Chapter 5160-15 Medical Transportation Services

5160-15-01 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 [Rescinded] 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 [Rescinded] 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 [Rescinded] 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 [Rescinded] 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 [Rescinded] 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 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 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 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 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 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 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 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 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 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 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 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