Non-Emergency Non-Ambulance Services - TRANSCITA

Transcription

1 Non-Emergency Non-Ambulance Services - TRANSCITA [Preauthorization Required] Medical Policy: MP-TRANS 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, 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. A non-emergency response is one where the need for transportation is due to a medical condition or a medical necessity that is not acute in nature and does not require an immediate response. These services can be facilitated in a coordinated or non-coordinated manner and can be provided by ambulance or non-ambulance vehicles depending on the medical necessity of the member. For these services to be provided by an ambulance the member should meet the medical necessity criteria as stimulated by Medicare and the health medical plan. In general, they are going to be those cases where transporting the member in another type of 1

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 non-emergency, nonambulance 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 I., (MCS) covers Non Emergency Patient Transport Service (PTS) (Non ambulance non emergency transportation) as an alternative mean of transportation after a proper evaluation assessment has been determined by MCS Case Management Program and the following criteria s are met: 2

3 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. Transfer from a hospital, which has appropriate facilities and staff for treatment to another hospital. 3

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 A0100 A0130 A0200 S0215 DESCRIPTION NON EMERGENCY TRANSPORTATION, TAXI NON EMERGENCY TRANSPORTATION : WHEELCHAIR VAN (WHEELCHAIR ROUND TRIP/ LEG/DIALYSIS /NON DIALYSIS NON EMERGENCY TRANSPORTATION : ANCILARY LODGING- ESCORT (PATIENT COMPANION TRIP/LEG) 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* V49.89* Bed Confinement Status 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 due to the medical condition of the member. V49.89 indicates that transportation by any other means is contraindicated due to the medical condition of the member. 4

5 REFERENCES 1. American Ambulance Association (Condition Code Training Guide). AAA Administracion de Seguros De Salud De Puerto Rico (ASES). Emergency Transportation Services, Section , Provisions of Physical Health Services Under the MiSalud Program. (October 2010). 3. Administración de Seguros De Salud De Puerto Rico (ASES). Basic Coverage, Section , 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: , Effective /Implementation Date CMS (Center for Medicare and Medicaid Services Part A and B, Trail Blazer Health Enterprise, LLC. Published May 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/ Centers for Medicare & Medicaid, Medicare Benefit Manual. Chapter 10-Ambulance Services (rev.125, ) Centers for Medicare & Medicaid, Medicare Claims Processing Manual. Chapter 15 Ambulance (rev. 1942, ) Centers for Medicare & Medicaid (CMS). The Medicare Ambulance Benefits & Statutory Bases for Denial of Claims and Transports and ABNs. July 10, POLICY HISTORY DATE ACTION COMMENT March 24, 2011 Origination of Policy 5

6 This document is for informational purposes only. It is not an authorization, certification, explanation of benefits, or contract. Receipt of benefits is subject to satisfaction of all terms and conditions of coverage. Eligibility and benefit coverage are determined in accordance with the terms of the member s plan in effect as of the date services are rendered., (MCS) medical policies are developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical practices in the treatment and diagnosis of disease. Because medical practice, information, and technology are constantly changing, Medical Card System, Inc., (MCS) reserves the right to review and update its medical policies at its discretion, (MCS) medical policies are intended to serve as a resource to the plan. They are not intended to limit the plan s ability to interpret plan language as deemed appropriate. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment they choose to provide. 6