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.

Advanced Life Support (ALS): Either transportation by ground ambulance vehicle, that has medically necessary supplies and services, and the treatment includes administration of at least three medications by intravenous push/bolus or by continuous infusion, excluding crystalloid, hypotonic, isotonic, and hypertonic solutions (Dextrose, Normal Saline, Ringer’s Lactate); or transportation, medically necessary supplies and services, and the provision of at least one ALS procedure as specified in 42 CFR 414.605, including:

1. Manual defibrillation/cardioversion.

2. Endotracheal intubation.

3. Central venous line.

4. Cardiac pacing.

5. Chest decompression.

6. Surgical airway, or

7. Intraosseous line.

Air Ambulance: A helicopter or fixed wing aircraft licensed under Arizona Department of Health Services (ADHS) as mandated in ARS 36-2201 to be used in the event of an emergency to transport members or to obtain services.

Ambulance: A motor vehicle licensed by Arizona Department of Health Services (ADHS) pursuant to ARS 36-2201 specially designed or constructed, equipped, and intended to be used, maintained, and operated for the transportation of individuals requiring ambulance services.

Ambulatory Transportation: A vehicle other than a taxi but includes vans, cars, minibus, or mountain area transport. The AHCCCS member shall be able to transfer with or without assistance into the vehicle and not require specialized transportation modes.

Basic Life Support (BLS): Transportation by ground ambulance vehicle that has medically necessary supplies and services, plus the provision of BLS ambulance services. The ambulance must be staffed by an individual who is qualified in accordance with State and local laws as specified in 42 CFR 414.605.

Emergency Ambulance Services: Transportation by an ambulance for an emergency condition.

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. Emergency transportation is needed 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:

1. Placing the member's health in serious jeopardy, or

2. Serious impairment of bodily functions, or

3. Serious dysfunction of any bodily organ or part, or

4. Serious physical harm to self or another individual.

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.

Non-Emergency Transportation (NEMT): 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.

Non-Emergency Transportation (NEMT) Broker: An entity which may provide administrative functions such as scheduling, verifying enrollment, validating service appointments when appropriate, as well as billing.

Public Transportation: Transportation via buses, trains, or other forms of transportation that run on a set route and schedule and are available to the public.

Stretcher Van: A vehicle that is specifically designed for the purpose of transportation of a member on a medically approved stretcher device. The stretcher shall be secured to avoid injury to the member or other passengers. Safety features of stretcher vans shall be maintained, as necessary. Any additional items being transported shall also be secured for safety. The AHCCCS member shall need to be transported by stretcher and shall be physically unable to sit or stand and any other means of transportation is medically contraindicated.

Taxi: A vehicle that has been issued and displays a special taxi license plate as specified in ARS 28-9506.

Wheelchair Van: A vehicle that is specifically equipped for the transportation of a member seated in a wheelchair. Wheelchair vans shall include doors wide enough to accommodate loading and unloading of a wheelchair, electronic lifts for loading and unloading wheelchairs, and restraints for securing wheelchairs during transit. Safety features of wheelchair vans shall be maintained, as necessary. Any additional items being transported shall also be secured for safety. The member shall require transportation by wheelchair and shall be physically unable to use other modes of ambulatory 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 Medical 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

• 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.

Emergency Transportation Provider Requirements for Emergency Transportation Services Provided to Members Residing on Tribal Lands

In addition to other requirements specified in this Policy, emergency transportation providers rendering services on Tribal Land shall meet the following requirements:

a. The Tribal Emergency Transportation providers shall be certified by the Tribe and Center for Medicare and Medicaid Services (CMS) as a qualified provider and shall be registered as an AHCCCS provider.

b. If a non-tribal Emergency Transportation provider renders services under a contract with a Tribe, either non-tribal land or to and from an off-tribal land location, the provider shall be State licensed and certified and shall be registered as an AHCCCS provider.

c. Non-tribal Emergency Transportation providers not under contract with a Tribe shall meet the requirements specified in this Policy for emergency transport providers.

The Emergency Transportation services are covered to manage an emergency physical or behavioral health condition and to the nearest appropriate facility capable of meeting the member’s health care needs as outlined in this Policy.

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.

Emergency Triage, Treat, And Transport Program

The services associated with the ET3 program are covered when an Emergency Transportation provider responds to a "9-1-1", fire, police, or other locally established system for emergency calls. AHCCCS registered Emergency Transportation Providers in possession of a Certificate of Necessity (CON) from ADHS, or tribal providers who have signed the AHCCCS attestation of CON equivalency, are allowed to transport a member to an Alternative Destination Partner or provide treatment to the member on scene as specified in AHCCCS AMPM 310 BB.

1. Transportation to an Alternative Destination Partner Upon the emergency response team’s arrival on the scene and their field evaluation of the member, if the services required at that time are determined to be medically necessary, but not emergent, the Emergency Transportation provider may transport the member to an Alternative Destination Partner. These transports are allowed when:

a. The transport to an Alternative Destination Partner will meet the member’s level of care more appropriately than transport to an emergency department,

b. The Alternative Destination Partner is within or near the responding emergency transportation provider’s service area,

c. The Emergency Transportation provider has a pre-established arrangement with the Alternative Destination Partners located within their region, and

d. The Emergency Transportation provider has knowledge of the Alternative Destination Partner’s:

i. Hours of operation,

ii. Clinical staff available,

iii. Services provided, and

iv. Ability to arrange transportation for the member to return home, when needed.

2. Treatment on Scene Upon the emergency response team’s arrival on the scene and their field evaluation of the member, if the services required at that time are determined to be medical necessary, but not emergent, the Emergency Transportation provider may provide treatment to the member in accordance with the provider’s scope of practice and their emergency transport service’s medical direction. Treatment on scene may also be performed, when medically indicated, via a telehealth visit performed in accordance with AMPM Policy 320-I.

Age Restrictions

Unless an exception, as described in this Policy, applies, members under the age of 18, who are not emancipated, shall be accompanied by a legal guardian or an adult, who is 18 years old or older, authorized by the legal guardian to accompany the member during the transport. Exceptions in which a member under the age of 18 may be transported alone are as follows:

For members enrolled with a Contractor, the Contractor, at its discretion, may allow members to be transported without the presence of a legal guardian, or designated adult, if the following apply:

1. For transportation provided by an NEMT or Transportation Network Company (TNC) Provider:

a. The member’s legal guardian has signed the Authorization and Release Form included as Attachment A allowing the member to be transported without the legal

guardian or a designated adult, the Form shall be retained by the provider and may be requested as part of claims review or other audit activities,

b. The member is between the ages of 16 and 17,

c. The NEMT driver transporting the minor shall have a valid level I fingerprint clearance card, as issued by the Arizona Department of Public Safety, and

d. The driver transports the member from the pickup location to the destination, including walking the member into the destination facility, the driver shall provide

assistance to the member as necessary.

2. For Transportation provided by a licensed health care facility in accordance with the AAC Title 9 Chapter 10, with the appropriate category of service for transportation, for the purpose of accessing health care services as outlined in the members service or treatment plan that has been approved by the member’s legal guardian.

3. Transportation of an unaccompanied minor requires prior authorization (PA). PA shall be requested from AHCCCS/DFSM by the licensed health care facility for the transport of an unaccompanied minor at least seven days prior to the transport. The PA request shall include the following:

a. Copy of the Authorization and Release Form (included as Attachment A) signed by the minor’s legal guardian,

b. Copy of the minor’s current treatment plan, and

c. Copy of the driver’s level I fingerprint clearance card issued by the Arizona Department of Public Safety.

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:

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.

Maternal and Newborn Transportation

The Maternal Transport Program (MTP) and the Newborn Intensive Care Program (NICP) administered by ADHS provides special training and education to designated staff responsible for the care of maternity and newborn emergencies during transport to a perinatal center. The high-risk transport team is dispatched after consultation with the MTP or NICP perinatologist or neonatologist. Only contracted MTP or NICP providers may provide air transport.

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.