Texas Medicaid re-affirms that ambulance providers must not complete Medicaid PAN forms in the December 2018 Provider Manual.  We may assist in providing only necessary information such as National Provider Identifier (NPI) number, fax number, and business address..

“For non-emergency ambulance transportation services rendered to a client, ambulance providers may
coordinate the nonemergency ambulance prior authorization request between the requesting provider,
which may include a physician, nursing facility, healthcare provider, or other responsible party.
Ambulance providers may assist in providing necessary information such as their National Provider
Identifier (NPI) number, fax number, and business address to the requesting provider. However, the
Non-emergency Ambulance Prior Authorization Request form must be signed and dated and submitted
by the Medicaid-enrolled requesting provider, not the ambulance provider.”