• No results found

Non-Emergency Non-Ambulance Services - TRANSCITA

N/A
N/A
Protected

Academic year: 2021

Share "Non-Emergency Non-Ambulance Services - TRANSCITA"

Copied!
6
0
0

Loading.... (view fulltext now)

Full text

(1)

Clinical Affairs Division

Non-Emergency Non-Ambulance Services - TRANSCITA

[Preauthorization Required]

Medical Policy: MP-TRANS-01-11

Original Effective Date: March 24, 2011

Reviewed: Revised:

This policy applies to products subscribed by the following corporations, MCS Health Management Options, Inc. (HMO) and MCS Advantage, Inc. (Classicare) and Medical Card System, Inc., provider’s contract; unless specific contract limitations, exclusions or exceptions apply. Please refer to the member’s benefit certification language for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply subject to the aforementioned exceptions.

This medical policy excludes MCS Life Insurance (Commercial) line of business. It is designed for MCS Advantage (Classicare) and MCS Health Management Options, (HMO) to establish non-emergency non-ambulance transportation necessity.

DESCRIPTION

Ambulance and Medical transport services involve the use of specially designed and equipped vehicles to transport ill or injured patients. These services may involve ground or air transport in both emergency and non-emergency situations.

An emergency response is one that, at the time the ambulance provider is called, it responds immediately. An emergency is a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical intervention could reasonably be expected to result in placing the patient’s health in serious impairment to bodily functions; or serious injury to any bodily organ or part.

(2)

vehicle is not secure for the member due to their medical condition, or because the member is considered “bed confined”.

For bed confinement, all of the following criteria must be met:  Patient is unable to get up from bed without assistance; and  Patient is unable to ambulate; and

 Patient is unable to sit in a chair or wheelchair

Non-Emergency Patient Transportation Services (PTS) Non-Ambulance: • Is any vehicle capable for transportation

• Is one that does not necessarily need to be equipped with a handicap ramp lifter and can be without any handicap modifications; (If special modifications are needed, depending on the medical necessity, special arrangements need to be made).

• Drivers do not necessarily need to be trained in medical emergencies

• Do not require the specialized services, equipment and personnel of an ambulance because the recipient is in stable condition and do not need constant observation. MCS recognizes that there are some unique challenges for members to access medically necessary treatments. (i.e. renal dialysis, radiotherapy, chemotherapy, physiotherapy, hyperbaric therapy and specialized wound care clinics).

Traditional Medicare does not cover non-emergency non-ambulance transportation services. This medical policy will address the indications for the coverage of emergency, non-ambulance transportation services only.

COVERAGE

Benefits may vary between groups and contracts. Please refer to the appropriate member certificate and subscriber agreement contract for applicable diagnostic imaging, DME, laboratory, machine tests, benefits and coverage.

INDICATIONS

(3)

Clinical Affairs Division

1. High-risk members that have problems accessing needed non-emergency medical treatments (i.e. renal dialysis, radiotherapy, chemotherapy, physiotherapy, hyperbaric therapy and specialized wound care clinics). The beneficiary must not be bed confined. (See definition to bed confinement above). In this case, the member may qualify for another type of ambulance transportation service).

2. The Member has no access to the needed transportation for treatment due to: • Member is not able to drive themselves (i.e. Poor vision, generalized

weakness, fatigue related to cardiac condition, ambulation difficulties, no transportation, etc.,); AND

• The Member has no access to public transportation or public transportation is not adequate due to mobility issues or health issues certified by the treating physician; AND

• MCS Case Management and Community Outreach Programs has validated that the enrollee lacks family and community support in relation to the transportation for medical treatments, as well the lack of income and/or financial constraints; AND

• The Member is not a candidate for an alternate mean of transportation such as the ones provided by the municipality, the government or non-profitable organizations that provides transportation to members for medical services. Note: Necessity for service should be re-evaluated every three (3) months.

EXCLUSION OF COVERAGE

1. Transportation to medical office visits. 2. Transport to a funeral home.

3. Transfer form one residence to another.

(4)

LIMITATIONS

1. Depending on the Members benefit of coverage, one trip per year is provided outside the MCS Management Program to the primary care physician (PCP) office for the Comprehensive Health Risk Assessment (CHRA). Authorization for additional transportation during the year is coordinated through the MCS case management program.

5. This medical policy is limited ONLY to MCS Advantage (Classicare) and MCS Health Management Options, (HMO) line of business.

CODING INFORMATION

CPT® Codes for Non-Emergency Patient Transport Service (PTS)

CPT® Codes DESCRIPTION

A0100 NON EMERGENCY TRANSPORTATION , TAXI

A0130 NON EMERGENCY TRANSPORTATION : WHEELCHAIR VAN (WHEELCHAIR ROUND TRIP/ LEG/DIALYSIS /NON DIALYSIS

A0200 NON EMERGENCY TRANSPORTATION : ANCILARY LODGING- ESCORT (PATIENT COMPANION TRIP/LEG)

S0215 NON EMERGENCY TRANSPORTATION : MILEAGE , PER MILE (CHARGES PER MILE IF TRIP RUNS OVER ; THE LOGISTIC DOMAINS OF 10 MILES ; EXCLUSION : IS NOT PAYABLE FOR DIALYSIS TRANSPORTATION SERVICES )

*Current Procedural Terminology (CPT®) 2010 American Medical Association: Chicago, IL.

ICD-9 CM® Diagnosis Codes

ICD-9 CM® CODES

DESCRIPTION

V49.84* Bed Confinement Status

V49.89* Other specified conditions influencing health status 2010 ICD-9-CM®For Physicians, VOLUMES I & II, Professional Edition (American Medical Association)

Note:V49.84 indicates that the member is bed confined and transportation by any other means is contraindicated

(5)

Clinical Affairs Division

REFERENCES

1. American Ambulance Association (Condition Code Training Guide). AAA 2006.

2. Administracion de Seguros De Salud De Puerto Rico (ASES). Emergency Transportation Services, Section 7.5.7 ., Provisions of Physical Health Services Under the MiSalud Program. (October 2010).

3. Administración de Seguros De Salud De Puerto Rico (ASES). Basic Coverage, Section 7.5.1., Provisions of Physical Health Services under the MiSalud Program. (October 2010).

4. Center for Medicare and Medicaid. Ambulance Fee Schedule. Medical Condition List Rev. 1942; Issued: 04-02-10, Effective /Implementation Date 05-03-10.

http://www.cms.gov/manuals/downloads/pim83c10.pdf

5. CMS (Center for Medicare and Medicaid Services Part A and B, Trail Blazer Health Enterprise, LLC. Published May 2010.

6. Centers for Medicare & Medicaid, First Coast Services Options, LCD for Non-Emergency Ground Ambulance Services (L29955). Original Determination Effective Date: 06/30/2009. Revision Effective Date (For services performed on or after 06/30/2009.

7. Centers for Medicare & Medicaid, Medicare Benefit Manual. Chapter 10-Ambulance Services (rev.125, 05-14-10). http://www.cms.gov/manuals/downloads/pim83c10.pdf

8. Centers for Medicare & Medicaid, Medicare Claims Processing Manual. Chapter 15 –Ambulance (rev. 1942, 04-02-10). http://www.cms.gov/manuals/downloads/clm104c15.pdf

9. Centers for Medicare & Medicaid (CMS). The Medicare Ambulance Benefits & Statutory Bases for Denial of Claims and Transports and ABNs. July 10, 2003.

http://www.cms.gov/AmbulanceFeeSchedule/downloads/ambabn71603.pdf

POLICY HISTORY

DATE ACTION COMMENT

(6)

References

Related documents

Transportation following a release from a hospital emergency room after non-emergency medical care is not covered unless the Medicaid contracted provider or ambulance has provided

Once a person who is a substance abuser (a chronic heavy user or a periodic heavy user, one who on occasion after periods of abstinence, gets out of control for a period of time,

Minor in Language and Area Studies in French, German, Italian, Japanese, Russian, or Spanish.

For example, System B with its additional system resources is currently only specified in the KNX Specification for Twisted Pair, while there is only one device model available

Activities Defined Software Configuration Management (SCM) standards and guidelines based on Unified Configuration and Change Management (UCCM) of Rational. Developed

You will hear five short recordings. For each recording, decide what each speaker is booking. :ULWHRQHOHWWHU $à+ QH[WWRWKHQXPEHURIWKHUHFRUGLQJ..

Our model contributes to the welfare analysis of protection by adding an endogenous labor supply choice, incorporating costs of adjustment to the installation of

The proposed peer assessment setup is expected to support group learning aspects with knowledge sharing through feedback and to prevent the Individual Group Assessment Problem,