Illinois Administrative Code
Title 89 - SOCIAL SERVICES
Part 140 - MEDICAL PAYMENT
Subpart L - UNAUTHORIZED USE OF MEDICAL ASSISTANCE
Table A - Criteria for Non-Emergency Ambulance Transportation
Current through Register Vol. 48, No. 38, September 20, 2024
a) To be eligible for non-emergency ambulance transportation, all other means of transportation, including taxi, wheelchair van, stretcher van or private automobile, must be contraindicated by the Department, a contracted MCO or their transportation broker.
b) In addition to adherence to the criteria in subsection (a), at least one of the following criteria shall be met. The criteria selected shall be supported by the patient's diagnosis, condition or treatment, as documented in the patient's medical record, and shall establish the need for non-emergency ambulance transportation service. Non-emergency ambulance transportation service will only be approved when clinical observation or treatment, as set forth in the criteria in this subsection (b), are medically necessary at the transferring facility and during transport, and are expected to be medically necessary at the destination. Examples for each criteria are provided for guidance, but are not intended to be an all-inclusive or an all exclusive list.
EXAMPLE - Inclusion: This criterion includes a patient who has a condition of methicillin-resistant Staphylococcus aureus (MRSA) infection, who is currently undergoing treatment for the infectious condition and who continues to have symptoms, such as cough, drainage or fever.
EXAMPLE - Inclusion: A patient with a dangerous communicable disease that has the potential to cause an epidemic or threaten serious illness or death to others if not controlled.
EXAMPLE - Inclusion: This includes a patient when "contact isolation" is ordered for Clostridium difficile diarrhea, often called C. difficile.
EXAMPLE - Exclusion: This criterion does not include a patient who has a history of MRSA or C. difficile, or has been treated for MRSA or C. difficile and is no longer symptomatic.
EXAMPLE - Exclusion: This criterion does not include a patient with surgical drainage complications for which wound care precautions are ordered, unless the patient's surgical complication includes a draining wound that saturates a dressing and requires that the patient be isolated from the public.
EXAMPLE - Exclusion: This criterion does not include a patient who has a surgical dressing, ostomy, G-tube or other dressing that is dry and intact.
EXAMPLE - Exclusion: This criterion does not include a patient who has an order for wound care precautions alone without an order for isolation precautions.
EXAMPLE - Exclusion: This criterion does not include a patient who is incontinent and who requires the use of adult diapers.
EXAMPLE - Inclusion: This criterion includes a patient for whom there is a reasonable medical expectation that the flow rate will need to be adjusted, and who requires pulse oxygen oximetry to guide administered flow rate with a prior order indicating the threshold level at or above which the oxygen saturation should be maintained.
EXAMPLE - Inclusion: This criterion includes a patient who has an order that specifies oxygen is to be administered by mask, nasal cannula or collar over tracheostomy at a specific flow rate (liters per minute).
EXAMPLE - Inclusion: This criterion includes a patient who has supplemental oxygen that is required and is administered prior to transport and for the duration of transport. Included in this group are patients who require third party assistance to administer, regulate or adjust oxygen during transport.
EXAMPLE - Exclusion: This criterion does not include patients who are capable of self-administration of portable or home oxygen or who have an available trained caregiver to administer oxygen.
EXAMPLE - Inclusion: A patient who is quadriplegic that requires advanced airway management including mechanical ventilation during transport.
EXAMPLE - Inclusion: A patient that requires continuous airway support via nasotracheal intubation, endotracheal intubation or tracheostomy, including the need for suctioning or the potential need for suctioning during transport.
EXAMPLE - Inclusion: This criterion includes any patient requiring deep suctioning to maintain the patient's airway.
EXAMPLE - Inclusion: This criterion includes a patient who requires en route suctioning by another person as documented through an order and prior medical condition.
EXAMPLE - Inclusion: This includes a patient who is in need of a secure airway before transport is initiated. Orders should provide specific directives such as assisted ventilation settings, oxygen concentration or flow rate and need for pulse oximetry.
EXAMPLE - Exclusion: This criterion does not include a patient who requires en route suctioning that can be administered by a trained caregiver available to travel with the patient.
EXAMPLE - Exclusion: This criterion does not include a patient who has a longstanding established tracheostomy with spontaneous respiratory effort without need for any type of assisted ventilation or that does not require medical monitoring or suctioning.
EXAMPLE - Inclusion: This criterion includes a patient who has orders that specify the type of intravenous fluids, rate of administration and site through which the fluids are to be administered.
EXAMPLE - Inclusion: This criterion includes intravenous fluid administration that is required during transport.
EXAMPLE - Exclusion: This criterion does not include a patient with a saline lock, a heparin lock, a peripherally inserted central catheter (PICC) or an infusion port for which ongoing administration of intravenous fluids or chemotherapy is not required during the transport to the destination.
EXAMPLE - Inclusion: This criterion includes a patient when the chemical restraint administered requires close surveillance of a patient's cardio-respiratory status, due to the central nervous system or respiratory system depressant resulting from the chemical restraint administered, prior to or during transport.
EXAMPLE - Exclusion: This criterion does not include a patient receiving the administration of psychotropic medications routinely taken for a pre-existing mental illness, unless there is an acute exacerbation of a psychiatric condition.
EXAMPLE - Exclusion: This criterion does not include a patient receiving the administration of routinely taken sedative medications.
EXAMPLE - Inclusion: This criterion includes a patient with an order for physical restraint administered for the explicit purpose of reducing a patient's functional capacity because the patient presents a danger to the physical safety of himself or herself and/or others during transport. This criterion requires an order for the type of physical restraint and monitoring required during the transport.
EXAMPLE - Inclusion: This criterion includes a patient being transported from or to a restrained facility, holding center or lockdown facility.
EXAMPLE - Exclusion: This criterion does not include a patient with an order for simple safety straps.
EXAMPLE - Inclusion: This criterion includes a patient who has a psychiatric condition or disease who is receiving medical care for an acute psychiatric crisis.
EXAMPLE - Exclusion: This criterion does not include a patient who has a history of a psychiatric condition but is not in an acute psychiatric crisis or condition.
EXAMPLE - Exclusion: This criterion does not include a patient who has a diagnosis of dementia, including Alzheimer's disease, other altered mental status or neurological condition, who is easily directed.
EXAMPLE - Inclusion: This criterion includes a patient who has been monitored via telemetry at the transferring facility for an arrhythmia, who continues to need telemetry monitoring during the transport, and who is expected to require telemetry monitoring after transport.
EXAMPLE - Inclusion: This criterion includes a patient who has an order for hemodynamic monitoring during transport.
EXAMPLE - Inclusion: This criterion includes a patient who has received a central nervous system and/or respiratory system depressant medication who requires cardiac and/or respiratory or hemodynamic monitoring. This criterion requires the documentation of the name, dosage, route, date and time of the medication administered. It also requires an order for the specific type of monitoring required.
EXAMPLE - Exclusion: This criterion does not include a patient who was not receiving cardiac monitoring or hemodynamic monitoring at the transferring facility and who is not expected to require cardiac monitoring or hemodynamic monitoring at the destination.
EXAMPLE - Inclusion: This includes a patient who requires specialized handling and positioning during transport, as well as the assistance of medically trained personnel to avoid further injury during transport. This criterion requires an order that documents the significant mobility deficit and the type of special positioning required.
EXAMPLE - Inclusion: The patient's diagnosis and the order for non-emergent ambulance transportation supports the need for special positioning due to contractures, spica cast, recent extremity fractures (e.g., post-operative hip) or other conditions, and the specific type of positioning required prior, during and after transport is appropriately documented in a order.
EXAMPLE - Inclusion: The criterion includes a patient utilizing an orthopedic device due to a medical condition requiring the use of a backboard or in halo traction. This criterion also includes patients who have external fixation, including external traction devices, which make it impractical for the patient to be positioned in a wheelchair or standard car seat. This criterion requires an order for non-emergent ambulance transportation and specialized handling for an orthopedic device or condition. The order must include the specific type of positioning required at the time of transport and through transport to the destination.
EXAMPLE - Inclusion: The criterion includes a patient with a medical diagnosis of multiple myeloma who has a history of pathologic fractures compromising his or her spinal cord causing paraplegia.
EXAMPLE - Exclusion: This criterion does not include a patient who is bed confined* but for whom there is no order or need for medical care, aid, monitoring or treatment during transport as detailed in any of the above criteria.
* Terms such as bedridden, bed confined, stretcher patient or required restraints do not, by themselves, support medical necessity. The determining factor is the condition of the patient. In addition, "bed confined" is not meant to be the sole criterion to be used in determining medical necessity.
EXAMPLE - Exclusion: This criterion does not include a quadriplegic or paraplegic patient who can be transported by wheelchair or stretcher, who does not meet any of the other criteria in this listing, or who does not have an order for special positioning or medical monitoring.
EXAMPLE - Exclusion: This criterion does not include a patient who has a Foley catheter, a G-tube, or other medical equipment for which there is no medical need or order for monitoring during transport.
EXAMPLE - Exclusion: This criterion does not include the transport of a patient with a stage I or II decubitus ulcer on the buttock with a travel time less than one hour.
EXAMPLE - Exclusion: This criterion excludes a patient transferring from a hospital to a long term care facility that does not require clinical observation or treatment as set forth in this subsection (b)(11).
