports the medical necessity of the transport.
Documentation to support medical necessity must include one of the following:
The client is bed-confined before, during and after the trip and alternate means of transport is medically contraindicated and would endanger the client’s health (i.e., injury, surgery, or the use of respiratory equipment). The functional, physical, and mental limitations that have rendered the client bed-confined must be documented.
Note:
The client’s medical or mental health condition is such that alternate means of the transport is medically contraindicated and would endanger the client’s health (e.g., injury, surgery, or the use of respiratory equipment).
The client is a direct threat to himself or herself or others, which requires the use of restraints (chemical or physical) or trained medical personnel during transport for client and staff safety (e.g., suicidal).
When physical restraints are needed, documentation must include, but is not limited to, the following:
Note:
5.1.8.5.2
The run sheet is used as a medical record for ambulance services and may serve as a legal document to verify the care that was provided, if necessary. The ambulance provider does not have to submit the run sheet with the claim.
The ambulance provider must have documentation to support the claim. Without documentation that would establish the medical necessity of a nonemergency ambulance transport, the transport may not be covered by Texas Medicaid.
The ambulance provider may decline the transport if the client’s medical or mental health condition does not meet the medical necessity requirements.
It is the responsibility of the ambulance provider to maintain (and furnish to Texas Medicaid upon request) concise and accurate documentation. The run sheet must include the client’s physical assessment that explains why the client requires ambulance transportation and cannot be safely transported by an alternate means of transport.
Coverage will not be allowed if the trip record does not contain a sufficient description of the client’s condition at the time of the transfer for Texas Medicaid to reasonably determine that other means of transportation are contraindicated. Coverage will not be allowed if the description of the client’s condition is limited to statements or opinions such as the following:
The run sheet should “paint a picture” of the client’s condition and must be consistent with documentation found in other supporting medical record documentation (including the nonemergency prior authorization request.)

Texas Medicaid & Healthcare Partnership
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