(a) In addition to the general requirements in §354.1001
of this subchapter (relating to Claim Information Requirements), the
following information is required on claims for ambulance services.
(1) Documentation of medical necessity in accordance
with codes representing medical conditions as designated by HHSC:
(A) the transport documentation must substantiate the
level of service and mode of transport provided;
(B) reimbursement is recouped when the documentation
does not substantiate that the level of service and mode of transport
provided accurately matches the level of service and mode of transport
claimed; and
(C) the level of service and mode of transport provided
must be medically necessary based on the clinical situation and needs
of the recipient.
(2) Type of ambulance service provided (e.g, air, ground,
or boat).
(3) Origin and destination of each separate trip.
(4) Charges for ambulance services, including base
rates and mileage rates.
(5) Documentation to support emergency triage, treat
and transport (ET3) services for transport to an alternative destination
site, for treatment in place at the scene, or treatment in place via
telemedicine or telehealth, if applicable.
(6) A prior authorization number (PAN) must be obtained
for nonemergency transport.
(b) Prior authorization is required when transporting
a recipient. A PAN must be obtained when an ambulance is used to transport
a recipient for:
(1) nonemergency transports; and
(2) out-of-state ambulance transports.
(c) Supporting documentation is required to be maintained
by both the ambulance provider and the requesting provider including
a physician, nursing facility, health care provider or other responsible
party. Supporting documentation is to be made available if requested
by the Office of Inspector General (OIG) or HHSC.
(1) An ambulance provider is required to maintain documentation
that represents the recipient's medical conditions and other clinical
information to substantiate medical necessity, the level of service,
and mode of transportation requested. This supporting documentation
is limited to documents developed by the ambulance provider.
(2) Physicians, nursing facilities, health care providers
or other responsible parties are required to maintain physician orders
related to requests for prior authorization of nonemergency and out-of-state
ambulance services. These providers must also maintain documentation
of medical necessity for the ambulance transport.
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Source Note: The provisions of this §354.1113 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 November 9, 2003, 28 TexReg 9521; amended to be effective August 26, 2007, 32 TexReg 5163; amended to be effective November 27, 2023, 48 TexReg 6885 |