Effective February 1, 2017: Emergency 911 ground transport claims for HCPCS: A0425 (mileage), A0429 (BLS), A0427 (ALS 1), A0433 (ALS2), and A0998 w/II modifier (R&E) will not require a prior authorization. Submit claims to Molina with supporting documentation including:
CMS-1500 (HCFA-1500), or UB-04
Patient Care Report (PCR)
EOB, if applicable
Hospital providers should include invoice of charges
Medical Care will not prior authorize a service unless it is required per handbook.
All other HCPCS codes pertaining to EMS transportation require prior authorization. Treat and Release at a higher level of service other than non-emergent BLS requires prior authorization prior to claim submission.
Please fax PA requests to: (877)-314-8781
Non-Emergency Ambulance Transport (NEMT)
Steps to obtain a NEMT prior authorization:
1. Gather participant history, physical, progress reports, discharge summary (if available), and any other information that may support the request readily available.
2. Call toll free at (800) 362-7648
3. Department will email requester with Department decision and authorization number if approved.
4. Provide services and print off NEMT Fax Cover Sheet (available under Forms on this page)
5. Fax completed cover sheet and supporting documentation to (877) 314-8781 to complete the authorization process.
NOTE: Cover Sheet and supporting documentation MUST be sent in to the Department to complete the prior authorization process. If a provider attempts to bill without completing step 5, the claim will deny.
All non-emergent transports such as CCT, rotary, fixed wing, and all revenue codes-Prior authorization from the Department is required.
The status of a prior authorization request may be checked online at the DXC Technology portal under “Authorization Status”, using your NPI, or by contacting DXC Technology at 866-686-4272.