Pre Authorization for Ambulance Transport
Ensure timely approval for your ambulance services by filling out the form below.
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Iowa Standardized Instructions
In Iowa, ambulance pre-authorization is handled via Medicaid’s pre-pay review process on the standard CMS-1500 form. Be sure to:
Use the correct HCPCS base-rate codes (e.g., A0428 for BLS, A0426 for ALS, A0434 for CCT) and mileage code A0425 (1 unit per mile).
Attach a “run report” documenting date, origin/destination, patient level of care, and units for each code whenever your claim includes more than one base-rate code or any “H” modifier—round trips count as two units.
Note that claims missing the required run report will be denied.
Submit Prior Authorization.
Please complete and submit the Prior Authorization Ambulance Form with all required patient and insurance information. Our team will process your request promptly.
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