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 |
Molina Prior Auth Form 2022 |
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)
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
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