Current through Register Vol. 24-18, September 15, 2024
(1) The medicaid agency pays for nonemergency
ground ambulance transportation when a client is transferred to a higher level
facility, or when all of the following requirements are met:
(a) The ambulance transportation is medically
necessary. See subsection (3) of this section for documentation
requirements.
(b) The agency pays
for nonemergency ground ambulance transportation with a completed PCS or NPCS
form.
(i) All requests for nonemergency
transports must be directed to the client's primary or attending physician or
health care team who will complete the physician certification statement (PCS)
form or nonphysician certification statement (NPCS) form. See subsection (3) of
this section. The PCS/NPCS form or medical documentation must be maintained in
the client's file.
(ii) In the
event that the provider is unable to obtain the PCS or NPCS, the provider must
maintain evidence of the attempts to obtain the PCS or NPCS in the client's
file.
(2) The
agency pays for nonemergency ground ambulance transportation at the BLS
ambulance level of service under the following conditions:
(a) The client is bed-confined and must be
transported by stretcher or gurney (in the prone or supine position) for
medical or safety reasons. Justification for stretcher or gurney must be
documented in the client's record; or
(b) The client's medical condition requires
that they have basic ambulance level medical attention available during
transportation, regardless of bed confinement.
(3) For nonemergency ambulance services from
a psychiatric unit within a hospital to a behavioral health facility, the
ambulance provider must obtain a licensed mental health professional (LMHP)
(e.g., psychiatrist, MSW) signed PCS or NPCS within forty-eight hours after the
transport.
(4) The agency covers
medically necessary nonemer-gency ambulance services that are either
unscheduled or that are scheduled on a nonrepetitive basis under the following
circumstances:
(a) From any point of origin
to the nearest hospital with the ability to provide the type and level of care
necessary for the client's illness or injury.
(b) From a hospital to the client's home when
the place of residence is a residential care facility, the client must be
transported by stretcher in a prone or supine position, the client is morbidly
obese, or medical attention/monitoring is required in transit.
(c) For a bed-confined client who is
receiving renal dialysis for treatment of end stage renal disease (ESRD), from
the place of origin to the nearest facility with the ability to provide renal
dialysis, including the return trip.
(5) The agency requires ambulance providers
to thoroughly document the medical necessity for use of nonemer-gency ground
ambulance transportation as follows:
(a) For
scheduled, nonemergency ambulance services that are repetitive in nature, the
ambulance provider must obtain a signed PCS from the client's attending
physician or other designated medical professional certifying that the
ambulance services are medically necessary. The PCS must specify the place of
origin, destination, and the expected duration of treatment or span of dates
during which the client requires repetitive nonemergency ambulance
services.
(b) A PCS for repetitive,
nonemergency ambulance services (e.g., wound treatment center) is valid for
sixty calendar days as long as the agency's medical necessity requirement for
use of ambulance transportation is met. A new PCS is required every thirty
calendar days after the initial sixty-day period for a client using repetitive,
nonemergency ambulance services. Kidney dialysis clients may receive
nonemergency ground ambulance transportation to and from outpatient kidney
dialysis services for up to three months per authorization span.
(c) For unscheduled, nonrepetitive,
nonemergency ambulance services, the ambulance provider must obtain a signed
PCS or NPCS within forty-eight hours after the transport. The PCS or NPCS must
specify the place of origin and destination and certify that the ambulance
services are medically necessary. If the provider is unable to obtain the
signed PCS or NPCS within twenty-one calendar days following the date of
transport from the attending physician or alternate provider, the provider must
submit a claim to the agency. The provider must be able to show acceptable
documentation of the attempts to obtain the PCS or NPCS.
(d) For an unscheduled, nonrepetitive,
nonemergency ambulance service, if the ambulance provider is not able to obtain
a signed PCS from the attending physician, a signed nonphysician certification
statement (NPCS) form must be obtained from a qualified provider who is
employed by the client's attending physician or by the hospital or facility
where the client is being treated and who has knowledge of the client's medical
condition at the time the ambulance service was furnished. One of the following
members of the client's health care team may sign the certification form:
(i) A physician assistant;
(ii) A nurse practitioner;
(iii) A registered nurse;
(iv) A clinical nurse specialist;
(v) A hospital discharge planner;
(vi) A licensed practical nurse;
(vii) A social worker; or
(viii) A case manager.
(e) A copy of the signed PCS or NPCS must
accompany the claim submitted to the agency.
(f) In addition to the signed PCS or NPCS,
all other program criteria must be met in order for the agency to pay for the
service.
(g) A signed PCS or NPCS
must be attached to the claim submission for the following conditions:
(i) Altered mental status (i.e., alzheimer,
dementia, acute psychosis, and suicide ideation - Not services that fall under
the Involuntary Treatment Act;
(ii)
Bariatric;
(iii) Bedbound (not able
to stand or bear weight unassisted);
(iv) Continuous cardiac monitoring;
(v) Quadriplegic;
(vi) Requires a ventilator;
(vii) Requires continuous oxygen usage in
transit; and
(viii) Tracheostomy
(needed for prolonged respiratory support).
11-14-075, recodified as §182-546-1000, filed
6/30/11, effective 7/1/11. Statutory Authority:
RCW
74.04.057,
74.08.090, and
74.09.510. 04-17-118, §
388-546-1000, filed 8/17/04, effective 9/17/04. Statutory Authority:
RCW
74.08.090,
74.09.500,
74.04.050,
74.04.055, and
74.04.057. 01-03-084, §
388-546-1000, filed 1/16/01, effective
2/16/01.
