Terms & Definitions
The following terms are commonly used in the administration of Medicaid transportation, as defined by the New York State Department of Health:
An ambulance is a motor vehicle, aircraft, boat or other form of transportation designed and equipped to provide emergency medical services during transit.
An ambulance service is any entity, as defined in Section 3001 of the Public Health Law, which is engaged in the provision of emergency medical services and the transportation of sick, disabled or injured persons by motor vehicle, aircraft, boat, or other form of transportation to or from facilities providing hospital services and which is certified or registered by the Department of Health as an ambulance service.
Ambulette, invalid coach or para-transit vehicle is a special-purpose vehicle designed and equipped to provide non-emergency transport that has either wheelchair-carrying capacity, stretcher-carrying capacity or the ability to carry transit-disabled individuals. A wheelchair-accessible minivan or similar vehicle is not an ambulette.
An ambulette service is an individual, partnership, association, corporation, or any other legal entity which transports the invalid, infirm or disabled by ambulette to or from facilities which provide medical care.
An ambulette service provides the invalid, infirm or disabled with personal assistance.
Common Medical Area
The common medical area is the geographic area from which a community customarily obtains its medical care and services.
Community means either the State, a portion of the State, a city or a particular classification of the population, such as all persons 65 years of age and older.
Day Treatment Program
A day treatment program or continuing treatment program is a planned combination of diagnostic, treatment and rehabilitative services certified by the Office for Persons with Developmental Disabilities or the Office of Mental Health.
Department Established Rate
The rate for any given mode of transportation which the department has determined will ensure the efficient provision of appropriate transportation to MA recipients in order for the recipients to obtain necessary medical care or services.
A medical or mental health condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention could reasonably be expected to result in placing the enrollee’s physical or mental health (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, serious dysfunction of any bodily organ or part, serious harm to self or others due to an alcohol or drug abuse emergency, injury to self or bodily harm to others, or with respect to a pregnant woman having contractions: (1) that there is inadequate time to effect a safe transfer to a hospital before delivery, or (2) that transfer may pose a threat to the health or safety of the woman or the unborn child.
- Emergency Ambulance Transportation
Ambulance transportation for the purpose of obtaining hospital services for an MA recipient who suffers from severe, life-threatening or potentially disabling conditions which require the provision of emergency medical services while the recipient is being transported.
- Emergency Medical Services
The provision of initial urgent medical care including, but not limited to, the treatment of trauma, burns, and respiratory, circulatory and obstetrical emergencies.
An enrollee is an individual who is enrolled in the Medicaid Program and is eligible to receive Medicaid services, including transportation.
The payment of a fee by the Department of Health directly to a service provider for a specified direct service.
HRA/DSS – Human Resources Association
The department of social services (DSS) which is the entity that authorizes a Medicaid enrollee’s eligibility for Medicaid in the 5 boroughs of New York City.
Local Department of Social Services (LDSS)
The local department of social services (LDSS) is the locality that authorizes a Medicaid enrollee’s eligibility for Medicaid. There are 60 LDSS in New York State, including the 5 boroughs of New York City, as well as both the New York State Office of Mental Health and the New York State Office for Persons with Developmental Disabilities. The LDSS is identified by county code during the eligibility verification process (e.g., 01-Albany, 02-Allegany, etc.). A list of county codes is available in the Medicaid Eligibility Verification System Manual and on eMedNY at http://www.emedny.org/ProviderManuals/index.html.
Local Department of Social Service contact information is available at https://www.health.ny.gov/health_care/medicaid/ldss.htm
A paid or unpaid individual or caregiver accompanying a program eligible enrollee who is physically, mentally, or developmentally disabled and unable to travel or wait without assistance or supervision to receive a Medicaid coverable service. The escort may drive or utilize transportation services with the program eligible enrollee.
Health care services are considered medically necessary when those services are:
- Medically appropriate;
- Necessary to meet the basic health needs of the enrollee;
- Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the covered service;
- Consistent in type, frequency, duration of treatment with scientifically based guidelines of national medical, research or health care coverage organizations or governmental agencies;
- Consistent with the diagnosis of the condition;
- Required for means other than convenience of the enrollee or his or her physician;
- No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency;
- Of demonstrated value; and
- No more intense level of service than can be safely provided.
Medical Service Provider
An individual, firm, corporation, hospital, nursing facility, or association that is enrolled as a Medicaid provider, or provides a Medicaid coverable service free of charge (for example, a Veterans Administration Hospital or local county Department of Health.)
The method used to provide transportation services to enrollees.
OMH and OPWDD are two State agencies operating as local departments of social services in New York. Upon eligibility verification, OMH is represented by county code 97 and OPWDD by county code 98. These agencies are responsible for the prior authorization of both emergency and non-emergency transportation services for enrollees assigned to them.
Non-Emergency Ambulance Transportation
Non-emergency ambulance transportation is the provision of ambulance transportation for the purpose of obtaining necessary medical care or services by a Medicaid enrollee whose medical condition requires transportation in a recumbent position.
Non-emergency ambulance transportation is transportation of a pre-planned nature where the patient must be transported on a stretcher or requires the administration of life support equipment, such as oxygen, by trained medical personnel.
The result of a Department of Health enrollee or transportation service provider not keeping an appointment and failing to cancel the appointment.
An attending physician or other medical practitioner who is requesting transportation on behalf of an enrollee in order that the enrollee may obtain medical care or services which are covered under New York State’s Medicaid program. The ordering practitioner is responsible for initially determining when a specific mode of transportation to a particular medical care or service is medically necessary.
This is when physical assistance is provided by an ambulette service to an enrollee for the purpose of assuring safe access to and from the enrollee’s place of residence, ambulette vehicle and health service provider’s place of business. Personal assistance is the rendering of physical assistance to the recipient in:
- walking, climbing or descending stairs, ramps, curbs or other obstacles;
opening or closing doors;
- accessing an ambulette vehicle;
- the moving of wheelchairs or other items of medical equipment and the removal of obstacles as necessary to assure the safe movement of the recipient.
In receiving personal assistance, the enrollee may receive assistance from the ambulette transportation provider including touching, or, if you prefer not to be touched, guiding close proximity that the transportation provider will be able to prevent any potential injury due to a sudden loss of steadiness or balance.
A recipient who can walk to and from a vehicle, his or her home and a place of medical services without such assistance is deemed not to require personal assistance.
A determination that payment for transportation is essential in order for a Medicaid enrollee to obtain necessary medical care and services and that the Medicaid Program accepts conditional liability for payment of the Medicaid enrollee’s transportation costs.
Ordering Medical Practitioner
An ordering practitioner is a Medicaid enrollee’s attending physician or other medical practitioner who is requesting transportation on behalf of an enrollee in order for the enrollee to receive medical care or services covered under Medicaid.
- Locally Prevailing Rate — A rate for a given mode of transportation which is established by a transit or transportation authority or commission empowered to establish rates for public transportation, a municipality, or a third-party payor, and which is charged to all persons using that mode of transportation in a given community.
- Locally Established Rate — The rate for any given mode of transportation which the social services official has determined will ensure the efficient provision of appropriate transportation for MA recipients in order for the recipients to obtain necessary medical care or services.
Simple Rotation System
A simple rotation system is a method to identify the next available transportation vendor in the transportation manager’s system that can perform the transportation service within the level transportation required. This system is used when an enrollee indicates they have no preference for a specific transportation vendor to perform the service.
A vehicle that transports a prone or supine person who does not require medical attention while traveling to services.
A transportation attendant is any individual authorized to ensure the enrollee receives safe transportation.
- the costs of transportation services; and
- the costs of outside meals and lodging incurred when going to and returning from medical care and services when distance and travel time require these costs.
A transportation provider is a lawfully authorized provider of transportation services who is actively enrolled in the Medicaid Program.
Transportation services are services by ambulance, ambulette or invalid coach, taxicab, common carrier or other means appropriate to an enrollee’s medical condition; and transportation attendant to accompany an enrollee, if necessary.
Such services may include the transportation attendant’s transportation, meals, lodging and salary; however, no salary will be paid to a transportation attendant who is a member of an enrollee’s family.
Undue Financial Hardship
This means transportation expenses which an enrollee cannot be expected to meet from monthly income or from available resources. Such transportation expenses may include those of a recurring nature or major one-time costs.
Urgent Care Transportation
“Urgent care” means that level of care ordered and verified by the individual’s physician (online, by phone or fax) to be necessary on the day the request is made. Examples include, but are not limited to, high temperature, persistent rash, vomiting or diarrhea, symptoms which are of sudden or severe onset, but which do not require emergency room services.
Urgent care is generally determined by the enrollee’s medical care provider, but not necessary. An appointment shall be considered urgent if the medical service provider grants an appointment within forty-eight (48) hours of the enrollee’s request.
A hospital discharge shall be considered an Urgent Trip.