Chapter 5160-15 Medical Transportation Services

5160-15-01 [Effective until 4/1/2016] Medical transportation services: definitions.

(A) The following definitions are applicable to this chapter

(1) "Advanced life support services" (ALS) are defined as those services which are beyond the scope of services that may be provided by EMT-basic and within the scope of practice of an EMT-intermediate or a paramedic in accordance with Chapter 4765. of the Revised Code.

(2) "Air ambulance" is defined as an air ambulance vehicle that is equipped and staffed to handle the transport of a patient whose condition meets the criteria for transport via air ambulance specified in paragraph (C) of rule 5101:3-15-03 of the Administrative Code.

(3) "Ambulance, land ambulance, or ground ambulance" is defined as a vehicle that is designed to transport individuals in a supine position and meets the standards and license requirements specified in Chapter 4766. of the Revised Code.

(4) "Ambulette" is defined as a vehicle that is designed to transport individuals sitting in wheelchairs and meets standards specified in rule 5101:3-15-02 of the Administrative Code.

(5) "Attendant" is defined as an individual employed by the transportation provider separate from the basic crew of the ambulance or ambulette vehicle who meets the qualifications specified in paragraph (B)(2) of rule 5101:3-15-02 of the Administrative Code for ambulance and paragraph (C)(3) of rule 5101:3-15-02 of the Administrative Code for ambulette and is present to aid in the transfer of medicaid covered patients who meet the criteria for transport specified in rule 5101:3-15-03 of the Administrative Code.

(6) "Attending practitioner" is defined as the practitioner (i.e., primary care practitioner or specialist) who provides care and treatment to the patient on an ongoing basis and who can certify the medical necessity for the transport. The attending practitioner is responsible for the ongoing care and management of the patient and can certify the non-ambulatory status of the patient and the medical need for ambulance or ambulette transport, the type of certification, and length of time the non-ambulatory status will remain unchanged. Attending practitioner also refers to a designated practitioner who is covering for the attending practitioner in his or her absence or a practitioner who is a member of the same group practice as the attending practitioner and in which it is customary for the members of the practice to cross cover for each other's patients. Practitioners must hold a valid and current license or certification to practice as at least one of the following:

(a) A doctor of medicine;

(b) A doctor of osteopathy;

(c) A doctor of podiatric medicine; or

(d) An advanced practice nurse (APN).

(7) "Basic crew" is defined as the minimum necessary staff members for each type of transport as set forth in rule 5101:3-15-03 of the Administrative Code and section 4765.43 of the Revised Code.

(8) "Basic life support services" (BLS) are defined as those services which are in the scope of services of an emergency medical technician-basic as set forth under section 4765.37 of the Revised Code.

(9) "Covered medical transportation services" are defined as those transports covered in accordance with rule 5101:3-15-03 of the Administrative Code.

(10) "Dispatcher" is defined as an individual employed by the transportation provider to set the schedule of transportation runs for the ambulette and/or ambulance vehicles.

(11) "Driver" is defined as an individual employed by the transportation provider as part of the basic crew to drive the ambulette or ambulance vehicle to the medicaid covered point(s) of transport and who meets the qualifications specified in paragraph (B)(2) of rule 5101:3-15-02 of the Administrative Code for ambulance and paragraph (C)(3) of rule 5101:3-15-02 of the Administrative Code for ambulette.

(12) "Emergency service" is a service that is provided after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity that in the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

(13) "Emergency medical technician" (EMT) is defined as an individual who holds a current, valid certificate as an emergency medical technician issued under section 4765.30 of the Revised Code.

(14) "Loaded mileage" is defined as the number of miles a patient is transported in the ambulance or ambulette to or from a medicaid covered service. Air ambulance mileage is statute miles.

(15) "Long term care facility" is defined as an intermediate care facility for the mentally retarded (ICF-MR) and/or a nursing facility (NF) as defined in paragraphs (N) and (Q) of rule 5101:3-3-01 of the Administrative Code.

(16) "Medicaid covered point(s) of transport" is defined as the origin, where transport begins or the destination, where transport ends. One of the points of transport, the origin or destination, must be a medicaid covered service. The modifier for the point(s) of transport must be specified as covered in rule 5101:3-15-03 of the Administrative Code.

(17) "Medicaid covered service" is defined as a service reimbursable under the Ohio medicaid program in accordance with Chapters 5101:3-1 to 5101:3-56 of the Administrative Code, excluding those services specified in paragraph (E) of rule 5101:3-15-03 of the Administrative Code.

(18) "Medical transportation service(s)" are defined as a general term for those service(s) covered in accordance with rule 5101:3-15-03 of the Administrative Code.

(19) "Medical transportation provider" is defined as a general term for providers of air ambulance, ambulance and ambulette services in accordance with this chapter.

(20) "Nonambulatory" for the purpose of this rule, is defined as those permanently or temporarily disabling conditions which preclude transportation in motor vehicle(s) or motor carriers as defined in section 4919.75 of the Revised Code that are not modified or created for transporting a person with a disabling condition. The permanently or temporarily disabling conditions must require transport by air ambulance, ambulance or ambulette (for example, patients requiring stretcher transportation or wheelchair-bound individuals) in accordance with this rule.

(21) "Non-emergency transportation" is defined as a prescheduled or unscheduled ambulance or ambulette transport for a patient whose medical condition does not require immediate response for the provision of medical treatment.

(22) "Paramedic" is defined as an individual who holds a current, valid certificate issued under section 4765.30 of the Revised Code.

(23) "Paramedic ALS Intercept" (PI) services are defined as ALS services furnished by an entity that does not provide the ambulance transport.

(24) "Pilot" is defined as an individual employed by the transportation provider as part of the basic crew to pilot the air ambulance and who meets the qualifications specified in paragraph (D)(2) of rule 5101:3-15-02 of the Administrative Code.

(25) "Practitioner certification form" is the general term for the JFS 01960 "Ambulance Certification of Medical Necessity Form" (rev. July 2003) that certifies the medical necessity of land ambulance services and the JFS 03452 "Ambulette Certification of Medical Necessity Form" (rev. July 2003) certifies the medical necessity of ambulette services and the written documentation required to certify medical necessity for air ambulance services.

(26) "Specialty care transport services (SCT)" is defined as a level of interhospital services which is beyond the scope of the paramedic and must be furnished by one or more health professionals who are trained in an appropriate specialty area (for example, nursing, emergency medicine, respiratory care, cardiovascular care or paramedic with additional training).

Replaces: 5101:3-15-01

Effective: 03/27/2006
R.C. 119.032 review dates: 03/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02
Prior Effective Dates: 4/7/77, 5/9/86, 12/1/89, 5/1/92 (Emer), 7/31/92, 3/01/00, 12/27/01, 10/1/03, 12/30/05 (Emer)

5160-15-01 [Effective 4/1/2016] Transportation: definitions.

(A) This chapter sets forth the transportation services that are available as benefits under the medicaid state plan. Provisions in this chapter do not apply to transportation services for which a per diem payment is made to a long-term care facility (LTCF) in accordance with Chapter 5160-3 of the Administrative Code.

(B) The following definitions apply to this chapter:

(1) "Advanced life support, level 1 (ALS1)" is transport by ground ambulance and the provision of medically necessary supplies and services at a level beyond the scope of an EMT-basic but within the scope of an EMT-intermediate or EMT-paramedic specified in Chapter 4765. of the Revised Code.

(2) "Advanced life support, level 2 (ALS2)" is ALS1 during which at least one of the following procedures is performed:

(a) At least three separate administrations of one or more medications (except crystalloid fluids) by intravenous means or by continuous infusion;

(b) Manual defibrillation or cardioversion;

(c) Endotracheal intubation;

(d) Establishment of a central venous line;

(e) Cardiac pacing;

(f) Chest decompression;

(g) Opening of a surgical airway; or

(h) Establishment of an intraosseous line.

(3) "Air ambulance transport" is transport by air ambulance and the provision of medically necessary supplies and services.

(4) "Ambulance" is an air ambulance or ground ambulance.

(a) "Air ambulance" is an aircraft that meets the definition of "fixed wing air ambulance" or "rotorcraft air ambulance" set forth in section 4766.01 of the Revised Code and meets the standards and license requirements specified in Chapter 4766. of the Revised Code.

(i) "Fixed-wing air ambulance" has the same meaning as "fixed wing air ambulance."

(ii) "Rotary-wing air ambulance" has the same meaning as "rotorcraft air ambulance."

(b) "Ground ambulance" is a vehicle that meets the definition of "ambulance" set forth in section 4766.01 of the Revised Code and meets the standards and license requirements specified in Chapter 4766. of the Revised Code.

(5) "Attendant" is an individual employed by a transportation provider, in addition to the minimum crew of a wheelchair van or a ground ambulance, who aids in the non-emergency transportation of medicaid-eligible individuals who require extra assistance.

(6) "Basic life support (BLS)" is transport by ground ambulance and the provision of medically necessary supplies and services at a level within the scope of an EMT-basic specified in Chapter 4765. of the Revised Code.

(7) "County department of job and family services (CDJFS)" is an entity established under section 329.01 of the Revised Code or a group of such entities acting together under a formal collaborative agreement.

(8) "Documentation" is information recorded in an appropriate medium for the purpose of substantiating an assertion. Information that is not relevant to a situation or does not support a statement about a situation is not documentation.

(9) "Eligible provider" has the same meaning as in Chapter 5160-1 of the Administrative Code.

(10) "Emergency" is a situation that requires immediate response for the provision of medical treatment, particularly a situation in which the sudden onset of a medical condition manifests itself in acute symptoms so severe that the absence of immediate medical attention could reasonably be expected to result in serious harm to an individual's health, significant impairment of a body function, or failure of a body organ or part. An ambulance service may be considered to be of an emergency nature when an individual, at the time of transport, requires health-related assistance including but not limited to the following services:

(a) Immediate medical attention for a serious injury, an acute illness, or the sudden instability of a physical condition;

(b) Prophylactic immobilization (e.g., for a possible fracture); or

(c) Transport to a trauma center.

(11) "Emergency medical technician (EMT)" is an individual who holds a current, valid certificate issued under Chapter 4765. of the Revised Code at one of three levels: EMT-basic, EMT-intermediate, or EMT-paramedic.

(12) "Loaded mileage" is the distance traveled to or from a medicaid-coverable service with a medicaid-eligible individual in the vehicle. Air ambulance mileage is expressed in statute miles.

(13) "Long-term care facility" is either an intermediate care facility for individuals with intellectual disabilities or a nursing facility, both of which are defined in Chapter 5160-3 of the Administrative Code.

(14) "Manual review" is the examination of a claim by an employee of the department for the purpose of determining whether it meets criteria for payment.

(15) "Medicaid-eligible individual" is an individual who meets eligibility requirements of the medicaid program.

(16) "Medicaid-coverable service" is a service or procedure, exclusive of the transportation services specified in this chapter, that either is itself payable under the Ohio medicaid program in accordance with agency 5160 of the Administrative Code or is intrinsically related to a payable service or procedure (e.g., a follow-up visit within a defined period after surgery).

(17) "Mobility-related assistive device" (or "mobility device") is a piece of equipment that is intended primarily to facilitate human locomotion and cannot be classified as a motor vehicle, common carrier, or similar conveyance. For purposes of this chapter, a mobility device is a manual wheelchair, power wheelchair, power-operated vehicle (scooter), or wheelbench (a device, similar in function to a wheelchair, that is used by a person in a recumbent position).

(18) "Non-emergency" is a situation that does not require immediate response for the provision of medical treatment.

(19) "Non-emergency transportation" is transportation for an individual whose medical condition does not require immediate response for the provision of medical treatment.

(20) "Personal assistant" is an individual who accompanies and provides necessary assistance to a medicaid-eligible individual during non-emergency transport that has been arranged through a county department of job and family services.

(21) "Point of transport" is the terminus of a trip, either the place of origin or the destination.

(22) "Signature" is a distinctive mark (usually taking the form of a name) that is made in order to indicate a person's responsibility for a document or other material. A signature may be written in someone's own hand or produced in any other legally valid manner.

(23) "Specialty care transport (SCT)" is interfacility transport of a critically injured or ill individual by ground ambulance and the provision of medically necessary supplies and services at a level beyond the scope of an EMT-paramedic that must be furnished by one or more health professionals in an appropriate specialty area (e.g., emergency or critical care nursing, emergency medicine, respiratory care, cardiovascular care) or by an EMT-paramedic with additional training.

(24) "Transportation provider" is an eligible provider that furnishes wheelchair van or ambulance services and meets the minimum requirements specified or referenced in this chapter. For purposes of this chapter, a vendor under contract with a CDJFS to transport medicaid-eligible individuals is not considered to be a transportation provider.

(25) "Wheelchair van" is a vehicle that meets the definition of "ambulette" set forth in section 4766.01 of the Revised Code, meets the standards and license requirements specified in Chapter 4766. of the Revised Code, and meets standards specified in Chapter 4766-3 of the Administrative Code.

Replaces: 5160-15-01, part of 5160-15-03

Effective: 4/1/2016
Five Year Review (FYR) Dates: 04/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/07/1977, 05/09/1986, 12/01/1989, 05/01/1992 (Emer), 07/31/1992, 07/05/1993, 03/01/2000, 12/27/2001, 10/01/2003, 12/30/2005 (Emer), 03/27/2006

5160-15-02 [Effective until 4/1/2016] Medical transportation services: provider participation and documentation requirements.

(A) General requirements for eligible providers of air ambulance, ambulance and ambulette services.

(1) Verification of compliance

Providers of air ambulance, ambulance and ambulette services who meet the minimum requirements specified in this rule are eligible to participate in the Ohio Medicaid program upon execution of a provider agreement. In determining whether applicant providers meet such requirements, the department will require verification of compliance as identified in each of the following paragraphs of this rule. The required documentation must apply to all air ambulance, ambulance and ambulette vehicles operated by the provider and to all air ambulance, ambulance and ambulette personnel. The department may contact enrolled providers to assure continued compliance with requirements contained in this rule.

(2) Federal, state and local laws and regulations

Providers of air ambulance, ambulance and ambulette services must operate in accordance with all applicable local, state, and federal laws and regulations, including any applicable requirements developed by the Ohio medical transportation board as provided in Chapter 4765. of the Revised Code or applicable requirements developed for transportation in accordance with Chapter 4766. of the Revised Code.

(3) Vehicle and staffing documentation

The following information must be available in the provider's office and provided to the department upon request:

(a) Documentation identifying the total number and type (ambulance, ambulette, fixed wing air ambulance or rotary wing air ambulance) of vehicles operated by the provider;

(b) Documentation that all vehicles meet the standards specified in this rule or Chapter 4766. of the Revised Code where applicable;

(c) A list of equipment carried in the vehicles as required in appendix A of rule 4766-11-02 of the Administrative Code for ambulance or paragraph (C)(1) of this rule for ambulette;

(d) Verification of personnel qualifications as required in paragraph (B)(2) of this rule for ambulance providers and paragraph (C)(3) of this rule for ambulette providers.

(B) Eligible providers of ambulance services

(1) Certification requirements

All providers of ground ambulance services must be certified under and participating in medicare. All Ohio providers of ground ambulance services must be licensed in accordance with Chapter 4766. of the Revised Code and comply with all specifications of Chapter 4766. of the Revised Code, unless the provider is exempt from licensure as specified in section 4766.09 of the Revised Code. Providers in states other than Ohio must be licensed by the state in which they are located.

(2) Driver and attendant qualifications

Providers of ambulance services must maintain on file records verifying that drivers and attendants meet the following requirements on the date of the transportation service:

(a) Each individual who functions primarily as an ambulance driver complies with local, state and federal laws and regulations.

(b) The qualifications of each ambulance driver meets the specifications set forth in Chapters 4765. and 4766. of the Revised Code; and

(c) Each ambulance attendant must have a current emergency medical technician (EMT) certification card issued by the division of emergency medical services (EMS) under the Ohio department of public safety; and

(d) Ambulance attendants employed by out of state providers must have a current EMT certification issued by the appropriate agency in the state in which they are employed; and

(e) The level of EMT certification must be appropriate to the level of service provided (i.e., advanced life support, basic life support, non-emergency).

(f) Effective January, 1 2004, each ambulance driver must provide from the bureau of motor vehicles his/her driving record at the time of application for employment and annually thereafter. The date of the driving record submitted at the time of application must be no more than fourteen calendar days prior to the date of application for employment. Persons having six or more points on their driving record in accordance with section 4507.02 of the Revised Code cannot be an ambulance driver. Providers may use documentation from their commercial insurance carrier as proof the standard in this paragraph has been met.

(C) Eligible providers of ambulette services.

(1) Vehicle requirements.

All ambulette vehicles operated by providers of ambulette services must have at a minimum the following equipment and features:

(a) Each vehicle must be specifically designed to transport one or more patients sitting in wheelchairs and have permanent fasteners to secure the wheelchair to the floor or side of the vehicle to prevent wheelchair movement; and

(b) Each vehicle must have safety restraints in the vehicle for the purpose of restraining the patient in the wheelchair; and

(c) Each vehicle must be equipped with a stable access ramp or hydraulic lift; and

(d) Each vehicle must have provisions for secure storage of removable equipment and passenger property in order to prevent projectile injuries to passengers and driver in the event of an accident; and

(e) Each vehicle must be equipped with, at a minimum, a fire extinguisher and an emergency first-aid kit that is safely secured; and

(f) Each vehicle must be equipped with a communication system capable of two-way communication. Cellular communication is an acceptable means of two-way communication; and

(g) Each vehicle must display the company logo, insignia, or name on both sides and rear of vehicle; and

(h) Each vehicle must have a minimum ceiling to floor height of fifty-six inches.

(2) All providers of ambulette services must comply with the following regulations and provide documentation of compliance to the department upon request:

(a) Each provider must conduct daily inspection and testing of the hydraulic lift or access ramp prior to transporting any wheelchair bound patient; and

(b) Each provider must complete vehicle inspection documentation in the form of a checklist to include at a minimum that the following was performed: the daily inspection and testing of the wheelchair restraints, wheelchair lifts and/or access ramps, the lights, the windshield wipers/washers, the emergency equipment, mirrors, and the brakes; and

(c) Each provider must provide evidence that at least an annual vehicle inspection was completed on each vehicle by the Ohio state highway patrol safety inspection unit, or a certified mechanic, and the vehicle has been determined to be in good working condition.

(3) Driver and attendant qualifications

(a) All drivers and attendants employed by providers of ambulette services must meet the following requirements specified in paragraph (C)(3)(a) of this rule and meet those qualifications on the effective date of this rule and thereafter:

(i) The qualifications of each driver and each attendant must comply with local, state and federal laws and regulations.

(ii) Each driver and each attendant must have a current card issued and signed by a certified trainer as proof of successful completion of the "American Red Cross" (or equivalent certifying organization) basic course in first aid and a CPR certificate or EMT certification. A copy of both sides of the card must be maintained by the provider and provided upon request to the department or their designee. All current employees must provide their current card (not a copy) for inspection upon request to ODJFS or its designee. Providers of ambulette services may keep and produce the current card on behalf of the employee upon request to ODJFS or its designee.

(iii) Each ambulette driver and each attendant must submit himself or herself for criminal background checks in accordance with section 109.572 of the Revised Code. Any applicant or employee who has been convicted of or pleaded guilty to violations cited in divisions (A)(1)(a), (A)(2)(a), (A)(4)(a), and/or (A)(5)(a) of section 109.572 of the Revised Code shall not provide services to medicaid patients unless the exceptions set forth in paragraphs (A) and (B) of rule 3701-13-06 of the Administrative Code apply.

(iv) Each ambulette driver and each attendant must provide a signed statement from a licensed physician declaring that he or she does not have a medical condition, a physical condition, including a vision impairment (not corrected), and a hearing impairment (not corrected), or mental condition which could interfere with safe driving, safe passenger assistance, the provision of emergency treatment activity, or could jeopardize the health or welfare of patients being transported.

(v) Each ambulette driver must undergo testing for alcohol and controlled substances by a laboratory certified for such testing under CLIA and be determined to be drug and alcohol free as specified in the paragraphs below:

(a) Except as provided for in paragraph (C)(3)(b) of this rule, the tests must be performed and the results placed in the employee's file prior to rendering ambulette services;

(b) Repeat drug and alcohol testing must be performed at a minimum whenever the driver has been involved in a motor vehicle accident for which he/she was the driver; and

(c) The drugs to be included in the drug testing are those required in accordance with 49 C.F.R. 382 (dated October 1, 2005).

(vi) Each ambulette driver must provide from the bureau of motor vehicles his/her driving record at the time of application for employment and annually thereafter. The date of the driving record submitted at the time of application must be no more than fourteen calendar days prior to the date of application for employment. Persons having six or more points on their driving record in accordance with section 4507.02 of the Revised Code cannot be an ambulette driver. Providers may use documentation from their commercial insurance carrier as proof the standard in this paragraph has been met.

(vii) Each ambulette driver and each attendant must have completed a passenger assistance training course to include at a minimum the basic characteristics of major disabling conditions affecting ambulation, basic considerations for functional factors, management of wheelchairs, assistance and transfer techniques, environmental considerations, and emergency procedures.

(viii) Each ambulette driver must have a valid driver's license and be eighteen years or older.

(ix) Each ambulette driver and each attendant must have an identification card visible to the patient identifying at a minimum his/her first name and last initial or unique identifier and company affiliation.

(b) A provider may employ an applicant on a temporary provisional basis pending the results of the required information set forth in paragraphs (C)(3)(a)(iii), (C)(3)(a)(iv) and (C)(3)(a)(v) of this rule if the following conditions are met. Providers who are in the process of becoming an enrolled provider cannot hire applicants on a temporary provisional basis.

(i) The length of the temporary provisional period shall be sixty days or the period established by another state government agency or board with the authority under Ohio law to regulate providers of ambulette services, whichever is greater.

(ii) No applicant shall be accepted for permanent employment as an ambulette driver or attendant unless all the requirements of paragraph (C)(3)(a) of this rule have been met.

(iii) A provider may employ an applicant only conditionally prior to obtaining the results of a criminal records check, the results of the drug and alcohol testing and/or the physician's statement for the applicant if the requirements listed in this paragraph are met.

(a) A provider shall not employ an applicant prior to obtaining the completed form(s) and fingerprint impression sheet(s) from the applicant as required in paragraph (F) of rule 3701-13-03 of the Administrative Code. For purposes of this prohibition, the applicant cannot perform or participate in any job related activity pertaining to a position involving the provision of direct care to an older adult that places the applicant in an active pay status.

(b) A provider shall request a criminal records check by submitting the request to BCII, no later than five business days after the individual begins conditional employment.

(c) The sample for the drug and alcohol testing has been obtained and submitted to the laboratory for testing.

(d) Arrangements have been made for the required physical.

(iv) A provider shall terminate the individual's conditional employment as an ambulette driver if:

(a) The results of any part of the records check, are not obtained within sixty days after the date the request is made; or

(b) The results of any part of the records check indicate that the individual has been convicted of or pleaded guilty to any of the offenses listed or described in paragraph (A) of rule 3701-13-05 of the Administrative Code, unless the organization chooses to employ the applicant pursuant to rule 3701-13-06 of the Administrative Code.

(c) The results of the drug and alcohol test do not come back as negative, or have not been received within the sixty days; or

(d) The signed physician statement is not obtained, or does not support that the individual meets the provisions of paragraph (C)(3)(a)(iv) of this rule.

(4) Insurance requirements

All ambulette vehicles operated by providers of ambulette services must have at a minimum the following insurance coverage:

(a) Every provider of ambulette services directed under this chapter must maintain and disclose upon the request of the department adequate evidence of liability insurance coverage, in an amount of not less than five hundred thousand dollars per occurrence and not less than five hundred thousand dollars in the aggregate, for any cause for which the provider would be liable.

(b) In addition to the insurance requirements of paragraph (C)(4)(a) of this rule, every provider shall carry bodily injury and property damage insurance with solvent and responsible insurers licensed to do business in this state for any loss or damage resulting from any occurrence arising out of or caused by the operation or use of any ambulette vehicle. The insurance plan shall insure each vehicle for the sum of not less than one hundred thousand dollars for bodily injury to or death of more than one person in any one accident and for the sum of fifty thousand dollars for damage to property arising from any one accident.

(c) Each policy or contract of insurance issued shall provide for the payment and satisfaction of any financial judgement entered against the provider and any person operating the vehicle and for a thirty-day cancellation notice to ODJFS.

(D) Eligible providers of air ambulance services

(1) Vehicle requirements

Providers of air ambulance services must assure their vehicles are operating in accordance with all applicable state laws for air ambulance.

(2) Providers of air ambulance services must maintain on file, records verifying that the pilot and basic crew meet the following requirements:

(a) A pilot must have a currently effective airman's license issued by the federal aviation administration.

(b) A paramedic must hold a current, valid certificate issued under section 4765.30 of the Revised Code.

(c) A respiratory therapist must hold a current, valid license issued under section 4761.05 of the Revised Code.

(d) A registered nurse must hold a current, valid license in accordance with section 4723.09 of the Revised Code.

(e) A doctor of medicine or doctor of osteopathy must hold a current, valid license in accordance with Chapter 4731-6 of the Administrative Code.

(E) Documentation requirements

(1) Providers of air ambulance, ambulance and ambulette services must maintain records which fully describe the extent of services provided. Services are not eligible for reimbursement if the documentation specified is not obtained prior to billing the department and maintained in accordance with paragraphs (E)(2)(a) to (E)(2)(d) of this rule.

(2) Records which must be maintained include, but are not limited to, the records listed in paragraph (E)(2)(a) to (E)(2)(d) of this rule. All records and documentation required by this rule must be retained in accordance with rules 5101:3-1-17.2 and 5101:3-1-27 of the Administrative Code.

(a) A record or set of records for all transports on that date of service which documents time of scheduled pick up and drop off, full name(s) of attendant(s), full name(s) of patient(s), medicaid patient number, full name of driver, vehicle identification, full name of the medicaid covered service provider which is one of the medicaid covered point(s) of transport, pick-up and drop-off times, complete medicaid covered point(s) of transport addresses, the type of transport provided, and mileage; and

(b) The original "practitioner certification form", completed by the attending practitioner, documenting the medical necessity of the transport, in accordance with this rule; and

(c) Copies of prior authorization forms, when applicable; and

(d) Copies of the pilot's/driver's/attendant's certification or licensure, which must be current at the time of the transport, in accordance with paragraph (D)(2) of this rule for air ambulance, paragraph (B)(2) of this rule for ambulance and paragraph (C)(3) of this rule for ambulette.

(3) Should ODJFS determine that the medical transportation provider was/is not in compliance with all licensure, certification and documentation requirements of this rule and all other provisions in Chapter 5101:3-15 of the Administrative Code on the date of the transportation service and was unable to supply the required documentation upon request, ODJFS will proceed in accordance with the provider agreement termination and denial provisions of rule 5101:3-1-17.6 of the Administrative Code. In addition, the department will seek remuneration for medicaid payments for the services that did not comply with Chapter 5101:3-15 of the Administrative Code.

(4) Practitioner certification form

(a) The attending practitioner, or a hospital discharge planner or a registered nurse acting under the orders of the attending practitioner in accordance with paragraph (E)(4)(b) of this rule, must complete a "Practitioner Certification Form" for all medical transportation services except:

(i) ALS and/or BLS ambulance transportation to a hospital emergency room in an emergency situation; or

(ii) Ambulance or ambulette transfer of a non-ambulatory patient from one hospital to another hospital if the services provided at the second hospital are covered by medicaid

(b) For the purpose of this rule, a registered nurse, with an order from the attending practitioner, may write the practitioner's name on the ordering line of the practitioner certification form, sign his or her own full name and the professional letters "R.N." after the practitioner's name on the signature line and enter the date of signature. The professional letters "R.N." must follow the nurse's last name or;

A hospital discharge planner with a written order from the attending practitioner, may write the practitioner's name on the ordering line of the practitioner certification form, sign his or her own full name on the signature line and enter the date of signature. The discharge planner must be employed by the hospital where the patient is being treated and from which the patient is transported. The discharge planner must be a social worker who is practicing within his or her scope of practice in accordance with Chapter 4757. of the Revised Code.

(c) Medical condition

The practitioner certification form must state the specific medical conditions related to the ambulatory status of the patient which contraindicate transportation by any other means on the date of the transport, and use the correct form which specifies the mode of medical transportation (ambulance or ambulette) the patient will require. The attending practitioner must clearly specify the condition of the patient which renders transport by ambulance or ambulette medically necessary.

(d) The practitioner certification form is required to certify that ambulance and ambulette services are medically necessary. The completed practitioner certification form must be signed and dated no more than one hundred eighty days after the first date of transport. The completed, signed and dated practitioner certification form must be obtained by the transportation provider before billing the department for the transport. The date of signature entered on the practitioner certification form must be the date that the practitioner certification form was actually signed and must be prior to the date of the claim submission

(i) Providers must always obtain the completed, signed and dated practitioner certification form before billing the transport. However, the following documented exceptions will be accepted if the practitioner certification form is not obtained within the one hundred- eighty-day period after the first date of transport.

(a) Patient is pending medicaid eligibility as specified in Chapters 5101:1-38 to 5101:1-40 of the Administrative Code;

(b) No response from patient's insurance after monthly (i.e., every thirty days) attempts to obtain the signed certification form;

(c) No response from practitioner after monthly (i.e., every thirty days) attempts to obtain the signed certification form;

(d) Process of trying to exhaust other insurance coverage is longer than one hundred eighty days;

(e) Documentation of the above reasons for the extension must be made in writing and maintained in the individuals patient's file.

(ii) The practitioner certification form must be maintained on file at the provider's office for a minimum of six years from the date of receipt of payment based upon those records or until any initiated audit or review is completed, whichever occurs later, in accordance with rule 5101:3-1-17.2 of the Administrative Code.

(iii) The practitioner certification form is non-transferrable from one transportation provider to another.

(e) The practitioner certification form is only valid as long as the patient's ambulatory status does not change. If a transportation provider suspects a patient has had a change in their ambulatory status the transportation provider will need to obtain a new form from the attending practitioner.

(f) Practitioner certification for patients who are permanently nonambulatory. The practitioner certification form is required to certify that ambulance and ambulette services are medically necessary. Providers may maintain annual certification for permanently nonambulatory patients. If a patient is determined by the attending practitioner to be permanently nonambulatory, the practitioner certification form documenting the permanently nonambulatory status is valid for three hundred sixty-five days from the date of first transport for ambulance and ambulette transports to all medicaid covered services.

(g) Practitioner certification for patients who are nonambulatory at the time of transport, but are temporarily nonambulatory. The practitioner certification form is required to certify that ambulance and ambulette service are medically necessary. The attending practitioner must certify the estimated length of time that individual is temporarily nonambulatory and transport by ambulance or ambulette would be required. The certification form documenting the temporary nonambulatory status is valid for the estimated length of time as designated by the attending practitioner unless the temporary nonambulatory status length of time exceeds ninety days. If the length of time exceeds ninety days a new certification form must be obtained to certify a new estimated length of time. Transport is certified for those only temporarily nonambulatory for the indicated time period to all medicaid covered services, except for persons certified solely because they are receiving dialysis treatment. These individuals can only be transported from their dialysis treatment as medically indicated.

Replaces: 5101:3-15-02

Effective: 03/27/2006
R.C. 119.032 review dates: 03/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 12/3/81, 8/15/82, 5/9/86, 12/1/90, 5/1/92 (Emer), 8/13/92, 7/5/93, 1/1/94, 4/1/94, 10/1/97, 3/1/00, 12/31/01, 10/1/03, 12/30/05 (Emer)

5160-15-02 [Rescinded effective 4/1/2016] Medical transportation services: provider participation and documentation requirements.

Effective: 4/1/2016
Five Year Review (FYR) Dates: 10/23/2015
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02, 5164.70
Prior Effective Dates: 04/07/1977, 12/21/1977, 12/30/1977, 12/03/1981, 08/15/1982, 05/09/1986, 12/01/1990, 05/01/1992 (Emer), 08/13/1992, 07/05/1993, 01/01/1994, 04/01/1994, 10/01/1997, 03/01/2000, 12/31/2001, 10/01/2003, 12/30/2005 (Emer), 03/27/2006

5160-15-02.8 [Effective until 4/1/2016] Medical transportation services: eligible providers.

(A) The following is in effect for providers who are enrolled after the effective date of this rule.

(1) Upon the completion of a signed medicaid provider agreement, any business or entity organized for the purpose of providing ground ambulance services may be enrolled as an ambulance provider and provide ground ambulance services under the Ohio medicaid program if the business or entity meets all of the requirements for participation set forth in paragraphs (A) and (B) of rule 5160-15-02 of the Administrative Code and has at least one ambulance vehicle.

(2) Upon the completion of a signed medicaid provider agreement, any business organized for the purpose of providing ambulette services may be enrolled as an ambulette provider and provide ambulette services under the Ohio medicaid program if the business or entity meets all the requirements for participation set forth in paragraphs (A) and (C) of rule 5160-15-02 of the Administrative Code and has at least one ambulette vehicle.

Ambulance providers may also be eligible providers of ambulette services and provide ambulette services under the Ohio medicaid program if they meet all the requirements for participation set forth in paragraphs (A), (B) and (C) of rule 5160-15-02 of the Administrative Code and have at least one ambulette vehicle.

(3) Upon the completion of a signed medicaid provider agreement, any business organized for the purpose of providing air ambulance services may be enrolled as an ambulance provider and provide air ambulance services under the Ohio medicaid program if the business or entity meets all the requirements for participation set forth in paragraphs (A) and (D) of rule 5160-15-02 of the Administrative Code and has at least one air ambulance vehicle.

(B) Effective on January 1, 2006, providers with a current valid provider agreement (i.e., enrolled prior to the effective date of this rule) must comply with paragraphs (A)(1) to (A)(3) of this rule. Prior to January 1, 2006, providers with a current valid provider agreement (i.e., enrolled prior to the effective date of this rule) must comply with paragraphs (A)(1) to (A)(3) of this rule except for the provision in paragraph (A)(1) of this rule to have at least one ambulance vehicle, for the provisions in paragraph (A)(2) of this rule to have at least one ambulette vehicle and for the provision in paragraph (A)(3) of this rule to have at least one air ambulance vehicle.

Effective: 12/31/2013
R.C. 119.032 review dates: 10/15/2013 and 12/31/2018
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02, 5165.01, 5165.47
Prior Effective Dates: 10/01/2003, 12/30/2005 (Emer), 03/27/2006, 07/31/2009 (Emer), 10/29/2009

5160-15-02.8 [Rescinded effective 4/1/2016] Medical transportation services: eligible providers.

Effective: 4/1/2016
Five Year Review (FYR) Dates: 10/23/2015
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02, 5164.70
Prior Effective Dates: 10/01/2003, 12/30/2005 (Emer), 03/27/2006, 07/31/2009 (Emer), 10/29/2009, 12/31/2013

5160-15-03 [Effective until 4/1/2016] Medical transportation: covered services and limitations.

(A) Land ambulance

(1) Covered land ambulance services

The following land ambulance services are covered if they meet the criteria for coverage as specified in paragraph (A)(2) of this rule.

(a) "Basic life support, emergency (BLS-emergency)" is the transport of one patient, or the first patient of a multi-passenger transport, who needs on an emergency basis the provision of basic life support services (BLS services) as defined in paragraph (A)(8) of rule 5101:3-15-01 of the Administrative Code.

(b) "Basic life support, non-emergency (BLS-non-emergency)" is the transport of one patient, or the first patient of a multiple passenger transport, who needs on a non-emergency basis the provision of basic life support services (BLS services) as defined in paragraph (A)(8) of rule 5101:3-15-01 of the Administrative Code.

(c) "Advanced life support services, level 1; emergency (ALS1-emergency)" is the transport of one patient, or the first patient of a multiple passenger transport, who needs an assessment by a crew member who is trained to the level of the EMT-intermediate or a paramedic and/or needs one or more advanced life support (ALS) services as defined in paragraph (A)(1) of rule 5101:3-15-01 of the Administrative Code.

(d) "Advanced life support services, level 1; non-emergency (ALS1-non-emergency)" is the transport of one patient who needs on a non-emergency basis an assessment by a crew member who is trained to the level of the EMT-intermediate or a paramedic and/or who needs advanced life support services as defined in paragraph (A)(1) of rule 5101:3-15-01 of the Administrative Code.

(e) "Advanced life support, level 2 (ALS2)" is the transport of one patient, or the first patient of a multiple passenger transport, who needs the provision at least three different medications and/or the provision of (or attempt of the provision) one or more of the following ALS procedures: Manual defibrillation/cardioversion, endotracheal intubation, central venous line, cardiac pacing, chest decompression, surgical airway or intraosseous line.

(f) "Specialty Care Transport (SCT)" is the transport of one patient, or the first patient of a multiple patient transport, who requires ongoing care that must be provided by one or more health professionals who are qualified to provide services which are beyond the scope of the paramedic.

(g) "Attendant services" are the services provided during a covered ambulance service by an attendant as defined in paragraph (A)(5) of rule 5101:3-15-01 of the Administrative Code.

(h) "Non-emergency ambulance, second passenger" is the transport of the second passenger of a multiple passenger transport and the level of the transport is non-emergency BLS or ALS.

(i) "Non-emergency ambulance, three or more passengers" is the transport of each passenger over two (i.e., the third passenger, fourth passenger, etc.) and the level of transport is non-emergency BLS or ALS.

(j) "Basic life support (BLS), emergency, second passenger" is the transport of the second passenger of a multiple passenger transport and the level of the transport is emergency BLS.

(k) "Basic life support (BLS), emergency, three or more passengers" is the transport of each passenger over two (i.e., the third passenger, fourth passenger, etc.) during a multiple passenger transport and the level of transport is emergency BLS.

(l) "Advance life support (ALS), emergency, second passenger" is the transport of the second passenger of a multiple passenger transport and the level of transport is emergency ALS1, or ALS2, or SCT.

(m) "Advanced life support (ALS), three or more passengers" is the transport of each passenger over two (i.e., the third passenger, fourth, etc.) during a multiple passenger transport and the level of transport is emergency ALS1, or ALS2 or SCT.

(2) Criteria for coverage

The criteria listed in this paragraph must be met for a land ambulance service to be covered.

(a) The land ambulance service must be medically necessary as specified in this paragraph.

(i) The patient's condition at the time of the transport is the determining factor in whether medical necessity is met, or not.

(ii) For emergency transports, ambulance services are determined to be medically necessary when one or more of the following apply: the individual needs immediate medical attention as a result of accident, injury or acute illness; the individual needs to be restrained; the individual is unconscious or in shock; the individual requires oxygen or other emergency treatment en route; the individual has to remain immobile due to untreated fracture or potential fracture; or the individual, for other reasons, must be moved only by stretcher or meet the requirements for transport to a trauma center in accordance with section 4765.4 of the Revised Code and the situation meets the definition of emergency service in accordance with paragraph (A)(12) of rule 5101:3-15-01 of the Administrative Code.

(iii) For non-emergency transports, ambulance services are medically necessary when the patient needs either prescheduled transportation or unscheduled transportation for which an immediate response is not required; and the patient's medical condition meets one of the descriptions in paragraphs (A)(2)(a)(iii)(a) to (A)(2)(a)(iii)(c) of this rule.

(a) An individual is nonambulatory and unable to use an ambulette because the individual is unable to get up from bed without assistance; the patient is unable to sit in a chair or wheelchair; and can only be moved only by a stretcher and/or needs to be restrained; or

(b) An individual is not in a life-threatening situation, but requires continuous medical supervision or treatment during the transport; or

(c) An individual does not meet the criteria in paragraph (A)(2)(a)(iii)(a) or paragraph (A)(2)(a)(iii)(b) of this rule, but requires oxygen administration during the transport, and the patient is unable to self-administer or self-regulate the oxygen or the patient requiring oxygen administration has been discharged from a hospital to a nursing facility.

(b) The vehicle used for the transport must be an ambulance as defined in paragraph (A)(3) of rule 5101:3-15-01 of the Administrative Code.

(c) The transport must be either transportation to a medicaid covered service or transportation from a medicaid covered service. "Medicaid covered service" is defined in paragraph (A)(17) of rule 5101:3-15-01 of the Administrative Code.

(d) The transport must provide transportation from a medicaid covered point of transport as listed in paragraph (D) of this rule. Point of transport not listed as covered in paragraph (D) of this rule may be covered on a case-by-case basis through the prior authorization process set forth in paragraph (F) of this rule.

(e) The transport must be staffed with the appropriate basic crew members corresponding to the level of service billed.

(i) The basic crew for a basic life support ambulance is defined as at least two emergency medical technicians (EMTs) as described in section 4765.43 of the Revised Code and the driver if the driver is not one of the two emergency medical technicians.

(ii) The basic crew for an advanced life support ambulance is defined as at least two emergency medical technicians as described in section 4765.43 of the Revised Code and the driver if the driver is not one of the two emergency medical technicians.

(iii) The basic crew for specialty care transport must be in accordance with Chapters 4765. and 4766. of the Revised Code.

(f) For services defined as emergency in the descriptor, the transport must be provided after an accident, injury or the sudden onset of a medical condition which manifests itself by acute symptoms of sufficient severity that in the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

(g) Ambulance services that do not meet the criteria for an emergency transport as described in paragraph (A)(2)(f) of this rule are covered only as a non-emergency transport.

(h) For attendant services, the use of additional attendant(s) must be related to extraordinary circumstances which would require the services of staff members in addition to the basic crew (e.g., existence of unusual structural barriers such as tight, angled hallways or excessive number of steps; unusual patient obesity; and/or necessity of special medical treatment in route to destination).

(i) Documentation supporting the need and use of the additional attendants(s) must be maintained by the provider.

(ii) Since medical facilities, especially hospitals, traditionally have access ramps and personnel to assist in maneuvering stretchers or wheelchairs, providers must make use of such existing resources without charging for additional attendant(s).

(i) Under the medicaid program services to individuals who are deceased are not covered. Therefore, the time of the pronouncement of death affects the coverage of ambulance services as described below:

(i) If the patient was pronounced dead by an individual who is licensed to pronounce death under Ohio law prior to the time that the ambulance is called, the ambulance service is not covered.

(ii) If the patient is pronounced dead after the ambulance is called but before the ambulance arrives at the scene, a BLS-emergency service is covered but compensation for loaded mileage is not covered.

(iii) If the patient is pronounced dead after being loaded into the ambulance, the ambulance transport is covered and reimbursed as if the death of the patient had not occurred.

(j) Ambulance services to all eligible medicare patient are to be billed to medicare. If the patient has medicare coverage, the department will reimburse only part-B co-insurance and deductible amounts.

(B) Ambulette services coverage and limitations

(1) Covered ambulette services

The following ambulette services are covered if the criteria for coverage is met in accordance with paragraph (B)(2) of this rule.

(a) "Ambulette services" is the transport of one individual, or the first passenger of a multiple passenger transport in an ambulette.

(b) "Ambulette services, second passenger" is the transport of the second passenger of a multiple passenger transport in an ambulette.

(c) "Ambulette services, three or more passengers" is the transport of each passage over two (i.e., the third passenger, fourth, etc.) during a multiple passenger transport in a ambulette

(d) "Attendant services" are the services provided during a covered medical transportation services by an attendant as defined in paragraph (A)(5) of rule 5101:3-15-01 of the Administrative Code.

(2) Covered ambulette transports

Except as provided elsewhere in this chapter, ambulette services are covered only when all the requirements in this paragraph are met.

(a) The ambulette services must be medically necessary as specified below:

(i) The individual has been determined and certified by the attending practitioner to be nonambulatory at the time of transport as defined in paragraph (A)(20) of rule 5101:3-15-01 of the Administrative Code; and

(ii) The attending practitioner has certified that the individual does not require ambulance services; the individual does not use passenger vehicles as defined in paragraph (A)(20) of rule 5101:3-15-01 of the Administrative Code as transport to non-medicaid services.; and the individual is physically able to be safely transported in a wheelchair.

(b) The vehicle used for the transport must be an ambulette as defined in paragraph (A)(4) of rule 5101:3-15-01 of the Administrative Code.

(c) The transport must be either transportation to a medicaid covered service or transportation from a medicaid covered service as defined in paragraph (A)(17) of rule 5101:3-15-01 of the Administrative Code.

(d) The transport must be transportation from a medicaid covered point of transport in accordance with paragraph (D) of this rule. Point of transport modifiers not listed as covered in paragraph (D) of this rule may be covered if prior authorized in accordance with paragraph (F) of this rule.

(e) The individual must actually be transported in a wheel chair.

(f) The basic crew for ambulette services includes only the driver. For attendant services to be covered, the use of an additional attendant can be covered and reimbursed only when the safe transportation of the patient requires additional handling, such as due to unusual patient obesity, or the need to negotiate a minimal number of accessible steps. Documentation supporting the need and use of the additional attendant(s) must be maintained by the provider. Providers must make use of existing medical facility resources (access ramps and personnel) without charging for an additional attendant. When the patient needs anticipated medical treatment or attention during the transport, the transport is not reimbursable as an ambulette service.

(C) Covered air ambulance transports

(1) Two types of air ambulance services are covered:

(a) "Fixed wing air ambulance (FWAIR)" is the transport of a patient in a fixed wing (i.e., airplane) air ambulance.

(b) "Rotary wing air ambulance (RWAIR)" is the transport of a patient in a rotary wing (i.e., helicopter) air ambulance.

(2) The criteria as detailed in this paragraph must be met for an air ambulance service to be covered:

(a) The medical condition of the patient at the time of the transport is such that transport by land ambulance is contraindicated and at least one of the following apply:

(i) The patient's medical condition meets the medical necessity requirements for land ambulance transport in accordance with paragraph (A)(2)(a) of this rule but the point of pick up is inaccessible by land ambulance;

(ii) The patient's medical condition meets the criteria for coverage of an emergency land ambulance service requiring the provision of advanced life support services and the time needed to transport the patient by land is a threat to the survival or seriously endangers the patient's health.

(a) The department will generally assume that air ambulance is necessary for emergency transports when the patient is critically ill or critically injured (e.g., multiple trauma, massive bleeding, severe burns, etc.) and it will take greater than thirty minutes to transport the patient by land ambulance to the nearest appropriate facility due to the distance by land or other obstacles (e.g., heavy traffic, or road blockage).

(b) The department will recognize that the medical necessity of air ambulance transport could also be established when the transport of a critically ill or critically injured patient by land ambulance would take less than thirty minutes if it is documented that the time saved by air transport significantly increased the patient's chances of survival and/or reduce the risk of further injury or bodily impairment; or

(iii) The patient's medical condition met the criteria for the coverage of non-emergency scheduled or unscheduled land ambulance; it is documented that the transport by land ambulance would endanger the health of the patient; and one of the situations in paragraphs (C)(2)(a)(iii)(a) and (C)(2)(a)(iii)(b) of this rule apply:

(a) The patient needed to be transferred from one acute care hospital to another acute care hospital because the hospital does not have adequate medical services needed by the patient (e.g., does not have burn units, cardiac units, and trauma units) and/or the physician specialty services needed (e.g., neurosurgeon); or

(b) The patient was not a hospital inpatient but has been approved by the department to receive services at an acute care hospital outside of Ohio or outside any of the states which are contiguous to Ohio; the hospitals in the aforementioned geographical area do not provide the medical specialty services needed by the patient; and the nearest appropriate facility is more than one hundred-eighty miles away from the patient's place of residence.

(b) The following air ambulance vehicle and staffing requirements must be met:

(i) The air ambulance is designed and equipped to respond to medical emergencies and in non-emergency situations able to provide the continual and expected care specific to the medical condition of the patient being transported;

(ii) The vehicle must comply with state and local laws governing licensing and certification of an emergency medical transportation vehicle and must contain at a minimum a stretcher, linens, emergency medical supplies, oxygen equipment, and be equipped with telecommunications equipment; and

(iii) The basic crew must include:

(a) A registered nurse; and

(b) One of the following health professionals: paramedic, respiratory therapist, doctor of medicine, doctor of osteopathy, advanced practice nurse or registered nurse. The health professional selected must be appropriate for the medical condition of the patient. The health professional must have any specialty care training appropriate to provide the medical care needed during the transport; and

(c) A pilot.

(c) The air ambulance service must be for transportation to a medicaid covered service or from a medicaid covered service as defined in paragraph (A)(17) of rule 5101:3-15-01 of the Administrative Code.

(d) The transport must be transportation from a medicaid covered point of transport as listed in paragraph (D) of this rule. Point of transport not listed as covered in paragraph (D) of this rule may be covered if prior authorized in accordance with paragraph (F) of this rule.

(e) Air ambulance services provided to all eligible medicare patients are to be billed to medicare. If a patient has medicare coverage, the department will reimburse part-A or part-B co-insurance and deductible amounts.

(f) The provisions of the pronouncement of death as specified in paragraph (A)(2)(i)(i) of this rule apply to air ambulance services except for paragraph (A)(2)(i)(ii) of this rule. Instead, if the patient is pronounced dead after the ambulance is called but before the ambulance arrives at the scene, a fixed wing air ambulance or rotary wing air ambulance service is covered but compensation for loaded mileage is not covered.

(D) Modifiers for the point of transport are required for all covered service codes as described in this rule.

(1) Modifiers for the point of transport is a two-position modifier that is constructed from the following values. The first position alphabetic value is used to report the origin or "from" of service. The second position alphabetic value is used for the destination or "to" of service.

(a) "D" is a diagnostic or therapeutic site other than P or H. Examples of this value would include but is not limited to alcohol and drug rehabilitation centers, independent laboratories, ambulatory surgical centers, oncology treatment centers, medical equipment supplier or any other medicaid provider entities not otherwise listed.

(b) "E" is a residential, domicilary, custodial facility (e.g. nursing home-not skilled nursing facility). Examples of this value would include but is not limited to nursing facilities or ICF-MR facilities.

(c) "G" is a hospital-based dialysis facility (hospital or hospital-related).

(d) "H" is a hospital. Examples of this value would include but is not limited to general, mental or TB hospital.

(e) "I" is a site of transfer. Examples of this value would include but is not limited to airport strips or helicopter pads.

(f) "J" is a non-hospital based dialysis facility

(g) "N" is a skilled nursing facility (SNF)

(h) "P" is a physician's office (includes HMO non-hospital facility, clinic, etc.) Examples of this value would include but is not limited to an individual or group: physician, osteopath, other health practitioners such as advanced practice nurses, chiropractors, optometrist, optician, podiatrist, physical therapist, psychologist, dentist. Other examples would include outpatient health facilities, rural health facilities, federally qualified health centers, public health center, or medical equipment supplier.

(i) "R" is a residence. Examples of this value would include but is not limited to any place where the patient permanently or temporarily resides other than a long term care facility.

(j) "S" is the scene of an accident or acute event.

(2) Instead of the two position point of transport modifiers identified in paragraph (D)(1) of this rule, "U4", medicaid level of care 4, origin school or work, and "U7", medicaid level of care 7, destination school or work, are used whenever the origin or destination, respectively, of a medicaid covered point of transport is school or work.

(3) The medicaid covered point of transport modifiers for non-emergency ground ambulance and ambulette services are DD, DE, DG, DH, DI, DJ, DN, DP, DR, ED, EE, EG, EH, EI, EJ, EN, EP, ER, GD, GE, GH, GI, GN, GP, GR, HD, HE, HH, HI, HJ, HN, HP, HR, ID, IE, IG, IH, II, IJ, IN, IP, IR, JD, JE, JH, JI, JJ, JN, JP, JR, ND, NE, NG, NH, NI, NJ, NN, NP, NR, PD, PE, PG, PH, PI, PJ, PN, PP, PR, RD, RE, RG, RH, RI, RJ, RN, and RP.

(4) The medicaid covered point of transport modifiers for emergency ground ambulance services are DH, DI, EH, EI, GH, GI, HH, HI, IH, II, JH, JI, NH, NI, PH, PI, RH, RI, SH, SI, and U4.

(5) The medicaid covered point of transport modifier for air ambulance fixed wing is II. The medicaid covered point of transport modifiers for air ambulance, rotary wing is DH, EH, GH, HH, IH, JH, NH, PH, RH, SH, DI, EI, GI, HI, II,JI, NI, PI, RI, SI, HE, HN, IE, and IN.

(6) Providers of medical transportation services may request that the department cover point of transport modifiers listed in paragraph (D)(1) or (D)(2) of this rule but not listed as covered in paragraph (D)(3), (D)(4) or (D)(5) of this rule. Providers may request special consideration in extraordinary circumstances by submitting their request to the prior authorization unit as specified in paragraph (F) of this rule. The appropriate point of transfer modifier constructed from paragraph (D)(1) of this rule would be used when billing.

Providers of medical transportation service may request the department cover additional point(s) of transport that are not listed in paragraph (D)(1) or (D)(2) of this rule by submitting their request to the prior authorization unit as specified in paragraph (F) of this rule. For those point(s) of transport the modifier "U5", medicaid level of care 5, origin/destination is not otherwise specified, is used.

(E) Service limitations

The following services are not covered:

(1) Unloaded transports (i.e., no medicaid patient in the vehicle);

(2) Services which are available to the general public without charge;

(3) Excessive mileage charges, resulting from the use of indirect routes;

(4) Non-emergency ambulance and ambulette services for transport of long-term care facility residents in order to receive services which are reimbursable to the long-term care facility; e.g., therapy services as defined in rule 5101:3-3-47.1 of the Administrative Code, are the responsibility of the facility and are not separately reimbursable to the transportation provider.

(5) Medical transportation providers cannot bill for the services of hospital staff as attendants during transportation. Services provided by hospital staff are covered and reimbursed as an inpatient or outpatient hospital services Services related to the use and operation of the transport vehicle, including standard equipment and driver, are reimbursed as an ambulance or ambulette service. The provisions of this paragraph apply to ambulance and ambulette services provided to or from the hospital, including interhospital air ambulance, ambulance or ambulette services.

(6) Transportation of passenger(s) accompanying the patient who requires the medical transportation services;

(7) Services available to the patient through county contract or the non-emergency transportation (NET) program as specified in Chapter 5101:3-24 of the Administrative Code;

(8) Transport of a patient who is ambulatory at the time of the transport unless the patient meets criteria in paragraph (A)(2) of this rule;

(9) Transportation of a patient for purposes other than for the receipt of medicaid covered services;

(10) Mileage and extra attendant charges for additional passengers;

(11) Transportation to outpatient services provided in psychiatric hospitals;

(12) Transport to a certified habilitation center that has been billed to the department.

(13) Transport to services that are covered by any HCBS waivers specified in division-level 5101:3 of the Administrative Code.

(14) Transport to services that are needed in order for the individual to receive medical care related to the terminal illness which are covered through the hospice services program as defined in Chapter 5101:3-56 of the Administrative Code;

(15) Transportation services for individuals who are not medicaid eligible at the time of transport.

(F) Prior authorization

(1) Prior authorization is required for the point of transport modifiers of medical transportation services as described in paragraph (D)(6) of this rule.

(2) All requests must be in writing. Approval of a prior authorization request confirms that the patient is in need of the medical transportation service and that the transportation service will be covered by the medicaid program if the patient is eligible on the date(s) of service.

(3) All requests for prior authorization of medical transportation services must include:

(a) A complete JFS 03142 "Prior Authorization Request Form" (rev. February 2003); and

(b) A complete description of the service requested, date(s) to be rendered, pick-up and destination points, special services involved and explanation of the need for any additional attendant(s); and

(c) A complete JFS 01960 "Ambulance Certification of Medical Necessity Form" (rev. July 2003) and JFS 03452 "Ambulette Certification of Medical Necessity Form" (rev. July 2003) establishing medical necessity as detailed in rule 5101:3-15-02 of the Administrative Code. .

(d) Details of any related special circumstances which should be considered in the review of the request for prior authorization.

(G) Transportation of Ohio medicaid patients to treatment facilities outside of Ohio.

If the patient is transported by a provider located in a state other than Ohio, the transportation provider may be reimbursed for the transport if the provider is an Ohio medicaid provider. If the provider is not an Ohio Medicaid provider at the time of transport, the provider may apply to become an Ohio medicaid provider. If approved for medicaid provider status in Ohio, the provider may submit a claim for the transport of the Ohio medicaid patient in accordance with rule 5101:3-1-19.3 of the Administrative Code.

Out-of-state destinations are approved for states contiguous to Ohio for ambulette or ground ambulance services as long as the conditions for coverage are met. Out-of-state destinations are approved to any state for the air ambulance as long as the conditions for coverage are met in accordance with rule 5101:3-15-03 of the Administrative Code.

(H) Medical transportation providers, when providing a non-emergency ground ambulance, or ambulette service must document the reason for transport when the destination occurs outside of the patient's community, (a fifty mile radius from the patient's residence). Mileage greater than fifty miles will not be covered if the provider is unable to produce the documentation which gives the reason for the transport to be out of the patient's community.

(I) Transportation to and from psychiatric hospitals

(1) Covered transportation services include the ambulance or ambulette transport of medicaid patients to and from public and private psychiatric hospitals for inpatient psychiatric hospital services only when the patient is age twenty-one and younger, or sixty-five and older, and the inpatient psychiatric services are eligible for reimbursement by medicaid in accordance the Chapter 5101:3-2 of the Administrative Code.

(2) Psychiatric hospital is defined as a hospital that is eligible to participate in the medicaid program only for the provision of inpatient psychiatric services.

(J) Critical care services provided by a physician or advanced nurse practitioner which are medically necessary are reimbursable services when provided and billed in accordance with rule 5101:3-4-06 or 5101:3-54-06.1 of the Administrative Code

(K) Medical transportation services cannot be billed to the department for medicaid patients enrolled in medicaid health maintenance organizations (HMOs) or medicaid managed care plans (MCPs) because transportation coverage is the responsibility of the HMO or MCP in which the patient is enrolled.

(L) Transport of an individual to a medicaid covered service that was cancelled or unavailable may be reimbursed if:

(1) The transport was provided in accordance with all other requirements of this chapter.

(2) The transportation provider had no prior notice of the unavailability or cancellation from the medicaid covered service provider or the individual.

(3) The medical transportation provider obtained written documentation, which can be handwritten, from the medicaid covered service provider before billing the department for transport. The written documentation must include:

(a) A business name, address, and phone number of the medicaid covered service provider,

(b) The date and time of the cancelled or unavailable service,

(c) A description of the reason(s) for the cancellation or unavailability of the service,

(d) A statement indicating that the medicaid covered service provider was unable to notify the medicaid transportation provider or the individual of the cancellation or unavailability of the service prior to the arrival at the destination, and

(e) The printed name and signature of the business/office manager or nurse.

(4) For reimbursement, the medical transportation provider must use modifier U6, service unavailable/cancelled; for both the base rate and loaded mileage procedure codes

(5) The reason for the cancellation or unavailability of the service did not occurs due to the action or inaction of the individual being transported or the medical transportation provider.

Replaces: 5101:3-15-03

Effective: 03/27/2006
R.C. 119.032 review dates: 03/01/2011
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02
Prior Effective Dates: 4/7/77, 5/9/86, 7/5/93, 3/01/00, 12/27/01, 10/1/03, 12/30/05 (Emer)

5160-15-03 [Rescinded effective 4/1/2016] Medical transportation: covered services and limitations.

Effective: 4/1/2016
Five Year Review (FYR) Dates: 10/23/2015
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02, 5164.70
Prior Effective Dates: 04/07/1977, 05/09/1986, 07/05/1993, 03/01/2000, 12/27/2001, 10/01/2003, 12/30/2005 (Emer), 03/27/2006

5160-15-04 [Effective until 4/1/2016] Medical transportation services: reimbursement.

Transportation services provided by land ambulance, by air ambulance, or by ambulette and covered in accordance with rule 5101:3-15-03 of the Administrative Code are reimbursed as set forth in this rule.

(A) For the one-way transport of one passenger, or the first passenger of a multiple-passenger trip, the provider is reimbursed a base amount for the service and a loaded mileage amount for each mile the passenger was transported.

(1) The base amount is the lesser of either the provider's billed charge or the medicaid maximum listed in appendix DD to rule 5101:3-1-60 of the Administrative Code.

(2) The loaded mileage amount is the lesser of either the provider's billed charge or the medicaid maximum listed in appendix DD to rule 5101:3-1-60 of the Administrative Code.

(B) For the one-way transport of each additional passenger of a multiple-passenger trip, the provider is reimbursed a base amount for the service.

(1) The base amount is the lesser of either the provider's billed charge or a fixed portion of the medicaid maximum listed in appendix DD to rule 5101:3-1-60 of the Administrative Code.

(a) For transport by land ambulance or by ambulette, the fixed portion for the second passenger is fifty per cent, and the fixed portion for each additional passenger thereafter is twenty-five per cent.

(b) For transport by air ambulance, the fixed portion for the second passenger and for each additional passenger thereafter is one hundred per cent.

(2) No reimbursement is made for loaded mileage.

(C) For attendant services provided in conjunction with transport by land ambulance or by ambulette, the provider is reimbursed the lesser of either the provider's billed charge or the medicaid maximum listed in appendix DD to rule 5101:3-1-60 of the Administrative Code.

(D) In billing for services, the provider must specify certain information:

(1) The most appropriate code for the base service and, where applicable, for the loaded mileage;

(2) The origin and destination of transport, where applicable;

(3) For a multi-passenger trip, whether the service was provided to the first passenger or to an additional passenger; and

(4) Any other factor necessary for the correct adjudication or payment of the claim.

Replaces: 5101:3-15-04

Effective: 07/01/2008
R.C. 119.032 review dates: 07/01/2013
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021
Prior Effective Dates: 08/15/1982, 06/03/1983, 04/29/1986, 01/13/1989 (Emer), 04/13/1989, 12/01/1990, 04/01/1994, 10/01/1997, 01/01/2000, 12/27/2001, 10/01/2003, 12/30/2005 (Emer), 03/27/2006

5160-15-04 [Rescinded effective 4/1/2016] Medical transportation services: reimbursement.

Effective: 4/1/2016
Five Year Review (FYR) Dates: 10/23/2015
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02, 5164.70
Prior Effective Dates: 08/15/1982, 06/03/1983, 04/29/1986, 01/13/1989 (Emer), 04/13/1989, 12/01/1990, 04/01/1994, 10/01/1997, 01/01/2000, 12/27/2001, 10/01/2003, 12/30/2005 (Emer), 03/27/2006, 07/01/2008

5160-15-05 [Effective until 4/1/2016] Medical transportation services: ambulette services provided by ground ambulance vehicles.

(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).

Effective: 01/01/2006
R.C. 119.032 review dates: 10/01/2008
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02
Prior Effective Dates: 10/1/03

5160-15-05 [Rescinded effective 4/1/2016] Medical transportation services: ambulette services provided by ground ambulance vehicles.

Effective: 4/1/2016
Five Year Review (FYR) Dates: 10/23/2015
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5162.03, 5164.02, 5164.70
Prior Effective Dates: 10/01/2003, 01/01/2006

5160-15-11 [Effective 4/1/2016] Transportation: non-emergency services through a CDJFS: general provisions.

(A) Each county department of job and family services (CDJFS) has the responsibility of ensuring necessary transportation of medicaid-eligible individuals for the purpose of obtaining medicaid-coverable services. This responsibility was previously carried out under the rubric "Enhanced Medicaid Transportation (EMT)" or "Non-Emergency Transportation (NET)."

(B) For each medicaid-eligible individual to whom transportation assistance is provided, the CDJFS must select the most cost-effective type of assistance that is appropriate to the individual's circumstances and enables the individual to access medicaid-coverable services in a timely manner.

(C) Whenever possible, medicaid-coverable services to or from which medicaid-eligible individuals travel should be accessed within the community specified by the CDJFS in accordance with rule 5160-15-13 of the Administrative Code. If it is appropriate for a medicaid-eligible individual to travel outside the community in order to obtain a medicaid-coverable service, then the CDJFS must ensure necessary transportation. If a medicaid-coverable service can be obtained at several locations, then the CDJFS may choose to provide assistance sufficient to enable travel only to or from the nearest location, unless a consideration other than distance (e.g., continuity of care, relative cost) overrides such a limitation.

(D) A CDJFS must provide a notice of state hearing rights, in accordance with Chapter 5101:6-2 of the Administrative Code, whenever it proposes to withhold, reduce, suspend, or terminate non-emergency transportation assistance or whenever a medicaid-eligible individual formally expresses disagreement with an action or lack of action taken by the CDJFS on a request for non-emergency transportation assistance.

(E) Documentation related to requests for transportation assistance provided by a CDJFS must be retained and disposed of in accordance with Chapter 5101:9-9 of the Administrative Code.

(F) In implementing the provisions of this chapter, each CDJFS must comply with all nondiscrimination requirements set forth in Chapter 5101:9-2 of the Administrative Code.

Replaces: Part of 5160-24-01, part of 5160-24-02, part of 5160-24-03

Effective: 4/1/2016
Five Year Review (FYR) Dates: 04/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 05/05/1988 (Emer), 08/06/1988, 01/01/1989, 12/31/1990, 08/26/2000, 01/01/2004, 01/01/2006, 01/01/2008

5160-15-12 [Effective 4/1/2016] Transportation: non-emergency services through a CDJFS: requirements and limitations.

(A) The county department of job and family services (CDJFS) must not provide transportation assistance if a medicaid-eligible individual qualifies for either of the following types of service:

(1) Transportation of a long-term care facility resident for which a per diem payment is made to the facility in accordance with Chapter 5160-3 of the Administrative Code; or

(2) Transportation provided or arranged for by a hospice in accordance with Chapter 5160-56 of the Administrative Code that is necessary for a medicaid-eligible individual to receive care related to a terminal illness.

(B) The CDJFS must provide transportation assistance if three conditions apply:

(1) Without such assistance, the medicaid-eligible individual will not be able to obtain a medicaid-coverable service (e.g., will not be able to keep an appointment with a medical practitioner);

(2) The medicaid-eligible individual either cannot use or has chosen not to use the following services:

(a) Transportation that a managed care plan (MCP) offers as an additional benefit but is not obligated to furnish under its provider agreement with the department; or

(b) Transportation that a federally qualified health center (FQHC) furnishes in accordance with Chapter 5160-28 of the Administrative Code; and

(3) No suitable transportation is readily available through a community source, either public or private, without charge to the medicaid-eligible individual.

(C) Parents and guardians are considered to be a community source of transportation for their children.

(D) Instead of using transportation assistance provided by a CDJFS, a medicaid-eligible individual who is not enrolled in an MCP may choose instead to access wheelchair van services furnished by an eligible provider on a fee-for-service basis, but is not required to do so, if the criteria specified in rule 5160-15-22 of the Administrative Code are met.

Replaces: Part of 5160-24-01, part of 5160-24-03

Effective: 4/1/2016
Five Year Review (FYR) Dates: 04/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 05/05/1988 (Emer), 08/06/1988, 01/01/1989, 12/31/1990, 08/26/2000, 01/01/2004, 01/01/2006, 01/01/2008

5160-15-13 [Effective 4/1/2016] Transportation: non-emergency services through a CDJFS: administration.

(A) Each county department of job and family services (CDJFS) must develop a community transportation plan to describe how it implements relevant provisions of this rule and rules 5160-15-11 and 5160-15-12 of the Administrative Code.

(1) The community transportation plan must include the following information:

(a) A listing of contact information for at least one CDJFS staff member who is responsible for administering county-based transportation assistance under the medicaid program;

(b) A description of how the CDJFS makes medicaid-eligible individuals aware both of the availability of transportation assistance and of the guidelines for using it;

(c) A description of how medicaid-eligible individuals request transportation assistance from the CDJFS or obtain referrals to other transportation sources;

(d) Delineation of the geographical area within which medicaid-eligible individuals and the general population in the county routinely access medical services (i.e., the "community");

(e) An explanation of the process for arranging transportation assistance for trips outside the community;

(f) For each type of transportation assistance listed in paragraph (B) of this rule, an indication of whether the CDJFS provides it routinely, provides it when other types of assistance do not fully meet a medicaid-eligible individual's needs, or cannot provide it because the service does not exist;

(g) When applicable, an explanation of how the CDJFS decides which type of transportation assistance is most cost-effective and best suited to the medicaid-eligible individual's needs;

(h) When applicable, a listing of contact information for each contract vendor and a summary of the contract, including its term and projected cost;

(i) An explanation of how the CDJFS determines that a medicaid-eligible individual needs the services of a personal assistant during transport, whether the personal assistant for a particular transport may be paid, and how the personal assistant's time is calculated;

(j) When applicable, an explanation of how the CDJFS addresses problems with or complaints about the quality of services provided by contract vendors or by CDJFS staff members; and

(k) An explanation of the policies and procedures implemented by the CDJFS to address misuse of transportation assistance by medicaid-eligible individuals.

(2) A revision of the community transportation plan, signed and dated by an appropriate CDJFS staff member, must be submitted to the department whenever changes are made but not less often than every twelve months.

(B) Every CDJFS may offer the following types of transportation assistance:

(1) Services provided under a vendor contract or agreement and billed afterward to the CDJFS:

(a) Livery service (e.g., taxicab rides);

(b) Fixed-route or demand-response transportation (e.g., rides provided by a public transit system, a human-service agency, a private company, or a transportation cooperative);

(c) The dispensing of fuel at participating service stations;

(2) Services not provided under a vendor contract or agreement:

(a) Prepayment of fares (e.g., purchase of bus tokens or passes);

(b) Prepayment for fuel at participating service stations (e.g., purchase of gasoline debit cards);

(c) Transportation of a medicaid-eligible individual by a CDJFS staff member in a CDJFS vehicle;

(d) Payment of mileage reimbursement to a medicaid-eligible individual or to a CDJFS staff member for the use of a private vehicle, at the same rate at which the county reimburses its employees for work-related travel expenses;

(e) Auxiliary services:

(i) Payment for the services of a personal assistant for up to eight hours per day, made at the greater of the current federal minimum wage or the current Ohio minimum wage, when a medicaid-eligible individual requires such services during transport, unless the personal assistant is the medicaid-eligible individual's relative (grandparent; parent, step-parent, or parent-in-law; sibling, step-sibling, or sibling-in-law; child, step-child, or child-in-law; grandchild; spouse or partner; legal guardian; or other person who stands in the place of a parent);

(ii) Payment for lodging, meals, and other travel-related expenses for a medicaid-eligible individual (and, when required, a personal assistant), at not less than the same rate at which the county reimburses its employees for work-related travel expenses;

(iii) Transportation, or payment for transportation, of a parent or legal guardian accompanying a medicaid-eligible individual who is younger than twenty-one years of age; and

(3) Other services approved in advance by the department.

(C) Documentation maintained by the CDJFS must make it possible to verify the following information concerning transportation assistance requested by a medicaid-eligible individual:

(1) The individual's medicaid identification number;

(2) The date on which the request for transportation assistance was made;

(3) The identity and location of the provider where the individual planned to obtain a medicaid-coverable service;

(4) The trip date or dates requested;

(5) The number of one-way trips involved;

(6) The type of transportation assistance provided or the reason why transportation assistance was not provided;

(7) The name of the transportation vendor, when applicable; and

(8) The name of the medicaid program area (such as pregnancy-related services, healthchek/EPSDT, or general non-emergency transportation) to which the cost should be allocated.

Replaces: Part of 5160-24-02, part of 5160-24-03

Effective: 4/1/2016
Five Year Review (FYR) Dates: 04/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 05/05/1988 (Emer), 08/06/1988, 01/01/1989, 12/31/1990, 08/26/2000, 01/01/2004, 01/01/2006, 01/01/2008

5160-15-21 [Effective 4/1/2016] Transportation: services from an eligible provider: provider requirements.

(A) The following eligible providers may render a transportation service:

(1) A wheelchair van provider;

(2) An ambulance provider;

(3) A hospital; or

(4) A provider under contract with a medicaid managed care plan.

(B) The following eligible providers may receive medicaid payment for submitting a claim for a transportation service:

(1) A wheelchair van provider;

(2) An ambulance provider;

(3) A hospital; or

(4) A provider under contract with a medicaid managed care plan.

(C) The necessity of a transportation service rendered on a fee-for-service basis must be certified by a practitioner holding a current, valid license or certificate to practice in a professional capacity.

(1) The following practitioners may certify the necessity of either a wheelchair van service or an ambulance service:

(a) An advanced practice registered nurse;

(b) A doctor of medicine, osteopathy, or podiatric medicine;

(c) A physician assistant; or

(d) Any other professional recognized by the department as having prescriptive authority.

(2) The following practitioners may certify the necessity of a wheelchair van service:

(a) A chiropractor;

(b) A licensed practical nurse or registered nurse;

(c) An occupational therapist or physical therapist;

(d) A psychologist;

(e) A certified rehabilitation counselor; or

(f) Any other professional recognized by the department as having the qualifications necessary to determine whether an individual requires the use of a mobility device.

(D) Each transportation provider, crew member, and attendant must comply with all applicable local, state, and federal laws, regulations, and rules, including all applicable certification or licensure requirements developed in accordance with Chapter 4765. or Chapter 4766. of the Revised Code.

(E) Each vehicle operated by a transportation provider must meet all applicable permit requirements developed in accordance with Chapter 4766. of the Revised Code.

(F) Each out-of-state provider must be approved in accordance with Chapter 5160-1 of the Administrative Code.

(G) Each provider of ground ambulance services must be enrolled in medicare as an ambulance service provider or supplier.

Replaces: Part of 5160-15-02

Effective: 4/1/2016
Five Year Review (FYR) Dates: 04/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/07/1977, 12/21/1977, 12/30/1977, 12/03/1981, 08/15/1982, 05/09/1986, 12/01/1990, 05/01/1992 (Emer), 08/13/1992, 07/05/1993, 01/01/1994, 04/01/1994, 10/01/1997, 03/01/2000, 12/31/2001, 10/01/2003, 12/30/2005 (Emer), 03/27/2006

5160-15-22 [Effective 4/1/2016] Transportation: services from an eligible provider: wheelchair van services.

(A) Payment may be made for the following wheelchair van services:

(1) Transport by wheelchair van;

(2) Mileage, wheelchair van; and

(3) Attendant services, wheelchair van.

(B) Payment may be made only if all the requirements in this paragraph are met.

(1) The necessity of the wheelchair van service is established. A necessary wheelchair van service is presumed to satisfy the criteria for medical necessity set forth in rule 5160-1-01 of the Administrative Code.

(a) The transfer by wheelchair van of a medicaid-eligible individual from one hospital to a second hospital is deemed to be necessary if two conditions apply:

(i) Both of the criteria listed in paragraph (B)(1)(b) of this rule are met; and

(ii) The services provided at the second hospital are coverable by medicaid.

(b) The necessity of all other wheelchair van services is determined by two criteria:

(i) The medicaid-eligible individual must be accompanied by a mobility-related assistive device from the point of pick-up to the point of drop-off; and

(ii) Transportation of the medicaid-eligible individual by standard passenger vehicle or common carrier is precluded or contraindicated. (Note: The use of a portable device such as a cane, crutch, or walker does not in and of itself preclude or contraindicate transportation by standard passenger vehicle or common carrier.)

(2) The transport vehicle is one of two types:

(a) A wheelchair van; or

(b) A ground ambulance used only under the following conditions:

(i) The transportation provider is an eligible provider of both wheelchair van services and ground ambulance services;

(ii) No wheelchair van is available for one of three reasons:

(a) A wheelchair van was originally scheduled for the transport but has been rendered inoperative or unavoidably delayed, and the transportation provider cannot substitute another wheelchair van within a reasonable time;

(b) The wheelchair vans operated by the transportation provider cannot accommodate the medicaid-eligible individual's mobility device; or

(c) The medicaid-eligible individual (or the medicaid-eligible individual's representative) requested a ground ambulance, and the ambulance crew discovered on arrival that wheelchair van service was needed;

(iii) The medicaid-eligible individual's mobility device can be safely transported with the medicaid-eligible individual in the ground ambulance;

(iv) The medicaid-eligible individual does not refuse the transport; and

(v) On the claim submitted for payment of wheelchair van service, the transportation provider indicates the use of a ground ambulance.

(3) The medicaid-eligible individual is transported either to or from a medicaid-coverable service.

(4) The medicaid-eligible individual is transported both to and from a recognized or approved point of transport.

(5) The services of an attendant are used only when such services are necessary for the safe transport of a medicaid-eligible individual. The transportation provider must maintain documentation of such necessity.

(6) The mobility device must be dropped off or picked up along with the medicaid-eligible individual at the location where the medicaid-coverable service is obtained.

(7) The medicaid-eligible individual must ride in or on the mobility device when moving between the wheelchair van and the location where the medicaid-coverable service is obtained.

Replaces: Part of 5160-15-03, 5160-15-05

Effective: 4/1/2016
Five Year Review (FYR) Dates: 04/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/07/1977, 05/09/1986, 07/05/1993, 03/01/2000, 12/27/2001, 10/01/2003, 12/30/2005 (Emer), 01/01/2006, 03/27/2006

5160-15-23 [Effective 4/1/2016] Transportation: services from an eligible provider: ground ambulance services.

(A) Payment may be made for the following ground ambulance services:

(1) Basic life support, provided in a non-emergency (BLS non-emergency);

(2) Basic life support, provided in an emergency (BLS emergency);

(3) Advanced life support, level 1, provided in a non-emergency (ALS1 non-emergency);

(4) Advanced life support, level 1, provided in an emergency (ALS1 emergency);

(5) Advanced life support, level 2 (ALS2);

(6) Specialty care transport (SCT);

(7) Mileage, ground ambulance; and

(8) Attendant services, ground ambulance.

(B) Payment may be made only if all the requirements in this paragraph are met.

(1) The necessity of ground ambulance service is established.

(a) Emergency ground ambulance services are deemed to be necessary. BLS emergency, ALS1 emergency, and associated loaded mileage are emergency services by definition. ALS2, specialty care transport, and associated loaded mileage are treated as emergency services.

(b) The non-emergency transfer by ground ambulance of a medicaid-eligible individual from one hospital to a second hospital is deemed to be necessary if two conditions apply:

(i) At least one of the criteria listed in paragraph (B)(1)(c) of this rule is met; and

(ii) The services provided at the second hospital are coverable by medicaid.

(c) The necessity of all other non-emergency ground ambulance services is determined by at least one of three criteria:

(i) The individual requires medical treatment or continuous supervision by an EMT during transport;

(ii) The individual requires the administration or regulation of oxygen by another person during transport; or

(iii) The individual requires supervised protective restraint during transport.

(2) The transport vehicle is a ground ambulance.

(3) The medicaid-eligible individual is transported either to or from a medicaid-coverable service.

(4) The medicaid-eligible individual is transported both to and from a recognized or approved point of transport.

(5) The services of an additional attendant are used only when such services are necessary for the safe transport of a medicaid-eligible individual. The transportation provider must maintain documentation of such necessity.

(C) A hospital that is an eligible provider may submit a claim for ground ambulance services on behalf of another entity if two conditions apply:

(1) The other entity is an eligible provider of ground ambulance services; and

(2) The hospital and the other entity have entered into an appropriate agreement or contract.

Replaces: Part of 5160-15-03

Effective: 4/1/2016
Five Year Review (FYR) Dates: 04/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/07/1977, 05/09/1986, 07/05/1993, 03/01/2000, 12/27/2001, 10/01/2003, 12/30/2005 (Emer), 03/27/2006

5160-15-24 [Effective 4/1/2016] Transportation: services from an eligible provider: air ambulance services.

(A) Payment may be made for the following air ambulance services:

(1) Ambulance transport, fixed-wing;

(2) Ambulance transport, rotary-wing;

(3) Mileage, fixed-wing ambulance; and

(4) Mileage, rotary-wing ambulance.

(B) Payment may be made only if all the requirements in this paragraph are met.

(1) The necessity of air ambulance service is established.

(a) Air ambulance services are deemed to be necessary when two criteria are met:

(i) Emergency ambulance service is required because the medicaid-eligible individual is critically ill or has critical injuries (e.g., multiple traumas, massive bleeding, severe burns); and

(ii) It is estimated that transporting the medicaid-eligible individual by ground ambulance to the nearest appropriate treatment facility will take more than thirty minutes.

(b) The necessity of other air ambulance services is determined by two criteria:

(i) The criteria have been met for determining the necessity of transport by ground ambulance in accordance with rule 5160-15-23 of the Administrative Code; and

(ii) At least one of the following conditions applies:

(a) The point of pick-up is inaccessible by ground ambulance;

(b) The additional time required for transport by ground ambulance would endanger the life or health of the medicaid-eligible individual;

(c) The time saved by air transport would significantly increase the chances of survival or reduce the risk of further injury or impairment; or

(d) The closest appropriate treatment facility is at least one hundred eighty miles from the point of pick-up.

(2) The transport vehicle is an air ambulance.

(3) The medicaid-eligible individual is transported either to or from a medicaid-coverable service.

(4) The medicaid-eligible individual is transported both to and from a recognized or approved point of transport.

(C) A hospital that is an eligible provider may submit a claim for air ambulance services on behalf of another entity if two conditions apply:

(1) The other entity is an eligible provider of air ambulance services; and

(2) The hospital and the other entity have entered into an appropriate agreement or contract.

(D) Separate payment may be made for critical care services, the provision of which is delineated in Chapter 5160-4 of the Administrative Code.

Replaces: Part of 5160-15-03

Effective: 4/1/2016
Five Year Review (FYR) Dates: 04/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/07/1977, 05/09/1986, 07/05/1993, 03/01/2000, 12/27/2001, 10/01/2003, 12/30/2005 (Emer), 03/27/2006

5160-15-25 [Effective 4/1/2016] Transportation: services from an eligible provider: points of transport.

(A) For purposes of this chapter, medicaid recognizes the following twelve points of transport, which represent the origin or destination of a discrete one-way trip:

(1) Ten points of transport recognized by the centers for medicare and medicaid services (CMS):

(a) A diagnostic or therapeutic site other than a practitioner's office or a hospital, such as an alcohol and drug rehabilitation center, an ambulatory surgery center, an independent diagnostic testing facility, or a medical equipment supplier;

(b) A residential, domiciliary, or custodial facility that is not a skilled nursing facility (e.g., an intermediate care facility for individuals with intellectual disabilities);

(c) A dialysis facility located in a hospital;

(d) A hospital;

(e) A site of transfer between modes of transport, such as an airstrip or a helipad;

(f) A dialysis facility not located in a hospital;

(g) A skilled nursing facility;

(h) A practitioner's office, which includes but is not limited to the office of an individual health professional or a group of health professionals (e.g., advanced practice registered nurses, chiropractors, dentists, occupational therapists, optometrists, opticians, podiatrists, physical therapists, physicians, physician assistants, psychiatrists, or psychologists) or a clinic;

(i) A residence other than a residential, domiciliary, or custodial facility; and

(j) The scene of an accident or an acute event;

(2) A workplace; and

(3) A school.

(B) On each claim for a transportation service provided by wheelchair van or by ambulance, the origin and the destination must be specified in accordance with current claim-submission instructions.

(1) A claim submitted for a wheelchair van service or an ambulance service requires manual review unless the combination of origin and destination has been exempted. A list of the exempted combinations for each service is shown in the appendix to rule 5160-15-28 of the Administrative Code.

(2) Transportation providers may request manual review of claims for services involving non-exempted combinations of origins and destinations. Transportation providers may also request manual review of claims for services involving origins and destinations that are not listed in paragraph (A) of this rule. Claims involving an unlisted origin or destination must indicate that fact explicitly.

(3) All requests for manual review of a claim for a transportation service must include the following information:

(a) A completed practitioner certification form when the claim does not concern emergency ambulance service;

(b) A complete description of the service requested, the date of service, the trip origin and destination, a description of any special services involved, and a justification for the use of an attendant (when applicable); and

(c) Details of any related circumstances that should be considered in the evaluation of the request for manual review.

Replaces: Part of 5160-15-03

Effective: 4/1/2016
Five Year Review (FYR) Dates: 04/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/07/1977, 05/09/1986, 07/05/1993, 03/01/2000, 12/27/2001, 10/01/2003, 12/30/2005 (Emer), 03/27/2006

5160-15-26 [Effective 4/1/2016] Transportation: services from an eligible provider: service limitations and allowances.

(A) No payment can be made for the following services and associated costs:

(1) Transportation services for an individual who is not medicaid-eligible at the time of transport;

(2) Transportation of a medicaid-eligible individual for a purpose other than the receipt of medicaid-coverable services;

(3) Transportation of a medicaid-eligible individual to or from a service provided outside the limits of the individual's medicaid benefit package;

(4) Transports during which there is no medicaid-eligible individual in the vehicle;

(5) Services that are available to the general public without charge;

(6) Excessive mileage resulting from the use of unnecessarily indirect routes;

(7) The service of hospital staff members as attendants during transportation to or from a hospital (which is treated as an inpatient or outpatient hospital service);

(8) Transportation of any person other than the medicaid-eligible individual and an attendant who accompanies the medicaid-eligible individual; and

(9) Duplicate attendant services provided by the same individual simultaneously to more than one passenger.

(B) Travel to the point of pick-up or from the point of drop-off is considered to be intrinsic to the transportation service. No separate payment is made for the cost of such travel, nor can it be billed to the medicaid-eligible individual.

(C) An entity that furnishes transportation to a medicaid-eligible individual but is not an eligible provider at the time of transport may submit a claim for that service in accordance with Chapter 5160-1 of the Administrative Code after it has become an eligible provider of transportation services.

(D) Certain coverage limitations are based on the length of a transport.

(1) A transportation provider must maintain additional documentation that justifies the distance of each transport by wheelchair van and each non-emergency transport by ground ambulance that is longer than fifty miles from the point of pick-up. Failure to do so will limit mileage payment for that transport to fifty miles.

(2) Claims for transportation by wheelchair van or by ground ambulance from an origin or to a destination that is not in Ohio nor in one of the states contiguous to Ohio require manual review.

(E) Claims for loaded mileage must not represent, either individually or collectively, more distance than was actually traveled. When more than one medicaid-eligible individual is transported at the same time, then loaded mileage for the shared portion of the trip must be allocated in a reasonable, consistent manner (e.g., claimed for only one of the medicaid-eligible individuals, split equally, or divided proportionately according to the total distance).

(F) Payment may be made for the transport of a medicaid-eligible individual to or from a medicaid-coverable service that is canceled (or otherwise becomes unavailable before the medicaid-eligible individual arrives) if the following conditions apply:

(1) The transport was provided in accordance with all applicable requirements of this chapter;

(2) The transportation provider received no prior notice of the cancellation or unavailability of the medicaid-coverable service either from the provider of the medicaid-coverable service or from the medicaid-eligible individual;

(3) The cancellation or unavailability of the medicaid-coverable service was not the result of any action or inaction on the part of the transportation provider;

(4) Before submitting a claim, the transportation provider obtains the following items from the provider of the medicaid-coverable service:

(a) The business name, address, and telephone number of the provider of the medicaid-coverable service;

(b) The scheduled date and time of the medicaid-coverable service that was canceled or became unavailable;

(c) A brief explanation of the reason for the cancellation or unavailability of the medicaid-coverable service;

(d) A statement that the provider of the medicaid-coverable service was unable to give notice of the cancellation or unavailability of the medicaid-coverable service before the medicaid-eligible individual was en route; and

(e) The printed name and the signature of an authorized representative of the provider of the medicaid-coverable service; and

(5) On the claim for both the transport and the actual loaded mileage, the transportation provider must indicate that the medicaid-coverable service was canceled or became unavailable.

(G) No payment can be made for services provided to an individual who has already died. The coverage of ambulance services is therefore affected by the time of pronouncement of death, which must be made by someone who is licensed to do so under Ohio law.

(1) If a medicaid-eligible individual is pronounced dead either before an ambulance is called or while arrangements for an ambulance can still be canceled, then no payment is made.

(2) If a medicaid-eligible individual is pronounced dead after an ambulance is called and either the ambulance has not yet begun transport or arrangements for the ambulance can no longer be canceled, then payment may be made for the transport but not for loaded mileage.

(a) If the vehicle is a ground ambulance, then payment may be made for BLS (either emergency or non-emergency). Payment may be made instead for ALS1 or ALS2, with manual review, if there is documentation that the ambulance crew provided a corresponding level of service at the scene.

(b) If the vehicle is an air ambulance, then payment may be made for the appropriate air transport.

(3) If a medicaid-eligible individual is pronounced dead in the ambulance en route to the destination, then payment is made as if the death of the medicaid-eligible individual had not occurred.

(H) Claims for ambulance services provided to medicaid-eligible individuals who also have medicare coverage are paid in accordance with Chapter 5160-1 of the Administrative Code. On claims for services provided to such dually eligible individuals, medicaid does not make separate payment for mileage beyond the closest appropriate facility.

(I) Wheelchair van service is always of a non-emergency nature and does not involve medical treatment. No part of a trip (transport, loaded mileage, or attendant services) may be claimed as wheelchair van service if there is an expectation in advance that the transportation provider will provide medical treatment to a medicaid-eligible individual en route.

Replaces: Part of 5160-15-03

Effective: 4/1/2016
Five Year Review (FYR) Dates: 04/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/07/1977, 05/09/1986, 07/05/1993, 03/01/2000, 12/27/2001, 10/01/2003, 12/30/2005 (Emer), 03/27/2006

5160-15-27 [Effective 4/1/2016] Transportation: services from an eligible provider: documentation.

(A) Certification is required to confirm the necessity of wheelchair van services and most non-emergency ambulance services. No certification is required for transportation services furnished by an eligible provider that are automatically deemed to be necessary in accordance with rule 5160-15-22, 5160-15-23, or 5160-15-24 of the Administrative Code. A managed care plan (MCP) is not required to use the practitioner certification process described in paragraph (B) of this rule to certify the necessity of a transportation service furnished to a medicaid-eligible individual enrolled in the MCP.

(B) For transportation services that require certification but are not furnished to a medicaid-eligible individual enrolled in an MCP, a practitioner certification form is used.

(1) The nature of the practitioner certification form depends on the type of transportation service.

(a) For wheelchair van services, an ODM 03452, "Certification of Necessity for Transportation by Wheelchair Van" (07/2015), must be used.

(b) For non-emergency ground ambulance services, documents required by the primary payer of the claim are acceptable; if medicaid is the primary payer, then an ODM 01960, "Certification of Necessity for Non-Emergency Transportation by Ground Ambulance" (07/2015), must be used.

(c) For air ambulance services, any document that includes the information specified in paragraph (B)(1)(b) of rule 5160-15-24 of the Administrative Code is acceptable.

(2) If practitioner certification for a transportation service is required, then the transportation provider must obtain a completed, signed, and dated practitioner certification form before submitting a claim.

(a) The date shown on the form must be the actual date of signature.

(b) The date of signature must be not more than one hundred eighty days after the latter of two dates:

(i) The first date of service; or

(ii) The date on which the transportation provider learns of the individual's medicaid eligibility.

(c) In no case does the date of signature on the practitioner certification form extend the limits specified in Chapter 5160-1 of the Administrative Code for the timely filing of claims.

(d) Persons who sign on behalf of the certifying practitioner, with proper authority or the approval of the certifying practitioner, must include the practitioner's name as well as their own signature and professional designation (e.g., MD, DO, DPM, RN, APN, PA, LSW).

(e) The certification must not create a conflict of interest for the practitioner.

(f) A photocopy, an electronic copy, or a facsimile transmittal of the completed, signed, and dated practitioner certification form is as valid as the original for documentation purposes.

(3) A transportation provider may submit a claim to the department for a specific one-way or round-trip transport after having obtained an incomplete practitioner certification form if the following conditions apply:

(a) The transportation provider has made three attempts to obtain the completed form;

(b) The transportation provider has allowed no fewer than thirty calendar days for receipt of a reply after each attempt; and

(c) The transportation provider has received no response from the practitioner.

(4) For wheelchair van services and non-emergency ground ambulance services, a practitioner may designate one of two certification periods, each of which begins on the earlier of the date of signature or the first date of service:

(a) Temporary certification for up to ninety days; or

(b) Ongoing certification for one year.

(5) If a change in a medicaid-eligible individual's status renders the current practitioner certification form obsolete, then a new form is required.

(6) No payment is to be made for transportation services provided during the certification period that do not meet the certification criteria. For example, payment cannot be made for a transport by wheelchair van provided during the certification period if no mobility device is involved.

(7) A patently incorrect practitioner certification form is invalid, even if it is signed.

(8) False certification constitutes medicaid fraud. The following examples illustrate false certification:

(a) For transport by wheelchair van, certification that a medicaid-eligible individual must be accompanied by a mobility device is false if the medicaid-eligible individual in fact has no need for and never uses a mobility device.

(b) For non-emergency transport by ground ambulance, certification that a medicaid-eligible individual requires medical treatment or continuous supervision by an EMT during transport is false if such treatment or supervision could reasonably and appropriately be supplied by someone who has not had training to the level of an EMT.

(9) Certification is not transferrable between medicaid-eligible individuals or transportation providers.

(C) Each transportation provider must maintain documentation that fully accounts for the services provided. No payment is to be made for a service if the transportation provider fails to obtain the required documentation before submitting a claim to the department or to an MCP. All records and documentation required by this rule must be retained in accordance with Chapter 5160-1 of the Administrative Code.

(D) Each transportation provider must maintain the following records:

(1) Copies of all certification or licensure documents required for crew members and attendants, which must be current at the time of the transport;

(2) Completed practitioner certification forms, when applicable;

(3) Copies of completed requests for manual review, when applicable;

(4) The relevant trip information specified in agency 4766 of the Administrative Code; and

(5) The following medicaid-specific trip information:

(a) Identification of the particular vehicle used;

(b) The name of each wheelchair van attendant, when applicable;

(c) The medicaid identification number of each medicaid-eligible individual; and

(d) For non-emergency trips, the signature of each medicaid-eligible individual transported.

(E) If a transportation provider fails to produce documentation requested by the department or an MCP to substantiate compliance with any provision in this chapter, then the department may terminate or deny reinstatement of the medicaid provider agreement in accordance with Chapter 5160-1 of the Administrative Code and may seek repayment for undocumented services.

Replaces: Part of 5160-15-02, part of 5160-15-03

Effective: 4/1/2016
Five Year Review (FYR) Dates: 04/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/07/1977, 12/21/1977, 12/30/1977, 12/03/1981, 08/15/1982, 05/09/1986, 12/01/1990, 05/01/1992 (Emer), 08/13/1992, 07/05/1993, 01/01/1994, 04/01/1994, 10/01/1997, 03/01/2000, 12/27/2001, 12/31/2001, 10/01/2003, 12/30/2005 (Emer), 03/27/2006

5160-15-28 [Effective 4/1/2016] Transportation: services from an eligible provider: payment.

The amount of payment for a transportation service furnished by an eligible provider on a fee-for-service basis is the lesser of either the provider's submitted charge or the medicaid maximum payment amount for the date of transport. The medicaid maximum payment amounts for transportation services are listed in the appendix to this rule.

Replaces: 5160-15-04

Click to view Appendix

Effective: 4/1/2016
Five Year Review (FYR) Dates: 04/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 08/15/1982, 06/03/1983, 04/29/1986, 01/13/1989 (Emer), 04/13/1989, 12/01/1990, 04/01/1994, 10/01/1997, 01/01/2000, 12/27/2001, 10/01/2003, 12/30/2005 (Emer), 03/27/2006, 07/01/2008