PCS: Forms & Information
City Ambulance Insurance Plan Forms
Authorization Payers
*Form can no longer be faxed. Authorizations can only be requested by portal or phone for UHC MCR and Commercial plans.
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| INSURANCE PLAN | DAYS TO SUBMIT AUTH | FAX | FORM NEEDED | PORTAL |
| Aetna Better Health Medicaid | 2 | 866-835-9589 | TX Standardized Form | Availity |
| Ambetter Marketplace | 2 | 855-537-3447 | Ambetter Superior Form | |
| BCBS CHIP or Medicaid | 2 | 855-653-8129 | TX Standardized Form | |
| BCBS Healthselect (JEA-JYA) | 2 | 888-579-7935 | Availity | |
| BCBS – prefix PPU (>$1250.00) | 2 | 480-894-8105 (1 Yr Retro) | Availity | |
| Community Health Choice Marketplace | 2 | 713-295-7019 | CHC Form | |
| Community First Medicaid/CHIP | 2 | 210-358-6274 | ||
| Community Health Choice HMO/DSNP | 2 | 713-295-7059 | CHC Form | |
| Driscoll Children’s Medicaid | 1 | 866-741-5650 | TX Standardized Form | |
| Immigration & Customs Enforcement | 3 | (ICE) 800-479-0523 | ||
| Molina Medicaid/Marketplace | 1 | 866-420-3639 | TX Standardized Form | |
| New Mexico Medicaid | nmmedicaid.portal.conduent.com | |||
| Oscar Health Marketplace | 2 | 844-965-9053 | ||
| Parkland Medicaid | 1 | 844-303-1382/214-266-2085 | ||
| Procare Advantage MAP/MMP/SNP | 3 | 833-610-2399 | ||
| Rightcare (BS&W) Medicaid | 2 | 800-626-3042 | ||
| Superior Medicaid | 1 | 800-690-7030 | ||
| Texas Children’s Medicaid | 1 | 832-825-8760 | TX Standardized Form | TMHP |
| Texas Medicaid (TMHP) | 2 | 512-514-4205 | TX Standardized Form | TMHP |
| UHC Community Plan Medicaid | 2 | 877-940-1972 | TX Standardized Form | |
| UHC Marketplace | 2 | UHC/Optum Provider Portal | ||
| Wellcare MAP/MMP/SNP | 3 | 877-894-2034 | Wellcare Form | |
| Wellcare Genesis IPA | 2 | 281-573-0767 | Wellcare Form | |
| Wellcare Kelsey IPA | 1 | 713-442-5333 | Wellcare Form | |
| Wellcare MCA Houston IPA | 2 | 713-973-2193 | Wellcare Form | |
| Wellcare NWDC IPA | 1 | 832-232-5607 | Wellcare Form | |
| Wellcare by Allwell | 2 | IPA/State Vendor | Wellcare Form | |
| Wellmed MAPMMP/SNP | 1 | 866-855-7784 | TX Standardized Form | |
| Wellpoint Medicaid (Formerly Amerigroup) | 2 | 866-249-1271 | TX Standardized Form |
Texas Ambulance Authorization Instructions
Texas Standardized Instruction Sheet
Section 1: Add insurance name, fax number, and date of request
Section 2: Non-urgent and initial request
Section 3: Patient information (Note: Insurance ID number is required)
Section 4: Facility and contact person information with signature
Section 5: Start date and end date for all lines (Should be date of transport)
Units for each procedure code are required: Round trips will require 2 units
BLS A0428
ALS A0426
SCT A0434
Mileage A0425 X ______ Units (# of miles)
BLS Disposable A0382
Oxygen A0422 (if needed)
A0433 (ALS2 can be non emergent)
Diagnosis and ICD code required
Section 6: Reason why the ambulance is required and destination of
transport.