Protocols for Non Emergency Medical Transportation Providers
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1 Protocols for Non Emergency Medical Transportation Providers CenCal Health members may access Non-Emergency Medical Transportation services when the member does not require emergency services or equipment during transport, but their medical and physical condition precludes the usage of public transportation or driving. The Non-Emergency Medical Transportation Provider will be responsible for determining the eligibility of the recipient, meeting the elements of and documenting services as indicated below, and in order to receive payment, for submitting claim forms to CenCal Health. Types of Services Provided SBHI and SLOHI Members The following Non-Emergency Medical Transportation Services are Covered Benefits for Santa Barbara Health Initiative (SBHI) and San Luis Obispo Health Initiative (SLOHI) members: Round trip transport between a medical facility or medical/dental office (non-routine appointments) and the member s residence, transportation between facilities, Mental Health services; Alcohol and Drug Services, including outpatient heroin detoxification Ground Medical Transportation by ambulances, litter vans, or wheelchair vans that are licensed, operated, and equipped in accordance with applicable state and local statutes, ordinances, and regulations Air Medical Transportation by air transport vehicles that are certified by the Department of Health Services (DHS) and Federal Aviation Agency (FAA), have an air medical transportation provider number, and if the transport meets one of the following conditions: o The medical condition of the member precludes the use of other forms of medical transportation o The member s location or the nearest hospital capable of meeting the member s medical needs is inaccessible by ground medical transportation o Other considerations make ground medical transportation not feasible PP2 Members The following Non-Emergency Medical Transportation Services are Covered Benefits for Prenatal Plus 2 (PP2) members: Transport by ambulance from a non-contracted hospital to a Hospital in the Service Area for admission. Transport from a hospital or other medical facility to the member s residence when the Member requires transport in a prone or supine position Transport from a hospital or other medical facility to the member s residence if the member requires specialized safety equipment. Page 1 of 5
2 Non-Covered Services SBHI and SLOHI Members The following Non-Emergency Medical Transportation Services are Non- Covered Services for SBHI and SLOHI members: Transportation services other than those specifically provided for in the provider s agreement and in the member s Evidence of Coverage, including but not limited to passenger car, taxi, or other form of public or private conveyance. Transportation for the following services: routine dental appointments. Services rendered by a provider who is not eligible with Medi-Cal, except in cases of out-ofstate transports Services outside the scope of a Medical Transportation Provider as set forth in the EDS Medi- Cal Provider Manual. PP2 Members The following Non-Emergency Medical Transportation Services are Non-Covered Services for PP2 members: Transportation services other than those specifically provided for in the provider s agreement and in the member s Evidence of Coverage, including but not limited to passenger car, taxi, or other form of public or private conveyance. Eligibility The Non-Emergency Medical Transportation Provider will be responsible for verifying the recipient is eligible with CenCal Health for the date of service. Eligibility can be verified by calling CenCal Health s eligibility line at (805) or through CenCal Health s website, Information regarding eligibility is in the Member Services Section of the Provider Manual. In the event the recipient is not eligible under any program administered by CenCal Health, payment for services provided to the recipient will not be the responsibility of CenCal Health. Authorizations Authorization is required for most Non-Emergency Medical Transportation transports by Litter Van or Wheelchair Van. Authorization shall be a prescription written by a physician contracted with CenCal Health. It may cover up to six (6) months and includes all transports, except those listed as Approved Exceptions below A prescription is not required from the referring physician for Members who: require treatment at a dialysis center reside in a skilled nursing facility (SNF) or intermediate care facility (ICF) who require medical treatment that can not be provided at their facilities. need transportation home, to a SNF, or ICF after being discharged from the hospital are eligible with California Children s Services (CCS) Page 2 of 5
3 Refusal of Service On occasion, a Non-Emergency Transportation Provider may have reason to refuse to transport a Member. Outlined below are the criteria and procedures that must be met and followed prior to refusing service. If a member notifies the Non-Emergency Transportation Provider at the time of pick-up that transportation is no longer needed or is not present at his/her pre-determined pick-up time on a minimum of three occasions, the Non-Emergency Transportation Provider may choose to suspend transport for up to one month. Insufficient notice of cancellation, defined as less than twenty-four (24) hours, will not jeopardize or suspend continued transport. The Non-Emergency Transportation Provider will provide CenCal Health s Member Services Department written notification of the documented incidents via facsimile within two (2) business days of the second incident. At that time, Member Services will educate members on the nature of the infraction and inform them that noncompliant behavior will jeopardize continued transport. If a member exhibits non-compliant behavior that results in a third incident, he/she will be notified by the Provider of their suspension. The Provider will notify CenCal Health s Member Services Department within two (2) business days from the date of third incident and the expected date that the suspension will be lifted. If the member s behavior threatens the member s, other passengers, or the driver of the transport vehicle s safety, the Non-Emergency Transportation Provider may suspend transport privileges indefinitely. In the above instance, the Provider will notify Member Services immediately. Co-payment Provider should reference the Provider Manual to obtain information on applicable copayments for programs administered by CenCal Health. Documentation of Services SBHI, SLOHI, PP2 Members The Non-Emergency Medical Transportation Provider shall document services by completing a claim form and submitting the form to CenCal Health. CenCal Health reserves the right to audit the Non-Emergency Medical Transportation Provider at any time upon notice of intent and upon provision of at least seven (7) business days advance notice. SLOHI Members under the age of 21, and Hospital to Hospital transports Provider shall submit their trip ticket with each claim. The trip ticket shall include the following information: (i) Member information (the Member s name and ID number), (ii) the origin of the pick-up, (iii) the arrival point, (iv) the type of transport (wheel chair versus gurney, etc), and (v) clinical information on the member s condition. Billing for Covered Services SBHI and SLOHI Members Provider shall bill CenCal Health for medical transportation services provided to an eligible member. Claims shall be submitted according to established protocols set forth in the EDS Medi-Cal Provider Manual. Claims must be submitted within one (1) year from the date of service, in accordance with the provisions of their Agreement. Claims submitted after six (6) months will be reduced Page 3 of 5
4 to 75% of the allowable, and those submitted after nine (9) months from the date of service will be reduced to 50% of the allowable. In the event the member has other coverage, or third-party liability is involved, the Provider shall follow the terms and conditions of their Agreement with CenCal Health, or as indicated in Other Health Coverage found in the Claims Section of this Provider Manual. The SBHI and SLOHI programs are the payors of last resort. PP2, Members Provider shall bill CenCal Health for medical transportation services provided to an eligible member. Claims must be submitted within one hundred and eighty (180) Days of the date of service. In the event the member has other coverage, or third-party liability is involved, the provider shall follow the terms and conditions of their Agreement with CenCal Health, or as indicated in Other Health Coverage found in the Claims Section of this Provider Manual. Reimbursement Provider shall be reimbursed by CenCal Health for Covered Services rendered to members as indicated in Exhibit A of the provider s Allied Amendment Agreement. Reimbursement from CenCal Health will constitute payment in full, excluding the collection of applicable co-payments. Procedure Codes SBHI and SLOHI Members Provider shall bill according to the guidelines set forth in the EDS Medi- Cal Provider Manual. PP2 Members Provider shall use the most recently published Healthcare Common Procedure Coding System (HCPCS) book as compiled and published by the Department of Health and Human Services when billing for services. Origin and Destination Modifiers SBHI, SLOHI, PP2 Members Provider must use a two digit-combination of the following HCPCS modifiers when submitting Transportation Claims. The first digit must be used to indicate the transport s place of origin, and the second digit must be used to indicate the destination, i.e. RH must be used for a transport from a residence to the hospital. Modifiers must be entered into field 24-D ( Modifier ) of the CMS-1500 form. For procedure codes that require two modifiers, the modifier that affects the reimbursement of the service must be indicated in the first place, and the modifier indicating the destination and origin must be indicated in the second place. Page 4 of 5
5 HCPCS MODIFIER D E G H I J M N P R S X DEFINITION Diagnostic or therapeutic site other than P or H Residential, domiciliary, custodial facility (Nursing Home, not Skilled Nursing Facility) Hospital-based dialysis facility (hospital or hospital-related) Hospital Site of transfer (for example, airport or helicopter pad) between types of ambulance Non-hospital-based dialysis facility Psychiatric Inpatient Hospital Skilled Nursing Facility (SNF) Physician s office (includes HMO non-hospital facility, clinic, etc.) Residence Scene of accident or acute event Intermediate stop at physician s office en route to the hospital (includes HMO non-hospital facility, clinic, etc.) NOTE: Modifier X can only be used in the second position of the modifiers 09/16 CS Page 5 of 5
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