HEADING 2 - NC DHHS Online Publications

North Carolina Department of Health and Human Services Division of Medical Assistance Medicaid Eligibility Unit FAMILY AND CHILDREN’S MEDICAID MANUAL MA-3550 MEDICAID TRANSPORTATION

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MA-3550 - MEDICAID TRANSPORTATION REVISED 11/01/06 – CHANGE NO. 15-06

I. BACKGROUND

Title XIX of the Social Security Act does not specifically mandate provision of transportation as a Medicaid service. However, federal regulations and interpretations of the Act authorize states to cover transportation as either an optional service and/or as an administrative service. North Carolina has federal approval to claim transportation as an administrative service reimbursement for transportation arranged and paid by the county department of social services (dss) as an agent for the state.

Medicaid only pays for transportation if the recipient receives a Medicaid covered service provided by a qualified Medicaid provider (enrolled as a NC Medicaid provider). Medicaid only pays for the least expensive means suitable to the recipient’s needs. This section contains procedures to comply with Federal and State Medicaid requirements regarding transporting Medicaid recipients to and from medical appointments.

A. Federal regulations pertaining to administration of the Medicaid Program

require the assurance of necessary transportation for recipients to and from medical providers. {42 CFR 43l.53}

B. Under authority of G.S. l08A-14 (3) & (5), the county DSS is responsible for

administering the public assistance programs and acting as an agent of the Social Services Commission and DHHS.

II. POLICY PRINCIPLES

A. The county dss must arrange for or provide transportation to Medicaid covered services for authorized recipients if the recipient is unable to arrange and/or pay for transportation. Refer to MA-2905, Medicaid Covered Services, and DMA website at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm, for information on Medicaid covered services.

B. Always inform Medicaid applicants/recipients of their right to Medicaid

transportation assistance. This includes all programs (including Presumptive Eligibility and Emergency Services for non-qualified aliens) except the Medicare Qualified Beneficiaries (MQB) programs and North Carolina Health Choice (NCHC). At each application and redetermination, the applicant/recipient must sign the DMA-5046, Medical Transportation Assistance, Notice of Rights.

C. Send the DMA-5024, Transportation Notification Request, to notify the a/r of

the action taken on his request for transportation. The recipient has the right to request a hearing upon receipt of the DMA-5024. Follow guidelines in MA-2420 or MA-3430, Notice and Hearings Process.

http://info.dhhs.state.nc.us/olm/manuals/dma/abd/man/MA2905.htm#TopOfPage

http://www.dhhs.state.nc.us/dma/mp/mpindex.htm

http://info.dhhs.state.nc.us/olm/forms/dma/dma-5046.pdf

http://info.dhhs.state.nc.us/olm/forms/dma/dma-5024-ia.pdf


http://info.dhhs.state.nc.us/olm/manuals/dma/fcm/man/MA3430.htm#TopOfPage

North Carolina Department of Health and Human Services FAMILY AND CHILDREN’S MEDICAID MANUAL MA-3550 MEDICAID TRANSPORTATION

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REVISED 11/01/06 – CHANGE NO. 15-06 (II.)

D. Do not require requests for Medicaid transportation to be made in person. Encourage recipients to request assistance as far in advance as possible.

E. Travel related expenses appropriate to the recipient’s needs are also allowable

expenses when applicable. The maximum reimbursement for travel related expenses cannot exceed state or county per diem for county employees, whichever is higher, and minimum hourly wage. If the county dss per diem is higher than the state per diem, the dss may choose, but is not required to use the higher reimbursement rate.

F. Transportation to and from providers is a critical component for Medicaid

recipients to obtain necessary health care. Transportation must be by the least expensive means suitable to the recipient’s needs. Medicaid will not fund transportation to a provider at a significantly greater distance from the recipient’s residence solely because of personal preference if a suitable local source is available.

G. DSS agencies must establish procedures to track each request for transportation

from intake through disposition. Purchased transportation costs must be separately identifiable. This includes contracts, written agreements, invoices, and expenditure reports.

H. The county dss decides where in the agency to place administrative

responsibility for assisting recipients with transportation needs. To assure that transportation is provided to Medicaid recipients in a timely and cost-effective manner, the county dss is encouraged to coordinate with other state and local agencies, private organizations, transportation planners, providers of transportation services and consumers by participating in the planning, design and delivery of local Medicaid transportation services with the local development of the Community Transportation Improvement Plan.

The scheduler must also make use of available resources such as family, friends, volunteers, community organizations, carpooling, and vanpooling. If the recipient, or his family, neighbors, friends, relatives, etc. can provide transportation, they are expected to do so without reimbursement. If transportation has been provided to the client at no cost, it is reasonable to expect this to continue, except in extreme circumstances or evident hardship (Refer to IV.C.1.d.). The scheduler must coordinate appointments with others who would be willing to provide transportation.

I. The county dss shall develop a No-Show Policy in coordination with the

Community Transportation System to limit the misuse of funds. The jointly developed No-Show policy will establish consistent rules and procedures that each agency will follow when a client misses a scheduled trip without a valid cancellation.


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REISSUED 11/01/06 – CHANGE NO. 15-06 (II.)

J. Transportation services are reimbursed at two different rates depending upon the type of service.

1. When the dss purchases transportation for a Medicaid recipient (e.g. bus

ticket, gas voucher, Community Transportation System, etc.), the county is reimbursed at the Federal Medical Assistance Percentage (FMAP) Rate. When dss directly provides the transportation (e.g. dss staff drivers), the agency is reimbursed for the costs related to the trip at the FMAP Rate.

2. Payments made directly to recipients or financially responsible spouses or

parents are reimbursed at the Administrative Rate. Costs related to dss staff time spent coordinating/arranging Medicaid transportation services are also reimbursed at the Administrative Rate.

K. Safety and Risk Management

1. Consideration of safety and liability issues are vital to decisions regarding

transportation. Properly equipped vehicles that meet the special needs of passengers are essential. All drivers (including state and county employees, contractors, contractor’s employees and volunteers, family and friends) must be at least 18 years of age and properly licensed to operate the specific vehicle used to transport the client(s). Their driving records should also be reviewed on a regular basis. The county may also consider requiring drivers to participate in a random drug and alcohol testing program

2. All vehicles used to transport clients (whether owned by the county, county

employees, contractors, contractor’s employees and volunteers, family and friends) must have a valid State Registration and State Inspection stickers.

3. The DSS must assure that transportation providers maintain the appropriate

level of liability insurance for vehicles used to transport dss Medicaid recipients.

L. Early Periodic Screening and Diagnostic Services (EPSDT)/Health Check

Offer assistance in providing transportation and scheduling visits for screening and other services to individuals eligible for Health Check (children through age 20).


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REISSUED 11/01/06 – CHANGE NO. 15-06 III. EXCLUSIONS

A. Do not claim Federal and State Medicaid reimbursement for the following:

1. Expenses of an attendant to sit with a patient after admission to a medical facility.

2. Transportation provided by other means when free transportation is available

and suitable to the recipient’s needs.

3. Direct reimbursement for purchase price of a vehicle for transportation. The purchase of a vehicle may be recovered over the life of the vehicle through trip reimbursement.

4. Use of an ambulance when it is not medically necessary and other means are

suitable.

5. Private or public provider costs which are higher than appropriate and less expensive means of transportation are available.

6. Routine transportation to school on a school day even though health services

may be provided in the school during the day.

7. Travel to visit a hospitalized patient (except to provide or learn to provide care for a patient).

8. Empty trip when recipient only travels one way of a two way trip.

9. Transportation of a deceased person by ambulance when the person was

pronounced dead by someone legally authorized to make such a pronouncement prior to calling the ambulance.

10. Transportation to a provider at a greater distance when the medical services

are available at a shorter distance.

11. Driver wait time (unless included in the per trip cost).

12. Transportation to an institution for mental disease (a facility primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases) for patients between the age of 21 – 65.

13. Transportation to receive a Medicaid covered service when medical care is

not the primary reason for the trip.


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REVISED 12/01/08 – CHANGE NO. 18-08 (III.A.)

14. Deadhead Miles

Miles from a transportation provider’s office/home/garage to the Medicaid recipient’s residence are deadhead miles. Medicaid only pays from point of pickup to the point of drop off. Deadhead miles should be factored in the total cost in setting mileage rates.

15. Transportation to receive a medical service when the medical provider is not a

qualified Medicaid provider (not enrolled in NC Medicaid).

16. Transportation to receive a medical service that is not a Medicaid covered service. This includes medical services that do not qualify for Medicaid payment due to coverage limitations (visit limit exceeded) or medical provider has not received prior approval when required.

17. Transportation to receive a Medicaid covered service when transportation

reimbursement has been added into the Medicaid provider’s fee.

a. The following Community Alternative Program – Mental Retardation/Developmental Disabilities (CAP-MR/DD) Waiver covered services have transportation included in the Medicaid provider’s fee:

CAP-MR/DD SERVICE CODE Day Supports – Individual T2021 Day Supports – Group T2021HQ Supported Employment – Individual H2025 Supported Employment – Group H2025HQ

b. The following Mental Health/Substance Abuse (MH/SA) Enhanced

Benefits covered services have transportation included in the Medicaid provider’s fee:

MH/SA ENHANCED BENEFIT SERVICE CODE Community Supports Service – Adult H0036HB Community Support Services – Child H0036HA Community Support Services – Group – Adult or Child H0036HQ Community Support Treatment Team (CST) H2015HT Assertive Community Treatment Team (ACTT) H0040 Intensive In-Home Services H2022 Mobile Crisis H2011 Multi-systemic Therapy (MST) H2033


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REVISED 12/01/08 – CHANGE NO. 18-08 (III.A.)

MH/SA ENHANCED BENEFIT SERVICE CODE Professional Treatment Services in Facility-Based Crisis Program

S9484

Substance Abuse Medically Monitored Residential Treatment

H0013

Substance Abuse Non-Medical Community Residential Treatment

H0012HB

Medically Supervised Detoxification/Crisis Stabilization H2036 Non-Hospital Medical Detoxification H0010

B. Deductibles/MQB/NCHC Recipients

Do not claim Medicaid transportation costs for:

1. A/R’s in deductible status.

2. NCHC children.

3. A/R’s eligible under Medicare Savings Programs MQB-Q, MQB-B, and MQB-E.

Inform the recipient of any other transportation resources which may be available.

C. No-Shows

Do not claim Medicaid transportation costs for individuals who miss medical appointments.

The dss must develop and implement a No-Show Policy. The No-Show policy must establish consistent rules and procedures to follow when a client misses a scheduled trip without valid cancellation. Agencies contracting for services with a community transportation system are encouraged to develop guidelines in coordination with the community transportation system. See Attachment 11, Model No-Show Policy for Community Transportation Systems.


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REVISED 11/01/06 – CHANGE NO.15-06 (III.C.)

If an individual has previously missed appointments (no-shows), counsel the individual on the importance of keeping appointments. If there is a family member available to help the recipient with his affairs, attempt to involve family members in helping the recipient understand his responsibility to keep appointments. Failure to keep appointments may result in temporarily limiting the availability of transportation services as well as affect the individual’s health and well-being.

IV. ELIGIBILITY AND ASSESSMENT OF NEED FOR ASSISTANCE

A. Eligibility

The dss must inform all Medicaid applicants/recipients of their right to assistance with transportation (unless the applicant is applying only for MQB or NCHC). This includes Presumptive Eligibility and Emergency Services for Non-qualified Aliens.

1. Right to Assistance with Transportation

Complete and have the applicant sign the DMA-5046, Medical Transportation Assistance – Notice of Rights, at each application and review. Mail-in applications and mail-in redeterminations require a DMA-5046 to be sent at disposition. It is not necessary for persons receiving long term care services to sign DMA-5046.

a. Inform a/r of rights and options on the Notice of Rights.

b. Explain that the a/r has the right to a written response to a request for

transportation assistance.

c. Retain a copy of the signed Notice of Rights in the eligibility or transportation record for documentation. If a mail-in application or mail-in redetermination is completed, the date the Notice of Rights is mailed must be documented in the eligibility or transportation record.

d. Explain the right to appeal, including the right to a local hearing, if the

recipient is dissatisfied with the decision on his request. This information is contained in the Notice of Rights.

2. Requesting Transportation Assistance

Advise the a/r to always request transportation assistance as far in advance as possible. Transportation requests do not have to be made in person. Requests may be made in writing or by telephone.




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REVISED 11/01/06 – CHANGE NO. 15-06 (IV.A.)

3. Transportation Expenses Used to Meet Deductible

Explain expenses, paid or incurred (including mileage or paying someone), for medical transportation prior to authorization may be applied to a current deductible if the expenses are incurred by the a/r or by another financially responsible person. The a/r will need to keep a record of such expenses including date(s) of travel and mileage.

4. Retroactive Approval

a. Explain that if Medicaid is authorized for retroactive dates (three month

retroactive period, appeal reversals, payment of services due to an emergency as defined in MA-2504, Citizen/Alien Requirements, or spend-down met or reserve reduced), he may request assistance for transportation expenses that he was unable to pay during the time for which he is authorized.

b. Assess the needs of the recipient for retroactive assistance by determining

if the recipient has unpaid bills for medically related transportation and his method of transportation prior to the retroactive period.

(1) If the recipient had a transportation resource prior to the retroactive

period, ask why that resource is no longer available.

(2) If the recipient was advised of transportation and refused because he had transportation available during the retroactive months and there has not been any change in his situation, retroactive reimbursement is not available.

B. Assessment of Need

When the a/r requests transportation assistance, complete the assessment or refer to appropriate worker for completion at the application interview (unless the applicant is applying only for MQB or NCHC) and each review. If transportation assistance is not requested at the time of the application or the review, but requested at a later date during the certification period, complete an assessment at that time. The purpose of the assessment is to:

1. Determine what resources the recipient has available to provide his own

transportation;

2. Determine mode of transportation appropriate for the recipient's medical needs;


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REVISED 11/01/06 – CHANGE NO. 15-06 (IV.B.)

3. Determine current and future medical needs of the a/r;

4. Assist the county transportation worker in evaluating subsequent requests for assistance with medical transportation and providing timely authorization and notice of decision.

C. Assessment Process

1. The a/r may request assistance with transportation in person or by telephone.

When a request is made, complete the DMA-5047, Medicaid Transportation Assessment, and notify the recipient by sending the DMA-5024, Transportation Request Notification

2. Evaluate the request for transportation assistance according to the procedures

and criteria below. Approve if eligible.

3. Be sensitive to transportation needs that must be responded to quickly in order to avert a crisis situation. Examples include but are not limited to, high risk pregnant women in need of medical care from specialists, recipients with life threatening illnesses such as unstable diabetes or advanced stages of cancer.

4. Discuss special needs of the recipient. Examples include but are not limited

to:

a. Wheelchair bound - requires vehicle with lift;

b. Disabled - requires attendant;

c. Does not speak English - requires a translator (not available with their medical provider);

d. No available childcare;

e. Restrictions necessary per the physician’s documented request.

D. Assessment Procedures

Complete the DMA-5047, Medicaid Transportation Assessment form.

1. Determine transportation resources available to the a/r. Evaluate the

availability of free transportation to maximize use of existing community resources. Medicaid transportation is unavailable if recipient has access to free transportation, except in the case of evident hardship. Evident hardship is defined as an obvious or apparent burden.


http://info.dhhs.state.nc.us/olm/forms/dma/dma-5024ia.pdf



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REVISED 11/01/06 – CHANGE NO. 15-06 (IV.D.1.)

a. Ask the a/r or representative if he has a vehicle which can be used for medical appointments and can purchase fuel.

b. Ask the client if his family, neighbors, friends, relatives, etc. provide

transportation. If transportation has been provided at no cost, it is reasonable to expect this to continue, except in extreme circumstances or evident hardship.

c. Ask the a/r how he or she has previously traveled to medical appointments

and if there is a reason why this method of transportation cannot continue to be used.

d. When an individual requests transportation assistance and has a reason

that prevents the use of an available resource, evaluate for evident hardship. Evaluate these requests on a case by case basis.

(1) Use the DMA-5048, Medicaid Transportation Medical Necessity

Verification, (Attachment 12), to request the necessary verification/documentation needed to make a determination that an evident hardship exists.

(2) If the a/r has a valid reason that prevents the use of an available

resource, then approve the transportation request.

(3) If assessment reveals the a/r still has an available resource for transportation, deny the request.

Example: Individual owns a vehicle that is insured, inspected, and registered. However, the individual is now unemployed and does not have the funds to purchase gas. This would constitute evident hardship. The individual would need to provide documentation that employment ended to prove that an evident hardship exists.

e. Check resource listing(s) to determine if the a/r has access to individual or

community based transportation and is able to get to pickup location.

2. Document the current Medicaid status - authorized, deductible, application pending.

a. The dss transportation worker must have verification that the a/r is

authorized prior to approving transportation services which will be reimbursed by Medicaid.


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REVISED 11/01/06 – CHANGE NO. 15-06 (IV.D.2.)

b. The Income Maintenance Caseworker should notify the transportation worker of the Medicaid eligibility status of an a/r who has requested assistance with transportation.

3. Document on the assessment form:

a. Request approved or denied and why.

b. If approved, means of transportation selected and why.

c. Medical provider(s) name, address and date of medical service(s) for the

provider(s) selected by the recipient to provide required services

d. Location, time and date(s) of trips (including return trip) scheduled.

e. Period of time approved for assistance with transportation.

f. That the a/r has been notified (DMA-5024 sent).

4. Retain a copy of the DMA-5047, Medicaid Transportation Assessment and the DMA-5024, Transportation Request Notification, in the eligibility file or transportation file for documentation.

E. Assessments by Other Agencies

The county may negotiate agreements to have transportation assessments completed by individuals in other agencies (e.g. case managers, etc.). However, the county dss is responsible for assuring that all requirements are met and that documentation of the decisions, copies of notices, authorizations, etc. are received in the DSS and comply with guidelines before reimbursement is requested.

V. ARRANGING TRANSPORTATION

If the recipient is unable to arrange and/or pay for medical transportation, the county department must arrange or provide transportation to services covered by North Carolina Medicaid for authorized recipients. However, Medicaid cannot pay for transportation unless medical care is the primary reason for service and the service is covered by Medicaid. Refer to Manual Section MA-2905 or MA-3540, Medicaid Covered Services, or DMA website at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm, for a listing of current Medicaid covered services. (This is not an all inclusive list.)




http://info.dhhs.state.nc.us/olm/manuals/dma/fcm/man/MA3540.htm#TopOfPage



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REISSUED 11/01/06 – CHANGE NO. 15-06 (V.)

A. Needs of Recipient

If the county department arranges transportation, the arranged transportation must meet the recipient’s needs. The agency must seek to alleviate scheduling problems by:

1. Coordinating scheduling with transportation providers.

2. Taking into account the need for adequate time for the recipient to be seen by

the medical provider.

3 Arranging transportation immediately when a need arises due to illness.

4. Arranging transportation for evenings and weekends if those are the ONLY times available.

B. Listing of Transportation Services

The transportation scheduler(s) must be aware of available transportation sources in the county and locality where the recipient lives. The scheduler must make use of the most appropriate and cost-effective method, including free transportation, for providing transportation services in each situation. Each county department of social services must maintain an updated listing of all available transportation services which includes:

1. Free transportation services available in the community;

2. Per mile or per trip costs for local, public or private transportation providers;

3. Listing of all routes covered by various methods. The list should include

fixed routes of city buses, volunteer organizations, county coordinated systems, etc. To the extent possible, the list should contain flexible routes of available transportation methods;

4. Availability of each service (dates and times);

5. The scheduler must also make use of available resources such as family,

friends and community organizations and help recipients coordinate appointments with others who would be willing to provide transportation.


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REISSUED 11/01/06 – CHANGE NO. 15-06 VI. METHODS OF TRANSPORTATION AND COVERED COSTS

Arrange transportation by the least expensive means suitable to the recipient's individual needs. Use the following criteria to assure transportation is provided by means appropriate to the recipient's situation.

A. Least Expensive Means

Should be determined in terms of cost per trip given the available means of transportation (e.g. bus, taxi, vouchers, coordinated transportation system, use of personal vehicle, etc.).

1. Consider all expenses such as vendor charges, dss staff salaries and vehicle

maintenance costs when justifying transportation costs.

2. Refer to the agency's listing of local transportation sources to determine expenses.

3. Always use community and other resources which are available at no charge

when appropriate to the recipient's needs.

B. Suitable Transportation

Transportation must be suitable to the recipient's needs. Consider the following physical/medical conditions and personal circumstances.

1. Physical/mental disability (e.g. wheelchair bound amputee, inability to follow

simple directions - contact provider if questionable or guidance needed.);

2. Physical stamina (e.g. ability to stand, sit/wait for extended periods of time, etc.);

3. Need to transport medical equipment and/or attendant;

4 Time frames and accessibility to bus stop, fixed schedule, pick-up, drop-off

and waiting times;

5. Work schedule;

6. Caregiver/Attendant responsibilities for the recipient;

7. Necessity of children accompanying the recipient to a medical appointment; and


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8. Necessity of a partner accompanying the recipient to a medical appointment (e.g. childbirth or parenting class, genetic counseling, etc.).

REVISED 11/01/06 – CHANGE NO. 15-06 (VI.B.)

9. Necessity of an interpreter/translator.

C. Appropriate Provider

The provider must be appropriate for the recipient's needs. "Appropriate" is determined by medical need and individual circumstances which include but are not limited to:

1. The recipient's medical condition;

2. The level of care/type of service required (i.e. routine versus specialized).

Contact the provider if questionable;

3. Availability of Medicaid providers for that particular service;

4. Ability to schedule appointment(s) during clinic or office hours;

5. Established relationship with a medical provider and undergoing a course of treatment.

If there are no critical factors, provide transportation to a local provider by the least expensive means available.

D. Provider of Choice

The recipient has the right to select his own medical provider. This is known as “freedom of choice”. Arrange transportation to the selected provider except that:

1. The dss is not required to provide transportation to a provider at a

significantly greater distance from the residence solely because of personal preference, if the needed services can be obtained locally. The dss cannot claim reimbursement if transportation is provided based on personal preference.

2. Discuss with the recipient and contact the provider if necessary to determine if

services can be obtained locally. Ask the provider to refer to a local source of treatment, if possible. If questionable, use the DMA-5048, Medicaid Transportation Medical Necessity Verification form to obtain a written statement from the provider as justification for providing transportation at a greater distance.

E. Special Medical Needs


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The dss must provide transportation when the recipient has the following medical needs and is unable to arrange or pay for his own transportation, regardless of location:

REVISED 11/01/06 – CHANGE NO. 15-06 (VI.E.)

1. The recipient is "locked in" to specific providers because of Carolina Access or other managed care plans;

2. The provider’s services cannot be obtained locally or local providers will not

accept Medicaid recipients;

3. The recipient is undergoing an established course of treatment which must be completed (e.g. chemotherapy, dialysis, prenatal care).

4. Medical Services in Another County or State

Transportation within the county of residence, across county lines, and for recipients living in border counties who commonly use providers in the adjoining state, if appropriate and necessary for a/r to receive treatment or preventive services.

5. Hospitalized Recipients

Transportation both to and from in-patient hospitalization if an ambulance is not medically necessary and the recipient's family or representative is unable to provide transportation.

F. Transportation will be provided at greater distance when:

1. The individual is in a Medicaid managed care plan such as Carolina Access

and requires a service that cannot be obtained locally.

2. The individual is in a series of treatments or visits such as OB-GYN, chemotherapy, treatment of chronic illness, or when local providers have refused to accept Medicaid recipients for treatment.

3. The individual has a special medical need.

4. Documented circumstances indicate another medical provider is necessary.

G. If transportation cannot be arranged prior to an appointment which is not an

urgent or emergency (instruct a/r to call 911 for emergencies), or if a decision cannot be made prior to the appointment, ask the recipient to reschedule the appointment.

1. If the recipient needs assistance in rescheduling, attempt to contact the

medical provider or case manager to verify if the appointment can be rescheduled. Use this opportunity to inquire about scheduling future appointments also.


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REVISED 11/01/06 – CHANGE NO. 15-06 (VI.G.)

2. If the recipient is able to make other arrangements, the dss may reimburse the recipient the amount that would normally be paid to the transportation provider had the recipient given sufficient notice for the dss to arrange transportation.

H. Wheel Chair Lifts

Federal Transit Authority (FTA) regulations state that Community Transportation Systems can transport individuals weighing up to 600 lbs. Transport of individuals between 600 lbs and 800 lbs. is at the discretion of the operator. Weight limit includes the weight of the wheel chair.

In situations where the individual exceeds Community Transportation Systems’ weight limit, but does not meet medically necessary criteria for non-emergency ambulance transportation, refer to VI. I. below.

I. Transport Using an Ambulance as a Last Resort

On very rare occasions, an ambulance is the only means of transport for an individual that does not meet emergency or non-emergency ambulance medically necessary criteria because he is not bed confined (e.g. weight exceeds lift van limit). In such cases, the county should negotiate a trip cost with the ambulance company for transport without basic life support or advanced life support services. Since the individual is not in need of ambulance services outlined in IV. J., the ambulance company does not directly bill the fiscal agent.

When an ambulance is contracted by the dss as a means of transport only, it is not a Medicaid covered service (does not meet emergency and non-emergency ambulance transportation criteria) and cannot be billed by the ambulance provider. The dss reimburses the transportation provider and is reimbursed by Medicaid for the non-county share. The individual’s record must document fully outlining the exhaustion of all other less expensive types of transport.

J. Related Travel Expenses

Medicaid transportation may include "related travel expenses" when the transportation need is other than routine. File claims for reimbursement by the appropriate method. Verification of medical necessity for related travel expenses may be verified by using the DMA-5048, Medicaid Transportation form (Attachment 12).


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REVISED 11/01/06 – CHANGE NO. 15-06 (VI.J.)

1. Overnight Lodging and Meals

When the medical service is available only in another county, city, or state, medical condition, travel time and distance may warrant staying overnight. Allowable expenses include overnight lodging and meals for eligible recipients while in transit to and from the medical resource. Lodging and transportation to and from the lodging must be determined to be less expensive than daily travel from home (unless deemed medically necessary).

2. Attendant Expenses

If medically necessary, the cost of an attendant (or possibly two attendants if doctor determines two attendants are needed to accompany and care for the individual) to accompany the recipient is also an allowable "related travel expense" and includes:

a. Overnight lodging

b. Meals

c. Salary

You may not claim reimbursement for payment of an attendant's salary when:

(1) Attendant is a member of the recipient's family, or

(2) Attendant is paid to remain with a recipient who is a patient in a

medical facility.

3. Parent/Guardian/Parental Designated Escort

Reimbursement for transportation costs and travel related expenses for one parent, guardian, or parental designated escort can be claimed when circumstances require. Salary to accompany a minor child is not an allowable travel expense.

a. If a parent/guardian states he is unable to accompany his child or locate an

escort to accompany the child and requests assistance locating an escort, the transportation scheduler should evaluate for possible referral. The worker should follow agency procedure and refer to the appropriate dss worker/department to provide assistance. However, it should be noted that the salary of a county dss employee, volunteer, etc., is not an allowable


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related travel expense when transporting in the capacity of a parental designated escort.

REVISED 11/01/06 – CHANGE NO. 15-06 (VI.J.3.)

b. Reimbursement for transportation costs and travel related expenses can be claimed when a parent/guardian requests transportation assistance to a medical facility to provide or learn to provide care for a Medicaid eligible child when requested by the child’s physician.

Note: The parent, guardian, or designated escort is not required to be a Medicaid recipient. For record keeping purposes, if the parent, guardian, or parental designated escort is not a recipient, list the recipient on DMA-2056, Transportation Log and DMA-2055, Reimbursement Request Form. List the parent, guardian, or parental designated escort's name directly below the a/r’s name and designate as parent/guardian or parental designated escort.

4. Translators/Deaf or Blind Interpreters

Reimbursement for transportation costs and travel related expenses can be claimed for a translator/interpreter when:

a. The medical provider has no staff that can translate or interpret, and

b. There is no other appropriate medical provider who has a translator or

interpreter on staff to whom the client can be transported such that the cost of transporting the client to that provider is less than transporting the client and a translator.

K. Ambulance Transportation

Emergency and non-emergency ambulance transportation is a Medicaid covered service, which is paid directly to the ambulance provider as a Medicaid claim and is available to all recipients when medically necessary.

Medical necessity is when the recipient’s condition requires ambulance transportation and any other means of transportation would endanger the recipient’s health or life. Medicaid covers ambulance services only if they are furnished to a recipient whose medical condition is such that other means of transportation would endanger the recipient’s health.

1. Ambulance – Ground Transportation

Ambulance transportation is a Medicaid covered service when transport by ambulance is medically necessary. Medical necessity is indicated when the patient's condition is such that any other means of transportation would




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endanger the recipient’s health. The ambulance provider must submit a claim to the Medicaid fiscal agent for reimbursement.

REVISED 11/01/06 – CHANGE NO. 15-06 (VI.K.1.)

a. Emergency

Basic Life Support (BLS) and Advanced Life Support (ALS) are covered when it is medically necessary for the recipient to receive immediate and prompt medical services which arise in an emergency situation.

(1) Basic Life Support

Basic Life Support includes the necessary equipment and staff to treat basic services when transport requires a stretcher.

(2) Advanced Life Support

An ALS ambulance is a vehicle with complex specialized life sustaining equipment and is ordinarily equipped for radio-telephone contact with a physician or hospital. It is staffed by trained personnel authorized to administer ALS services.

Examples of Emergency Ground Transport: unconsciousness or shock, severe burns, diabetic coma or insulin shock, severe anaphylactic reaction, rape victim, overdose, severe injury resulting from an accident.

b. Non-emergency Medically Necessary

An individual must be bed-confined and have debilitating physical condition(s) that requires travel by stretcher only and require ground transportation to receive medical services.

(1) Non-emergency ambulance transportation is covered for care

which cannot be rendered in the place of residence and when it is medically necessary that the recipient be transported by ambulance due to a medical/physical condition.

(a) The recipient’s condition must meet the definition of

medical necessity which is defined as a condition which requires ambulance transportation and any other means of transportation would endanger the recipient’s health or life.

(b) The fiscal agent makes the final determination of medical

necessity for Medicaid coverage and reimbursement. Documentation is provided by condition codes. If it is


20

determined that documentation is insufficient to warrant ambulance transportation, the claim will be denied.

REISSUED 11/01/06 – CHANGE NO. 15-06 (VI.K.1.b.)

(2) This level of coverage will also pay for return trips from in-patient hospitalization to the patient's residence when it is medically necessary that the individual be transported by ambulance.

2. Air Ambulance Transportation

Air transportation by helicopter and fixed wing crafts is a Medicaid covered service when the individual’s medical condition requires immediate and rapid transportation that cannot be provided by ground ambulance. Transportation must be to the nearest hospital with appropriate facilities.

Examples: Intracranial bleeding requiring neurological intervention, cardiogenic shock, burns requiring treatment at a burn center, multiple severe life threatening injuries, life threatening trauma.

3. State to State Placement

Payment of ambulance transportation is provided when a recipient must be transported to an out of state facility or returned to North Carolina by ground or air ambulance. This transportation applies to non-emergency situations; however, medical necessity must be met in that transport by any other means would endanger the recipient's health and safety.

Example: Placement in an out-of-state rehabilitation facility, return from out-of-state care to N.C. to appropriate facility.

The county department of social services is to initiate and complete the prior approval process for transportation for State-to-State Placement.

a. The county’s contact person telephones the fiscal agent prior approval

unit. During the discussion, the prior approval analyst verifies that the services requested require prior approval. The county verifies that there are no other resources other than Medicaid.

b. The prior approval analyst mails a Prior Approval Request Form to the

appropriate county. Included in this packet is an instruction sheet for completing the form and a sample document. Services requiring prior approval may not be rendered before approval is given except in some cases of retroactive Medicaid eligibility.


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c. The county obtains the requested documentation and completes the Prior Approval Request Form. Attached to these forms must be a letter (signed by the attending physician) which includes the medical diagnosis and recipient’s physical condition and justifies the means of transportation.

REISSUED 11/01/06 – CHANGE NO. 15-06 (VI.K.3.)

d. To expedite processing, the county mails the completed form and documentation to the fiscal agent’s address listed on the cover page of the Aged, Blind and Disabled/Family & Children’s Medicaid Manual.

L. Types of Approvals for Transportation Assistance

The county department may approve transportation in one of the following manners based on the recipient's individual situation and needs:

1. Individual Medical Trips

Approve individual medical trips as needed for recipients that meet transportation requirements for assistance. The recipient must contact the transportation coordinator to request assistance for all medical visits during the certification period. Record the trip on the DMA-2056, Transportation Log. Send a DMA-5024, Transportation Request Notification, for each request.

In order to prevent providing services to ineligible individuals, Medicaid eligibility must be verified prior to each individual trip.

2. Series of Appointments

Approve transportation with a specific provider for a series of appointments with a medical provider. The recipient must contact the transportation coordinator to request assistance for all medical visits during the designated period of time. The transportation coordinator must verify Medicaid eligibility prior to scheduling each trip in the series of appointments. If the recipient is approved for an extended period or series of visits:

a. Send a referral to the transportation provider identifying the scheduled

appointments. The referral document should include the recipients’ eligibility dates and program category.

b. Attachment 2 is an example of a suggested form for the county to send the

provider to use for tracking and billing purposes.

c. The transportation provider may bill the county for transportation using the form as documentation.




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d. Written documentation (when needed) may be requested from the medical provider verifying the provider’s address and date of medical treatment.


REVISED 11/01/06 – CHANGE NO. 15-06

(VI.L.) 3. Blanket Approval

If the recipient meets requirements for transportation assistance, a blanket period of time not to exceed the Medicaid certification period can be approved for a specific method of transportation (e.g. bus, voucher, mileage, volunteer, etc.). Approved blanket period of time transportation assistance must meet least expensive means and meet appropriateness to the recipient’s situation criteria. Refer to VI.

a. To be eligible for the approved transportation services, the recipient must

be eligible on the date of service. An approved authorization is not a guarantee that Medicaid will reimburse. Medicaid eligibility must be verified prior to each individual trip.

b. To be eligible for the approved transportation services, the recipient must

be requesting transportation assistance to receive a Medicaid covered service. The guidelines and restrictions for Medicaid covered services are listed in MA-2905/MA-3540, Medicaid Covered Services. The DMA website at http://www.dhhs.state.nc.us/dma/mp/mpindex.htm can also be accessed for specific clinical coverage criteria. For Medicaid covered services not listed, obtain the billing code for the medical service from the medical provider and contact the Managed Care Unit at (919) 647-8170 for verification.

c. Send a DMA-5024, Transportation Request Notification approving

transportation assistance for a specific transportation method for a period of time not to exceed the Medicaid eligibility period. The DMA-5024 approval must document;

(1) Specific method for transportation assistance.

(2) Beginning and ending certification period, and

(3) Specific medically related travel needs. Refer to VI.J.

d. Send a referral to the transportation provider when appropriate, identifying

the Medicaid recipient, Medicaid ID number, and the certification period. Also document medically related travel needs approved by dss.



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e. Inform the recipient to contact the individual designated by the county dss who is responsible for scheduling transportation for medical trips. All trips scheduled during the blanket period must be recorded on the DMA-2056, Transportation Log.

REVISED 11/01/06 – CHANGE NO. 15-06 (VI.L.3.)

f. When a Medicaid recipient requests transportation assistance during the blanket approved certification period which requires a different method of transport, including a change in transportation provider, or requests additional medically related travel needs not initially approved, send a new DMA-5024, Transportation Request Notification, of the actions taken on his request.


M. Notification

Notify the a/r by means of DMA-5024, Transportation Request Notification, of the actions taken on his request even if verbally notified at time of assessment.

1. Document on the DMA-5024 the reasons for the county's decision(s) on the

a/r's request for assistance.

2. Send the DMA-5024 even if transportation services have already been provided.

3. If a recipient is approved for a "blanket" period of time or “series of visits,” it

is not necessary to send the DMA-5024 each time the individual requests that a trip be arranged or when he arranges his own transportation. Refer to VI.K. above. If multiple recipients in a household are approved, all recipients can be listed on the same approval letter. Re-evaluate at the end of the approved period/series of visits.

4. Retain a copy in the transportation/eligibility record.

N. Documentation

Documentation must support expenditures and requests for reimbursement for transportation services provided to Medicaid recipients. The agency may elect to maintain the documentation in the Income Maintenance case record, a transportation record for the recipient, or centralized system.

1. Maintain documentation in the transportation/eligibility record of the dss's

evaluation of:

a. Each individual recipient's transportation resources,






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b. The decision on mode of transport, and

c. Destination.

REVISED 11/01/06 – CHANGE NO. 15-06 (VI.M.)

2. County records are subject to the county's single audit as well as follow-up monitoring and review by state and federal agencies.

VII. STAFFING

A. Transportation Coordinator

1. The individual(s) responsible for coordinating transportation must be knowledgeable of procedures and available resources for providing transportation services.

2. Establish one or more individuals in the agency who are responsible for

handling all requests for transportation.

3. Establish procedures to track each request from intake through disposition.

B. Referrals and Communication

Develop an in-house mechanism for referrals and communication between the Income Maintenance Section and Transportation Services to assure timely response to transportation requests

1. The IMC must provide information regarding Medicaid eligibility and/or

ineligibility to the individual(s) responsible for coordinating Medicaid related transportation assistance.

2. If an applicant/recipient is referred for transportation assessment at the time of

application/review for benefits, forward available Medicaid eligibility information via the DSS-8194, Income Maintenance Transmittal Form.

3. When assistance is requested at other times, the person completing the

assessment must verify eligibility through EIS or by contacting the caseworker.

C. County Transfers/Incorrect County Coding/Temporary Absence from

County/Adoption Cases/Foster Care Cases

1. County Transfers/Incorrect County Coding

http://info.dhhs.state.nc.us/olm/forms/dss/dss-8194-ia.pdf


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The county in which the Medicaid recipient physically resides is responsible for arranging, providing and requesting reimbursement for transportation. (e.g.: county transfer, SSI recipient shown in the incorrect county.)

REVISED 11/01/06 – CHANGE NO. 15-06 (VII.C.)

2. Temporary Absence/Adoption Cases/Foster Care Cases

The county where the Medicaid case is located is responsible for arranging and providing the transportation. However, the county where the recipient lives and the county where the Medicaid case is located should work together. The county where the Medicaid case is located is financially responsible for the transportation and responsible for filing for Medicaid transportation reimbursement.

VIII. SAFETY AND RISK MANAGEMENT

Liability considerations related to personal injury lawsuits could apply not only to services provided by private transportation vendors, but also to agency staff who transport clients. The dss must assure that all contracted transportation providers, agency staff, and agency-approved volunteers, relatives and friends who transport clients for mileage reimbursement (including foster care parents) are in compliance with the following risk management procedures.

A. Liability Insurance

Sufficient insurance coverage is necessary to adequately protect the agency and the individuals transported. A guide for minimum coverage shall be the amount required for common carrier-passenger vehicles by the North Carolina Utilities Commission, Department of Commerce, 430 N. Salisbury Street, 4325 Mail Service Center, Raleigh, NC 27699-4325.

1. Commercial Vehicles

When commercial vehicles (16 passengers or more) are used to provide client transportation services, agencies should obtain a copy of the private contractor’s Certificate of Insurance documenting that the DSS Director or designee is an “additional insured.” The party identified as an “additional insured” will be notified 30 days in advance of a contractor dropping any coverage. Agencies should also require contract transportation providers to carry increased liability limits beyond the minimum statutory requirements.

2. “For Hire” Vehicles


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“For Hire” passenger vehicles are defined as vehicles used for compensation to transport the general public as well as human service recipients and are, therefore, subject to the regulations of the N.C. Public Utilities Commission.

REISSUED 11/01/06 – CHANGE NO. 15-06 (VIII.A.2.)

Transportation providers licensed as “For Hire” public conveyance operators must meet statutory requirements for their classification and operator responsibilities. Currently, $1.5 million liability insurance coverage is required on vehicles with a seating capacity of 15 passengers or less and $5 million coverage for vehicles designed to transport more than 15 passengers, including the driver.

Taxi cabs and public transportation systems do not fall into this category.

3. Agency Owned Vehicles

Agencies that use their own vehicles to provide client transportation should carry “Symbol 1,” insurance which provides additional protection in the event of a lawsuit over a vehicle accident involving a volunteer, employee or contract transportation provider.

4. Non-Owned Auto Coverage

Agencies that do not own vehicles should carry “Symbol 9 - Non-Owned Auto Coverage,” insurance which protects the agency in the event of a lawsuit over a vehicle accident involving a volunteer, employee or contract transportation provider.

5. Staff and Volunteers

Staff and agency-approved volunteers who transport clients for mileage reimbursement (including foster care parents) must maintain minimum liability insurance coverage for their vehicle's particular classification.

B. Licensed Operator

The dss is required to ensure that all drivers (including county employees, contractors, contractor’s employees, and volunteers) are at least 18 years of age and properly licensed to operate the specific vehicle used to transport recipients. This applies to family members, friends, etc., paid by the agency to transport the recipient.

C. State Inspection


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The dss is required to ensure that all vehicles used to transport clients (whether owned by the county, county employee, contractor, contractors’ employees, or volunteers) have valid State registration and State inspection. This applies to family members, friends, etc., paid by the agency to transport the recipient.

REISSUED 11/01/06 – CHANGE NO. 15-06 (VIII.)

D. Alcohol and Drug Testing

It is recommended that the dss require both private and public contract transportation providers to participate in a random alcohol and drug testing program.

E. Driving Records

The dss is encouraged to have a driver screening policy. The driving records of all drivers, including agency employees who transport clients and contract transportation providers, should be reviewed every 12 months. The agency should consider any evidence that the driver has violated laws governing the operation of motor vehicles. The agency should give weight to violations such as speeding, reckless driving, and driving while impaired by use of alcohol or an impairing substance. Applicants for driver positions should be required to submit a list of all convictions for violations of motor vehicle laws or ordinances (other than violations involving parking only) during the three years preceding the date of the application.

F. Transportation Contract

A written contract/agreement/memorandum or understanding, signed by the provider, should be obtained by the agency when purchasing public or private transportation. The document must authorize services and provide a guarantee that the contractor will meet safety and liability insurance requirements.

IX. COORDINATION OF TRANSPORTATION SERVICES

A. Participation in the Community Transportation Improvement Plan (CTIP)

Every county has an approved CTIP or Transportation Development Plan (TDP) which must be updated periodically. The Department of Transportation provides guidance and oversight to counties in preparing and maintaining a CTIP/TDP. The purposes of a CTIP/TDP include:

1. Identifying existing or expected transportation needs.

2. Identifying future capital and operating costs associated with service delivery

and funding sources available.


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3. Identify alternatives for providing coordinated transportation.

4. Developing a detailed service design to meet these needs in the most cost effective manner.

5. Coordinating transportation resources at the local level to provide effective

use of resources to the general public.

REVISED 11/01/06 – CHANGE NO. 15-06 (IX.)

B. Local Transit Systems

When available and cost effective, the local transit system should be utilized to transport Medicaid recipients. In urban areas where fixed route bus services are available, Medicaid recipients should use the bus service unless there is a valid reason that would prohibit the individual from using this mode of transportation. Monthly bus passes may be purchased in lieu of individual bus tickets when the Medicaid recipient has multiple medical appointments during the month and it is determined that a monthly bus pass would be more economical. A monthly bus pass would entitle the Medicaid recipient to unlimited bus service during the month.

X. REIMBURSEMENT

A. Transportation Costs Eligible for Reimbursement at the Federal Medicaid Assistance Percentages (FMAP) Rate

DMA reimburses the county for the Federal and State share of certain transportation costs for direct services provided to recipients. Federal and state financial participation is limited to the following costs associated with administration of transportation and payment for trips:

1. Fares for public transportation (taxis, buses, or contracted service under local

Transportation Development Plans),

2. Operating costs per passenger trip with agency owned vehicles or vehicles in the county's coordinated transportation system as described in the CTIP/TDP,

3. Mileage costs (not to exceed the current state or county reimbursement rate

for state or county employees, whichever is higher. If the county dss per diem is higher than the state per diem, the dss may choose, but is not required to use the higher rate) for private vehicles owned by friends, non-financially responsible relatives, or volunteers to transport authorized Medicaid recipients to medical appointments when payment is made directly to the friend, relative, or volunteer,

4. Mileage costs incurred by dss staff using private vehicles,


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5. Salary compensation for transportation aides employed by the dss (Although the State and Federal share is reimbursed for this service, you must claim reimbursement on DSS-1571. Refer to Attachment 11.),

6. Attendant expenses, appropriate to individual’s needs and the least costly,

during transportation not to exceed state or county per diem at the county’s discretion and minimum hourly wage (attendant may also be the driver if it’s the least expensive means),

REVISED 11/01/06 – CHANGE NO. 15-06

(X.A.) 7. Provider delivery charges for prescriptions as long as it meets least expensive

criteria,

8. Reimbursement for travel is allowable for parents/guardians to visit an inpatient child to care for, or be taught how to care for the child,

9. Gas Vouchers

Vouchers are issued to eligible recipients who can use their car or friend or relative’s car for transportation to a Medicaid reimbursable appointment. Vouchers can be redeemed at local gas stations.

B. Transportation Costs Reimbursed at 50% Administrative Rate

1. Direct Payments to Recipients - Reimbursed by DMA

DMA reimburses the following direct payments to recipients as an administrative cost.

a. Direct payments to recipients/financially responsible spouses or parents

for mileage and related travel expenses.

b. Reimbursement to a recipient who is authorized to arrange and pay his own transportation, bus/cab fare, etc.

2. Staff Administrative Costs - Reimbursed by DSS

The Division of Social Services reimburses administrative costs for salary for social services staff or contracted staff to coordinate or provide transportation.

C. Maximum Reimbursement to Recipients

Reimbursement for related travel expenses may not exceed the amounts established in G.S. 138-6 (the General Statute which sets the per diem rate for state employees) or at the county's reimbursement rates, whichever is higher, for travel expenses for its employees. If the county dss per diem is higher than the state per diem, the dss may choose, but is not required to use the higher reimbursement rate. The state mileage,


30

subsistence and lodging reimbursement rates can be found at http://www.osbm.state.nc.us/files/pdf_files/2003_budget_manual.pdf.

1. Breakfast

Under State policy, reimbursement for breakfast may be claimed if the recipient must leave before 6:00 a.m.

REVISED 11/01/06 – CHANGE NO. 15-06 (X.C.)

2. Lunch

Reimbursement for lunch is only allowable on overnight stays. If a day trip will last from morning through afternoon the county department should counsel the recipient to make arrangements for lunch. At the county’s discretion, lunch may be provided for the recipient and attendant. However, reimbursement is not allowable.

3. Dinner

Reimbursement for dinner is allowable if the recipient does not return until after 8:00 p.m.

4. Mileage

Mileage costs, not to exceed the current state rate or at the county reimbursement rate, whichever is higher, can be reimbursed. If the county per diem is higher than the state per diem, the dss may choose, but is not required to use the higher reimbursement rate. The county is paid from the point of pick up (where the individual is) to the provider and from the provider to where he is dropped off.

5. Parking Fees

Reimbursement for parking fees is allowable if reimbursement is based only on mileage. If transportation is reimbursed on a per-trip basis, parking fees are already included in the payment for the trip.

6. Overnight Lodging

Overnight lodging, not to exceed the state rate or at the county reimbursement rate, whichever is higher, can be reimbursed. If the county per diem is higher than the state per diem, the dss may choose, but is not required to use the higher reimbursement rate. Refer to VI.J.1. above for applicable criteria.

7. Salary

http://www.osbm.state.nc.us/files/pdf_files/2003_budget_manual.pdf.


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Maximum reimbursement for a medically necessary attendant or translator/interpreter cannot exceed the hourly minimum wage. Salary for a parent/guardian/parental designated escort is not an allowable travel related expense and cannot be reimbursed. Refer to VI.J. for applicable criteria.

REVISED 11/01/06 – CHANGE NO. 15-06 (X.)

D. Reimbursement to Nursing Facilities

1. Direct Reimbursement

DMA directly reimburses long term care facilities for non-ambulance transportation of Medicaid eligible patients to receive medical care that cannot be provided in the facility. This reimbursement is included in the total cost of care paid to the facility. Family members are encouraged to provide transportation when they can as a means to provide critical family and social support to the patient. Costs for routine transportation may not be charged to the family or to the patient's funds. It is not necessary for dss to have Notice of Rights for transportation signed for applications and redeterminations since nursing homes provide their own transportation.

2. Arranging Transportation

The facility will be responsible for arranging or providing non-ambulance transportation for all Medicaid recipients (even if dss has guardianship) who do not have family assistance. The facility may contract with providers (including local county services) to provide transportation or may provide transportation services using its own vehicles, whichever is more cost effective.

3. Ambulance Transportation

Ambulance transportation for nursing home residents is permitted only by medical necessity as specified in Section VI. above.

If a nursing facility schedules non-emergency ambulance transportation for a Medicaid recipient and the claim is denied due to lack of justification for medical necessity (the individual’s medical/physical condition did not warrant stretcher transport), the nursing facility is responsible for payment. The facility cannot bill the patient or his family for non-covered services.

E. Reimbursement to Adult Care Homes


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1. Direct Payment

Adult Care Home facilities receive a direct daily per diem payment from the Division of Medical Assistance to cover routine transportation services for each recipient receiving Medicaid.

REVISED 11/01/06 – CHANGE NO. 15-06 (X.E.)

2. Arranging Transportation

The facility will be responsible for arranging or providing non-ambulance transportation for routine medical visits for all Medicaid recipients who do not have family assistance.

The facility may contract with providers (including local county social services) to provide transportation or may provide transportation services using its own vehicle, whichever is more cost effective.

3. Ambulance Transportation

Ambulance transportation for adult care home residents is permitted only by medical necessity as specified in Section VI. above.

If an adult care home schedules non-emergency ambulance transportation for a Medicaid recipient and the claim is denied due to lack of justification for medical necessity (the individual’s medical/physical condition did not warrant stretcher transport), the adult care home facility is responsible for payment. The facility cannot bill the patient or his family for non-covered services.

F. Reimbursing the Recipient

The county department has the option of providing money for travel related expenses to the recipient in advance or after the trip is completed. If the worker feels that verification of the appointment is necessary, he should request the appointment card or contact the provider.

G. Time Limitation for Filing Transportation Claims

Claims for payment to recipient or provider of service shall be submitted to DMA within one year of the date of service.

XI. REPORTING MEDICALLY RELATED TRANSPORTATION COSTS

A. Direct Payment for Services


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1. Report direct payment for services on the DMA-2055. These include:

a. Costs for medically related transportation services purchased for Medicaid

recipients,

b. Direct payments to Medicaid recipients for medically related transportation,

c. Related travel expenses.

REVISED 11/01/06 – CHANGE NO. 15-06 (XI.A.)

2. Completing the DMA-2055

a. In item 1, report direct reimbursements to the recipient (or individual financially responsible for the recipient) for transportation, including direct reimbursement for related travel expenses such as reimbursement for meals or lodging. These costs are reimbursed at the 50% administrative match.

b. In item 2, report transportation services purchased for the recipient such as

payments to entities or individuals (not financially responsible for the recipient) to transport the recipient, purchase of bus passes, purchase of gas vouchers, attendant expenses, transportation of caretakers, etc. These costs are reimbursed at the FMAP rate.

B. Agency Costs

1. Report agency costs for the following on the DSS-1571:

a. Operating agency owned vehicles for medically related transportation of

Medicaid recipients,

b. Operating DSS staff owned vehicles for medically related transportation of Medicaid recipients,

c. DSS staff time used in directly providing medically related transportation

of Medicaid recipients,

d. DSS staff time used in coordinating and arranging medically related transportation for Medicaid recipients.

2. DSS costs associated with staff time spent directly providing Medicaid

transportation services (actual drive time) should be reported on the DSS-1571, Part IA, Personnel Cost Statement as Function Code 06, under Column 15 (Application Code 377-Med Trans Svc). These costs are reimbursed at the FMAP rate. Staff time spent providing the trip should be reported on the DSS-4263, Worker Daily Report of Services to Clients (the “day sheet”) to SIS Code 250, Program Code T.




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DSS costs for staff or contract staff that arrange, certify, and/or coordinate Medicaid transportation should be reported on the DSS-1571, Part IA, as Function Code 01, under Column 15 (Application Code 375-Med Trans Adm). These costs are reimbursed at the 50% administrative rate. Staff time spent arranging/coordinating Medicaid transportation should be reported on the DSS-4263 to SIS codes 380 (Case Management) or 381 (Service Intake), Program Code T.

REISSUED 11/01/06 – CHANGE NO. 15-06 (XI.B.2.)

If the DSS worker uses his/her own vehicle to provide the Medicaid trip, the worker’s mileage reimbursement is reported on the DSS-1571, Part 1A based on the functional pool into which the worker falls – Application code 349 for Services and Application code 359 for Income Maintenance. Do not report this travel as code 310 or code 311 since this would result in a portion of Services travel (for example) being allocated to Income Maintenance.

Travel of administrative staff (travel to meetings and conferences) should be reported as Code 310, since those costs are appropriately distributable to all programs. Reimbursement rate for cost allocated transportation will vary each month based on total expenditures, distribution of staff time, and available funding.

3. Operating and maintenance costs for agency vehicles used to provide

transportation that have been cost allocated across all programs must be cost allocated as well. Costs of this type should be reported on the DSS-1571 in the same manner as the vehicle purchase was originally reported. These costs should not be reported on the DMA-2055.

4. If the agency has purchased a vehicle dedicated solely to Medicaid

transportation, it cannot be directly reimbursed for the vehicle’s purchase. However, the purchase price may be recouped over the life of the vehicle through actual operating costs per trip or a use allowance, and the county will be reimbursed at the FMAP rate. Report this on Part II of the DSS-1571 as Code 378. Do not cost allocate the purchase or operating costs of these vehicles.

Attachments 1 – 12

1. Section 16 & 18 Grant Program for Non-Urban Areas 2. Provider Transportation Record (Suggested Form) 3. DMA-5046 Notice of Rights 4. DMA-5046 Notice of Rights (Spanish) 5. DMA-5047 Medicaid Transportation Assessment 6. DMA-5024 Transportation Request Notification 7. DMA-5024 Transportation Request Notification (Spanish)



http://info.dhhs.state.nc.us/olm/forms/dma/dma-5046s.pdf



http://info.dhhs.state.nc.us/olm/forms/dma/dma-5024sp-ia.pdf


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8. DMA-2056 Title XIX Transportation Log 9. DMA-2055 Reimbursement Request Form 10. DSS-8194 Income Maintenance Transmittal Form 11. Model No-Show Policy for Community Transportation Systems 12. Medicaid Transportation Medical Necessity Verification



http://info.dhhs.state.nc.us/olm/forms/dss/dss-8194-ia.pdf

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