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December 2016 Texas Medicaid Provider Procedures Manual

Ambulance ServicesHandbook : 2 Ambulance Services : 2.3 Documentation Requirements

2.3
The requesting provider, which may include a physician, nursing facility, health-care provider, or other responsible party, is required to maintain the supporting documentation, physician’s orders, the Non-emergency Ambulance Prior Authorization Request form and if applicable, the Nonemergency Ambulance Exception form.
An ambulance provider is required to maintain documentation that represents the client’s medical condition and other clinical information to substantiate medical necessity, the level of service, and the mode of transportation requested. This supporting documentation is limited to documents developed or maintained by the ambulance provider.
Physicians, nursing facilities, health-care providers, or other responsible parties are required to maintain physician orders related to requests for prior authorization of nonemergency and out-of-state ambulance services. These providers must also maintain documentation of medical necessity for the ambulance transport.
In hospital-to-hospital transports or hospital-to-outpatient medical facility transports, the TMHP Ambulance Unit considers information by telephone from the hospital. Providers are not required to fax medical documentation to TMHP; however, in certain circumstances, TMHP may request that the hospital fax the supporting documentation. Hospitals are allowed to release a client’s protected health information (PHI) to a transporting emergency medical services provider for treatment, payment, and health-care operations.
Providers 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.
The hospital must maintain documentation of medical necessity, including a copy of the authorization from TMHP in the client’s medical record for any item or service that requires prior authorization. The services provided must be clearly documented in the medical record with all pertinent information regarding the client’s condition to substantiate the need and medical necessity for the services.

Texas Medicaid & Healthcare Partnership
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