Fillable Texas Medicaid and Children with Special Health Care (Cook Children's Health Plan)

Fill Online, Printable, Fillable, Blank Texas Medicaid and Children with Special Health Care (Cook Children's Health Plan) Form

Use Fill to complete blank online COOK CHILDREN'S HEALTH PLAN pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Texas Medicaid and Children with Special Health Care (Cook Children's Health Plan)

On average this form takes 22 minutes to complete

The Texas Medicaid and Children with Special Health Care (Cook Children's Health Plan) form is 3 pages long and contains:

  • 0 signatures
  • 44 check-boxes
  • 68 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Cook Children's Health Plan forms online.

BROWSE COOK CHILDREN'S HEALTH PLAN FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Texas Medicaid and Children with Special Health Care Needs (CSHCN) Services Program
Non-emergency Ambulance Prior Authorization Request
Prior Authorization Request Submitter Certification Statement
I certify and affirm that I am either the Provider, or have been specifically authorized by the Provider (hereinafter "Prior
Authorization Request Submitter") to submit this prior authorization request.
The Provider and Prior Authorization Request Submitter certify and affirm under penalty of perjury that they are personally
acquainted with the information supplied on the prior authorization form and any attachments or accompanying information
and that it constitutes true, correct, complete and accurate information; does not contain any misrepresentations; and does not
fail to include any information that might be deemed relevant or pertinent to the decision on which a prior authorization for
payment would be made.
The Provider and Prior Authorization Request Submitter certify and affirm under penalty of perjury that the information
supplied on the prior authorization form and any attachments or accompanying information was made by a person with
knowledge of the act, event, condition, opinion, or diagnosis recorded; is kept in the ordinary course of business of the
Provider; is the original or an exact duplicate of the original; and is maintained in the individual patient's medical record in
accordance with the Texas Medicaid Provider Procedures Manual (TMPPM).
The Provider and Prior Authorization Request Submitter certify and affirm that they understand and agree that prior
authorization is a condition of reimbursement and is not a guarantee of payment.
The Provider and Prior Authorization Request Submitter understand that payment of claims related to this prior authorization
will be from Federal and State funds, and that any false claims, statements or documents, concealment of a material fact, or
omitting relevant or pertinent information may constitute fraud and may be prosecuted under applicable federal and/or State
laws. The Provider and Prior Authorization Request Submitter understand and agree that failure to provide true and accurate
information, omit information, or provide notice of changes to the information previously provided may result in termination
of the provider’s Medicaid enrollment and/or personal exclusion from Texas Medicaid.
The Provider and Prior Authorization Request Submitter certify, affirm and agree that by checking "We Agree" that they have
read and understand the Prior Authorization Agreement requirements as stated in the relevant Texas Medicaid Provider
Procedures Manual and they agree and consent to the Certification above and to the Texas Medicaid & Healthcare Partnership
(TMHP) Terms and Conditions.
□ We Agree
Submit completed form by fax to:
682-885-8402
F00045 Page 1 of 5
RevOct19
Texas Medicaid and Children with Special Health Care Needs (CSHCN) Services Program
Non-emergency Ambulance Prior Authorization Request
Requesting Provider Information
Provider Name: Date Request Submitted:
TPI or NPI: Taxonomy Code:
Contact Name: Ambulance Provider:
Phone: Fax: Ambulance TPI or NPI:
Client Information
Client Name: (Last, First, MI):
Client Medicaid/CSHCN Number: Date of Birth:
Is the client morbidly obese? □ No □ Yes
Client weight (pounds):
Are all other means of transport contraindicated? □ No □ Yes
If “no,” this client does not qualify for non-emergency ambulance transport.
If “yes,” please complete the remainder of the form.
Reason for Transport:
Origin: Destination:
Method of Transport: □ Ground □ Fixed Wing □ Helicopter □ Specialized
Request Type
□ One-Time, Non-repeating Date:
□ Recurring Number of days requested: _________ days (2-60 days) Begin Date: ___________________
Note: For an exception to the one-time or recurring request type, refer to the Non-emergency Ambulance Exception request in
the applicable provider manual, and submit with the Non-emergency Ambulance Exception Request Form.
Reason for Recurring Transport (2-60 day request type):
□ Dialysis □ Radiation Therapy □ Physical Therapy □ Hyperbaric Therapy □ Other (explain below):
________________________________________________________________________________________________
Estimated number of visits during these authorization dates: ___________
Explain why transport is more cost effective than servicing the client at residence:
________________________________________________________________________________________________
Requested Services
HCPCS Procedure Code: Brief Description of Services:
Submit completed form by fax to: 682-885-8402
F00045 Page 2 of 5
RevOct19
Texas Medicaid and Children with Special Health Care Needs (CSHCN) Services Program
Non-emergency Ambulance Prior Authorization Request
Condition Affecting Transport (Check Each Applicable Condition)
Physical or mental condition affecting transport:
Client requires monitoring by trained staff because:
□ Oxygen (portable O2 does not apply) □ Airway □ Suction □ Hyperbaric Therapy
□ Comatose □ Cardiac □ Life Support □ Behavioral
How does the client transfer? □ Assisted □ Unassisted
Is the client bed-confined (i.e., unable to sit in a chair, stand and ambulate)? □ Yes □ No
If “No,” please indicate the following:
Does the client use an assistive walking device? □ Yes □ No
Is the client able to stand? □ Yes □ No
The client is able to sit in which of the following for the duration of the transport:
□ Chair □ Wheelchair □ Geri-Chair □ Cardiac Chair If able to sit up, for how long: ____________
Does the client pose immediate danger to self or others? □ Yes □ No If “Yes,” describe circumstances below:
In addition to ambulance standards, does the client require additional physical restraint? □ Yes □ No
If “Yes,” select the type: □ Wrist □ Vest □ Straps □ Other (describe): ___________________________________
□ Extra Attendant must be certified by DSHS to provide emergency medical services (reason):
□ Continuous IV therapy or enteral/parenteral feedings* □ Advanced decubitus ulcers*
□ Chemical sedation* □ Contractures limiting mobility*
□ Decreased level of consciousness* □ Must remain immobile (i.e., fracture, etc.)*
□ Isolation precautions (VRE, MRSA, etc.)* □ Decreased sitting tolerance time or balance*
□ Wound precautions* □ Active seizures*
* Provide additional detail (i.e., type of seizure or IV therapy, body part affected, supports needed, or time period for the
condition) or provide detail of the client’s other conditions requiring transport by ambulance:
Certification
I certify that the information supplied in this document constitutes true, accurate, and complete information and is
supported in the medical record of the patient. I understand that the information I am supplying will be utilized to
determine approval of services resulting in payment of state and federal funds. I understand that falsifying entries,
concealment of a material fact, or pertinent omissions may constitute fraud and may be prosecuted under applicable federal
and/or state law which can result in fines or imprisonment, in addition to recoupment of funds paid and administrative
sanctions authorized by law.
Printed Name:
Title: □ Physician □ Advanced Practice RN □ Physician’s Assistant □ RN □ Discharge Planner
Provider Identifier (Medicaid/CSHCN TPI or NPI):
Signature: Date Signed:
Submit completed form by fax to: 682-885-8402
F00045 Page 3 of 5
RevOct19
Texas Medicaid and Children with Special Health Care Needs (CSHCN) Services Program
Non-emergency Ambulance Prior Authorization Request
Provider Instructions for Non-emergency Ambulance Prior Authorization Request Form
This form must be completed by the provider requesting non-emergency ambulance transportation. [Medicaid Reference: Chapter
32.024(t) Texas Human Resources Code]
All non-emergency ambulance transportation must be medically necessary. Texas Medicaid, CSHCN Services Program, and
Medicare have similar requirements for this service to qualify for reimbursement. This form is intended to accommodate all of the
programs’ requirements. For additional information and changes to this policy and process refer to the respective program
information: Texas Medicaid’s Provider Procedures Manual, CSHCN Services Program Provider Manual, and Banner Messages; and
to Medicare’s manuals, newsletters and other publications.
1. Requesting Provider Information—Enter the name of the entity requesting authorization. (i.e., hospital, nursing facility, dialysis
facility, physician).
2. Request Date—Enter the date the form is submitted.
3. Requesting Provider Identifiers—Enter the following information for the requesting provider (facility or physician):
• Enter the Texas Provider Identifier (TPI) number.
• Enter the National Provider Identifier (NPI) number. An NPI is a ten-digit number issued by the National Plan and Provider
Enumeration System (NPPES).
• Enter the primary national taxonomy code. This is a ten-digit code associated with your provider type and specialty.
Taxonomy codes can be obtained from the Washington Publishing Company website at www.wpc-edi.com.
4. Ambulance Provider Identifier— Enter the TPI or NPI number of the requested ambulance provider.
5. Client Information— This section must be filled out to indicate the client’s name in the proper order (last, first, middle initial).
Enter the client’s date of birth and client number. The client’s weight must be listed in pounds. Check yes if the physician has
documented that the client is morbidly obese. If a client is currently an inpatient at a hospital facility, any ambulance transports
are the responsibility of the hospital. One time ambulance transports that are related to a hospital discharge may be considered for
prior authorization.
6. Requested Services—Enter the requested Healthcare Common Procedure Coding System (HCPCS) procedure code and a brief
description of the requested services. The applicable codes are listed below:
Procedure Codes
A0382 A0398 A0420 A0422
A0424 A0425 A0426 A0428
A0430 A0431 A0433 A0434
A0435 A0436 A0999
7. Client’s Current Condition—This section must be filled out to indicate the client’s current condition and not to list all historical
diagnoses. Do not submit a list of the client’s diagnoses unless the diagnoses are relevant to transport (i.e., if client has a diagnosis
of hip fracture, the date the fracture was sustained must be included in documentation). It must be clear to TMHP when
reviewing the request form, exactly why the client requires transport by ambulance and cannot be safely transported by any other
means.
8. Details for Checked Boxes—For questions with check boxes at least one box must be checked. When sections requiring a detail
explanation the information must be provided (i.e., if contractures is checked, please give the location and degree of
contracture[s]).
Submit completed form by fax to: 682-885-8402
F00045 Page 4 of 5
RevOct19
Texas Medicaid and Children with Special Health Care Needs (CSHCN) Services Program
Non-emergency Ambulance Prior Authorization Request
9. Isolation Precautions—Vancomycin-Resistant Enterococci (VRE) and Methicillin-Resistant Staphylococcus Aureus (MRSA) are
just two examples of isolation precautions. Please indicate in the notes exactly what type of precaution is indicated.
10. Request Type—Check the box for the request type. A One Time, non-repeating request is for a one day period. A Recurring
request is for a period of 2-60 days. The provider must indicate the number of days being requested along with the begin date.
11. Name of Person Signing the Request—All request forms require a signature, date, and title of the person signing the form. A
One Time request must be signed and dated by a physician, physician assistant (PA), nurse practitioner (NP), clinical nurse
specialist (CNS), registered nurse (RN), or discharge planner with knowledge of the client’s condition. A Recurring request must
be signed and dated by a physician, physician assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS). The
signature must be dated not earlier than the 60th day before the date on which the request for authorization is made.
12. Signing Provider Identifier—This field is for the TPI or NPI number of the requesting facility or provider signing the form
Submit completed form by fax to: 682-885-8402
F00045 Page 5 of 5
RevOct19
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Texas Medicaid and Children with Special Health Care (Cook Children's Health Plan)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 7 May 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document