Section He-W 572.06 - Authorization Requirements for Scheduled and Routine Ambulance Transportation(a) Scheduled and routine ambulance transportation shall require authorization to be a covered service.(b) A complete authorization request shall: (1) Be submitted by the ambulance provider to the department or its prior authorization agent by either fax or mail; and(2) Include the following forms, completed and legible: a. Form 272AMB "Scheduled and Routine Ambulance Transportation Authorization Request Form" (3/13) signed and dated by the ambulance provider; andb. Form 272MN "Medical Necessity for Ambulance Services Form" (3/13) dated and signed by the recipient's attending physician, doctor of osteopathy, physician assistant, clinical nurse specialist, advanced practice registered nurse, registered nurse, licensed practical nurse, or discharge planner employed by the facility where the recipient is being treated.(c) Authorization requests shall be submitted prior to or within 30 days of the service being delivered.(d) A complete authorization request shall be approved by the department or its prior authorization agent if: (1) The recipient is bed confined, as described in (e) below; or(2) The recipient has a condition such that all other methods of transportation are contraindicated by the recipient's condition, and therefore, the recipient cannot be transported by any other means from the origin to the destination without endangering the recipient's health.(e) In order to be considered bed confined, a recipient shall be: (1) Unable to get up from bed without assistance;(2) Unable to ambulate; and(3) Unable to sit in a chair or wheelchair.(f) Authorizations shall be approved for a specified number of trips over a specified period of time, not to exceed a maximum of 3 months, after which a new complete authorization request shall be submitted in accordance with (b) above.(g) If the department or its prior authorization agent denies the authorization request, it shall forward a notice of denial to the recipient and the requesting provider on the department Form 272a, "Medical Assistance Program Denial for Prior Authorized Services," including the following:(1) The reason for, and legal basis of, the denial; and(2) Information that a fair hearing on the denial may be requested within 30 calendar days of the date on the notice of the denial, in accordance with He-C 200.N.H. Admin. Code § He-W 572.06
(See Revision Note at chapter heading He-W 500); ss by #6641, eff 11-27-97; EXPIRED: 11-27-05
New. #8502, INTERIM, eff 12-2-05, EXPIRES: 5-31-06; ss by #8638, eff 5-30-06; ss by #10294, eff 12-1-13