Medical Transportation -- Ground (mc tran gnd)

By Jean Parker,2014-08-28 13:58
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Medical Transportation -- Ground (mc tran gnd)

     mc tran gnd

    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.


    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


    Eligibility Requirements To receive reimbursement, a recipient must be eligible for Medi-Cal on

    the date of service.

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    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


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    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


    ; 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


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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


    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


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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


    ; 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


    ; Transfers from an acute care facility to another acute care


    ; 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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