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December 2016 Texas Medicaid Provider Procedures Manual

Medical Transportation Program Handbook : 2 Individual Transportation Provider (ITP) : 2.2 Prior Authorization for ITPs

Once an ITP is enrolled with TMHP and a client calls MTP to request a ride, MTP will mail a preprinted ITP Service Record (Form H3017) to the MTP client. The H3017 is the form the provider must mail to TMHP to be reimbursed for the ride.
Refer to:

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.