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December 2016 Texas Medicaid Provider Procedures Manual

Ambulance ServicesHandbook : 2 Ambulance Services : 2.4 Claims Filing and Reimbursement : 2.4.3 Medicare and Medicaid Coverage

2.4.3
All ambulance claims are exempt from Medicare equalization, which pays the lesser of the coinsurance and deductible or the remainder of the amount that Medicaid would have paid for the same service minus what Medicare has already paid on Medicare crossover claims.
All claims for ambulance services provided to dual-eligible clients are reimbursed the full amount of the Medicare coinsurance and deductible for Part B claims and Part C claims from non-contracted Medicare Advantage Plans.
Medicaid prior authorization is not required for ambulance services for Qualified Medicare Beneficiary (QMB) clients because QMB clients are not eligible for Medicaid benefits. Providers can contact Medicare for the Medicare prior authorization guidelines.
Medicaid Qualified Medicare Beneficiary (MQMB) clients are eligible for all Medicaid benefits; therefore, the provider should simultaneously request prior authorization for the nonemergency transport from TMHP for the MQMB client in the event the service requested is denied by Medicare as a non-covered service.
Refer to:
Subsection 4.11, “Medicare and Medicaid Dual Eligibility” in Section 4, “Client Eligibility” (Vol. 1, General Information).
Subsection 2.7, “Medicare Crossover Claim Reimbursement” (Vol. 1, General Information), for additional information about Medicare coinsurance and deductible payments and exceptions.

Texas Medicaid & Healthcare Partnership
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