(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
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