5160-15-03 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)