SERVICES FOR FACILITIES

To facilitate innovative alternate payment models for ambulance service, such as payment for Treatment in Place (TIP) and Transport to Alternate Destinations (TAD), MedStar is in-network with the following payers:

Amerigroup

Care ‘N Care

Cigna Healthcare

Cook Children’s Health Plan

Molina Healthcare

Facility & Hospital Documents

• NEW – Physician Certification Statement (PCS)

General Information for Facilities

• Consent for Treatment & Transport, NPP Acknowledgement
• Comment/Complaint Form

Medicare & Medicaid Reference Information

• Ambulance & Related Service Fees 2023-24
• Ambulance Transportation Estimate
• Insurance Prior Authorization Contact List
• Texas Standard Prior Authorization Form and Instructions
• Texas Medicaid Non-Emergency Ambulance Prior Authorization Request Form
• Amerigroup Medicaid & Chip Authorization Request Form
• Amerigroup Medicare Non-Emergency Ambulance Prior Authorization Request Form
• Medicare Manual for Part A and Part B Ambulance Services
• Instructions for Physician Certification Statement for Ambulance Transport
• Texas Medicaid Guidance on Provider Assistance Seeking Prior Authorization
• Texas Medicaid Information for Hospitals, Nursing Homes, and Physicians on Requesting Client Transport
• Baylor Scott & White Health Plan Prior Authorization Notice
• Baylor Scott & White Health Plan Prior Authorization Form

Return signed forms to:

Metropolitan Area EMS Authority

2900 Alta Mere Drive

Fort Worth, Texas 76116

(817) 632-0537 – Business Office Fax

(817) 927-9671 – Communications Center Fax