How to Request Prior Approval for State to State Ambulance Transportation

There are several important considerations when requesting prior approval (PA) for State to State Ambulance Transportation:

- Providers may either enter the prior approval request via the secure NCTracks Provider Portal or fax/mail the request to NCTracks. Providers are encouraged to submit prior approval requests via the portal to expedite evaluation of the request. If the request is submitted via the portal, it is preferable to upload supporting documentation as an attachment. However, if the supporting documentation is going to be faxed or mailed, the provider must indicate this when entering the PA request on the portal and a link to a cover sheet will be presented. The cover sheet should be printed and accompany the supporting documentation when it is faxed or mailed. The cover sheet has a bar code that will link the supporting documentation to the prior approval request.

- If providers fax or mail the prior approval request, they must use the forms on the NCTracks Prior Approval page. (See link below) If prior approval for State to State Ambulance Transportation is requested via fax or mail, the provider should submit the Medical Request for Prior Approval (DMA 372-118) form, as well as the State to State Ambulance Transportation Addendum (DMA 372-118A). Both of the forms must be submitted together.

- If the Medical Request for Prior Approval (DMA 372-118) is being submitted for State to State Ambulance Transportation, no other services should be included on the form. For example, prior approval requests for out-of-state surgery or medical services should be submitted on a separate Medical Request for Prior Approval (DMA 372-118) form.

Also, note that when entering the REQ. END DATE on the prior approval request, do not use 12/31/9999. Enter the expected end date, which can be no more than 365 days from the REQ. BEGIN DATE.

Following these guidelines will help to facilitate the timely review and disposition of prior approval requests for State to State Ambulance Transportation.