Summary of update: Effective August 1, 2018, the Amerigroup Non-emergency Ambulance Prior Authorization Request form will be updated to reflect the content of the Texas Medicaid and Healthcare Partnership form, including a section for the HCPCS procedure code and a brief description of services. The acceptable HCPCS codes are included in the instructions section of the form. This form is used for one-time transports or recurring transports up to 60 days.

A new form will also be available for recurring transports greater than 60 days where the member has a debilitating condition of at least a 12-month duration that has been documented by the member’s physician. The Non-emergency Ambulance Exception form must be submitted for this type of request in addition to the Non-emergency Ambulance Prior Authorization Request form.

Non-Emergency Ambulance Request Form

Non-emergency Ambulance Exception Form (180-Day PA)