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Medical Transportation – Ground 1
This section contains information on ground medical transportation services and program coverage (California Code of Regulations [CCR], Title 22, Section 51323). For additional help, refer to the Medical
Transportation – Ground: Billing Examples section in this manual.
GENERAL INFORMATION
Program Coverage Medi-Cal covers ambulance and other medical transportation only
when ordinary public or private conveyance is medically contra-
indicated and transportation is required for obtaining needed medical
care.
Eligibility Requirements To receive reimbursement, a recipient must be eligible for Medi-Cal on
the date of service.
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EMERGENCY GROUND MEDICAL TRANSPORTATION
Transportation to Medi-Cal covers emergency ground medical transportation to the Nearest Hospital nearest hospital capable of meeting a recipient’s needs. When the
geographically nearest facility cannot meet the needs of a recipient,
transportation to the closest facility that can provide the necessary
medical care is appropriate under Medi-Cal. Coverage will be
jeopardized if a recipient is not transported to the nearest acute
hospital capable of meeting a recipient’s emergency medical needs
(contract or non-contract).
Note: In non-emergency situations, physicians and hospitals must
adhere to hospital contract regulations and admit recipients to
the nearest contract hospital.
Transportation to a Recipients transported to a non-contract hospital must be taken to the Second Facility nearest contract hospital as soon as they are stable. Recipients are
considered stable for transport when they are able to sustain transport
in an ambulance staffed by an Emergency Medical Technician I
(EMT I) with no expected increase in morbidity or mortality as a result
of the transportation. In addition, if a recipient is an infant, the
ambulance must have necessary modular equipment.
When the nearest facility serves as the closest source of emergency
care and a recipient is promptly transferred to a more appropriate care
facility, transportation from the first to the second facility is considered
a continuation of the initial emergency trip. However, the transfer is
not considered a continuation of the initial emergency trip if the
provider vehicle leaves the facility to return to its place of business or
accepts another call.
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Emergency Statement All emergency medical transportation requires a statement in the
Reserved for Local Use field (Box 19) of the claim, or on an
attachment, supporting that an emergency existed. The statement
may be made by the provider of transportation and must include:
; The name of the person or agency that requested the service
; The nature of the emergency
; The name of the hospital to which a recipient was transported
; Clinical information on a recipient’s condition
; The reason the services were considered to be immediately
necessary (medical necessity)
; The name of the physician accepting responsibility for the
recipient
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NON-EMERGENCY GROUND MEDICAL TRANSPORTATION
Non-Emergency Coverage Non-emergency medical transportation is covered only when a
recipient’s medical and physical condition does not allow that recipient
to travel by bus, passenger car, taxicab, or another form of public or
private conveyance. Transport is not covered if the care to be
obtained is not a Medi-Cal benefit. In addition, please see the
Optional Benefits Exclusion section in the appropriate Part 2 manual
for additional information on excluded optional benefits.
Non-emergency medical transportation necessary to obtain
medical services is covered subject to the written prescription of a
physician, dentist or podiatrist.
Authorization A Treatment Authorization Request (TAR) is required for
non-emergency transportation. A legible prescription (or order sheet
signed by the physician for institutional recipients) must accompany
the TAR.
All TARs for non-emergency medical transportation must be
submitted to either the Sacramento or San Diego Medi-Cal Field
Office. See the TAR Field Office Addresses section in this manual
for regional coverage by the appropriate Medi-Cal field office.
Inter-Facility Transport – Please refer to the Evaluation and Management section of the Part 2
Pediatric Critical Care manual for information regarding facility-to-facility transport of critically
ill or critically injured pediatric patients (24 months of age or less) with
an attending physician.
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Prescription Requirements The prescription (or order sheet signed by the physician for
institutional recipients) that is submitted with a TAR must include the
following:
; Purpose of the trip
; Frequency of necessary medical visits/trips or the inclusive
dates of the requested medical transportation
; Medical or physical condition that makes normal public or
private transportation inadvisable
Note: When transportation is requested on an ongoing basis,
the chronic nature of a recipient’s medical or physical
condition must be indicated and a treatment plan from
the physician or therapist must be included. A diagnosis
alone, such as “multiple sclerosis” or “stroke,” will not
satisfy this requirement.
The Medi-Cal field office consultant needs the above information to
determine the medical necessity of a specialized medical transport
vehicle and the purpose of the trip. Incomplete information will delay
approval.
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Transport From Acute A TAR is not required for non-emergency transportation from an acute Care Hospital to Long care hospital to a long term care facility. This is an exception to the Term Care Facility prior authorization requirement. This policy applies to transportation for
recipients who received acute care as hospital inpatients who are
being transferred to a Nursing Facility (NF) Level A or B.
This service must be billed with one of the appropriate non-emergency
transportation codes (HCPCS codes X0400 – X0416). Refer to the
Medical Transportation – Ground: Billing Codes and Reimbursement
Rates section in this manual for code descriptions and rates. Services
billed with other non-emergency transportation codes require prior
authorization.
Note: Medi-Cal does not cover waiting time or night calls for transport
from an acute care facility to NF-A care.
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Transportation to Adult Non-emergency transportation between a recipient’s home and an
Day Health Care Adult Day Health Care (ADHC) center is included in the per diem (ADHC) Centers reimbursement rate paid to an ADHC center and is not separately
reimbursable. Therefore, a TAR submitted to the field office for
non-emergency transportation between a recipient’s home and an
ADHC center will be denied.
A TAR is required for non-emergency transportation services provided
to and from medical, dental or podiatry appointments only. (An ADHC
center provides health, therapeutic and social services in a
community-based day care program for recipients 18 years of age or
older.)
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Reimbursement Separate reimbursement is not made for services or items included in
the base rate, such as:
; Backboards
; Flat/scoop stretchers
; Long boards
; Disposable oxygen masks and tubing
; Disposable I.V. tubing
; Childbirth assistance
; Restraint of recipient
; Suction/suction equipment
; Resuscitation
; Ventilator/Respirator/Intermittent Positive Pressure Breathing
(IPPB)
; A crew of two persons
; Pick-up off paved road
; Pick-up of overweight or difficult-to-reach recipients
; Linens and blankets
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Types of Ground Medical Non-emergency medical transportation is provided by three types of Transportation vehicles: ambulance, litter van and wheelchair van.
Ambulance: Ambulances are generally used for emergencies, but may provide Qualified Recipients non-emergency transport for certain types of recipients.
Non-emergency transport by ambulance can include:
; Transfers between facilities for recipients who require
continuous intravenous medication, medical monitoring or
observation
; Transfers from an acute care facility to another acute care
facility
; Transport for recipients who have recently been placed on
oxygen (not chronic emphysema recipients who carry their own
oxygen for continuous use)
; Transport for recipients with chronic conditions who require
oxygen if monitoring is required
Ambulance: Non-emergency transport by ambulance does not include: Non-Qualified Recipients
; Individuals with chronic conditions who require oxygen, but do
not require monitoring. Such individuals should be transported
in a litter van or wheelchair van when all of the following criteria
are met:
– Cannot use public or private means of transportation
– Clinically stable
– Can transport upright in a litter van or wheelchair van
– Able to self-monitor oxygen delivery system
– No other excluding conditions
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Litter Van Transport by litter van is appropriate when a recipient’s medical and
physical condition:
; Require that the recipient be transported in a prone or supine
position because the recipient is not able to sit for the period of
time needed for transport.
; Require specialized equipment and/or more space than is
normally available in passenger cars, taxicabs or other forms of
public transportation.
; Do not require the specialized services, equipment and
personnel of an ambulance because the recipient is in a stable
condition and does not need constant observation.
Examples of recipients who qualify for litter van transport include:
; Recipients in a spica cast
; Bed bound recipients
; Post-operative, stable recipients who cannot tolerate sitting
upright for the time required for transport from pick-up point
to destination
; Individuals with chronic conditions who require oxygen, but
do not require monitoring
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