Non-Emergency Medical. Transportation. Transportation. Transportation Benefit Manager Department of Health Care Policy and Financing.

Transcription

1 Non-Emergency Medical 2013 Doug van Hee Benefit Manager Department of Health Care Policy and Financing

2 Training Objectives Understand: Difference between Emergency and Non- Emergency County responsibilities Modes of Role of First Transit Additional services

3 Health Emergency Emergency Sudden Unexpected Requires immediate medical attention because a person s life, bodily functions, or overall health are in serious jeopardy Bells and Whistles

4 Emergency Medical (EMT) Includes: Ambulance Air Ambulance Requires a physician s statement of medical necessity or trip report Subject to audit Billed directly to the fiscal agent Does not require a Prior Authorization Request (PAR)

5 Non-Emergency Medical (NEMT) ALL NEMT MUST BE APPROVED BY THE COUNTY OR BROKER PRIOR TO THE TRIP TAKING PLACE. Who qualifies for NEMT: All fully benefitted Medicaid clients that have no other means of transportation to and/or from Medicaid appointments. Who does not qualify for NEMT: Clients under the following Medicaid programs do not qualify: CHP+, QMB, SLMB, QI-1 and OAP-state only.

6 NEMT to and/or from Medicaid treatment that is not an emergency in nature Scheduled; including urgent care Only available when the client has no other means of transportation

7 NEMT The following are not benefits of the Colorado Medicaid NEMT Program: Waiting time Charges when the client is not in vehicle when not medically necessary

8 IMPORTANT! Non-medical transportation may be covered for eligible clients under the HCBS Waiver Program For more information refer to the HCBS Billing Manual

9 QUESTIONS?

10 Counties As the State Designated Entity (SDE) the Department of Human/Social Services in each county is federally mandated to provide NEMT for any Medicaid client that has no other means of transportation The SDE is required to query clients requesting NEMT to determine if the client is being transported to a Medicaid covered service that all means of accessing other transportation have been exhausted by the client

11 Counties: Basic NEMT Requirements EACH COUNTY MUST: Verify with the physician s office that each appointment is medically necessary and a benefit of the Colorado Medical Assistance Program Each appointment is to the closest, most medically appropriate provider Although current provider-client relationship does need to be considered The mode of transportation must be the least costly, most medically appropriate option Documentation must be available for audit to verify the above information.

12 Counties: Denial Procedure SDEs are required to inform clients, in writing, of any benefitted transportation service that is being denied The denial letter must include: Why the service was denied Client Appeal Right language and instructions Can be found on the back of all formal claim denials sent from Xerox, on the Department s Website, or in the HCPF Operations Manual

13 Counties Some counties have elected to opt out of their transportation administration duties by contracting with private transportation brokers This is an option for counties as long as NEMT services continue to be provided to all qualified Medicaid clients, follow all applicable regulations and there is no additional cost to the Colorado Medicaid Program SDEs must adhere to the current transportation rules, guidelines and rates established by Medicaid

14 Counties It is the responsibility of the SDE to stay informed via Bulletins, Agency Letters, and through the web portal

15 QUESTIONS?

16 First Transit The nine counties under First Transit s brokerage are: Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, Jefferson, Larimer and Weld providers serving the nine front range counties do not bill Medicaid for NEMT All NEMT services for the nine front-range counties must be authorized, approved, arranged and paid through First Transit * First Transit is the only official Medicaid NEMT broker

17 First Transit First Transit Reservation Line: CO4-NEMT ( ) Comment Line: (1-855-NEMT-1 st ) Or visit their website at:

18 QUESTIONS?

19 Modes of NEMT includes: Standard vehicle Wheelchair van Non-emergency ambulance Taxi Intra/Inter-State Train or Bus Plane Gas reimbursement for private vehicle usage Public Transit tokens or passes The appropriate mode of transportation is determined by the client s physician.

20 Modes Standard vehicles are provided when the client has no transportation and it is the least costly, most appropriate mode for their condition. A wheelchair van is a benefit only when: The client is a physician verified wheelchair user and The vehicle has been appropriately modified to transport wheelchair users only.

21 Modes A wheelchair van must be specifically designated to accommodate the needs of wheelchair users only Unlike standard vehicles, wheelchair van service is not regulated by the Public Utilities Commission (PUC) Oxygen administration can only be billed when medically necessary and it is the wheelchair van s oxygen Submit claims for wheelchair van and oxygen together

22 Public Transit Public Transit tokens or passes are available when this is the least expensive, most appropriate mode for a client. Passes can be used when multiple trips can be scheduled at one time and it is most cost effective. Reimbursement consideration: Only when every citizen would be charged for the service will Medicaid reimburse for the trip. Example: if a local organization provides free rides, they cannot bill Medicaid for a client, they must charge every rider, every time in order to bill Medicaid.

23 Non-Emergency Bus and Train Benefits are provided when: Client is traveling a great distance or; Client s condition prohibits transporting by other less costly means of NEMT or; It is the least costly means of transportation Bus or Train No PAR required ; unless traveling out of state

24 Mileage Reimbursement The SDE must also obtain copies of the following information before reimbursement of personal vehicle mileage Name and address of vehicle owner Policy number and name of the insurance carrier Driver s license number and expiration date for the driver of the vehicle (For auditing purposes, documentation must be kept on file for 6 years)

25 Mileage Reimbursement For purposes of continuity, we suggest calculating mileage by using an online mapping service or a GPS device Refer to the October 2007 Bulletin B The trip must be the most direct route to and/or from the medical appointment with the closest qualified provider The appointment must be a benefit of the Colorado Medical Assistance Program

26 Multiple Riders When taxi or standard vehicle services are provided to more than one client, multiple rider exceptions apply: Client traveling farthest distance is reimbursed at the full rate The client traveling the second farthest distance is reimbursed at ½ the rate Any additional client shall be reimbursed at ¼ the rate of the first client No Prior Authorization Request (PAR) required

27 Out-of-State If a patient requires out-of-state hospitalization, please contact: ColoradoPAR Program to find out if the out of state location is authorized and what forms need to be completed. Provider must also verify the out of state service has been prior authorized ALL Non-Emergency Medical PARs are to be submitted online directly to the ColoradoPAR Program at Phone Number: Fax Number:

28 Air Modes: Air Ambulance, Helicopter or Commercial Air. PAR required (*Hospital to Hospital transports do not require a PAR and can be billed directly by the hospital) PAR must be completed by the SDE and submitted to ColoradoPAR Program online at

29 Air Benefits are provided when: Point of pickup is inaccessible by land vehicle, great distances prohibit transporting Great distances prohibit transporting client to nearest appropriate location and client needs immediate attention Patient is suffering from an illness that makes other forms of transportation inadvisable

30 QUESTIONS?

31 Additional Services Additional Services Out-of-State transportation Over-the-Cap Expenses (bariatric & mental health) Ancillary Services (Meals and Lodging) Ronald McDonald House provides free food/meals.

32 Ancillary Services Ancillary services are supplemental services that are a benefit in addition to transportation. Ancillary services: Meals and lodging Only approved if the trip cannot be completed in one calendar day. Clients staying at RMH are expected to make use of the free meals available to them. Escort: May be available for at-risk adults or children.

33 Over-the-Cap Expenses Over the cap expenses exceed the maximum allowable -Examples include specialized transport (i.e. bariatric ambulance) or Air Ambulances Mental health hold clients only qualify when being transported to Fort Logan or the State facility in Pueblo

34 Health Care Policy and Financing s Home Page The Department s web site links to: Departmental Reference Material - Volume 8 Regulations Staff Resources Directory The Provider Web Portal Click on the Providers tab on the menu at the top of the web page to navigate to the Provider Services tab for Information Documents Publications

35 QUESTIONS?

36 This is the end of the road, Thank You! Doug van Hee & Chris Acker Benefit Manager