Effective December 1, 2021: Clinical Policies

Date: 11/01/21

Superior HealthPlan has added and retired certain clinical policies to ensure medical necessity review criteria is current and appropriate for members and the scope of services provided. As a result the following policies are effective on December 1, 2021, at 12:00AM.

POLICY	APPLICABLE PRODUCTS	NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS
Handling Authorizations for Transportation TX.UM.10.07	Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP	Policy Retired Criteria for all transportation that require PA is now encompassed within TX.CP.MP.507 Non-Emergent Ambulance Transportation
Non-Emergent Ambulance Transportation TX.CP.MP.507	Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP	New Policy Overview: Description: Non-emergent ambulance transport is defined as ambulance transport provided for a member to or from a scheduled medical appointment, to or from a licensed facility for treatment, or to the member’s home after discharge when the member has a medical condition such that the use of an ambulance is the only appropriate means of transportation All non-emergent ambulance transportation requires prior authorization If the member’s condition meets the definition of an emergency medical condition, as per 1 TAC §353.2, prior authorization is not required Medically necessary criteria for non-emergent ground ambulance transportation are as follows: The member is bed-confined The member’s medical or mental health condition is such that alternate means of the transport is medically contraindicated and would endanger the member’s health The member is a direct threat to himself or herself or others Other Information Included: Ambulance transportation limitations Specifies what documentation should be included with prior authorization requests Specifies a Medicaid-enrolled physician, nursing facility, health-care provider, or other responsible party is required to obtain authorization before an ambulance is used to transport a member in circumstances not involving an emergency Specific information is provided regarding reimbursement for non-emergent ambulance transport for STAR Health members and defines a primary medical needs member List of non-covered services

POLICY

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

Handling Authorizations for Transportation

TX.UM.10.07

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP

Policy Retired

Criteria for all transportation that require PA is now encompassed within TX.CP.MP.507 Non-Emergent Ambulance Transportation

Non-Emergent Ambulance Transportation TX.CP.MP.507

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP

New Policy Overview:

Description:

Non-emergent ambulance transport is defined as ambulance transport provided for a member to or from a scheduled medical appointment, to or from a licensed facility for treatment, or to the member’s home after discharge when the member has a medical condition such that the use of an ambulance is the only appropriate means of transportation
All non-emergent ambulance transportation requires prior authorization
If the member’s condition meets the definition of an emergency medical condition, as per 1 TAC §353.2, prior authorization is not required

Medically necessary criteria for non-emergent ground ambulance transportation are as follows:

The member is bed-confined
The member’s medical or mental health condition is such that alternate means of the transport is medically contraindicated and would endanger the member’s health
The member is a direct threat to himself or herself or others

Other Information Included:

Ambulance transportation limitations
Specifies what documentation should be included with prior authorization requests
Specifies a Medicaid-enrolled physician, nursing facility, health-care provider, or other responsible party is required to obtain authorization before an ambulance is used to transport a member in circumstances not involving an emergency
Specific information is provided regarding reimbursement for non-emergent ambulance transport for STAR Health members and defines a primary medical needs member
List of non-covered services

To review all policies, please visit Superior’s Clinical, Payment & Pharmacy Policies webpage.

Prior to updates, Medical Clinical policies are reviewed and approved by the Utilization Management Committee.

For questions or additional information, contact Superior HealthPlan Prior Authorization department at 1-800-218-7508.