Current through Register Vol. 63, No. 9, September 1, 2024
(1) The Authority
may enroll governmental transportation brokerages (local units of government)
or other entities contracted with the Authority as a "contractor" to arrange
rides. Transportation brokerages pay subcontractors for NEMT services. The
Authority may limit the enrollment with transportation brokerages to units of
local government; Transportation brokerages shall be enrolled as an Oregon
Health Plan (OHP) provider and meet all requirements of OAR
410-120-1260 prior to delivering
NEMT services or receiving payment. A governmental transportation brokerage
signing the Provider Enrollment Agreement constitute agreement to comply with
all applicable Authority OHP provider rules and federal and state laws and
regulations.
(2) The actions
described in this rule may not be delegated and must be performed by the
brokerage contracted with the Authority. The brokerage shall:
(a) Prior authorize and pay subcontractors
for the least costly but most appropriate mode of transport for the client's
medical needs to and from an OHP covered medical service. The most appropriate
and least costly ride may include requiring the client to share the ride with
other clients;
(b) Verify that the
client is obtaining OHP covered medical services in the client's local
area;
(c) Verify the client's OHP
eligibility and that the client's benefit package includes NEMT services on the
scheduled date of service for the requested transport. The brokerage shall
verify this through electronic eligibility information with the Authority
Electronic Data Interchange (EDI);
(d) Assess the client's access to other means
of transportation, such as driving their own car or getting a ride from a
friend, family member or neighbor;
(e) Verify the client's attendance for
continuing requests for rides if the medical provider could not affirm an
appointment for a previous ride;
(f) Schedule a ride with an alternate
subcontractor if the subcontractor originally assigned is unable to provide the
ride; and
(g) Assign rides to the
subcontractor based on an evaluation of several factors including, but not
limited to:
(A) Cost;
(B) The client's need for appropriate
equipment and transportation;
(C)
Any factors related to a subcontractor's capabilities, availability, and past
performance; and
(D) Any factors
related to the brokerage's need to maintain sufficient service capacity to meet
client needs.
(4) Pursuant to OAR
410-120-1210, Medical Assistance
Benefit Packages and Delivery System, clients receiving the Qualified Medicare
Beneficiary (QMB) only benefit package are not eligible for NEMT.
(5) The brokerage shall maintain records of
prior authorization approval and denials of NEMT services. The brokerage shall
also include the reasons for authorizing a ride:
(a) That is not cost effective or not based
on the factors specified in section (2) of this rule;
(b) With more than two (2) attendants for an
ambulance or stretcher car; or
(c)
With more than one (1) attendant for a wheelchair van.
(6) The brokerage shall provide a ride to a
client to fill prescription medication only in the following situation:
(a) The client needs to stop on the way home
to fill or pick up prescribed medication related to the covered service for
which the brokerage provided the ride;
(b) It is medically necessary to fill or pick
up the medication immediately; and
(c) The pharmacy is located on the return
route or is the closest pharmacy to the return route.
(7) The brokerage may provide a ride to a
client to fill prescribed medication under the following situations:
(a) The brokerage asks the client if the
prescription service is available through the Authority's contracted postal
prescription service, and the client responds that it is not available through
that source;
(b) The client has an
urgent need to fill or pick up prescribed medication because the postal
prescription service mailed the wrong medication, or the client has an
unexpected problem caused by the medication; or
(c) The client is transient or without
regular access to a mailbox. In this situation, the brokerage may evaluate the
need on a case-by-case basis.
(8) The brokerage shall provide rides outside
the brokerage's local service area as described in section (2)(b) of this rule,
under the following circumstances:
(a) The
client is receiving a covered service that is not available in the service or
local area but is available in another area of the state;
(b) The client is receiving a covered service
in California, Idaho, or Washington where the service location is no more than
75 miles from the Oregon border; or
(c) No local medical provider or facility
will provide the covered services for the client.
(9) Brokerages may coordinate to provide a
return ride to a client who receives a covered service outside the client's
local area.
(10) Brokerages shall
retroactively authorize and pay for NEMT services that have already occurred
only when the brokerage could not prior authorize the service because the
brokerage was closed, and the request for authorization is received by the
brokerage within thirty (30) days of the date of service. The brokerage shall
confirm with the medical provider that one of the following circumstances
supported the ride:
(a) The client needed
urgent medical care;
(b) The client
required secured transport pursuant to OAR
410-136-3120, Secured
Transports; or
(c) The client was
in a hospital, and the hospital discharged or transferred the client.
(11) In addition to section (10)
of this rule, a brokerage shall retroactively authorize NEMT services for
ambulance transports when:
(a) An ambulance
provider responds to an emergency call, but the client's medical condition does
not warrant an emergency transport;
(b) The ambulance provider transports the
client as a NEMT service; and
(c)
The ambulance provider requests retroactive authorization within thirty (30)
days of the NEMT date of service.
(12) Brokerages shall not authorize or pay
subcontracted providers for rides outside their service areas based only on
client preference or convenience.
(13) Brokerages shall provide toll-free call
centers for clients to request rides. Brokerages shall have written policies
and procedures regarding its NEMT services that include all the requirements in
this rule. Brokerages shall meet all the following requirements pertaining to
the brokerage's call center and scheduling of rides:
(a) The call center shall operate at a
minimum Monday through Friday from 9:00 a.m. to 5:00 p.m., but the brokerage
may close the call center on New Year's Day, Memorial Day, July 4th, Labor Day,
Thanksgiving, and Christmas. The Authority may approve, in writing, additional
days of closure if the brokerage requests the closure at least thirty (30) days
in advance.
(b) Brokerages shall
make all reasonable efforts for clients to have access to available NEMT
services 24 hours a day. When the call center is closed, the brokerages shall
provide a recording or answering service in at a minimum, English and Spanish,
to refer the client directly to a subcontractor. If no subcontractor is
available, the brokerage must provide clients with recorded information in at a
minimum, English and Spanish, about service hours and how to reach emergency
services by calling 911;
(c) The
brokerage shall allow a client or their representative to schedule rides at
least ninety (90) days in advance of the covered service;
(d) The brokerage shall allow a client or
their representative to request multiple ride requests at one time;
(e) The brokerage shall develop and make all
policies and procedures regarding its NEMT services available to clients either
in a OHP Open Card Member Handbook or in a stand-alone document referred to as
a "OHP Open Card NEMT rider guide" that meets the delivery and content
specifications defined by the Authority. The brokerage's written policies and
procedures regarding NEMT services must be shared to subcontractors and shall
be available upon request to the Authority for review.
(f) Allow a client or their representative,
including providers in accordance with OAR
410-172-0780, to schedule:
(A) NEMT services up to ninety (90) days in
advance;
(B) Multiple NEMT services
at one time for recurring appointments up to ninety (90) days in advance;
and
(C) Same-day NEMT
services.
(g) Comply
with the following criteria for client drop-offs and pick-up protocols. A
brokerage or subcontractors' drivers are not permitted to:
(A) Drop off a client at an appointment more
than 15 minutes prior to the office or other facility opening for business
unless requested by the client or, as applicable, the client's guardian,
parent, or representative; and
(B)
Pick up a client from an appointment more than 15 minutes after the office or
facility closes for business unless the appointment is not reasonably expected
to end within 15 minutes after closing, or as requested by the client, or as
applicable, the client's guardian, parent, or representative.
(h) The brokerage shall provide to
the client, or as applicable, the client's guardian, parent, or representative
the name of subcontractor, or name and telephone number of the driver when
available;
(i) The brokerage shall
confirm the scheduled pick-up time and address with the client;
(j) The brokerage shall make reasonable
efforts to arrange a ride requested on the day of the medical service when the
service is:
(A) For an urgent medical
condition; and
(B) Due to the
urgency of the medical condition, the client scheduled an immediate medical
appointment.
(14) The brokerage is not responsible for
providing emergency medical transportation services. However, brokerages shall
have procedures for referring clients requesting emergency medical
transportation services to the appropriate emergency transportation resources
and procedures for subcontractors per OAR
410-136-3040, Vehicle Equipment
and Subcontractor Standards.
(15)
The Authority shall collaborate with brokerages and CCOs to develop and conduct
a statewide client NEMT satisfaction survey at least once every two years. The
Authority may contract with one or more brokerages, or a third party, to
conduct the survey. The Authority shall use the results of the survey to
identify and address potential operational deficiencies and to identify and
share successes in the NEMT program.
(16) Brokerages shall establish regional
advisory groups consisting of representatives from the Authority, ODHS, Area
Agencies on Aging, consumers, representatives of client advocacy groups from
within the service or local area, brokerage subcontractors, and providers of
NEMT ambulance services. The role of the group includes, but is not limited to:
(a) Assisting in monitoring and evaluating
the NEMT program; and
(b)
Recommending potential policy or procedure changes and program improvements to
brokerages and the Authority and assisting in prioritizing those changes and
improvements.
(17)
Brokerages shall have the discretion to use or not use Oregon Department of
Human Services (ODHS)-approved volunteers. ODHS shall provide brokerages with a
list of approved and trained volunteers. ODHS shall supervise the volunteers
and assumes all liability for each volunteer as provided by law.
(18) Brokerages or their subcontractors shall
not bill eligible client for any NEMT service to and from a covered service or
any transports where the Authority denies reimbursement. Brokerages or their
subcontractors shall not collect payment from the client, or assign an unpaid
claim to a collection agency, or similar entity pursuant to ORS
414.066.
(19) On a minimum of five percent of the ride
requests, brokerages shall contact medical providers to verify appointments and
that the appointments are for covered medical services.
(20) Brokerages may purchase tickets for
common carrier transportation, such as inter- or intra-city bus, train, or
commercial airline when deemed cost effective and safe for the
client.
Statutory/Other Authority: ORS
413.042
Statutes/Other Implemented: ORS
414.065
