Current through all regulations passed and filed through September 16, 2024
(A) Certification
is
needed to confirm the necessity of wheelchair van
services and most non-emergency ambulance services. No certification is
needed
for transportation services furnished by an eligible provider that are
automatically deemed to be necessary in accordance with rule 5160-15-22,
5160-15-23, or
5160-15-24 of the Administrative
Code. A
medicaid managed care organization (MCO) is not
obliged to use the practitioner certification process
described in paragraph (B) of this rule to certify the necessity of a
transportation service furnished to a medicaid-eligible individual enrolled in
the
MCO.
(B)
For transportation services that
need certification but are not furnished to a
medicaid-eligible individual enrolled in an
MCO, a
practitioner certification form is used.
(1)
The nature of the practitioner certification form depends on the type of
transportation service.
(a) For wheelchair van
services, an ODM 03452, "Certification of Necessity for Transportation by
Wheelchair Van" (07/2015),
is used.
(b) For non-emergency ground ambulance
services, documents required by the primary payer of the claim are acceptable;
if medicaid is the primary payer, then an ODM 01960, "Certification of
Necessity for NonEmergency Transportation by Ground Ambulance" (07/2015),
is
used.
(c) For air ambulance
services, any document that includes the information specified in paragraph
(B)(1)(b) of rule
5160-15-24 of the Administrative
Code is acceptable.
(2)
If practitioner certification for a transportation service is
needed, then the transportation provider
obtains a completed, signed, and dated practitioner
certification form before submitting a claim.
(a) The date shown on the form
is
the actual date of signature.
(b)
The date of signature
cannot be more than one hundred eighty days after
the latter of two dates:
(i) The first date of
service; or
(ii) The date on which
the transportation provider learns of the individual's medicaid
eligibility.
(c) In no
case does the date of signature on the practitioner certification form extend
the limits specified in Chapter 5160-1 of the Administrative Code for the
timely filing of claims.
(d)
Persons who sign on behalf of the certifying practitioner, with proper
authority or the approval of the certifying practitioner,
are to
add the practitioner's name as well as their own signature and
professional designation (
such as MD, DO, DPM, RN, APN, PA, LSW).
(e) A
photocopy, an electronic copy, or a facsimile transmittal of the completed,
signed, and dated practitioner certification form is as valid as the original
for documentation purposes.
(3)
Certification
cannot create a conflict of interest for the practitioner. No person employed
by, under contract with, serving in a volunteer capacity for, or otherwise
associated with a transportation provider can certify the necessity of a
service furnished by that provider.
(4) A transportation
provider may submit a claim to the Ohio
department of medicaid (ODM) for a specific
one-way or round-trip transport after having obtained an incomplete
practitioner certification form if the following conditions apply:
(a) The transportation provider has made
three attempts to obtain the completed form;
(b) The transportation provider has allowed
no fewer than thirty calendar days for receipt of a reply after each attempt;
and
(c) The transportation provider
has received no response from the practitioner.
(5)
For wheelchair van services and non-emergency ground ambulance services, a
practitioner may designate one of two certification periods, each of which
begins on the earlier of the date of signature or the first date of service:
(a) Temporary certification for up to ninety
days; or
(b) Ongoing certification
for one year.
(6) If a change in a
medicaid-eligible individual's status renders the current practitioner
certification form obsolete, then a new form is
to be
completed.
(7) No payment is to be made for transportation
services provided during the certification period that do not meet the
certification criteria. For example, payment cannot be made for a transport by
wheelchair van provided during the certification period if no mobility device
is involved.
(8) A patently incorrect practitioner certification
form is invalid, even if it is signed.
(9) False
certification constitutes medicaid fraud. The following examples illustrate
false certification:
(a) For transport by
wheelchair van, certification that a medicaid-eligible individual must be
accompanied by a mobility device is false if the medicaid-eligible individual
in fact has no need for and never uses a mobility device.
(b) For non-emergency transport by ground
ambulance, certification that a medicaid-eligible individual requires medical
treatment or continuous supervision by an EMT during transport is false if such
treatment or supervision could reasonably and appropriately be supplied by
someone who has not had training to the level of an EMT.
(10)
Certification is not transferrable between medicaid-eligible individuals or
transportation providers.
(C) Each transportation provider
is expected
to maintain documentation that fully accounts for the services provided.
No payment is to be made for a service
for which a transportation provider
fails to obtain
necessary documentation before submitting a claim
to
ODM or to an
MCO. All records and documentation
related to transportation services are
subject to retention provisions set forth in Chapter 5160-1 of the
Administrative Code.
(D) Each
transportation provider
is to maintain the following records:
(1) Copies of all certification or licensure
documents required for crew members and attendants, which must be current at
the time of the transport;
(2)
Completed practitioner certification forms, when applicable;
(3) Copies of completed requests for manual
review, when applicable;
(4) The
relevant trip information specified in agency 4766 of the Administrative Code;
and
(5) The following
medicaid-specific trip information:
(a)
Identification of the particular vehicle used;
(b) The name of each wheelchair van
attendant, when applicable;
(c) The
medicaid identification number of each medicaid-eligible individual;
and
(d) For non-emergency trips,
the signature of each medicaid-eligible individual transported.
(E) If a transportation
provider fails to produce documentation requested by ODM or
an
MCO to
substantiate compliance with any provision in this chapter, then
ODM may terminate or deny reinstatement of the
medicaid provider agreement in accordance with
rule
5160-1-17.6
of the
Administrative Code and may seek repayment for undocumented services.
