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February 26, 2017

Emergency Ambulance Services

Effective February 1, 2017: Emergency 911 ground transport claims for HCPCS: A0425 (mileage), A0429 (BLS), A0427 (ALS 1), A0433 (ALS2), and A0998 (R&E) will not require a prior authorization. Claims should be submitted through 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

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 transports, CCT, rotary, fixed wing, and all revenue codes must receive prior authorization BEFORE transport.  To obtain prior authorization for non-emergency ambulance services:

  • Fill out CMS-1500 (HCFA-1500), or UB-04

  • Gather history, physical, progress reports, discharge summary (if available), and any other information that may support the request 

  • Call toll free at (800) 362-7648

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

Email:
MedicalCareUnit@DHW.idaho.gov