Non-emergent fixed wing air ambulance prior authorization request form
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Form and process for requesting prior authorization for non-emergent fixed-wing air ambulance transport for Aspirus Arise members; applies to ordering practitioners, servicing and receiving providers, and administrative staff submitting requests. Emergent transports do not require prior authorization.
No material clinical or coverage changes in this revision.
Medical Necessity and Coverage Criteria
Medical necessity and documentation criteria
Medical necessity must be documented on the form and supported by clinical notes; select appropriate clinical reason(s) and required monitoring and explain facility differences.
ALL of the following
Clinical reason (select ONE or more)
- Burn
- Cardiac
- Neonatal
- Neurological
- Psychiatric inpatient
- Respiratory
- Trauma
- Other (specify)
Monitoring needs (select ONE or more)
- Oxygen (portable O2 does not apply)
- Comatose
- Cardiac monitoring
- Airway management
- Life support
- Suction
- Behavioral monitoring
- Hyperbaric therapy
- Other (specify)
- Explain the specialty care the accepting/receiving facility provides that cannot be provided at the current facility (required)
- Attach clinical notes supporting any of the above; incomplete submissions can delay decision time (required)
Air Ambulance Codes and Billing Rules
Prior Authorization Submission & Request Processing
Submission Instructions — Prior Authorization Required
Complete and submit the Non-Emergent Fixed Wing Air Ambulance Prior Authorization Request Form and include all required clinical documentation to support medical necessity. Fax the completed form and relevant clinical documentation to: 715.787.7316. No prior authorization is required for emergent transportation. Incomplete, illegible, or inaccurate forms will be returned to the sender; failure to provide required documentation may result in denial or delay of the request.
- Complete the entire prior authorization request form
- Include supporting clinical notes and documentation with the submission
- Fax to 715.787.7316
- Emergent transports: no prior authorization required
Request Type and Timeframes
Please select whether this is a STANDARD REQUEST or an EXPEDITED REQUEST on the form before submission. Choose EXPEDITED only when waiting for the standard review timeframe could jeopardize the member's health, life, or ability to regain function. Billing and retrospective authorizations are not eligible for expedited review.
- STANDARD REQUEST — Medicare and Medical Assistance decision within 10 business days.
- EXPEDITED REQUEST — Medicare and Medical Assistance decision within 72 hours; include clinical reason for urgency and a contact name/number available during review; billing and retrospective requests are not expedited.
Documentation Requirements and Consequences of Incomplete Submissions
Confirm and complete all required steps before submitting. Ensure clinical notes supporting the request are attached — incomplete submissions can delay decision time. Illegible or missing information may cause the form to be returned and will delay or jeopardize authorization decisions. Sign and date the form (Physician/Practitioner Signature, Date).
- Attach clinical notes supporting medical necessity
- Incomplete, illegible, or inaccurate forms will be returned
- Ensure designated contact for expedited requests is readily accessible
Important Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.