Content for id "login" Goes Here

login

DOH Medicaid Q&A

 

Advertising Business

An owner of a taxi company wants more work for his business. I told him that he needs to

provide good customer service and let people know that he will be on time, have clean vehicles

etc. to expand his business. While I know that there are limits on what you can do to “advertise”

your Medicaid Transportation business, I need to confirm that he can tell facilities that he is in

business, reliable etc… and allow him to pass out business cards, etc.

 

Response

Your advice is correct.

"Solicitation" is a specific term that can lead to unacceptable practices, as defined in 18 NYCRR

§504 (provider responsibilities). As you can imagine, he cannot solicit business by giving a

lottery ticket to every rider, or submitting names of every rider for a weekly free television

drawing. Likewise, he cannot put up a billboard stating "free transportation to Medicaid riders!"

 

Ambulance Medicare Crossover Claim to Medicaid

An enrollee in insured by Medicare and Medicaid. An ambulance provider contacted us

requesting a prior authorization for oxygen, because that part of the claim had been denied by

Medicare.

Should we issue a prior authorization for oxygen only?

 

Response

Since Medicare does not reimburse oxygen as a separate amount (the costs of any oxygen used 

is included in the base rate approved by Medicare), they request a prior approval from Medicaid

transportation staff for the oxygen amount. This oxygen amount is over and above the coinsurance and deductible amount that Medicaid has to reimburse on a Medicare approved claim.

 

When Medicare approves an ambulance claim, Medicaid will pay up to the approved

amount, i.e., Medicaid will pay the coinsurance and deductible amount. Therefore, it is

inappropriate for Medicaid to pay more than the Medicare approved amount.

If a provider's ambulance claim has been approved by Medicare, the provider does not need a

prior authorization from Medicaid, as the claim is submitted directly to Medicaid.

Medicaid will pay the difference between the Medicare approved amount and the Medicare paid

amount.

 

Ambulette Service

 

Our main provider of ambulette and assisted taxi services historically has not routinely gone into

an enrollee’s home. They do not normally assist enrollees with putting on or taking off their

coats. They will meet the person at the door, if needed. They will help individuals ambulate

from the front door to and into the vehicle. They will not move individuals in wheelchairs up or down stairs, citing the liability of dropping the person. They do not regularly have additional staff available to go as an assistant on these trips. They rightfully express concerns about leaving other riders unattended in their vehicles when assisting other passengers. The situation is getting worse as the medical conditions of those receiving home care become more severe. We know that there are gray areas - we always do our best to maximize resources and save money while also ensuring that the mode of transport is appropriate. What is the responsibility of the transportation provider? At what point is paying for an assistant appropriate?

 

Response

Title 18 NYCRR § 505.10(16) reads:

Personal assistance means the provision of physical assistance by a provider of

ambulette services or the provider's employee to an MA enrollee for the purpose of

assuring safe access to and from the enrollee's place of residence, ambulette vehicle and

MA covered health service provider's place of business.

Personal assistance is the rendering of physical assistance to the enrollee in walking,

climbing or descending stairs, ramps, curbs or other obstacles; opening or closing doors;

accessing an ambulette vehicle; and the moving of wheelchairs or other items of medical

equipment and the removal of obstacles as necessary to assure the safe movement of the

enrollee.

In providing personal assistance, the provider or the provider's employee will physically

assist the enrollee which shall include touching, or, if the enrollee prefers not to be

touched, guiding the enrollee in such close proximity that the provider of services will be

able to prevent any potential injury due to a sudden loss of steadiness or balance.

Medicaid Transportation Policy Manual

Version 2010-1 October 2010 Page 7 of 63

An enrollee 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.

 

Here is our expectation of an ambulette service:

--The provider does not need to go into the home. To the door is appropriate.

--The provider should not dress the enrollee.

--An ambulette service is required provide transportation to the paratransit disabled in its

geographic region. Certainly, some trips will be easy (an apartment building with an

elevator), while others will be more difficult (down a driveway in the midst of a

snowstorm). Similarly, some wheelchair users need to be transported over curbs and up

and down steps. We expect the ambulette company to do these trips also--safely. If this

requires a second employee, then a second employee should be used.

 

The issue here is the reimbursement from Medicaid. It is our belief that an established amount,

say $24 one way, is to cover the costs of the provider over a period of time. Some trips are short,

and therefore profitable, and some trips take more time, somewhat more unprofitable. One day,

the provider may be able to group some rides, whole another day, there are few trips. Thus, what

is the intent of the amount the county has established? Is it intended to cover more expensive

transports, such as a two employee trip? Some districts have chosen to add on an "extra man"

charge, when needed. Others say: it’s included in the rate. You decide.

 

Do not allow the provider to dictate what is and what is not in the reimbursement

fee as this enables the provider to skim off all the "cream" trips, and refuse the

unprofitable trips.

 

We expect that riders on an ambulette are able to wait in the vehicle while another passenger is

dealt with. However, we do not expect that the cognitively disabled are dumped with the

ambulette provider, with the expectation that the driver will drive, and monitor against selfinjury

or getting out of one's seat. This "attendant" service is to be provided by a relative, or the

staff of the nursing home, or a paid attendant. We require the ambulette service to deliver safe

transportation. The provider is not to act as a medical attendant.

 

 

Ambulette at Taxi Rate

An ambulette company wants to add taxis to their fleet. Could the ambulettes be used as a taxi

and paid the taxi rate?

 

Response

Yes. Medicaid pays for taxi service in an appropriately licensed vehicle. This does not mean

that a taxi vehicle must be used. Taxi service is curb-to-curb, ambulette service is door-to-door.

 

The LDSS can reimburse the ambulette provider at the taxi amount, but cannot use a taxi

procedure code. The LDSS will either have to use the unassigned ambulette code or the

“ambulette as taxi service” procedure code.

 

 

Association for Retarded Citizens (ARC): Responsibility to

Transport

The LDSS receives requests to transport ARC enrollees to medical appointments. Isn’t ARC

responsible for transportation?

 

Response

Day treatment transportation is the responsibility of the ARC day treatment program.

For all other transports, the following applies:

--If the enrollee resides in an OMRDD-certified intermediate care facility (ICF), a

supervised community residence, a supervised and supportive individualized residential

alternative; or attends day habilitation, the residence is responsible for all non-ambulance

transportation. The LDSS is responsible for ambulance transportation.

--If the enrollee lives at home, or in a Family Care home, the LDSS is responsible for

medical transportation.

Reference: April 2008 Medicaid Update, Responsibility for Transportation Provider Reimbursement.

 

Automobile Accident

When a Medicaid beneficiary is involved in an automobile accident and we are unable to obtain

their automobile insurance information, can the beneficiary be held responsible for the bill or are

we to bill Medicaid?

 

I know if it is a hit and run, we bill Medicaid after obtaining documentation from the police

department confirming a hit and run, but the situations I’m asking about occur when either the

patient fails to contact us with auto insurance information or we are unable to contact the patient

due to poor address and telephone information.

 

Can they be held responsible for their auto accident bills?

 

Response

You are to bill Medicaid for emergency ambulance services rendered to a Medicaid enrollee.

If you do receive reimbursement from another insurance company, then you would adjust the

paid Medicaid claim.

 

 

Billing Regional Perinatal Center

When Rural Metro transports a newborn to and from Women & Children’s Regional Perinatal

Center in Buffalo, who bills the transport?

And, what about trips from the Regional Perinatal Center to and from an out-of-state hospital for

more specialized care?

 

Response

The RPC pays for transportation of the child from the community hospital to the Center. The

county can authorize transportation from the RPC back to the community hospital, as needed.

The out of state hospital situation described should be billed to Medicaid directly.

Reference: August 2008 Medicaid Update, Regional Perinatal Center Transportation.

 

 

Claims: Enrollee Signature

Does the Medicaid Program require the enrollee’s signature on file when submitting a claim for

services rendered?

 

Response

For ambulance transportation claims, the Medicaid Program does not require the ambulance

provider to have the Medicaid enrollee's signature on file as a precondition of submitting a valid

claim to the Program. Some counties have enrolled in a Signature Verification program in which a patient’s signature is obtained when transporting to a Medicaid service, as a condition of authorizing the trip.

 

 

Communication Gap with Nursing Home

 

A dialysis patient lives in a nursing home. She went into the hospital, but no one from the

nursing home notified us or the transport company that she was hospitalized. Of course, the

transportation provider arrived for pick up and the patient was a no-show, twice.

We told the transporter that we could not reimburse them for the no-shows. They said that if we

did not pay them, they would quit transporting the patient. The company was our last resort for

this patient as two other companies had refused to transport.

We feel this should be paid by the nursing home. The nursing home refuses and wanted the

patient to pay out of her expenses. She doesn’t have the money, and it wasn’t the patient’s fault.

Are we correct that the nursing home should pay this expense?

 

Response

 

It seems as if this has happened to other providers, since the others have refused to transport this

enrollee. It sounds like the nursing home is having a communication problem, not the LDSS.

The LDSS has fulfilled their end of the bargain by assuring transportation is available for this

enrollee. That being said, it should not be the LDSS’ problem to rectify this situation, nor the

enrollee’s, nor the transportation provider’s.

 

You are correct - you cannot reimburse a transportation provider if they did not provide a

service. No-show enrollees are an unfortunate cost of doing business. We expect Medicaid

enrollees to be treated in the same manner as the general public for no-shows and therefore

should not seek reimbursement when a Medicaid enrollee is a no-show.

 

The nursing home should arrange a way to communicate with the transportation providers

regarding this patient. For example, perhaps the nursing home should call the transportation

provider (or vice versa) on the day before a scheduled pick up to assure pick up is needed.

I suggest the LDSS did their part by assuring transportation is available for this enrollee. Now,

it’s up to the nursing home to work out the situation with the provider(s). A partnership, in a

way, to assure transportation is available to enrollees at this nursing home.

 

 

Eligibility Changed to Family Health Plus – What Happens with

Existing Prior Authorizations

 

A beneficiary needed transportation to medical appointments, so we issued a standing order prior

authorization for six months. Several months into the prior authorization, the transportation provider notified us that they had not been paid for the past few months. In researching the case, it turns out that after we’d issued the prior authorization, the beneficiary’s eligibility changed to Family Health Plus (which does not cover transportation). Why didn’t eMedNY reject the prior authorization?

 

Response

When you issue a prior authorization, the system checks eligibility on the date you enter the

authorization. It cannot guess that in two months, a person will die or otherwise become

ineligible for services.

 

This is why it is CRUCIAL that transportation providers check a person’s eligibility prior to each

date of service. Medicaid will not pay for these claims as the beneficiary is enrolled in Family

Health Plus.

 

 

Hospital to Hospital Transport

 

A transportation provider belongs to a hospital in Clinton County. The enrollee is being

transported in the Emergency Room at this hospital. The transportation provider is transporting

the enrollee to a nearby facility for a CT scan and return back to the hospital via ambulance

because the hospital’s CT scanner is not available.

 

Can we require the hospital/transportation provider to provide further explanation why the CT

scanner is unavailable?

 

Response

With any request for approval of Medicaid transportation, you have the responsibility to request

any and all information you deem necessary in order for you to make a determination that

authorization of transportation expenses, in this instance, is required.

Once you are satisfied with an explanation, either verbally or in writing, you can then authorize

expenses.

 

 

Liability Insurance for Ambulettes

 

Does any government entity (local, state or federal) impose a higher standard of liability

insurance for vehicles transporting Medicaid enrollees?

 

Response

The New York State Department of Transportation (DOT) is the agency that governs the liability

insurance (and licensing) issue with the transportation providers. Applicants must submit a form

"E" for the file at DOT as proof of insurance. In 2006, Medicaid Provider Enrollment staff estimated the minimum amount of coverage that DOT required is around $500,000.

 

 

Managed Care and Transportation

 

If a TBI enrollee is enrolled in a Managed Care Plan that covers transportation in its monthly

rate, are there any services should we authorize transportation on their behalf?

 

Response

No. If the enrollee is in a Medicaid Managed Care Plan that covers transportation in its monthly

rate/scope of benefits, the plan is responsible for all transportation.

Family Health Plus does not cover fee-for-service transportation.

 

 

Monitoring of Transportation Vendors

 

Is there anything in the regulations that requires LDSS to review or monitor the provision of nonemergency Medicaid transportation?

I know DOT is responsible for some issues, DOH is responsible for certifying ambulette and

ambulances, what about LDSS?

 

Response

There is no regulatory requirement for the LDSS to review or monitor the provision of nonemergency transportation. Other agencies license and/or monitor transportation vendors.

Essentially, we just purchase transportation services. You have no specific role to assess

whether the quality of transportation is safe and proper. In the counties which have established a transportation coordinator/broker, we do instruct district staff to require some type of monitoring of transportation vendors to be done by the coordinator. However, this is a typical function the district is purchasing when a coordinator is in use. This leads to the provision of quality transportation services.

 

 

No-Show Reimbursement

 

In the past, this County has allowed a transporter to charge one base rate if an enrollee is a no show or cancels at pickup. Is it legal for the transport to bill the enrollee directly for a no-show?

 

Response

If the provider has accepted payment from Medicaid, the provider is not allowed to bill the

enrollee for additional payment. In the situation you describe, no Medicaid service is provided. There is no legal issue involved. We would expect the Medicaid enrollee would be treated in the same manner as the general public. I assume the company does not bill the general public for no-shows; therefore, the company should not bill the Medicaid enrollee.

 

 

Offline Reimbursements for Providers

If we reimburse our providers offline at the Medicaid rate, must they be enrolled in the Medicaid

Program?

 

Response

No, at this time, they do not need to be enrolled in the Medicaid Program as offline

reimbursements are “transparent” to us. Providers enrolled in the Medicaid Program receive a provider identification number that allows them to bill eMedNY for reimbursement.

 

 

Out-of-State Provider

We are having a difficult time obtaining ambulette or ambulance service for some of our

enrollees currently in the State of Connecticut. We have found an ambulance company that will

provide transport but they are not a NYS provider.

 

How should we suggest they bill for services?

 

Response

When you have an out-of-state vendor, who is not enrolled in New York Medicaid, your only

option is to pay the vendor directly. That expenditure can be claimed on the financial form

Schedule E, in order to secure the State and Federal share of payment.

 

 

Parking Fee

A taxi provider stated that taxis could no longer wait in front of the hospital, but must use the

hospital parking lot. Should the LDSS reimburse the parking fee?

Response

Yes. The provider should submit the receipt to the LDSS.

 

 

Problem Vendor: Services No Longer Wanted

What can we do with a taxi vendor who provides minimal service for us, has billing problems,

and continues to call us even after we’ve instructed them what to do? Can we no longer utilize

them?

Response

The basic goal of the Medicaid Transportation Program is to assure enrollees have transportation

to and from their medical appointments. As long as the transportation needs of enrollees in your

county are met, you can use the most appropriate vendor.

 

 

Procedure for Payment of Non-Emergency Ambulance Claims

Denied by Medicare

The following policy, disseminated to counties in March 2001, applies to non-emergency

ambulance claims that have been denied by Medicare.

· The ambulance company must continue to seek payment from the Medicare program

through the appeals process for the denied claim.

· The ambulance company will contact the fiscally responsible local department of social

services (LDSS) to request a prior authorization for the non-emergency transport.

· The LDSS will determine whether the ambulance transport was necessary based upon

documentation supplied by the ambulance company.

· If approved, the LDSS will prior authorize the ambulance transport at the Medicaid

payment amount.

· The ambulance company must follow the existing zero-fill procedures and use the prior

approval number in its resulting claim to the Medicaid Program.

· If a subsequent decision by Medicare results in a Medicare payment to the provider, the

provider is required to adjust any Medicaid paid claims to reflect the Medicare approved

and Medicare paid amounts in accordance with 18 NYCRR 540.6.

· The effective date of this revised payment policy is January 1, 2000.

 

 

Reimbursement to TBI Agency

Aides employed by a local TBI agency transport Medicaid beneficiaries covered by the TBI

waiver to waivered services. Should counties reimburse the employee or the TBI agency for

incurred mileage?

 

Response

Transportation reimbursement should not be made directly to an agency's employees. Rather,

reimbursement can be made to the agency, which then would reimburse their employees. The

Medicaid payment for TBI services to the agency does not include the costs of transportation of

the beneficiaries. Without this arrangement, DSS would need to find other vendors to do this

transportation.

 

 

Service Definitions

The State has always defined each mode of transportation. Do individual counties have the right

to redefine these modes?

 

Response

No. The definition for ambulance and ambulette are in regulation 18 NYCRR 505.10.

There is no definition for taxi.

(b) Definitions.

(1) Ambulance means a motor vehicle, aircraft, boat or other form of transportation

designed and equipped to provide emergency medical services during transit.

(2) Ambulance service means 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

currently certified or registered by the Department of Health as an ambulance service.

(3) Ambulette or invalid coach means a special-purpose vehicle, designed and equipped

to provide nonemergency transport, that has wheelchair-carrying capacity, stretcher carrying capacity, or the ability to carry disabled individuals.

(4) Ambulette service means 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 as defined in this subdivision.

 

 

Third Party Insurance

If a patient has a commercial insurance as their primary insurance and Medicaid as their

secondary insurance and the primary pays an amount and list the balance as copay or deductible,

can we bill this to Medicaid?

 

If so, up until what dollar amount will Medicaid pay? Do they pay only up until the amount they

would have paid if they were primary? If we cannot bill this to Medicaid can we bill the patient?

 

Response

Since Medicaid is the payer of last resort, a provider needs to bill the third party insurance prior

to billing Medicaid. After adjudication of the third party claim, the provider can bill Medicaid for the co-pay and deductible amount. However, Medicaid will only pay up to either:

--the total co-pay or deductible amount, or

--the Medicaid fee or rate on file, whichever amount is lower. The Medicaid payment is then considered to be payment in full.If the Medicaid payment is less than the co-payment or deductible amount, providers can not bill the enrollee for the outstanding balance of the co-payment or deductible amount (because Medicaid payment is payment in full). The only instance in which providers can bill the enrollee is when the provider enters into a private-pay agreement with the enrollee, prior to the rendering of the care or service. In this instance, there is no Medicaid involvement.

 

 

Transportation from Morgue to Funeral Home

A hospital called to request Medicaid to pay for an ambulance to transport of a deceased

Medicaid beneficiary from the morgue to a funeral home. Apparently, the decedent weighed

approximately 600 pounds, and no hearse is qualified to carry that much weight.

 

Response

Transportation to a funeral home is not a Medicaid-covered service, so Medicaid cannot pay for

transportation in this case.

Medicaid Transportation Policy Manual

Version 2010-1 October 2010 Page 16 of 63

 

 

Transportation of Prosthetics

A wheelchair vendor was scheduled a trip to take a enrollee to an appointment with a prosthetic

provider. But when they arrived at the nursing home to pick up the resident, the staff handed the

driver the resident's legs. The resident remained in the facility. Nursing home staff told the

driver to take the legs to the provider. Later, the transporter was called to return to pick up the

legs and return them to the resident in the nursing home. I have since been told that the prosthetic vendor was putting the "flesh leg look" on the legs, and since it takes some time to do so, the nursing home decided the resident did not need to go along. In the past, we have taken enrollees in for adjustments to their wheelchairs, or fittings for stockings, etc., but the enrollee has always gone on the trip. This is different. The transporter provided the transport in good faith, and I don't want to penalize them by not paying them and I'm assuming this is a Medicaid billable service, but I really don't know that either. What do you think?

 

Response

Prosthetics are covered under the Medicaid Program. However, it is up to the prosthetic dealer to

go and get prosthetics that need repair, or a new shade of color. It is included in the fee paid for

the prosthetics. I am appalled that the nursing home called for a very expensive mode of transportation.

 

We pay for the transportation of a Medicaid enrollee. If we transport legs, a body has to be part

of the package. I suggest you write a letter to the nursing home, stating:

our policy,

that nursing home staff were wrong to think Medicaid will pay for an unnecessarily

expensive mode of transportation of these legs, and

that they are responsible to pay the ambulette provider directly.

If the nursing home has questions, you are free to refer them to me.

 

 

Transportation Provider Refuses to Provide Taxi Transport to

Nursing Home Resident

One of our primary ambulette/taxi transporters was contacted by a local nursing home for a taxi

transport to an appointment. The transportation provider indicated that they cannot do taxi

transports for nursing home residents – mentioning safety and leaving them at the curb, which in

this case is the front door.

Is this correct and do you have any written policy on this?

 

Response

Medicaid Transportation Policy Manual

Version 2010-1 October 2010 Page 17 of 63

Medicaid does not have any policy on disallowing taxi transports of nursing home residents.

As you know, we rely on the medical practitioner, in this situation nursing home staff, to

determine and request the most appropriate mode of transportation--this is our policy. Nursing

home staff know the mobility needs of residents. If there is any type of exclusion of taxi

transportation, I would expect that nursing home staff would be aware of this exclusion.

I surmise the taxi provider has had very few requests to transport nursing home residents; i.e., the

level medical care needed for a person to qualify for nursing home placement usually is at such a

level that only ambulette/ambulance transportation is ever requested.

 

 

Two Ambulance Companies–One Transport: Who Pays?

After an emergency ground ambulance responds to a call, it is then determined by the ground

crew that a helicopter is necessary for transport. Company A paramedics ride with the patient on the Company B’s helicopter from the scene to the hospital. Since Company A does not own the helicopter, Medicare requires us to bill with procedure code A0999 (unlisted ambulance procedure). Company A bills Medicare for the use of our paramedics aboard the Company B helicopter. Medicare does not cover this service because

Company A is not actually transporting the patient. Will Medicaid reimburse Company A?

 

Response:

No, our position is the same as Medicare’s. Company A did not provide the transportation

service, so we should see/pay no claim.

 

 

Vendor Raising Fees without Agreement

Do vendors have to give notice before raising their fees? From one month to the next, one of our

vendors raised their rates by $2.00 each way. This particular vendor is currently upset with us

over billing issues, and since then I have noticed that the fees increased on a few bills. Could

you please let me know how I should approach this issue and if this is something that is allowed?

 

Response

The amount you reimburse for a Medicaid transport is based upon an agreement between the

county and the provider. A provider can not force you to pay any amount. Even when a

provider's public rates increase, the agreement has to be reached with you before Medicaid will

pay the higher amount.

 

You can instruct the provider that we, New York State, will not allow you to reimburse a higher

amount without our approval of the increase in taxi reimbursement.

 

All billing questions should be directed to

Computer Sciences Corporation (CSC).

Providers can call CSC at (800) 343-9000.