Insurance Plan |
Phone |
Fax |
Form Needed |
|---|---|---|---|
AARP Medicare Advantage |
877-757-4440 |
866-322-7276 |
2023 Texas Standard Form |
AARP Secure Horizon |
877-757-4440 |
866-322-7276 |
AARP Secure Horizons Form 2023 |
Aetna/CHIP Medicaid |
800-306-8612 |
866-835-9589 |
2023 Texas Standard Form |
Aetna Medicare 800-624-0756 |
Must Call Plan |
Must Call Plan |
Texas Standard Prior Authorization |
Ambetter |
877-687-1196 |
855-537-3447 |
Ambetter Form 2023 |
Amerigroup/CHIP Medicaid |
713-218-5151 ext . 35889 |
866-249-1271 |
Amerigroup MCD Form 2023 |
Amerigroup-Integranet |
281-591-5289 |
281-405-3431 |
Integranet Portal |
Baylor Scott and White |
888- 316-7947 |
800- 626-3042 |
2023 Texas Standard Form |
BCBS Medicaid CHIP/STAR |
877-560-8055 |
1-855-653-8129 |
2023 Texas Standard Form |
Blue Cross/Blue ShieldMedicare Advantage Plan, no PAN needed for ground transports. |
Must call plan |
Must call plan |
2023 Texas Standard FormProvider Portal |
Care N Care |
855-359-9999 |
888-965-1964 |
2023 Texas Standard Form |
Children’s Medical Center |
800-947-4969 |
214-861-5510 |
2023 Texas Standard Form |
Cigna Healthspring Medicaid |
877-562-4402 |
877-809-0787 |
2023 Texas Standard FormProvider Portal |
Cigna Healthspring Medicare |
800-280-8888 |
Must Call Plan |
2023 Texas Standard FormProvider Portal |
Cook Children/CHIP Cook |
888-243-3312 |
682-885-8402 |
Cook Children’s Prior Authorization 2023 |
Driscoll Medicaid |
877-324-3627 |
866-741-5650 |
2023 Texas Standard Form |
First Care Medicaid |
800-884-4905 |
800-248-1852 |
2023 Texas Standard Form |
Humana Gold Plus (HMO) |
877-757-4440 |
866-322-7276 |
2023 Texas Standard Form |
Medicaid TMHP/CHIP |
800-540-0694 |
512-514-4205 |
TMHP Form |
Molina Medicaid |
866-449-6849 |
866-420-3639 |
Molina Medicaid Form 2023 |
Molina Medicare MMP |
866-448-6849 |
844-251-1451 |
Molina Prior Authorization Form 2023 |
Parkland Community Health Plan |
800-306-8612 |
800-240-0410 |
TMHP Form 2023 |
RightCare Scott & White |
855-897-4448 |
512-383-8703 |
RightCare Form 2023 |
Scott and White |
888-316-7947 |
800-626-3042 |
2023 Texas Standard Form |
Superior Medicaid |
877-391-5921 |
844-560-8993 |
2023 Texas Standard Form |
Superior Medicare (MMP) |
800-218-7508 |
877-808-9368 |
2023 Texas Standard Form |
Tricare Prime |
800- 444-5445 |
877- 548-1547 |
Provider Portal |
UHC Community Medicaid |
866-331-2243 |
877-940-1973 |
2023 Texas Standard Form |
United Healthcare Dual Plan |
877-757-4440 |
866-322-7276 |
2023 Texas Standard Form |
Wellcare |
855-538-0454 |
877-894-2034 |
Provider PortalWellcare Form 2023 |
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)
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.
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