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:

The links below will take you to a third party site

Amerigroup

Care ‘N Care

Cigna Healthcare

Cook Children’s Health Plan

Molina Healthcare

Facility & Hospital Documents

• NEW – Physician Certification Statement (PCS)(DOCX, 57KB)

General Information for Facilities

• Consent for Treatment & Transport, NPP Acknowledgement(PDF, 404KB)
• Comment/Complaint Form

Medicare & Medicaid Reference Information

• Ambulance & Related Service Fees 2023-24(PDF, 336KB)
• Ambulance Transportation Estimate(PDF, 994KB)
• Insurance Prior Authorization Contact List(PDF, 110KB)
• Texas Standard Prior Authorization Form and Instructions(PDF, 303KB)
• Texas Medicaid Non-Emergency Ambulance Prior Authorization Request Form(PDF, 3MB)
• Amerigroup Medicaid & Chip Authorization Request Form(PDF, 446KB)
• Amerigroup Medicare Non-Emergency Ambulance Prior Authorization Request Form(PDF, 488KB)
• Medicare Manual for Part A and Part B Ambulance Services(PDF, 727KB)
• Instructions for Physician Certification Statement for Ambulance Transport(PDF, 199KB)
• Texas Medicaid Guidance on Provider Assistance Seeking Prior Authorization(PDF, 115KB)
• Texas Medicaid Information for Hospitals, Nursing Homes, and Physicians on Requesting Client Transport(PDF, 29KB)
• Baylor Scott & White Health Plan Prior Authorization Notice(PDF, 95KB)
• Baylor Scott & White Health Plan Prior Authorization Form(PDF, 588KB)