Prior Authorization Request Form

Amerigroup nonemergency ambulance prior authorization request

_

_

1.) Is an ambulance the only appropriate means of transport?

Yes

No

2.) If no, this client does not qualify for nonemergency ambulance transport.

3.) If yes, please complete the remainder of the form.

In order for this service to be covered, the service must be medically necessary and reasonable. Medical necessity is established when the member’s medical condition is

such that the use of an ambulance is the only appropriate means of transport and other alternate means of transport are medically contraindicated. Alternate means of

transport include services provided through Medicaid's Medical Transportation Program or services included in the rate for long-term care - nursing facilities, if applicable.

This form is to be completed by the

Requesting provider

provider requesting nonemergency

Name:

ambulance transportation. An

ambulance provider may not request a

Provider TPI:

NPI:

Taxonomy:

___

________

prior authorization for nonemergent

ambulance transports.

Contact name:

Phone:

Fax:

[Medicaid Reference: Chapter 32.024(t)

Texas Human Resources Code]

Ambulance provider name:

Date request submitted:

Ambulance provider identifier:

Ambulance provider contact name: _ _________________

____Phone:

Fax:__________ _____

Submit by fax to 1-866-249-1271

To BH/IDD fax to 1-866-5229

Member information

Last name:

First name:

MI:

Date of birth:

/

/

Client Medicaid or Amerigroup ID number:

Member’s current condition(s) affecting transport

*

Physical restraint or chemical sedation

Diagnoses affecting transport:

*

Decreased level of consciousness

*

Isolation precautions (VRE, MRSA, etc.)

(Check each applicable condition)

*

Wound precautions

Member requires monitoring by trained staff for:

Oxygen

Airway

Suction

*

Advanced decubitus ulcers

Cardiac

Comatose

Life support

*

Contractures limiting mobility

Ventilator dependent

*

Must remain immobile (i.e., fracture, etc.)

*

Poses immediate danger to self or others

Decreased sitting tolerance time or balance

*

*

Active seizures

Continuous IV therapy or parenteral feedings

* Additional information needed to support condition specified

Extra attendant?

YES___ NO ___ Reason:

Reason for transport

Hospital discharge?

Yes

No

If yes, expected transport time:

Other purpose:

_______________________________

Origin:

Destination:

Method of transport:

Ground

Fixed wing

Helicopter

Specialized vehicle

___Codes/modifiers

Begin date:

/

/

:

End date

__/

__/

Frequency of transportation needed:

Certification:

I certify that the information supplied in this document constitutes true, accurate and complete information and is supported in the medical record of the

patient. I understand that the information I am supplying will be utilized to determine approval of services resulting in payment of state and federal funds. I understand

that falsifying entries, concealment of a material fact or pertinent omissions may constitute fraud and may be prosecuted under applicable federal and/or state law which

can result in fines or imprisonment, in addition to recoupment of funds paid and administrative sanctions authorized by law.

Name:

Title:

Provider NPI:

Signature:

Date signed:

/

/

TXPEC-1561-16

February 2016