Handbook Section or Appendix Description
Wisconsin Medicaid Ambulance Services Handbook, Part Q, Division I:
Wisconsin Medicaid Ambulance Services Handbook, Part Q, Division I:
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Page Numbers

PDF File for downloading

• Cover of handbook.

• Introduction to the handbook.

• Transmittal log.

• Table of contents for sections and appendices.

PDF
(301 kb)

Section I - General Information

1Q1-001
to
1Q1-004

PDF
(358 kb)

Section II - Covered Services & Related Limitations

1Q2-001
to
1Q2-003

PDF
(247 kb)

Section III - Prior Authorization

1Q3-001

PDF
(81 kb)

Section IV - Billing Information.

1Q4-001
to
1Q4-002

PDF
(201 kb)

Appendix 1a: HCFA 1500 Claim Form Sample for Ambulance - Emergency, One Round Trip with Nonemergency Return Destination

1Q5-003

PDF
PDF
(128 kb)

Appendix 1b: HCFA 1500 Claim Form Sample for Ambulance - Emergency Trip

1Q5-005

PDF
(125 kb)

Appendix 1c: HCFA 1500 Claim Form Sample for Ambulance - Nonemergency, One Round Trip with One Medical Facility Destination

1Q5-007

PDF
PDF
(129 kb)

Appendix 1d: HCFA 1500 Claim Form Sample for Ambulance - Sample EMC Screen

1Q5-009

PDF
(68 kb)

Appendix 2: HCFA 1500 Claim Form Completion Instructions

1Q5-011

PDF
(464 kb)

Appendix 3: HCPCS Procedure Codes, Type of Service, Place of Service, and Copayment Table

1Q5-017

PDF
(64 kb)

Appendix 4: Wisconsin Medicaid-Allowable Place of Service and Type of Service Codes for Ambulance Services

1Q5-019

PDF
(26 kb)

Appendix 5: Prior Authorization Request Form (PA/RF) Sample

1Q5-021

PDF
(71 kb)

Appendix 6: Prior Authorization Request Form (PA/RF) Completion Instructions

1Q5-023

PDF
(174 kb)

Appendix 7: Prior Authorization Physician Attachment (PA/PA) Sample

1Q5-025

PDF
(92 kb)

Appendix 8: Prior Authorization Physician Attachment (PA/PA) Completion Instructions | Revised Instructions (PDF, 12 KB) | Revised Form (PDF, 66 KB)

1Q5-027

PDF
(98 kb)

Appendix 9: EMC Questionnaire

1Q5-029

PDF
(52 kb)

Entire Ambulance Services Handbook, Part Q, Division I

All

PDF
(2647 kb)

All Handbook Sections (except Appendices). Includes Table of Contents and Section I, II, III, and IV.

Everything except Appendices

PDF
(986 kb)

All Appendices. Includes Appendix Table of Contents as well as Appendix 1 to Appendix 9

Appendices only

PDF
(1505 kb)