Chapter 5160-15 | Healthcare-Related Transportation

Rule 5160-15-01 | Transportation: definitions.

• Effective: July 1, 2021
• Promulgated Under: 119.03

(A) Provisions in this chapter do not necessarily apply to transportation furnished in accordance with other chapters of agency 5160 of the Administrative Code.

(B) The following definitions apply to this chapter:

(1) Terms that have the same meaning as in 42 C.F.R. 414.605 (October 1, 2020) include the following items:

(a) "Advanced life support, level 1 (ALS1)";

(b) "Advanced life support, level 2 (ALS2)";

(c) "Basic life support (BLS)";

(d) "EMT-basic," "EMT-intermediate, and "EMT-paramedic" (collectively, "advanced life support (ALS) personnel");

(e) "Fixed wing air ambulance";

(f) "Rotary wing air ambulance"; and

(g) "Specialty care transport (SCT)."

(2) "Ambulance" is a collective term for air ambulance and ground ambulance.

(a) "Air ambulance" is a collective term for "fixed wing air ambulance" and "rotary wing air ambulance."

(b) "Ground ambulance" is a collective term for land ambulance and water ambulance.

(3) "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 need extra assistance.

(4) "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.

(5) "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.

(6) "Eligible provider" has the same meaning as in Chapter 5160-1 of the Administrative Code.

(7) "Emergency" is a situation that calls for an 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, needs 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; or

(c) Transport to a trauma center.

(8) "Emergency medical technician (EMT)" is a collective term for EMT-basic, EMT-intermediate, and EMT-paramedic.

(9) "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.

(10) "Long-term care facility" is a collective term for intermediate care facility for individuals with intellectual disabilities (ICFIID), nursing facility (NF), and skilled nursing facility (SNF). Neither an assisted living facility nor a group home is an LTCF.

(11) "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.

(12) "Medicaid-eligible individual" is an individual who meets eligibility criteria of the medicaid program.

(13) "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.

(14) "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).

(15) "Non-emergency" is a situation for which immediate response is not needed for the provision of medical treatment.

(16) "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.

(17) "Point of transport" is the terminus of a trip, either the place of origin or the destination.

(18) "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.

(19) "Transportation provider" is an eligible provider that furnishes wheelchair van or ambulance services and meets the minimum criteria 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 medicaid transportation provider.

(20) "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 conditions for licensure specified in Chapter 4766. of the Revised Code, and meets standards specified in Chapter 4766-3 of the Administrative Code.

Last updated July 1, 2021 at 11:00 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2026
Prior Effective Dates: 4/7/1977

Rule 5160-15-10 | Transportation: non-emergency services through a CDJFS.

• Effective: July 1, 2021
• Promulgated Under: 119.03

(A) Pursuant to 42 C.F.R. 431.53, the Ohio department of medicaid (ODM) is obligated to ensure necessary transportation for medicaid-eligible individuals to and from providers of covered healthcare services. ODM fulfills this obligation in large measure through three-way subgrant agreements with the Ohio department of job and family services (ODJFS) and with each county department of job and family services (CDJFS). This rule sets forth the responsibilities and expectations placed by ODM on each CDJFS in the administration of this medicaid-funded non-emergency transportation assistance benefit. In signing a subgrant agreement, a CDJFS agrees to be bound by this rule and by any other applicable provision of the Administrative Code.

(B) For each individual to whom non-emergency transportation assistance is provided, a CDJFS is expected to select the type of assistance that is most cost-effective, is suitable to the individual's needs and circumstances, and enables timely access. If one type of assistance proves infeasible, a CDJFS may select another type.

(1) A CDJFS may decline to provide medicaid-funded non-emergency transportation assistance to a medicaid-eligible individual under this rule if either of the following criteria is met:

(a) The associated healthcare service is not part of the individual's medicaid benefit package; or

(b) The requested non-emergency transportation assistance is not necessary for any of the following reasons:

(i) A medicaid managed care organization (MCO) is obligated to furnish transportation to the individual under its provider agreement with ODM;

(ii) The individual is a resident of a long-term care facility (nursing facility, skilled nursing facility, or intermediate care facility for individuals with intellectual disabilities), for whom transportation is provided in accordance with Chapter 5160-3 or Chapter 5123:2-7 of the Administrative Code;

(iii) A medicaid hospice provider is obligated to provide or arrange transportation that is necessary for the individual to receive care related to a terminal illness;

(iv) Suitable transportation is available free of charge to the general public; or

(v) Failure to provide the requested assistance will have no effect on the individual's ability to obtain the healthcare service.

(2) A request made on behalf of a minor child for non-emergency transportation assistance entails additional considerations.

(a) Responsibility for transporting a child normally falls to a parent or guardian. In reviewing a request, a CDJFS should take into account the impact, if any, of the following factors:

(i) Whether a family member or friend is available to provide transportation;

(ii) Whether the family has ready access to a reliable vehicle;

(iii) Whether the family has sufficient financial resources (including any adoption or foster care subsidy); and

(iv) Whether another entity such as a school system is or should be involved.

(b) A request for non-emergency transportation assistance to enable another person, such as a parent, to be with a child in a healthcare facility may be approved if two criteria are met:

(i) The presence of the other person is needed for an identifiable healthcare purpose that will benefit the child; and

(ii) The other person lacks the resources necessary to make the trip (or trips).

(3) A CDJFS may temporarily restrict or suspend a particular type of non-emergency transportation assistance or non-emergency transportation assistance in general for an individual for reasons including but not limited to the following examples:

(a) Misuse by the individual, as determined by the CDJFS;

(b) Dangerous, threatening, or disruptive behavior on the part of the individual; or

(c) Presence in the individual of a communicable disease or condition (other than a mild endemic illness such as the common cold) that constitutes a danger to public health.

(4) A CDJFS is to provide a notice of state hearing rights whenever it proposes to withhold, reduce, suspend, or terminate the medicaid-funded non-emergency transportation assistance benefit 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. The following examples, however, do not constitute restrictions by the CDJFS of the medicaid benefit and are not subject to state hearing:

(a) The refusal of a request for a specific trip, particularly because of factors beyond the control of the CDJFS such as a scheduling conflict, lack of sufficient advance notice, or adverse weather conditions; and

(b) Failure to provide further non-emergency transportation assistance when all options have been exhausted.

(C) The community service area of a CDJFS is the geographical area within which medicaid-eligible individuals and the general population in the county routinely access healthcare services.

(1) The community service area comprises at least the county or counties served by the CDJFS, and it may also include specific locations in contiguous Ohio counties, non-contiguous Ohio counties, and bordering states.

(2) It is expected that medicaid-eligible individuals will access covered healthcare services within the community service area. If a covered healthcare service can be obtained only outside the community service area, the CDJFS may choose to provide assistance sufficient to enable travel only to or from the nearest location, unless a documented consideration other than distance overrides such a limitation.

(D) Every CDJFS may offer a variety of transportation assistance options.

(1) These options include the following examples:

(a) Contracted livery service;

(b) Payment for fixed-route or demand-response transportation;

(c) Vouchers for fuel at participating service stations;

(d) Prepayment of fares;

(e) Prepayment for fuel;

(f) Transportation by a CDJFS staff member in a CDJFS vehicle;

(g) Payment of mileage reimbursement;

(h) Reimbursement for travel-related expenses that represent a necessary out-of-pocket cost to a medicaid-eligible individual;

(i) 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

(j) Other services approved in advance by ODM.

(2) The types of non-emergency transportation assistance offered by a CDJFS generally reflect the resources available within its community service area. In a large metropolitan area with an extensive public transit system and numerous taxicab and transportation network companies, for example, the CDJFS may choose to offer rides rather than payment of vehicle costs; in a very rural area with no public transit and few livery options, the CDJFS may choose to offer fuel subsidy as its main form of assistance. Every CDJFS, however, regardless of community service area, is expected to develop a process for identifying transportation sources and to make a good-faith effort to secure rides for individuals who need actual transportation.

(E) Each CDJFS shares basic information about its administration of the transportation assistance benefit by submitting form ODM 10241, "Medicaid County Transportation Profile" (rev. 4/2021), to ODM and revising the document whenever changes are made but not less often than every twelve months.

(F) Of all the records created in the course of administering medicaid-funded non-emergency transportation assistance, ODM expects a CDJFS to collect the following types for purposes of data analysis and program integrity:

(1) Documentation of each request for non-emergency transportation assistance, maintained in such a manner that ODM can readily verify the following information:

(a) The individual's medicaid identification number;

(b) The date on which the request for transportation assistance was made;

(c) The identity and location of the healthcare provider where the individual planned to obtain a covered service;

(d) The trip date or dates requested;

(e) The number of one-way trips involved;

(f) The type of transportation assistance provided or the reason why transportation assistance was not provided;

(g) The name of the transportation vendor, when applicable;

(h) The scheduled pick-up and drop-off times and the actual pick-up and drop-off times, when applicable; and

(i) 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;

(2) Results of criminal background checks and database searches conducted in accordance with rule 5160-15-14 of the Administrative Code; and

(3) Complaints and suggestions received from passengers and, if applicable, from vendors.

Last updated July 1, 2021 at 11:01 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2026
Prior Effective Dates: 5/5/1988 (Emer.), 12/31/1990

Rule 5160-15-14 | Transportation: non-emergency services through a CDJFS: program integrity provisions.

• Effective: July 1, 2022
• Promulgated Under: 119.03

(A) Definitions.

(1) "Private transportation vendor (PTV)" is an entity that meets the following criteria:

(a) It seeks to establish or to maintain a contract with a county department of job and family services (CDJFS) to supply transportation service to medicaid recipients in accordance with rule 5160-15-10 of the Administrative Code; and

(b) It is not a government agency, transit authority, public transportation system, or other quasi-governmental organization.

(2) "PTV owner/manager" is a person having an ownership or control interest in the PTV, as defined in 42 C.F.R. 455.101 (October 1, 2020).

(3) "Related enterprise" is any other business in which a PTV owner/manager has an ownership or control interest.

(4) "Direct-service PTV employee" is a PTV employee who provides direct services to medicaid recipients.

(B) A CDJFS may hold a contract with a PTV only if the following conditions are met:

(1) All applicable disclosure provisions set forth in 42 C.F.R. Part 455, Subpart B (October 1, 2020) are satisfied;

(2) Whenever a contract between the CDJFS and the PTV is established or renewed and whenever the PTV is considering an applicant for a position as a direct-service PTV employee, the following four conditions are met:

(a) Each driver holding or applying for a position with the PTV has a valid driver's license;

(b) For each driver holding or applying for a position with the PTV, a certified driving record history is obtained from the bureau of motor vehicles of the Ohio department of public safety and provided to the CDJFS;

(c) A criminal background check performed in accordance with section 109.572 of the Revised Code on each direct-service PTV employee or applicant returns one of two results:

(i) The direct-service PTV employee or applicant has never been convicted of or pleaded guilty to an offense listed in divisions (A)(3)(a) to (A)(3)(e) of section 109.572 of the Revised Code (a disqualifying offense); or

(ii) The direct-service PTV employee or applicant has been convicted of or pleaded guilty to a disqualifying offense and one of the following criteria is met:

(a) The individual has satisfied the conditions associated with any applicable exclusionary periods set forth in rule 5160-1-17.8 of the Administrative Code; or

(b) The individual has obtained a certificate of qualification for employment in accordance with section 2953.25 of the Revised Code or an equivalent certification issued by another state or federal jurisdiction; and

(d) A search substantiates that no PTV, PTV owner/manager, or direct-service PTV employee or applicant is currently listed as sanctioned or excluded in either of the following databases:

(i) The system for award management (SAM) maintained by the United States general services administration; or

(ii) The list of excluded individuals and entities (LEIE) maintained by the office of inspector general in the United States department of health and human services.

(C) Not later than thirty calendar days either after a contract period has started or after a criminal background check and database search have been performed for an applicant, the CDJFS documents and submits to the department or its designee the relevant information indicated in paragraph (B) of this rule, in the format specified by the department or its designee.

Last updated March 22, 2024 at 10:33 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2026
Prior Effective Dates: 7/1/2021

Rule 5160-15-21 | Transportation: services from an eligible provider: conditions of provider participation.

• Effective: July 1, 2021
• Promulgated Under: 119.03

(A) Definition. "Eligible provider" has the same meaning as in rule 5160-1-17 of the Administrative Code.

(B) Transportation-specific criteria. For each entity enrolled as an eligible provider of transportation services, the following conditions are met:

(1) The entity, each crew member, and each attendant comply with all applicable local, state, and federal laws, regulations, and rules, including all applicable provisions developed in accordance with Chapter 4765. or Chapter 4766. of the Revised Code;

(2) Each vehicle meets all applicable permit provisions developed in accordance with Chapter 4766. of the Revised Code; and

(3) If the entity provides ground ambulance services, it is also enrolled in medicare as an ambulance service provider or supplier.

(C) Rendering provider. 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 organization.

(D) Billing ("pay to") provider. 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 organization.

(E) Prescribing or referring provider.

(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 needs a mobility device.

Last updated July 1, 2021 at 11:02 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2026
Prior Effective Dates: 8/15/1982, 12/1/1990, 5/1/1992 (Emer.), 8/13/1992, 1/1/1994, 12/31/2001, 4/1/2016

Rule 5160-15-22 | Transportation: services from an eligible provider: wheelchair van services.

• Effective: July 1, 2021
• Promulgated Under: 119.03

(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 conditions 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 needs to be accompanied by a mobility-related assistive device from the point of pick-up to the point of drop-off. This need is demonstrated by the following indicators:

(a) The mobility device is dropped off or picked up along with the medicaid-eligible individual at the location where the medicaid-coverable service is obtained; and

(b) The medicaid-eligible individual rides in or on the mobility device when moving between the wheelchair van and the location where the medicaid-coverable service is obtained.

(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, and the transportation provider maintains documentation of such necessity.

Last updated July 1, 2021 at 11:02 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2026
Prior Effective Dates: 12/30/2005 (Emer.)

Rule 5160-15-23 | Transportation: services from an eligible provider: ground ambulance services.

• Effective: July 1, 2021
• Promulgated Under: 119.03

(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) Any other non-emergency ground ambulance service is determined to be necessary if the individual needs at least one of the following services during transport:

(i) Medical treatment or continuous supervision by an EMT;

(ii) The administration or regulation of oxygen by another person; or

(iii) Supervised protective restraint.

(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, and the transportation provider maintains 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.

Last updated July 1, 2021 at 11:03 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2026
Prior Effective Dates: 5/9/1986, 7/5/1993, 3/1/2000, 3/27/2006, 4/1/2016

Rule 5160-15-24 | Transportation: services from an eligible provider: air ambulance services.

• Effective: July 1, 2021
• Promulgated Under: 119.03

(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 necessary because the medicaid-eligible individual is critically ill or has critical injuries; 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 needed 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.

Last updated July 1, 2021 at 11:03 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2026
Prior Effective Dates: 3/27/2006

Rule 5160-15-25 | Transportation: services from an eligible provider: points of transport.

• Effective: July 1, 2021
• Promulgated Under: 119.03

(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;

(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, the office of a group of health professionals, 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 are specified in accordance with current claim-submission instructions.

(1) A claim submitted for a wheelchair van service or an ambulance service is subject to 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 a claim for a service involving an origin or destination not listed in paragraph (A) of this rule if they indicate that fact explicitly on the claim.

(3) A request for manual review of a claim for a transportation service includes 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.

Last updated July 1, 2021 at 11:03 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2026
Prior Effective Dates: 4/7/1977, 7/5/1993, 3/1/2000, 10/1/2003

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

• Effective: July 1, 2021
• Promulgated Under: 119.03

(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) Mileage payment for a non-emergency transport (either by wheelchair van or by ground ambulance) that is longer than fifty miles from the point of pick-up will be limited to fifty miles unless a transportation provider maintains additional documentation that justifies the distance.

(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 are subject to manual review.

(E) Claims for loaded mileage are to represent, individually and collectively, only the distance that 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 should be allocated in a reasonable, consistent manner.

(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 indicates 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 can be made only 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) can 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.

Last updated July 1, 2021 at 11:03 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2026
Prior Effective Dates: 4/1/2016

Rule 5160-15-27 | Transportation: services from an eligible provider: documentation.

• Effective: July 1, 2021
• Promulgated Under: 119.03

(A) Certification is needed to confirm the necessity of wheelchair van services and most non-emergency ambulance services. No certification is needed 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 medicaid managed care organization (MCO) is not obliged 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 MCO.

(B) For transportation services that need certification but are not furnished to a medicaid-eligible individual enrolled in an MCO, 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), is 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), is 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 needed, then the transportation provider obtains a completed, signed, and dated practitioner certification form before submitting a claim.

(a) The date shown on the form is the actual date of signature.

(b) The date of signature cannot be 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, are to add the practitioner's name as well as their own signature and professional designation (such as MD, DO, DPM, RN, APN, PA, LSW).

(e) 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) Certification cannot create a conflict of interest for the practitioner. No person employed by, under contract with, serving in a volunteer capacity for, or otherwise associated with a transportation provider can certify the necessity of a service furnished by that provider.

(4) A transportation provider may submit a claim to the Ohio department of medicaid (ODM) 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.

(5) 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.

(6) If a change in a medicaid-eligible individual's status renders the current practitioner certification form obsolete, then a new form is to be completed.

(7) 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.

(8) A patently incorrect practitioner certification form is invalid, even if it is signed.

(9) 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.

(10) Certification is not transferrable between medicaid-eligible individuals or transportation providers.

(C) Each transportation provider is expected to maintain documentation that fully accounts for the services provided. No payment is to be made for a service for which a transportation provider fails to obtain necessary documentation before submitting a claim to ODM or to an MCO. All records and documentation related to transportation services are subject to retention provisions set forth in Chapter 5160-1 of the Administrative Code.

(D) Each transportation provider is to 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 ODM or an MCO to substantiate compliance with any provision in this chapter, then ODM may terminate or deny reinstatement of the medicaid provider agreement in accordance with rule 5160-1-17.6 of the Administrative Code and may seek repayment for undocumented services.

Last updated July 1, 2021 at 11:04 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2026
Prior Effective Dates: 12/30/1977, 5/9/1986, 5/1/1992 (Emer.), 8/13/1992, 4/1/1994, 3/27/2006

Rule 5160-15-28 | Transportation: services from an eligible provider: payment.

• Effective: January 1, 2024
• Promulgated Under: 119.03

(A) 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.

(B) The amount of payment for a transportation service furnished by an eligible provider under an arrangement with a medicaid managed care organization (MCO) is determined by the provider agreement established in accordance with Chapter 5160-26 of the Administrative Code.

View Appendix

Last updated January 2, 2024 at 9:01 AM

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/1/2026
Prior Effective Dates: 8/15/1982, 1/13/1989 (Emer.), 12/1/1990, 4/1/1994, 12/27/2001, 10/1/2003, 12/30/2005 (Emer.), 7/1/2008, 4/1/2016