The following words and terms, when used in this subchapter,
shall have the following meanings, unless the context clearly indicates
otherwise.
(1) Ambulance provider--A provider of ambulance services
who:
(A) is enrolled as an ambulance provider in the Texas
Medicaid Program to provide ambulance services for Medicaid recipients;
(B) is licensed with the Department of State Health
Services, Emergency Medical Services Division;
(C) is enrolled in Medicare;
(D) agrees to accept assignment on all Medicare/Medicaid
claims; and
(E) agrees to provide these services according to state
and local laws, regulations, and guidelines governing ambulance services.
(2) Appropriate facility--The nearest medical facility
that is equipped to provide medical care for the illness or injury
of the Medicaid recipient involved. It is the institution, equipment,
personnel, and capability to provide the services necessary to support
the required medical care that determine whether a facility is appropriate.
(3) Designee--The contractor responsible for reimbursing
Medicaid providers of ambulance transport services for Medicaid recipients.
(4) Emergency medical condition--A medical condition
(including emergency labor and delivery) manifesting itself by acute
symptoms of sufficient severity (including severe pain, psychiatric
disturbances, or symptoms of substance abuse) such that a prudent
layperson with an average knowledge of health and medicine, could
reasonably expect the absence of immediate medical attention to result
in one of the following:
(A) placing the recipient's health (or, with respect
to a pregnant woman, the health of the woman or her unborn child)
in serious jeopardy;
(B) serious impairment to bodily functions; or
(C) serious dysfunction of any bodily organ or part.
(5) Emergency triage, treat and transport (ET3) services--ET3
services are emergency ground ambulance services and include:
(A) transporting Medicaid recipients to alternative
destination sites other than an emergency department, including primary
care physician offices and urgent care clinics;
(B) initiating and facilitating appropriate treatment
in place at the scene; or
(C) initiating and facilitating appropriate treatment
in place via telemedicine or telehealth.
(6) Emergency transport--Transport provided by an ambulance
provider for a Medicaid recipient whose condition meets the definition
of an emergency medical condition. Facility-to-facility transports
are appropriate as emergencies if the required treatment for the emergency
medical condition is not available at the first facility.
(7) HHSC--The Texas Health and Human Services Commission
or its designee.
(8) Medically necessary--When the condition of the
Medicaid recipient meets the definition of emergency medical condition
or meets the requirements for nonemergency transport.
(9) Nonemergency transport--Transport provided by an
ambulance provider for a Medicaid recipient to or from a scheduled
medical appointment, to or from another licensed facility for treatment,
or to the recipient's home after discharge from a hospital. Nonemergency
transport is appropriate when the Medicaid recipient's medical condition
is such that the use of an ambulance is medically required, e.g.,
bed confinement, and alternate means of transport are medically contraindicated.
|
| Source Note: The provisions of this §354.1111 adopted to be effective April 1, 1995, 20 TexReg 1651; transferred effective September 1, 2001, as published in the Texas Register May 24, 2002, 27 TexReg 4561; amended to be effective August 26, 2007, 32 TexReg 5163; amended to be effective November 27, 2023, 48 TexReg 6885 |
