Forms & Information

Traditional Medicaid TMHP Form
Texas Standardized Form  
(use for Parkland Community Health Plan, Aetna Medicaid & CHIP, UnitedHealthcare Community Plan)
Amerigroup Ambulance Prior Auth Form
Amerigroup Ambulance Exception Form (180-day PA)
Molina Healthcare Prior Auth Form (Texas Standardized Form)
Superior Healthplan STAR+PLUS MMP Plan -Prior Auth Form
Superior Healthplan Advantage (Medicare)-Auth Form
Superior Medicaid
BC/BS (Blue HMO) Medicaid (STAR), STAR Kids and CHIP 
Scott & White Health Plan
Community First Health- Authorization Process
Community Health Choice- Reference Guide (call 713.295.2295 for authorization)
Texas Children’s Health Plan- Auth Form
UnitedHealthcare Community Plan- Auth Information
Sendero Health Plan- Auth Form
Cook Children’s Health Plan- Auth Form
Seton Health Plan- Auth Form
Wellcare Auth Form
Cigna HeathSpring Auth Form
WellMed

 Acadian Ambulance Service of Texas, LLC

NPI #: 1750676870

Texas Provider Identifier (TPI) #318533201
Tax ID #:30-0688582

Dispatch # (800)-259-1111

Acadian Transport Assistance Center (ATAC) # (737)-209-6665

ATAC Fax # (337)-291-2271

Learn more about Acadian Ambulance

Click here for a complete list of participating health plans


Procedure Codes for Ambulance Transportation

A0434 Critical Care Transport- 

For patients who require ALS monitoring that also requires the use of a ventilator and IV pump.

CCT units are staffed with at least one CCT Paramedic.

  • Ventilator management (CPAP/BIPAP, Intubated Patients, Trach patients on a Ventilator) (<50 mL Tidal Volume is the only limitation)
    • CPAP/BIPAP, AC (V/P), SIMV (V/P)
    • PEEP up to 25
    • FiO2 21-100%
    • I:E Ratio 1:1-1:15
    • Full Drug Infusion capabilities (Continuation of sedation/Paralytics, Cardiac, and or OB/GYN emergencies, Vasopressors, Blood and Blood products) NOTE* – Pumps can accommodate up to three different lines.
  • EKG Monitoring and Interpretation
  • Blood Pressure
  • Pulse Oximetry
  • Oxygen
  • Capnography
  • Vent Management
  • All IV Therapy (Including TPA and Blood Products)
  • Chest Tubes
  • Wound pumps
  • Foley –
    Rectal Tubes

A0426- Advanced Life Support

For patients who require BLS monitoring, plus IV monitoring, cardiac monitoring, and medication administration.  ALS units are staffed with at least one Paramedic.

  • Peripheral IV access with TPN, NS, LR, Antibiotics, Electrolytes (Excluding Potassium and Magnesium)
  • EKG Monitoring and Interpretation
  • Blood Pressure
  • Pulse Oximetry -Oxygen
  • Capnography
  • TPN, NS, LR, Antibiotics, Electrolytes (Excluding Potassium and Magnesium)
  • Non-Vent dependant Tracheostomy (Able to deep suction)
  • Wound pumps
  • Foley Catheter
  • Rectal Tubes

A0428- Basic Life Support

For patients who are bed-confined or cannot be transported by other means than a stretcher, requiring only basic monitoring (vital signs, airway) and require nothing more involved than oxygen.  BLS units are typically staffed with Basic EMTs.  However, ALS units can transport BLS patients.

  • Blood Pressure
  • Pulse Oximetry
  • Oxygen
  • Non-Vent dependent Tracheostomy (Exclude patients with deep suctioning needs)
  • Wound pumps
  • Foley Catheter
  • Rectal Tubes
  • Peripheral IV access with SALINE LOCK.

Last medication must have been given over one hour ago, excluding: TPN, NS, LR, Antibiotics, Electrolytes (Potassium and Magnesium must have been given prior to the one hour window)

A0425 Mileage – number of unit will equal the number of miles

A0382 Disposables- 1 unit

A0422 Oxygen- 1 unit (if applicable)

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