The New York State Medicaid Program recognizes that certain Medicaid enrollees are not able to use mass transit or other forms of transportation to get to and from a doctor’s appointment and “[i]f the enrollee cannot get to medical services, then the Program fails from the start.” To that end, Medicaid covers the least costly, most medically appropriate level of transportation to and from services covered by the Medicaid Program.
Choosing Medically Appropriate Transportation
Fee-for-service providers ordering transportation for their patients must select the medically appropriate mode of transportation for the patient. When deciding whether to order livery, ambulette, or non-emergency ambulance services, the New York State Medicaid Transportation Guidelines (Guidelines) instruct providers to order “the least specialized mode” required based upon the enrollee’s current medical condition. “A basic consideration for this should be the enrollee’s current level of mobility and functional independence,” advise the Guidelines.
An ambulance service is typically requested by a provider when Medicaid enrollees need to be transported in a recumbent position or requires medical attention while en route to their medical appointments.
Ambulette service is requested by a provider when a Medicaid enrollee requires personal assistance of the staff of the ambulette company. It is the door-to-door service from the patient’s home through the door of the medical office where the appointment is scheduled. The Guidelines view personal assistance as help provided by transportation staff to Medicaid enrollees with walking, ascending or descending stairs, and opening doors.
Ambulette service could also be requested when a Medicaid enrollee has a specific medical condition outlined in the program Guidelines.
Livery service should be requested by providers when personal assistance is not necessary and/or is not provided.
Prior Authorization and Documentation
Prior authorization by the Medicaid enrollee’s attending physician, physician assistant, nurse or other provider permitted to request any level of transportation services is required. Furthermore, according to the Guidelines, providers must also fill-out medical justification form 2015 which supplants, but does not replace, a prior authorization request. Providers must also remember to note in the patient’s medical record the condition that qualifies for the use of ambulance, ambulette or livery transportation.
It should be noted that ordering providers can be audited for compliance by the Office of the Medicaid Inspector General (OMIG). OMIG has the authority to sanction providers if the agency deems a provider in violation of the rules.
If you have questions about the new transportation requirements, New York Medicaid Program or need other legal assistance, please contact us.