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2013
Doug van Hee
Transportation Benefit Manager Department of Health Care Policy and Financing
Non-Emergency Medical
Transportation
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Training Objectives
Understand:
• Difference between Emergency and Non-Emergency Transportation
• County responsibilities
• Modes of Transportation
• Role of First Transit
• Additional services
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Health Emergency
• Emergency
– Sudden
– Unexpected
– Requires immediate medical attention because a
person’s life, bodily functions, or overall health are in
serious jeopardy
– “Bells and Whistles”
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Emergency Medical
Transportation (EMT)
• Includes:
– Ambulance
– Air Ambulance
• Requires a physician’s statement of medical necessity or
trip report
– Subject to audit
• Billed directly to the fiscal agent
• Does not require a Prior Authorization Request (PAR)
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Non-Emergency Medical
Transportation (NEMT)
• ALL NEMT MUST BE APPROVED BY THE
COUNTY OR BROKER PRIOR TO THE TRIP
TAKING PLACE.
• Who qualifies for NEMT: All fully benefitted Medicaid
clients that have no other means of transportation to
and/or from Medicaid appointments.
• Who does not qualify for NEMT: Clients under the
following Medicaid programs do not qualify: CHP+,
QMB, SLMB, QI-1 and OAP-state only.
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NEMT • Transportation to and/or from Medicaid treatment that
is not an emergency in nature
• Scheduled; including urgent care
• Only available when the client has no other means of
transportation
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NEMT
• The following are not benefits of the Colorado
Medicaid NEMT Program:
– Waiting time
– Charges when the client is not in vehicle
– Transportation when not medically necessary
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IMPORTANT!
• Non-medical transportation may be
covered for eligible clients under the
HCBS Waiver Program
• For more information refer to the HCBS
Billing Manual
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QUESTIONS?
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Counties
• As the State Designated Entity (SDE) the Department of
Human/Social Services in each county is federally
mandated to provide NEMT for any Medicaid client that
has no other means of transportation
• The SDE is required to query clients requesting NEMT to
determine
– if the client is being transported to a Medicaid covered
service
– that all means of accessing other transportation have
been exhausted by the client
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Counties: Basic NEMT
Requirements
• EACH COUNTY MUST:
– Verify with the physician’s office that each appointment is
medically necessary and a benefit of the Colorado Medical
Assistance Program
– Each appointment is to the closest, most medically appropriate
provider
• Although current provider-client relationship does need to
be considered
– The mode of transportation must be the least costly, most
medically appropriate option
– Documentation must be available for audit to verify the above
information.
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Counties: Denial Procedure
SDEs are required to inform clients, in writing, of any
benefitted transportation service that is being denied
The denial letter must include:
• Why the service was denied
• Client Appeal Right language and instructions
– Can be found on the back of all formal claim
denials sent from Xerox, on the Department’s
Website, or in the HCPF Operations Manual
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Counties
Some counties have elected to opt out of their
transportation administration duties by contracting
with private transportation brokers
This is an option for counties as long as NEMT
services continue to be provided to all qualified
Medicaid clients, follow all applicable regulations and
there is no additional cost to the Colorado Medicaid
Program
SDEs must adhere to the current transportation
rules, guidelines and rates established by Medicaid
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Counties
It is the responsibility of the SDE to stay informed via
Bulletins, Agency Letters, and through the web portal
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QUESTIONS?
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First Transit
• The nine counties under First Transit’s brokerage are: Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, Jefferson, Larimer and Weld
• Transportation providers serving the nine front range counties do not bill Medicaid for NEMT
– All NEMT services for the nine front-range counties must be authorized, approved, arranged and paid through First Transit
* First Transit is the only official Medicaid NEMT broker
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First Transit
First Transit
Reservation Line: 1-855-CO4-NEMT (1-855-264-6368)
Comment Line: 1-855-636-8178 (1-855-NEMT-1st)
Or visit their website at: WWW.MedicaidCO.Com
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QUESTIONS?
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Modes of Transportation
NEMT includes:
• Standard vehicle • Wheelchair van • Non-emergency ambulance • Taxi • Intra/Inter-State Train or Bus • Plane • Gas reimbursement for private vehicle usage • Public Transit tokens or passes • The appropriate mode of transportation is
determined by the client’s physician.
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Modes
• Standard vehicles are provided when
the client has no transportation and it
is the least costly, most appropriate
mode for their condition.
• A wheelchair van is a benefit only
when:
– The client is a physician verified
wheelchair user and
– The vehicle has been
appropriately modified to
transport wheelchair users only.
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Modes
• A wheelchair van must be specifically designated to
accommodate the needs of wheelchair users only
• Unlike standard vehicles, wheelchair van service is not
regulated by the Public Utilities Commission (PUC)
• Oxygen administration can only be billed when medically
necessary and it is the wheelchair van’s oxygen
• Submit claims for wheelchair van and oxygen together
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Public Transit
• Public Transit tokens or passes are available when this is
the least expensive, most appropriate mode for a client. – Passes can be used when multiple trips can be scheduled at one time and it is most
cost effective.
• Reimbursement consideration:
– Only when every citizen would be charged for the
service will Medicaid reimburse for the trip.
• Example: if a local organization provides free rides,
they cannot bill Medicaid for a client, they must
charge every rider, every time in order to bill
Medicaid.
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Non-Emergency Bus and
Train • Benefits are provided when:
– Client is traveling a great distance or;
– Client’s condition prohibits transporting by other less costly means of NEMT or;
– It is the least costly means of transportation
• Bus or Train
– No PAR required ; unless traveling out of state
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Mileage Reimbursement
• The SDE must also obtain copies of the following
information before reimbursement of personal vehicle
mileage
– Name and address of vehicle owner
– Policy number and name of the insurance carrier
– Driver’s license number and expiration date for the
driver of the vehicle
(For auditing purposes, documentation must be kept on
file for 6 years)
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Mileage Reimbursement
• For purposes of continuity, we suggest calculating mileage
by using an online mapping service or a GPS device
• The trip must be the most direct route to and/or from the
medical appointment with the closest qualified provider
• The appointment must be a benefit of the Colorado
Medical Assistance Program
Refer to the
October
2007 Bulletin
B0700238
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Multiple Riders
• When taxi or standard vehicle services are provided to
more than one client, multiple rider exceptions apply:
• Client traveling farthest distance is reimbursed at the full
rate
• The client traveling the second farthest distance is
reimbursed at ½ the rate
• Any additional client shall be reimbursed at ¼ the rate of
the first client
• No Prior Authorization Request (PAR) required
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Out-of-State Transportation
• If a patient requires out-of-state hospitalization, please contact: ColoradoPAR Program to find out if the out of state location is authorized and what forms need to be completed.
• Provider must also verify the out of state service has been prior authorized
• ALL Non-Emergency Medical Transportation PARs are to be submitted online directly to the ColoradoPAR Program at www.coloradopar.com
Phone Number: 1-888-454-7686
Fax Number: 1-866-492-3176
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Air Transportation
Modes: Air Ambulance, Helicopter or Commercial Air.
• PAR required (*Hospital to Hospital transports do not
require a PAR and can be billed directly by the hospital) • PAR must be completed by the SDE and submitted to
ColoradoPAR Program online at www.coloradopar.com
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Air Transportation
• Benefits are provided when:
– Point of pickup is inaccessible by land vehicle, great
distances prohibit transporting
– Great distances prohibit transporting client to nearest
appropriate location and client needs immediate
attention
– Patient is suffering from an illness that makes other
forms of transportation inadvisable
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QUESTIONS?
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Additional Services
• Additional Services
– Out-of-State transportation
– Over-the-Cap Expenses (bariatric & mental health)
– Ancillary Services (Meals and Lodging)
• Ronald McDonald House provides free food/meals.
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Ancillary Services
Ancillary services are supplemental services that are a benefit in addition to transportation.
• Ancillary services:
– Meals and lodging
• Only approved if the trip cannot be completed in one calendar day. Clients staying at RMH are expected to make use of the free meals available to them.
– Escort:
• May be available for at-risk adults or children.
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Over-the-Cap Expenses
Over the cap expenses exceed the maximum allowable -Examples include specialized transport (i.e. bariatric ambulance) or Air Ambulances
Mental health hold clients only qualify when being transported to Fort Logan or the State facility in Pueblo
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www.colorado.gov/hcpf
Health Care Policy and
Financing’s Home Page
The Department’s web site links to:
•Departmental Reference Material - Volume 8 Regulations
•Staff Resources Directory
•The Provider Web Portal
Click on the Providers tab on the menu at the top of the
web page to navigate to the Provider Services tab for
•Information
•Documents
•Publications
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QUESTIONS?
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This is the end of the road,
Thank You! Doug van Hee & Chris Acker
Transportation Benefit Manager
303-866-3920
