In addition to the requirements stated in this section, a provider
must comply with §354.1001 of this subchapter (relating to Claim
Information Requirements), and §354.1113 of this division (relating
to Additional Claim Information Requirements).
(1) Emergency ambulance transportation. HHSC will reimburse
a Medicaid-enrolled ambulance provider for the emergency transport
of a Medicaid recipient with an emergency medical condition in accordance
with the following criteria.
(A) Transport must be to an appropriate facility. If
the transport is made to a facility other than an appropriate facility,
payment is limited to the amount that would be payable to an appropriate
facility.
(B) Transport by air or boat ambulance is reimbursable
if the time and distance required to reach an appropriate facility
make the transport by ground ambulance impractical or would endanger
the life or safety of the recipient. If the recipient's medical condition
does not meet the emergency air or boat criteria, but does meet the
emergency ground transportation criteria, the payment to the provider
is limited to the amount that would be payable at the emergency ground
transportation rate.
(2) Emergency triage, treat and transport (ET3) services.
HHSC may reimburse a Medicaid-enrolled ambulance provider responding
to a call initiated by an emergency response system and upon arrival
at the scene the ambulance provider determines the recipient's needs
are nonemergent, but medically necessary. ET3 services may be reimbursed
for:
(A) transporting Medicaid recipients to alternative
destination sites other than an emergency department;
(B) initiating and facilitating treatment in place
at the scene; and
(C) initiating and facilitating treatment in place
via telemedicine or telehealth.
(3) Nonemergency ambulance transportation. HHSC may
reimburse a Medicaid-enrolled ambulance provider for nonemergency
transport when the following requirements are met:
(A) A physician, nursing facility, health care provider,
or other responsible party, must obtain prior authorization from HHSC
when an ambulance is used to transport a recipient in circumstances
not involving an emergency.
(i) Except as provided by clause (iii) of this subparagraph,
a request for prior authorization must be evaluated by HHSC based
on the recipient's medical needs and may be granted for a length of
time appropriate to the recipient's medical condition;
(ii) Except as provided by clause (iii) of this subparagraph,
a response to a request for prior authorization must be made by HHSC
not later than 48 hours after receipt of the request; and
(iii) A request for prior authorization must be granted
immediately by HHSC and must be effective for a period of not more
than 180 days from the date of issuance if the request includes a
written statement from a physician that:
(I) states that alternative means of transporting the
recipient are contraindicated; and
(II) is dated not earlier than the 60th day before
the date on which the request for authorization is made.
(B) If the request is for authorization of ambulance
transportation for only one day in circumstances not involving an
emergency, a physician, nursing facility, health care provider, or
other responsible party must obtain authorization from HHSC no later
than the next business day following the day of transport;
(C) If the request is for authorization of ambulance
transportation for more than one day in circumstances not involving
an emergency, a physician, nursing facility, health care provider,
or other responsible party must obtain a single authorization before
an ambulance is used to transport a recipient;
(D) A person denied payment for ambulance services
rendered is entitled to payment from the nursing facility, healthcare
provider, or other responsible party that requested the services if:
(i) payment under the Medicaid program is denied because
of lack of prior authorization; and
(ii) the person provides the nursing facility, healthcare
provider, or other responsible party with a copy of the bill for which
payment was denied.
(E) HHSC must be available to evaluate requests for
authorization under this section not less than 12 hours each day,
excluding weekends and state holidays.
(4) Hearings. For information about recipient fair
hearings, refer to HHSC's fair hearing rules, Chapter 357 of this
title (relating to Hearings).
(5) Provider appeal. An ambulance provider denied payment
for services rendered because of failure to obtain prior authorization,
or because a request for prior authorization was denied, is entitled
to appeal the denial of payment to HHSC. A denial of a claim may be
appealed by a provider under HHSC's appeals procedures contained in
the Texas Medicaid Provider Procedures Manual and §354.1003 of
this subchapter (relating to Time Limits for Submitted Claims).
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| Source Note: The provisions of this §354.1115 adopted to be effective April 1, 1995, 20 TexReg 1651; amended to be effective March 10, 1998, 23 TexReg 2292; amended to be effective November 22, 2000, 25 TexReg 11387; 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 September 1, 2009, 34 TexReg 5653; amended to be effective November 27, 2023, 48 TexReg 6885 |
