Current through Register Vol. 30, No. 38, September 20, 2024
A. Emergency
ambulance services.
1. A member shall receive
medically necessary emergency transportation in a ground or air ambulance:
a. To the nearest appropriate provider or
medical facility capable of meeting the member's medical needs, and
b. If no other appropriate means of
transportation is available.
2. The Administration or a member's
contractor shall reimburse a ground or air ambulance transport that originates
in response to a 911 call or other emergency response system:
a. If the member's medical condition
justifies the medical necessity of the type of ambulance transportation
received,
b. The transport is to
the nearest appropriate provider or medical facility capable of meeting the
member's medical needs, and
c. No
prior authorization is required for reimbursement of these
transports.
3. The
member's medical condition at the time of transport determines whether the
transport is medically necessary.
4. A ground or air ambulance provider
furnishing transport in response to a 911 call or other emergency response
system shall notify the member's contractor within 10 working days from the
date of transport. Failure of the provider to provide notification is cause for
denial.
5. Notification to the
Administration of emergency transportation provided to a FFS member is not
required, but the provider shall submit documentation with the claim that
justifies the service.
B. The Administration or a contractor covers
air ambulance services only if at least one criterion in subsection (B)(1) is
met and at least one criterion in subsection (B)(2), or the criterion in
subsection (B)(3) is met. The criteria are:
1.
The air ambulance transport is initiated at the request of:
a. An emergency response unit,
b. A law enforcement official,
c. A clinic or hospital medical staff member,
or
d. A physician or practitioner,
and
2. The point of
pickup:
a. Is inaccessible by ground
ambulance, or
b. Is a great
distance from the nearest hospital or other provider with appropriate
facilities to treat the member's condition and ground ambulance service will
not suffice, or
3. The
medical condition of the member requires immediate intervention from emergency
ambulance personnel or providers with the appropriate facilities to treat the
member's condition.
C.
Coverage of medically necessary nonemergency transportation is limited to the
cost of transporting the member to an appropriate provider capable of meeting
the member's medical needs.
1. As specified in
contract, a contractor shall arrange or provide medically necessary
nonemergency transportation services for a member who is unable to arrange
transportation to a service site or location.
2. For a fee-for-service member, the
Administration shall authorize medically necessary nonemergency transportation
for a member who is unable to arrange transportation to a service site or
location.
D. For the
purposes of this subsection, an individual means a person who is not in the
business of providing transportation services such as a family or household
member, friend, or neighbor. The Administration or a contractor shall cover
expenses for transportation in traveling to and returning from an approved and
prior authorized health care service site provided by an individual if:
1. The transportation services are authorized
by the Administration or the member's contractor or designee,
2. The individual is an AHCCCS registered
provider, and
3. No other means of
appropriate transportation is available.
E. The Administration or a contractor shall
cover expenses for meals, lodging, and transportation for a member traveling to
and returning from an approved health care service site outside of the member's
service area or county of residence.
F. The Administration or a contractor shall
cover the expense of meals, lodging, and transportation for:
1. A family member accompanying a member if:
a. The member is traveling to or returning
from an approved health care service site outside of the member's service area
or county of residence; and
b. The
meals, lodging, and transportation services are authorized by the
Administration or the member's contractor or designee.
2. An escort who is not a family member as
follows:
a. If the member is travelling to or
returning from an approved and prior authorized health care service site,
including an inpatient facility, outside of the member's service area or county
of residence;
b. If the escort
services are authorized by the Administration or the member's contractor or
designee; and
c. Wage paid to an
escort as reimbursement shall not exceed the federal minimum wage.
G. A provider shall
obtain prior authorization from the Administration for transportation services
provided for a member for the following:
1.
Medically necessary nonemergency transportation services not originated through
a 911 call or other emergency response system when the distance traveled
exceeds 100 miles (whether one way or round trip); and
2. All meals, lodging, and services of an
escort accompanying the member under this Section.
H. A charitable organization routinely
providing transportation service at no cost to an ambulatory or chairbound
person shall not charge or seek reimbursement from the Administration or a
contractor for the provision of the service to a member but may enter into a
subcontract with a contractor for medically necessary transportation services
provided to a member.
