Prior Authorization Request Form

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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

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