Lawriter - OAC - 5160-15-26 Transportation: services from an eligible provider: service limitations and allowances.

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