SECTION 354.1113. Additional Claim Information Requirements

(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.

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