REFERRAL FORM FOR TRANSPORTATION SERVICES AND PHYSICIAN CERTIFICATION STATEMENT (PCS)
The Department of Health Care Services (DHCS) requires that a PCS Form is used to process and determine the appropriate
level of Non-Emergency Medical Transportation (NEMT) services. Completed and signed forms must be promptly submitted
to
Attn: L.A. Care Health Plan’s (L.A. Care) Utilization Review (UR) Transportation Unit via facsimile “fax” to: 213-438-2201.
PCS forms for transportation that meet the criteria for Automatic Approval (AA) shall be submitted within 24 hours of
NEMT services being arranged to document activity and avoid unnecessary delays. AA is typically for transports in response
to discharges, transfers, dialysis, chemotherapy, mammogram, radiation treatment, and surgery follow-up appointments.
All other PCS forms for Prior Authorizations must be reviewed and approved by L.A. Care’s UR team before NEMT services
are arranged. Incomplete or inaccurate forms may cause delays and/or denials. L.A. Care’s standard UR turn-around time is
five (5) business days. The PCS Form is not required for Non-Medical Transportation (NMT) services. To schedule NMT, AA
NEMT, or authorized NEMT, please call L.A. Care Health Plan at 877-431-2273 and select option 4 for transportation. Again,
PCS forms for NEMT only.
Patient Information:
First Name: Last Name: Date of Birth:
ID Number / CIN#: Phone Number:
Address: Caregiver Name:
City: State: Zip: Caregiver Phone Number:
Provider Information:
Provider’s Full Name (Print):
Title: Provider NPI:
Phone Number: Fax Number: Email:
Authorization Level: If request is for AA, please CHECK AA and CONFIRM vehicle type below.
Automatic Approval (AA) Prior Authorization
Does Patient Need Prior Authorization for NEMT? Complete the NEMT section below.
NEMT – PROVIDER CERTIFICATION, JUSTIFICATION & SIGNATURE REQUIRED
Disclaimer: L.A. Care is required to authorize the lowest cost type of NEMT services that is adequate for the member’s
medical needs. Once the PCS is submitted, L.A. Care cannot modify the authorization to a lower level without a new PCS
form from the provider.
NEMT Vehicle Type & Door-Through-Door
Ambulance:
Basic Life Support (BLS) Advanced Life Support (ALS)
Specialty Care Transport (SCT)
Litter/Gurney Van Wheelchair Van Air Ambulance
NEMT Anticipated Duration:
Start Date: End Date:
30 Days Six (6) Months 12 Months
Justification: Provide specific physical and medical limitations that preclude the member’s ability to reasonably ambulate
without assistance or be transported by public or private vehicles. Include medical, behavioral health, or the physical
condition that prevents ordinary means of public transportation (provide justification here):
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Diagnosis: ICD-10 Code(s):
Certification Statement: This form must be signed by the physician, physician assistant, nurse practitioner, certified nurse
midwife, physical therapist, speech therapist, occupational therapist, dentist, podiatrist, mental health or substance use
disorder provider responsible for providing care to the member and responsible for determining medical necessity of
transportation consistent with the scope of their practice. By my signature, I certify that medical necessity was used to
determine the type of transport being requested.
Signature (Required):
X _________________________________________
Date:
___________________________________________
March 2019
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