FEE SCHEDULE NEW YORK STATE MEDICAID TRANSPORTATION

FEE SCHEDULE NEW YORK STATE MEDICAID TRANSPORTATION

NYS Medicaid Transportation Schedule Ambulance A0422 A0420 A0424 A0425 A0426 A0427 A0428 A0429 A0430 A0431 A0432 A0433 A0434 A0435 A0436 A0999 Advanced Life Support or Basic Life Support Oxygen and Oxygen Supplies Life Sustaining Situation Wait Time (ALS or BLS) One Half Hour Increments Extra attendant, ALS or BLS (Requires Medical Review) Ground Mileage per Statute Mile Advanced Life Support, Non-Emergency, Level 1 (ALS1) Advanced Life Support, Emergency, Level 1 (ALS1 Emergency) Basic Life Support, Non-Emergency (BLS) Basic Life Support, Emergency (BLS Emergency) Conventional Air Services, Transport, One Way (Fixed Wing) Conventional Air Services, Transport, One Way (Rotary Wing) Paramedic Intercept Advanced Life Support, Level 2 (ALS2) Specialty Care Transport (SCT) Fixed Wing air mileage, per statute mile Rotary Wing air mileage, per statute mile Unassigned Established March 2005 1

NYS Medicaid Transportation Schedule Ambulette/Wheelchair Van NY100 NY101 NY102 NY103 NY104 NY105 NY106 NY107 NY108 NY109 NY110 NY111 NY112 NY113 NY114 NY115 NY116 NY117 NY118 NY119 NY120 NY121 NY122 NY123 NY124 NY125 NY126 NY127 NY128 NY129 NY130 NY131 NY132 NY133 One way trip inside common medical marketing area One way evening, weekend, holiday One way outside common medical marketing area Mileage Roundtrip Additional recipients in vehicle at the same time One Way to recurring appointments, i.e., dialysis Add-on for long distance trip Add-on for exceptional travel situations requiring increased reimbursement (i.e., carrydown) Attendant Attendant evening, weekend, holiday Stretcher: One way inside common medical marketing area Stretcher: One way outside common medical marketing area Stretcher: Add-on for exceptional travel situations requiring increased reimbursement Stretcher: Roundtrip Stretcher: Mileage Drug store stop/other/extra stop Tolls Ambulette Used as Taxi/Livery Ambulette Used as Taxi/Livery: ambulatory Multi-purpose vehicle used as ambulette/taxi/livery Ambulette as Taxi/Livery: mileage Ambulette as Taxi/Livery: outside common medical marketing area Ambulette as Taxi/Livery: additional recipients in vehicle Group Ride: one way per person ambulatory Group Ride: one way per person wheelchair Group Ride: extra recipient traveling at the same time Group Ride: outside common medical marketing area Group Ride: outside county Group Ride: Roundtrip Group Ride: attendant Group Ride: Mileage Established March 2005 2

NYS Medicaid Transportation Schedule Ambulette/Wheelchair Van continued NY134 NY135 NY136 NY137 NY138 NY139 NY140 NY199 Mileage: Mileage: Mileage: Mileage: Stretcher: Stretcher: Unassigned available for extraordinary transports Established March 2005 3

NYS Medicaid Transportation Schedule Taxi/Livery/Van NY200 NY201 NY202 NY203 NY204 NY205 NY206 NY207 NY208 NY209 NY210 NY211 NY212 NY213 NY214 NY215 NY216 NY217 NY218 NY219 NY220 NY221 NY222 NY223 NY224 NY225 NY226 NY227 NY228 NY229 NY230 NY231 NY232 NY233 NY234 NY235 NY298 NY299 One way inside common medical marketing area One way evening, weekend, holiday One way outside common medical marketing area Roundtrip Inside County Outside county Mileage Additional recipients in vehicle at same time Regularly recurring trip, i.e., dialysis Attendant Add-on for long distance trip Add-on for exceptional travel situations requiring increased reimbursement Group Ride: One way inside common medical marketing area Group Ride: One way outside common medical marketing area Group Ride: Roundtrip Group Ride: Inside county Group Ride: Outside county Group Ride: One way ambulatory per person Group Ride: One way wheelchair per person Group Ride: One way ambulatory additional recipient in vehicle at same time Group Ride: One way wheelchair additional recipient in vehicle at same time Group Ride: Mileage Group Ride: Ambulatory Mileage Group Ride: Wheelchair mileage Group Ride: Attendant Group Ride: to Medical Appointment Drugstore stop/extra stop Tolls Group Ride One way zone 1 or county specific Group Ride One way zone 2 or county specific Group Ride One way zone 3 or county specific Group Ride One way zone 4 or county specific Group Ride One way zone 5 or county specific Group Ride One way zone 6 or county specific Group Ride: Unassigned for extraordinary transports Taxi/Livery: Unassigned for extraordinary transports Established March 2005 4

NYS Medicaid Transportation Fee Schedule For information on Medicaid transportation reimbursement amounts and procedure codes, please contact the Local Department of Social Services (LDSS) Medicaid transportation staff. LDSS contact information is located in the Information for All Providers Inquiry manual, available online at: http://www.emedny.org/providermanuals/allproviders/index.html. Version 2006-1 June 9, 2006 Page 1 of 1