Forms & Information

Insurance Plan

Phone

Fax

Form Needed

 AARP Medicare Advantage

877-757-4440

866-322-7276

Texas Standard Prior Authorization

AARP Secure Horizon

877-757-4440

866-322-7276

Texas Standard Prior Authorization

Aetna/CHIP Medicaid

800-306-8612

866-835-9589

Texas Standard Prior Authorization

Aetna Medicare 800-624-0756

Must Call Plan

Must Call Plan

Texas Standard Prior Authorization

Ambetter

877-687-1196

855-537-3447

Texas Standard Prior Authorization

Amerigroup/CHIP Amerigroup

713-218-5151 ext . 35889

866-249-1271

Amerigroup/CHIP Amerigroup Form

Amerigroup-Integranet

281-591-5289

281-405-3431

Integranet Portal

Baylor Scott and White

888- 316-7947

800- 626-3042

Texas Standard Prior Authorization

Blue Cross/Anthem Medicare

855-878-1785 ext. 35278

888-235-8468

Texas Standard Prior Authorization

Blue Cross BS Medicaid

888-292-4487

855-879-7180

Texas Standard Prior Authorization

Bright Healthcare

844-926-4525

877-438-6832

Texas Standard Prior Authorization

Blue Cross Blue Shield

Must call plan

Must call plan

Texas Standard Prior Authorization

Care N Care

855-359-9999

888-965-1964

Texas Standard Prior Authorization

Children’s Medical Center

800-947-4969

214-861-5510

Texas Standard Prior Authorization

Cigna Healthspring Medicaid

877-562-4402

877-809-0787

Texas Standard Prior Authorization

Cigna Healthspring Medicare

800-280-8888

Must Call Plan

Texas Standard Prior Authorization

Cook Children/CHIP Cook

800-862-2247

682-885-8402

Texas Standard Prior Authorization

Driscoll Medicaid

877-324-3627

866-741-5650

Texas Standard Prior Authorization

First Care Medicaid

800-431-7798

800-248-1852

Texas Standard Prior Authorization

Humana Gold Plus (HMO)

877-757-4440

866-322-7276

Texas Standard Prior Authorization

Medicaid TMHP/CHIP

800-540-0694

512-514-4205

TMHP Form

Molina Medicaid

866-449-6849

866-420-3639

Texas Standard Prior Authorization

Molina Medicare MMP

866-448-6849

844-251-1451

Texas Standard Prior Authorization

Parkland Medicaid

800-306-8612

800-240-0410

Texas Standard Prior Authorization

RightCare Scott & White

855-897-4448

512-383-8703

Texas Standard Prior Authorization

Scott and White

888-316-7947

800-626-3042

Texas Standard Prior Authorization

Superior Medicaid

877-391-5921

844-560-8993

Texas Standard Prior Authorization

Superior Medicare (MMP)

800-218-7508

877-808-9368

Texas Standard Prior Authorization

Tricare Prime

800- 444-5445

877- 548-1547

Texas Standard Prior Authorization

UHC Community Medicaid

866-331-2243

877-940-1973

Texas Standard Prior Authorization

United Healthcare Dual Plan

877-757-4440

866-322-7276

Texas Standard Prior Authorization

Wellcare

855-538-0454

877-894-2034

Texas Standard Prior Authorization

Wellmed 877-757-4440 Call only Call only

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 X ______ Units (# of miles)
ALS Disposable A04398
BLS Disposable A0382
Oxygen A0422 (if needed)

Diagnosis and ICD code required
Section 6: Reason why the ambulance is required and destination of
transport.
After faxing the request with supporting clinical documentation to the
Insurance company, forward all documentation to Acadian Ambulance at:
(337)-291-2271 or ATAC@Acadian.com. Be sure to include the Fax Confirmation receipt.


 Acadian Ambulance Service of Texas, LLC

NPI #: 1750676870

Texas Provider Identifier (TPI) #318533201

Tax ID #72-0701964

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


Disclaimer:  Although this website may include links providing direct access to other Internet resources, including Web sites, this forum is not responsible for the accuracy or content of information contained in these sites.

 

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