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December 05, 2016

Emergency Ambulance Services

The Medical Care Unit is responsible for reviewing payment authorization for Ambulance Services. To obtain authorization for payment for emergency ambulance services, please fax or mail the appropriate form:

Non-Hospital Provider

Hospital Provider

· CMS – 1500 (HCFA-1500)

· Patient Care Report

· EOB if Applicable

· UB-04

· Invoice of Carges

· Patient Care Report (PCR)

· EOB if applicable

The status of your authorization request may be checked online at the Molina Health PAS portal under “Authorization Status”, using your NPI, or by contacting Molina at 866-686-4272. 


Non-Emergency Ambulance Services

For non-emergency ambulance services, please note that ALL transports must receive prior authorization BEFORE the actual transport.  To obtain prior authorization for non-emergency ambulance services:

  • Call our Medical Program Specialist toll free at (800) 362-7648 or in the Boise area at (208) 287-1157. Please refer to the CMS-1500 (HCFA-1500), or UB-04, for information that will be needed for a prior authorization.

  • Fax updated History and Physical, Progress Reports, Discharge Summary (if available), and any other information that may be needed for Physician Review of medical necessity for transport by ambulance.

  • After hours, if there are any questions or further information that may be needed, please call and leave all the information on the voice mail, with a return name and phone number. 

The status of a prior authorization request may be checked online at the Molina Health PAS portal under “Authorization Status”, using your NPI, or by contacting Molina at 866-686-4272. 

Contact

Attn: Ambulance Review
Division of Medicaid
3232 Elder St.
Boise, ID 83705-4711

 Phone: 1 (800) 362-7648
Fax: 1 (877) 314-8781