Current through all regulations passed and filed through September 16, 2024
(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.
