SoonerCare requires this certification when a member needs non-emergency transport by ground ambulance, fixed-wing air ambulance or rotary air, moving between an originating and an accepting facility. The ordering provider documents diagnosis, ability to sit up, airway and oxygen status, the reason for transfer and transport team needs. Signing affirms that any other method of transportation is contraindicated.
The ordering provider completes and signs it; the form states it must be signed by a physician, NP or PA. Contacts for the originating facility, accepting facility and transportation provider are recorded on it.
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Physician's Certification Statement for Medical Transportation Member
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The form states it must be signed by a physician, nurse practitioner or physician assistant. The ordering provider signs and dates it, affirming that the information is correct and that using any other method of transportation is contraindicated for the member.
HCA-27 asks whether the transport is related to care outside Oklahoma. If it is, the form directs the provider to form HCA-65, the Out of State Prior Authorization Request, which must be completed to request prior authorization for the out-of-state care.
Three: ground ambulance, fixed-wing air ambulance and rotary air transportation. The provider also indicates whether a guardian or medical escort will travel, whether a special team such as NICU or ALS is needed, and whether a transportation provider has agreed to take the member.