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