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

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 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

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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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