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December 2016 Texas Medicaid Provider Procedures Manual

Ambulance ServicesHandbook : 2 Ambulance Services : 2.2 Services, Benefits, Limitations, and Prior Authorization : 2.2.5 Types of Transport : 2.2.5.8 Transports for Nursing Facility Residents

2.2.5.8
Nursing facilities are responsible for providing or arranging transportation for their residents. Arranging transportation for Medicaid clients includes obtaining prior authorizations for nonemergency ambulance transports. The Nonemergency 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.
Transports from a nursing facility to a hospital are covered if the client’s condition meets emergency criteria.
A return trip to a nursing facility following an emergency transport is not considered routine; therefore, transport back to the facility must be requested by the discharging hospital. Nonemergency transport for the purpose of required diagnostic or treatment procedures that are not available in the nursing facility (such as dialysis treatments at a freestanding facility) are also allowable only for clients whose medical condition is such that the use of an ambulance is the only appropriate means of transport (e.g., alternate means of transport are medically contraindicated).
The cost of routine nonemergency transportation is included in the nursing facility vendor rate. This nonemergency transport requires the nursing facility to request and obtain a Prior Authorization Number (PAN) from the TMHP Ambulance Unit before contacting the ambulance company for the transport.
Transports of nursing facility residents for rehabilitative treatment (e.g., physical therapy) to outpatient departments or physicians’ offices for recertification examinations for nursing facility care are not reimbursable ambulance services.
Claims for services to nursing facility residents must indicate the medical diagnosis or problem requiring treatment, the medical necessity for use of an ambulance for the transport, and the type of treatment rendered at the destination (e.g., admission or X-ray).
If a client is returned by ambulance to a nursing facility following inpatient hospitalization, the acute condition requiring hospitalization must be noted on the ambulance claim form. This transport is considered for payment only if the client’s medical condition is appropriate for transport by ambulance. This nonemergency transport requires the nursing facility to request and obtain a PAN from the TMHP Ambulance Unit before contacting the ambulance company for the transport.
Ambulance providers may bill a nursing facility or client for a nonemergency ambulance transport only under the following circumstances:
Providers may bill the nursing facility when the nursing facility requests the nonemergency ambulance transport without a PAN.
Providers may bill the client only when the client requests transport that is not an emergency and the client does not have a medical condition such that the use of an ambulance is the only appropriate means of transport (i.e., alternate means of transport are medically contraindicated). The provider must advise the client of acceptance as a private pay patient at the time the service is provided, and the client is responsible for payment of all services. Providers are encouraged to have the client sign the Private Pay Agreement.
Providers may refer questions about a nursing facility’s responsibility for payment of a transport to the TMHP Contact Center at 1-800-925-9126 or TMHP provider relations representatives.

Texas Medicaid & Healthcare Partnership
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