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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Effective July 1, 2019, there will be changes to ambulance services prior authorization requirements and forms for Texas Medicaid and the Children with Special Health Care Needs (CSHCN) Services Program. Claims reprocessing will be included for procedure code A0420.
Benefit Changes for Procedure Code A0420
Prior authorization is not required for procedure code A0420 (waiting time) for nonemergency ambulance transportation services. Paid transport is required to be on the same claim form as procedure code A0420.
Medicaid and CSHCN Prior Authorization Forms
The following Medicaid and Children with Special Health Care Needs ambulance services prior authorization forms will be revised and updated, and the forms will be available on July 1, 2019. The following revised forms will be fillable PDFs on the TMHP website under “Prior Authorization – (Medicaid or CSHCN) PA Forms – Prior Authorization,” and on TMHP’s Prior Authorization on the Portal:
- F00044: Texas Medicaid and Children with Special Health Care Needs (CSHCN) Services Program Non-emergency Ambulance Exception
- F00045: Texas Medicaid and Children with Special Health Care Needs (CSHCN) Services Program Non-emergency Ambulance Prior Authorization Request
The forms will be updated to remove procedure code A0420 as a code that requires prior authorization from the instructions page.
The forms will be updated with an effective date of July 1, 2019. TMHP will accept previous versions of the forms through July 31, 2019. Effective August 1, 2019, TMHP will only accept the new forms.
TMHP will return and mark as deficient previous versions of the forms, which include an effective date prior to July 1, 2019, received on or after August 1, 2019.
Claims Reprocessing for Procedure Code A0420
Affected claims that were submitted with dates of service from May 1, 2018, through June 28, 2019, will be reprocessed and may result in an additional payment or recoupment, which will be reflected on future Remittance and Status Reports. No action on the part of the provider is required.
For more information, call the TMHP Contact Center at 800-925-9126 or the TMHP-CSHCN Services Program Contact Center at 800-568-2413.