Children's Ambulance Service
Pre Authorization: Forms and Information
Ensure fast approval for your ambulance transport.
INSURANCE PLAN FORMS
Authorization Payers
Form can no longer be faxed. Authorizations can only be requested by portal or phone for UHC MCR and Commercial plans.
| INSURANCE PLAN | DAYS TO SUBMIT AUTH | FAX | FORM NEEDED | PORTAL |
| Aetna Better Health Medicaid | 2 | 866-835-9589 | TX Standardized Form | Availity |
| Ambetter Marketplace | 2 | 855-537-3447 | Ambetter Superior Form | |
| BCBS CHIP or Medicaid | 2 | 855-653-8129 | TX Standardized Form | |
| BCBS Healthselect (JEA-JYA) | 2 | 888-579-7935 | Availity | |
| BCBS – prefix PPU (>$1250.00) | 2 | 480-894-8105 (1 Yr Retro) | Availity | |
| Community Health Choice Marketplace | 2 | 713-295-7019 | CHC Form | |
| Community First Medicaid/CHIP | 2 | 210-358-6274 | ||
| Community Health Choice HMO/DSNP | 2 | 713-295-7059 | CHC Form | |
| Driscoll Children’s Medicaid | 1 | 866-741-5650 | TX Standardized Form | |
| Immigration & Customs Enforcement | 3 | (ICE) 800-479-0523 | ||
| Molina Medicaid/Marketplace | 1 | 866-420-3639 | TX Standardized Form | |
| New Mexico Medicaid | nmmedicaid.portal.conduent.com | |||
| Oscar Health Marketplace | 2 | 844-965-9053 | ||
| Parkland Medicaid | 1 | 844-303-1382/214-266-2085 | ||
| Procare Advantage MAP/MMP/SNP | 3 | 833-610-2399 | ||
| Rightcare (BS&W) Medicaid | 2 | 800-626-3042 | ||
| Superior Medicaid | 1 | 800-690-7030 | ||
| Texas Children’s Medicaid | 1 | 832-825-8760 | TX Standardized Form | TMHP |
| Texas Medicaid (TMHP) | 2 | 512-514-4205 | TX Standardized Form | TMHP |
| UHC Community Plan Medicaid | 2 | 877-940-1972 | TX Standardized Form | |
| UHC Marketplace | 2 | UHC/Optum Provider Portal | ||
| Wellcare MAP/MMP/SNP | 3 | 877-894-2034 | Wellcare Form | |
| Wellcare Genesis IPA | 2 | 281-573-0767 | Wellcare Form | |
| Wellcare Kelsey IPA | 1 | 713-442-5333 | Wellcare Form | |
| Wellcare MCA Houston IPA | 2 | 713-973-2193 | Wellcare Form | |
| Wellcare NWDC IPA | 1 | 832-232-5607 | Wellcare Form | |
| Wellcare by Allwell | 2 | IPA/State Vendor | Wellcare Form | |
| Wellmed MAPMMP/SNP | 1 | 866-855-7784 | TX Standardized Form | |
| Wellpoint Medicaid (Formerly Amerigroup) | 2 | 866-249-1271 | TX Standardized Form |
AUTHORIZATION INSTRUCTIONS
Texas Standardized Instruction Sheet
Section 1: Add insurance name, fax number, and date of request
Section 2: Non-urgent and initial request
Section 3: Patient information (Note: Insurance ID number is required)
Section 4: Facility and contact person information with signature
Section 5: Start date and end date for all lines (Should be date of transport)
Units for each procedure code are required. Round trips will require 2 units:
- BLS A0428
- ALS A0426
- SCT A0434
- Mileage A0425 × [number of miles]
- BLS Disposable A0382
- Oxygen A0422 (if needed)
- A0433 (ALS2 can be non-emergent)
Diagnosis and ICD code required
Section 6: Reason why the ambulance is required and destination of transport.