SECTION 354.1115. Authorized Ambulance Services

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).

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