DCS Comprehensive Health Plan

Transportation

Statement/Purpose

This policy outlines emergency and non-emergency transportation coverage within certain limitations for DCS Comprehensive Health Plan (DCS CHP) members.

Definitions

Alternative Destination Partner: An AHCCCS registered provider, such as a Federally Qualified Healthcare Center/Rural Health Clinic (FQHC/RHC), primary care doctor, specialist, behavioral health center or urgent care clinic.

Emergency Triage, Treat, and Transport (ET3): A program designed to allow greater flexibility for ambulance providers registered with AHCCCS as Emergency Transportation providers to address a member’s health care needs following a 9-1-1 call. ET3 permits Emergency Transportation providers to transport a member to an Alternative Destination Partner, and to initiate and facilitate a members’ receipt of medically necessary covered service(s) at the scene of a 9-1-1 response either in-person on the scene or via telehealth.

Emergency Transportation: Ground and air ambulance services that are medically necessary to manage an emergency physical or behavioral health condition and which provide transport to the nearest appropriate facility capable of treating the individual’s condition. When due to a sudden onset of a physical or behavioral health condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could be expected to result in an adverse condition. Determination of whether a transport is an emergency is based on the member's medical condition at the time of transport.

Non-Emergency Transportation: Non-emergency medically necessary transportation is furnished by non-emergency transportation providers to transport the member to and from a covered physical or behavioral health service. Such transportation services may also be provided by Emergency Transportation providers after an assessment by the Emergency Transportation team or Paramedic team determines that the member’s condition requires medically necessary transportation.

Policy

The health plan covers transportation within certain limitations for all members based on member age and eligibility, as specified in A.A.C. R9-22-211. Covered transportation services include:

• Emergency transportation;

• Medically necessary non-emergency transportation;

• Medically necessary maternal and newborn transportation through the Maternal Transport Program and the Newborn Intensive Care Program.

• Medically necessary transportation under the Emergency Triage, Treat and Transport (ET3) program.

• Emergency and non-emergent transportation from crisis receiving facilities

Emergency Medical Transportation

Emergency medical transportation may be necessary due to a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could be expected to result in:

• Placing the member's health in serious jeopardy;

• Serious impairment of bodily functions;

• Serious dysfunction of any bodily organ or part; or

• That Serious harm to another person.

The health plan covers emergency medical transportation, including transportation initiated by an emergency response system such as 911, by ground, air or water ambulance to manage a member’s emergency medical condition at an emergency scene and transport the member to the nearest appropriate medical facility. The nearest appropriate facility is the nearest hospital medically equipped to provide definitive medical care. This includes the transportation of a member to a higher level of care for immediate medically necessary treatment, even after stabilization at an emergency facility.

Emergency medical transportation is covered for those emergencies in which specially staffed and equipped ambulance transportation is required to safely manage the member's medical condition. Basic life support, advanced life support, and air ambulance services are covered depending upon the member's medical needs.

Acute conditions requiring emergency transportation to obtain immediate treatment include, but are not limited to:

• Untreated fracture or suspected fracture of spine or long bones;

• Severe head injury or coma;

• Serious abdominal or chest injury;

• Severe hemorrhage;

• Serious complications of pregnancy;

• Shock, heart attack or suspected heart attack, stroke or unconsciousness;

• Uncontrolled seizures; and

• Condition warranting use of restraints to safely transport to medical care.

Air ambulance services are covered under the following conditions:

• The point of pickup is inaccessible by ground ambulance;

• Great distances or other obstacles are involved in getting the member to the nearest hospital with appropriate facilities; or

• The medical condition of the member requires ambulance service, and ground ambulance services will not suffice.

Non-Emergency Medical Transportation

DCS CHP, through its contracted Managed Care Organization (MCO), covers non-emergency medical transportation when members are unable to provide or secure their own transportation for medically necessary services using the appropriate mode based on the needs of the member.

Medically necessary non-emergency transportation are covered when

• The member is not able to secure their own transportation and free transportation is not available;

• The service that requires transportation is a covered AHCCCS service;

• Transportation is provided to and from the AHCCCS registered provider/service;

• To obtain Medicare part D covered prescriptions.

Non-emergency medically necessary transportation includes but is not limited to:

• Medical and behavioral health visits;

• Dental visits;

• Pharmacy;

• Emergency Department or Urgent Care; and

• Women’s, Infant and Children (WIC).

Such services may also be provided by emergency transportation providers, after assessment by an Emergency Medical Technician (EMT) or paramedic team, that the member's condition requires medically necessary transportation, but not emergency transportation.

Reliable non-emergency, medically necessary transportation services are arranged for members and out-of-home caregivers who are unable to arrange safe transportation to a service site or location, if no other appropriate means of transportation is available. Transportation services are coordinated with transportation providers and members to facilitate timely pick up for regularly scheduled appointments and completion of the entire scheduled treatment.

Members and caregivers are instructed to request non-emergency transportation within 48-72 hours prior to the needed transportation, if possible. An adult (over the age of 18 years) accompanies the member.

Medically Necessary Transportation Furnished by Ambulance Providers

Round-trip air or ground transportation services may be covered if an inpatient member goes to another facility to obtain necessary, specialized diagnostic and/or therapeutic services. Such transportation may be covered if the following requirements are met:

• Member's condition is such that the use of any other method of transportation is contraindicated;

• Services are not available in the hospital in which the member is an inpatient;

• Member returns to the point of origin;

• Hospital furnishing the services is the nearest one with such facilities, or the one specified by the health plan; and/or

• Transport initiated through an emergency response system and, upon examination by emergency medical personnel, the member's condition is determined to be non-emergent but requires medically necessary transportation.

Procedure

Emergency Transportation

Prior Authorization (PA) is not required for reimbursement of emergency transports when the claim billing form contains the emergency indicators and is submitted along with a copy of the trip report.

The ground or air ambulance provider furnishing transport generally notifies the health plan within 10 business days from the date of transport. The notification is assessed for the following:

• Member name, date of birth, Member ID number and appropriate eligibility;

• Name of transportation provider;

• Name of receiving medical facility;

• Reason for transport;

• Member diagnosis, date and time of service; and

• Any additional information useful for coordination of care.

Pertinent medical information obtained from the transport notification form or attached documentation, is reviewed for care coordination. The member’s Custodial Agency Representative is contacted for coordination of services, as needed.

For utilization review, appropriateness of the request for emergency services is determined by whether a prudent layperson, if in a similar situation, would have requested such services.

The health plan is responsible for the reimbursement of emergency medically necessary transportation for members.

The health plan may establish preferred hospital arrangements, and communicate those arrangements with emergency service providers.

Medically Needed Non Emergency Transportation

Caregivers should transport members to and from medical and behavioral health appointments. If the member needs a ride to an appointment, caregivers are instructed to seek assistance from a relative, friend or use public transportation. If caregivers are unable to get a ride for a behavioral health appointment, they can contact member’s Child and Family Team to coordinate the ride. If caregivers are unable to get a ride for a medical appointment, they can contact the health plan Member Services to arrange for transportation or the member’s assigned DCS Specialist.

The health plan is responsible for the reimbursement of non-emergency, medically necessary transportation based upon notification of need and/or AHCCCS PA guidelines.