(A) The transportation provider, who meets the requirements set forth for both ambulette and ground ambulance providers as specified in rule 5101:3-15-02 of the Administrative Code, may be reimbursed for providing the ambulette service with an ambulance vehicle if the following criteria are met.
(1) The patient must meet the criteria for the ambulette service as specified in paragraph (B) of rule 5101:3-15-03 of the Administrative Code except for paragraphs (B)(2)(b) and (B)(2)(e) of rule 5101:3-15-03 of the Administrative Code.
(2) The ground ambulance vehicle must meet requirements as specified in rule 5101:3-15-02 of the Administrative Code.
(3) The rendering transportation provider has documented that its ambulette vehicles were unavailable and has documented referral attempts to a competing transportation provider or the rendering transportation provider has documented that delaying, deferring or missing the transport to or from the medicaid covered service would jeopardize the patient's health or cause excessive patient waiting time.
(4) The rendering transportation provider has taken appropriate preventive measure(s) and developed protocols for telephone screening to encourage institutions, facilities and patients to request the appropriate type of transport.
(5) The rendering transportation provider, who owns at least one ambulette vehicle, is using the ambulance transport as backup to its ambulette vehicle and not because the provider has intentionally over booked its ambulette vans and is relying on the ambulance as primary transport for patients needing the ambulette service.
(6) The safety of the patient is assured by adhering to all standards specified for ambulance transport in accordance with rule 5101:3-15-02 of the Administrative Code. The unoccupied patient's wheelchair cannot be transported unsecured inside the ambulance. The method for securing the wheelchair must assure that during transport or an accident that the wheelchair will not move.
(7) Documentation must be provided upon request verifying paragraphs (A)(2) to (A)(6) of this rule to ODJFS.
(B) Reimbursement of the ambulette service provided in an ambulance as specified in paragraph (B) of this rule is as follows:
(1) For the one-way ground ambulance transport of one passenger, the provider shall be reimbursed a base rate for the service and a loaded mileage rate for each mile the passenger was transported.
(a) The amount of reimbursement for the base rate shall be the lesser of the provider's billed charge or twenty-eight per cent of the medicaid maximum rate as set forth in appendix DD of rule 5101:3-1-60 of the Administrative Code for"Basic life support, non-emergency (BLS non-emergency)"; and
(b) The amount of reimbursement for the loaded mileage shall be the lesser of the provider's billed charge or forty-eight per cent of the loaded mileage code for ambulances.
(c) For the total reimbursement, the provider must bill the "Basic life support, non emergency (BLS-non-emergency)" code and the code for the loaded land ambulance mileage. Both codes must be modified with the appropriate medicaid covered point of transport modifier and U3, ambulette service by ambulance vehicle, modifier (two modifiers in total).
(2) For the one-way ground ambulance transport of two or more passengers, the provider shall be reimbursed only a base rate for the service. No reimbursement shall be made for loaded mileage.
(a) The amount of reimbursement for the base rate for the second passengers of a multiple passenger transport will be further reduced by fifty per cent and the amount of reimbursement for the base rate for two or more passengers will be further reduced by twenty-five per cent.
(b) For reimbursement the provider must bill the base rate with the U3, ambulette service by ambulance vehicle, modifier, the appropriate medicaid covered point of transport modifier, and the appropriate multiple passenger modifier, U1, second passenger modifier, or U2, three or more passenger modifier (three modifiers in total).