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December 2016 Texas Medicaid Provider Procedures Manual

Ambulance ServicesHandbook : 2 Ambulance Services : 2.2 Services, Benefits, Limitations, and Prior Authorization : 2.2.2 Nonemergency Ambulance Transport Services

According to 1 TAC §354.1111, nonemergency transport is defined as ambulance transport provided for a Medicaid client to or from a scheduled medical appointment, to or from a licensed facility for treatment, or to the client’s home after discharge from a hospital when the client has a medical condition such that the use of an ambulance is the only appropriate means of transportation (i.e., alternate means of transportation are medically contraindicated).
In this circumstance, contraindicated means that the client cannot be transported by any other means from the origin to the destination without endangering the individual’s health.
According to Human Resource Code (HRC) §32.024 (t), a Medicaid-enrolled physician, nursing facility, health-care provider, or other responsible party is required to obtain authorization before an ambulance is used to transport a client in circumstances not involving an emergency.
Providers requesting prior authorization must document whether the client is currently an inpatient in a hospital when requesting prior authorization. Prior authorization will not be approved if the provider indicates the client is currently an inpatient in a hospital, except for one-time transports immediately after the client’s discharge from the hospital.
Medical necessity must be established through prior authorization for all nonemergency ambulance transports. Retrospective review may be performed to ensure that documentation supports the medical necessity of the transport.
Clients who do not meet medical necessity requirements for nonemergency ambulance transport may be able to receive transport through the Medical Transportation Program (MTP).
Transports must be limited to those situations where the transportation of the client is less costly than bringing the service to the client.
The Non-emergency Ambulance Prior Authorization Request form must be filled out and submitted to TMHP by the facility or the physician’s staff that is most familiar with the client’s condition. The ambulance provider must not assist in completing or submitting any portion of this form.
Refer to:
Subsection 5.1.8, “Prior Authorization for Nonemergency Ambulance Transport” in Section 5, “Prior Authorization” (Vol 1, General Information) for more information about nonemergency ambulance transport prior authorization requests and appeals.
The Medical Transportation Program Handbook (Vol. 2, Provider Handbooks) for more information about the Medical Transportation Program.

Texas Medicaid & Healthcare Partnership
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