New Hampshire Code of Administrative Rules
He - Department of Health and Human Services
Subtitle He-W - Former Division of Human Services
Chapter He-W 500 - MEDICAL ASSISTANCE
Part He-W 574 - GENERAL MEDICAL TRANSPORTATION
Section He-W 574.09 - Extenuating Circumstances
Universal Citation: NH Admin Rules He-W 574.09
Current through Register No. 40, October 3, 2024
(a) Notwithstanding He-W 574.04(d) and (e) , respectively, the department shall allow general medical transportation reimbursement payments under the following conditions and in accordance with this section:
(1) The recipient found it necessary to take
more than one trip per day; and
(2)
The point of origin of the medical transportation is not the recipient's
residence.
(b) The recipient shall provide following documentation when the recipient found it necessary to take more than one trip in a day:
(1) The recipient's name and
address;
(2) The recipient's
medicaid identification number; and
(3) Either:
a. A letter from the medicaid enrolled
provider which includes details regarding the necessity of the second trip
sufficient to enable the department to understand the necessity of the second
trip; or
b. A letter from the
medicaid enrolled provider which includes details regarding a referral made to
another medicaid enrolled provider who was able to see the recipient the same
day.
(c) The recipient shall provide following documentation when the point of origin is not the recipient's address:
(1) The recipient's
name and address;
(2) The
recipient's medicaid identification number; and
(3) Either:
a. A statement, signed by the recipient and
the medicaid enrolled provider, containing sufficient detail to enable the
department to understand the need for medical or dental services and why the
point of origin was not the recipient's residence; or
b. If the recipient must provide care for
another party at the residence of the other party, and this is the reason why
the transportation was not the recipient's residence:
(i) A statement from the other party's
medicaid enrolled provider of the necessity of and the amount of time of the
care provided by the recipient for the other party; and
(ii) A statement, signed by the recipient and
the recipient's medicaid enrolled provider, containing sufficient detail to
enable the department to understand that the need for medical or dental
services.
(See Revision Note at chapter heading He-W 500); ss by #6163, eff 1-4-96, EXPIRED: 1-4-04
New. #8732, eff 9-30-06
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