Physicians Medical Necessity Certification For Nonemergency Ambulance printable pdf download

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D.33 Physician’s Medical Necessity Certification for Nonemergency Ambulance

Transports (Texas Medicaid Program)

Request Date: __________/__________/ __________

Transport Date: __________/__________/ __________

Patient’s Name:

Medicaid Number:

Transported From:

Transported To:

Physician’s Printed Name:

Physician License #:

In order for ambulance services to be covered, they must be medically necessary and reasonable. Medical

necessity is established when the patient’s condition is clinically considered severely disabled and as such that

transportation by any other means (including services provided through the Medicaid Medical Transportation

Program or through that which is included in the rate for Long Term Care - Nursing Facilities) is contraindicated. A

round-trip transport from the client’s home to a scheduled medical appointment (e.g., an outpatient or freestanding

dialysis or radiation facility) is covered when the client meets the definition of severely disabled.

The HHSC Medicaid Program has defined “severely disabled” as that client’s physical condition limits mobility and

requires the client to be bed-confined at all times, unable to sit unassisted at all times, or requires continuous

life-support systems (including oxygen or IV infusion).

Please complete the questions below in order for the authorization to be evaluated under Medicaid coverage

criteria.

❏

1.)Is the patient severely disabled as defined by the above definition?

Yes

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

3.)If yes, please check the appropriate medical condition listed below.

This patient:

❏

Requires continuous oxygen and monitoring by trained staff

❏

Requires airway monitoring or suction

❏

Requires restraints or sedation (MUST BE EXPLAINED IN OTHER)

❏

Comatose and requires trained monitoring

❏

Is actively seizure-prone and requires trained monitoring

❏

Had to remain immobile because of a fracture/possibility of a fracture that had not been set

❏

Patient is ventilator-dependent

❏

Contractures (MUST BE EXPLAINED IN OTHER)

❏

Has advanced decubitus ulcers and requires wound precautions (MUST BE EXPLAINED IN OTHER)

❏

Requires isolation precautions (VRE, MRSA, etc.) (MUST BE EXPLAINED IN OTHER)

❏

Patient requires continuous IV therapy

❏

Requires cardiac monitoring

❏

Is exhibiting signs of a decreased level of consciousness (MUST BE EXPLAINED IN OTHER)

❏

Total hip replacement requires hip precautions and cannot sit safely (MUST BE EXPLAINED IN OTHER)

❏

Other (explain)

I CERTIFY THAT THE INFORMATION CONTAINED HEREIN IS, TO THE BEST OF MY KNOWLEDGE, COMPLETE AND

ACCURATE AND SUPPORTED IN THE MEDICAL RECORD OF THE PATIENT. THE INFORMATION BEING UTILIZED ON

THIS FORM IS BEING GATHERED TO ASSIST IN SEEKING REIMBURSEMENT FOR A NONEMERGENCY AMBULANCE

TRANSPORT FROM THE MEDICAID PROGRAM. I UNDERSTAND THAT ANY INTENTIONAL MISREPRESENTATION OR

FALSIFICATION OF ESSENTIAL INFORMATION, WHICH LEADS TO INAPPROPRIATE PAYMENTS, ARE SUBJECT TO

INVESTIGATIONS UNDER APPLICABLE FEDERAL AND STATE LAWS. * THIS AUTHORIZATION WILL BE VALID FOR

180 DAYS FROM THE DATE OF ISSUANCE AND WILL CERTIFY THAT THE PATIENT REMAINS SEVERELY

DISABLED FOR THAT PERIOD OF TIME.

_______/_______/________

Signature of Attending or Patient’s Personal Physician

Date Signed

Requesting Provider

____

TPI

Fax #

D–67

Physicians Medical Necessity Certification For Nonemergency Ambulance

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