INSURANCE & PRE-AUTHORIZATION FORMS

Carrousel MTS understands that each individual patient has its own challenges, diagnosis, and medical conditions unique to him or her. Each patient or caregiver must be interviewed regarding the patient’s medical conditions, activities of daily living, mobility status, and the patient must be physically assessed in order to be pre-qualified for NON-EMERGENCY AMBULANCE TRANSPORT.

ONCE A PATIENT HAS BEEN PRE-QUALIFIED FOR NON-EMERGENCY AMBULANCE TRANSPORTATION SERVICES, CARROUSEL MTS ADMINISTRATIVE STAFF WILL COORDINATE WITH THE CAREGIVERS AND PRIMARY CARE PHYSICIAN (PCP) IN ORDER TO OBTAIN A PHYSICIAN CERTIFICATION STATEMENT (PCS) THAT ATTEST AND CORROBORATE MEDICAL NECESSITY FOR AMBULANCE TRANSPORTATION SERVICES. ALL FORMS ARE REQUIRED TO BE SUBMITTED DIRECTLY TO THE INSURANCE PROVIDER BY THE REQUESTING PROVIDER (PHYSICIANS OFFICE), NOT CARROUSEL MEDICAL TRANSPORT SERVICE.

As of 2016 all Health Plans require that a prior authorization be obtained for all non-emergency transportation services before patients first transport. 

Prior Authorization requests must be completed and signed by patients primary care physician. In addition, the PCP must submit a SIGNIFICANT AMOUNT OF SUPPORTING DOCUMENTATION that the patient not only qualifies for non-emergency ambulance services but serves as a medical necessity and safety precaution for the patients well being and that transportation by any other means would be a contraindication to his health and safety.  

Below we have listed different request forms that vary from insurance to insurance, along with outlined and detailed examples of how each form should look like once completed and signed by a the primary care physician. Please remember to fill out forms COMPLETELY. CLICK ON FORMS BELOW.

​As of September 2015, the State of Texas issued out a standardized Prior Authorization Request Form that can be used for any health care service that most to all Health Plan insurances must accept. The attached form is now primarily used for the following insurances: Cigna Healthspring , Driscoll Health Plan , Molina Healthcare, Blue Cross Blue Shield and Aetna.

• Medicare PCS Form
• ​TMHP Medicaid Prior Authorization Request​​
• Superior Prior Authorization Request
• Texas Standard Prior Auth Request Form

EXAMPLES – FORMS MUST BE FILLED OUT COMPLETELY