Lawriter - OAC - 5160-15-27 Transportation: services from an eligible provider: documentation.

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