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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 Prior Authorization and Retroactive Eligibility
Retroactive eligibility occurs when the effective date of a client’s Medicaid coverage is before the eligibility “add date,” which is the date the client’s Medicaid eligibility is added to TMHP’s eligibility file.
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 that are provided to fee-for-service Medicaid clients during a client’s retroactive eligibility period (i.e., the period from the effective date to the add date), providers must obtain prior authorization within 95 days of the client’s add date and before submitting a claim for those services to TMHP.
For services provided on or after the client’s add date, the provider must obtain prior authorization within three business days of the date of service.
The provider is responsible for verifying eligibility. The provider is strongly encouraged to verify client eligibility through 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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