Current through Reg. 49, No. 38; September 20, 2024
(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.
