Commonwealth of Massachusetts
Executive Office of Health and Human Services
Division of Medical Assistance
600 Washington Street Boston, MA 02111 www.mass.gov/dma

MASSHEALTH
TRANSMITTAL LETTER TRN-27
September 2003
TO:      Transportation Providers Participating in MassHealth FROM:      Douglas S. Brown, Acting Commissioner
RE:      Transportation Manual (Revised Regulations and Service Codes)
Revised Regulations
This letter transmits revisions to the MassHealth transportation regulations. The Division has revised its transportation regulations to update terminology and to clarify policy. The revised regulations:
 •	provide new definitions;
 •	replace the term chair car with the term wheelchair van;
 •	specify that transportation to a medical service that is within .75 miles of the member’s residence is not covered if the member is able to ambulate freely;
 •	remove the locality restriction exclusion for MassHealth members enrolled in managed care;
 •	specify that when two or more members are traveling together to the same locality, only one member may request personal reimbursement;
 •	eliminate the statement that the Division will pay 150% of the service payment, consisting of the base rate plus mileage per loaded mile for trips in excess of 50 miles; and
 •	comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
These revisions are effective October 1, 2003.
Revised Subchapter 6
This letter also transmits revisions to Subchapter 6 (service codes and descriptions) of the Transportation Manual. The revised Subchapter 6 is effective for dates of service on or after October 1, 2003.
The Centers for Medicare and Medicaid Services (CMS) have revised the Healthcare Common Procedure Coding System (HCPCS) for 2003. New national service codes have been added, and MassHealth local codes have been removed from the Transportation Manual. Please note that you must use modifiers with some codes to accurately reflect the service provided. The attached Subchapter 6 contains codes with modifiers, where applicable. Service Code X0165 has been deleted.

MASSHEALTH
TRANSMITTAL LETTER TRN-27 September 2003 Page 2
Crosswalks
Attached are two crosswalks that show the obsolete MassHealth local service codes and the new national service codes and modifiers. Attachment 1 is for independent transportation providers, and Attachment 2 is for regional transit authorities. These crosswalks contain important billing information for both the DMA proprietary paper and electronic formats and for the 837 Professional (837P) claim format. Please be sure to read the crosswalk that applies to you carefully.
Informational Bulletin from the Division of Health Care Finance and Policy
If you wish to obtain a copy of the Division of Health Care Finance and Policy’s Informational Bulletin 02-14 about the conversion of these codes, submit a request to the address or phone number listed below.
Division of Health Care Finance and Policy Two Boylston Street Boston, MA 02116 Telephone: 617-988-3100
You can also view this bulletin on line at www.mass.gov/dhcfp.
Web Site Access and Questions
This transmittal letter is available on the Division’s Web site at www.mass.gov/dma.
If you have any questions, please call MassHealth Provider Services at 617-628-4141 or 1-800-325-5231.
NEW MATERIAL
(The pages listed here contain new or revised language.)
Transportation Manual
Pages iv, vi, 4-1 through 4-20, 6-1, and 6-2
OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)
Transportation Manual
Pages iv, iv-a, v, and 4-1 through 4-22 — transmitted by Transmittal Letter TRN-25
Pages 6-1 and 6-2 — transmitted by Transmittal Letter TRN-26

Transportation Provider Service Code Crosswalk
Effective October 1, 2003

MassHealth
Transmittal Letter TRN-27
September 2003
Attachment 1
Page 1

Service	Obsolete Code	Description	New Code-	Description	Additional Billing Instructions:			

	

			

	

	
	Paper Claim 07/EMC		837P Claim Transaction		

	

		

	

	
	Number of Miles	Place of Service	Round Trip Indicator	Additional Modifiers	
Type			Modifier		Item 20	Item 22 No change. Continue to use this field to indicate origin and destination.	Loop 2300 (line level) or Loop 2400 (claim level); Field CR103	Use origin and destination modifiers in accordance with HIPAA. Do not use a place of service code or field for this purpose.	
Dial-a-Ride	X0137	One way	A0120	Nonemergency transportation: mini-	Enter 1.	Use POS.		Origin and destination modifiers	
Services		dial-a-ride services		bus, mountain area transports, or other transportation systems (IC)		Enter the two-digit place of service (POS) code from your Subchapter 5 that describes the origin and destination of the trip. When billing for a round trip, enter the POS code that describes the first leg of the trip.		Use origin and destination modifiers in accordance with HIPAA. The first single-character modifier indicates the origin of the trip; the second single-character modifier indicates the destination of the trip. These may be combined into one two-character modifier, in that order.	

	X0138	Round trip	A0120	Nonemergency transportation: mini-	Enter 2.	Use POS.	Enter Ambulance Transport	Origin and destination modifiers	
		dial-a-ride		bus, mountain area transports, or			Code X to indicate a round		
		services		other transportation systems (IC)			trip.		
Taxi	None		A0100	Nonemergency transportation; taxi	Enter 1 for one-way;	Use POS.	Enter Ambulance Transport Origin and destination modifiers	
Services				(use for one passenger, intra-city transportation)	2 for round trip.		Code X to indicate a round trip, as appropriate.		
Chair-Car	None		A0130	Nonemergency transportation:	Enter 1 for one-way;	Use POS.	Enter Ambulance Transport	Origin and destination modifiers	
Services				wheelchair van	2 for round trip.		Code X to indicate a round trip, as appropriate.		
	X0147	Wheelchair vans, each additional person, each way (No mileage fee allowed.)	A0130-TK	Nonemergency transportation; wheelchair van (extra patient or passenger, non-ambulance) (No mileage fee allowed).	Enter 1.	Use POS.		Origin and destination modifiers	
	X0153	Second attendant each way	T2001	Nonemergency transportation; patient attendant/escort (Use for second attendant.)	Enter 1.	Use POS.		Origin and destination modifiers	

Transportation Provider Service Code Crosswalk
Effective October 1, 2003

MassHealth
Transmittal Letter TRN-27
September 2003
Attachment 1
Page 2

Service Type	Obsolete Code	Description	New Code-Modifier	Description	Additional Billing Instructions:			

	

			

	

	Paper Claim 07/EMC		837P Claim Transaction		

	

		

	

	
	Number of Miles
Item 20	Place of Service
Item 22 No change. Continue to use this field to indicate origin and destination.	Round Trip Indicator
Loop 2300 (line level) or Loop 2400 (claim level); Field CR103	Additional Modifiers
Use origin and destination modifiers in accordance with HIPAA. Do not use a place of service code or field for this purpose.	
Ambulance
Services –
BLS	X0174	Mileage for wheelchair vans, each way	S0215	Nonemergency transportation; mileage, per mile (Wheelchair vans must use this code for mileage. Do not use A0425).	Enter number of miles.	Use POS.		Origin and destination modifiers	

	None		A0428      Ambulance service, basic life
support, nonemergency transport (BLS)	Enter 1.	Use POS.		Origin and destination modifiers	
	None		A0429      Ambulance service, basic life
support, emergency transport (BLS - emergency)	Enter 1.	Use POS.		Origin and destination modifiers	
Other                      None
Licensed
Carriers		A0140      Nonemergency transportation and    Enter 1 for one-way;   Use POS. air travel (private or commercial),      2 for round trip. intra- or interstate	Enter ambulance transport   Origin and destination modifiers code X to indicate a round trip, as appropriate.	

MassHealth
Transmittal Letter TRN- 27
September 2003
Attachment 2
Page 1
Transportation Provider
Service Codes Crosswalk
RTA-Specific Codes
Effective October 1, 2003

				Additional Billing Instructions:	
				Paper Claim                 837P Claim Transaction
I 07/EMC	
Service Type	Obsolete Code	Description	New Code-Modifier	Description	Number of Miles          Place of Item 20                          Service Item 22 No change. Continue to use this field to indicate origin and destination.	Round-Trip Indicator
Loop 2300 (line level) or Loop 2400 (claim level); Field CR103	Additional Modifiers
Use origin and destination modifiers in accordance with HIPAA. Do not use a place of service code or field for this purpose.	
RTA-Specific
Codes
Ambulatory	X1998	Ambulatory rate, one way, contracted	T2003	Nonemergency transportation, encounter/trip (Use for contracted ambulatory service.)	Enter 1.	Use POS.		Origin and destination modifiers	
	X1999	Ambulatory rate, round trip, contracted	T2003	Nonemergency transportation, encounter/trip (Use for contracted ambulatory service.)	Enter 2.	Use POS.	Enter ambulance transport code X to indicate a round trip.	Origin and destination modifiers	
RTA-Specific
Codes
Nonambulatory	X0155	Wheelchair van service, one way base rate, contracted	A0130	Non-emergency transportation; wheelchair van	Enter 1.	Use POS.		Origin and destination modifiers	
	X0156	Wheelchair van service, round trip base rate, contracted	A0130	Non-emergency transportation; wheelchair van	Enter 2.	Use POS.	Enter ambulance transport code X to indicate a round trip.	Origin and destination modifiers	
	X0157	Wheelchair van service, one way second attendant, contracted	T2001	Nonemergency transportation; patient attendant/escort (Use for second attendant.)	Enter 1.	Use POS.		Origin and destination modifiers	

MassHealth
Transmittal Letter TRN- 27
September 2003
Attachment 2
Page 2
Transportation Provider
Service Codes Crosswalk
RTA-Specific Codes
Effective October 1, 2003

				Additional Billing Instructions:	
				Paper Claim                 837P Claim Transaction
I 07/EMC	
Service Type	Obsolete Code	Description	New Code-Modifier	Description	Number of Miles          Place of Item 20                          Service Item 22 No change. Continue to use this field to indicate origin and destination.	Round-Trip Indicator
Loop 2300 (line level) or Loop 2400 (claim level); Field CR103	Additional Modifiers
Use origin and destination modifiers in accordance with HIPAA. Do not use a place of service code or field for this purpose.	
	X0158	Wheelchair van service, round trip second Attendant, contracted	T2001	Non-emergency transportation; patient attendant/escort (Use for second attendant.)	Enter 2.	Use POS.	Enter ambulance transport code X to indicate a round trip.	Origin and destination modifiers	
	X0130	Wheelchair van service, Each additional recipient, one way (No addn'l mileage fee allowed), contracted	A0130-TK	Nonemergency transportation; wheelchair van (extra patient or passenger, non-ambulance) (No mileage fee allowed.)	Enter 1.	Use POS.		Origin and destination modifiers	
	X0124	DPH Early Childhood Intervention transportation, one way	A0110-TL	Non-emergency transportation and bus, intra- or interstate carrier (early
intervention/individualized family service plan (ifsp)) (Use for Department of Public Health Early Intervention transportation.)	Enter 1.	Use POS.		Origin and destination modifiers	

MassHealth
Transmittal Letter TRN- 27
September 2003
Attachment 2
Page 3
Transportation Provider
Service Codes Crosswalk
RTA-Specific Codes
Effective October 1, 2003

				Additional Billing Instructions:	
				Paper Claim                 837P Claim Transaction
I 07/EMC	
Service Type	Obsolete Code	Description	New Code-Modifier	Description	Number of Miles          Place of Item 20                          Service Item 22 No change. Continue to use this field to indicate origin and destination.	Round-Trip Indicator
Loop 2300 (line level) or Loop 2400 (claim level); Field CR103	Additional Modifiers
Use origin and destination modifiers in accordance with HIPAA. Do not use a place of service code or field for this purpose.	
	X0131	Wheelchair van service, each additional recipient, round trip (No addn'l mileage fee allowed), contracted	A0130-TK	Nonemergency transportation; wheelchair van (Extra patient or passenger, non-ambulance) (No mileage fee allowed.)	Enter 2.	Use POS.	Enter ambulance transport code X to indicate a round trip.	Origin and destination modifiers	
	X0168	Wheelchair van mileage, one way, per loaded mile add-on, contracted	S0215	Nonemergency transportation; mileage, per mile (Wheel chair vans must use this code for mileage. Do not use A0425.)	Enter number of miles.	Use POS.		Origin and destination modifiers	
	X0170	Wheelchair van mileage, round trip, per loaded mile beginning with first mile, contracted	S0215	Nonemergency transportation; mileage, per mile (Wheel chair vans must use this code for mileage. Do not use A0425.)	Enter number of miles.	Use POS.		Origin and destination modifiers	

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
TABLE OF CONTENTS	PAGE
iv	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
4.   PROGRAM REGULATIONS
407.401:     Introduction 		4-1
407.402:     Definitions 		4-1
407.403:     Eligible Members 		4-3
407.404:     Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services ....	4-3
407.405:     Provider Eligibility: In State 		4-4
407.406:     Provider Eligibility: Out-of-State Emergency Services 		4-4
407.407:     Selective Contracting 		4-4
(130 CMR 407.408 through 407.410 Reserved)
407.411:     Transportation Utilization Restrictions 		4-5
(130 CMR 407.412 through 407.420 Reserved)
407.421:     Authorization for Transportation 		4-7
(130 CMR 407.422 through 407.430 Reserved)
407.431:     Reimbursement to Members for Transportation Expenses 		4-9
407.432:     Payment to Providers for Transportation Services 		4-10
(130 CMR 407.433 through 407.440 Reserved)
407.441:     Dial-a-Ride 		4-11
(130 CMR 407.442 through 407.450 Reserved)
407.451:     Taxi 		4-13
(130 CMR 407.452 through 407.470 Reserved)
407.471:     Nonemergency Wheelchair Van 		4-16
(130 CMR 407.472 through 407.480 Reserved)
407.481:     Ambulance 		4-18
(130 CMR 407.482 through 407.490 Reserved)
407.491:     Other Licensed Carriers 		4-20

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
TABLE OF CONTENTS	PAGE
vi	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
6. SERVICE CODES 		6-1
Appendix A. DIRECTORY 		A-1
Appendix B. ENROLLMENT CENTERS 		B-1
Appendix C. THIRD-PARTY-LIABILITY CODES 		C-1
Appendix W. EPSDT SERVICES: MEDICAL PROTOCOL AND
PERIODICITY SCHEDULE 		W-1
Appendix X. FAMILY ASSISTANCE COPAYMENTS AND DEDUCTIBLES 		X-1
Appendix Y. REVS/CODES MESSAGES 		Y-1
Appendix Z. EPSDT SERVICES LABORATORY CODES 		Z-1

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 407.000)	PAGE
4-1	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
407.401: Introduction
All transportation providers participating in MassHealth must comply with the regulations of the Division governing MassHealth, including but not limited to Division regulations set forth in 130 CMR 407.000 and 450.000.
407.402: Definitions
The following terms used in 130 CMR 407.000 and Subchapter 6 of the Transportation Manual have the meanings given in 130 CMR 407.402, unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 407.000 is not determined by these definitions, but by application of regulations elsewhere in 130 CMR 407.000 and 450.000.
Additional person — a person traveling in the same vehicle with another person for the purpose of receiving services covered by MassHealth.
Advanced Life Support, Level 1 (ALS1) — When medically necessary, the provision of an assessment by an advanced life support (ALS) ambulance provider or supplier and the furnishing of one or more ALS interventions. An ALS assessment is performed by an ALS crew and results in the determination that the patient’s condition requires an ALS level of care, even if no other ALS intervention is performed. An ALS provider or supplier is defined as a provider trained to the level of the Emergency Medical Technician-Intermediate (EMT-Intermediate) or Paramedic as defined in the National Emergency Medicine Services (EMS) Education and Practice Blueprint. An ALS intervention is defined as a procedure beyond the scope of an EMT-Basic as defined in the National EMS Education and Practice Blueprint as most recently published in the Federal Register.
Advanced Life Support, Level 2 (ALS2) — When medically necessary, the administration of at least three different medications or the provision of one or more of the following ALS procedures: manual defibrillation/cardioversion, endotracheal intubation, central venous line, cardiac pacing, chest decompression, surgical airway, intraosseus line as most recently published in the Federal Register.
Ambulance — An aircraft, boat, motor vehicle, or other means of transportation, including a dual-purpose vehicle, however named, whether privately or publicly owned, that is intended to be used for and is maintained and operated for the transportation of sick, injured, or disabled persons and that has in force a valid certificate of inspection and license issued by the Department of Public Health as set forth in 105 CMR 170.000 of the regulation for the implementation of M.G.L. c. 111C, regulating Ambulances and Ambulance Services (Department of Public Health).
Basic Life Support (BLS) — When medically necessary, the provision of basic life support (BLS) services as defined in the National EMS Education and Practice Blueprint for the EMT-Basic including the establishment of a peripheral intravenous (IV) line as most recently published in the Federal Register.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 407.000)	PAGE
4-2	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
Dial-a-Ride — a motor vehicle for hire that is used to transport ambulatory persons on a demand-response, shared-ride basis, and is licensed by the city or town in which the business is located.
Division — the Division of Medical Assistance or an agent contracted with the Division to act on its behalf.
Emergency Medical Condition — a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of the member or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. section 1395dd(e)(1)(B).
Emergency Services — medical services that are provided by a provider that is qualified to provide such services, and are needed to evaluate or stabilize an emergency medical condition.
Escort — an individual who physically assists a member with ambulating to and from a medical appointment. An escort can be an individual who physically assists a member with ambulating; a parent or guardian of a child under age 17; or a caretaker or guardian of a mentally incompetent member.
Loaded Miles — the distance traveled while a member is in the vehicle.
Managed-Care Representative — a clinical employee of a managed-care organization (MCO) or other MassHealth managed-care provider who has been designated to handle the transportation requests of enrolled members, including a physician and nurse practitioner, or a registered nurse, licensed practical nurse, and a licensed social worker under the supervision of a physician or nurse practitioner. For MassHealth managed-care providers of mental health and substance abuse services, a clinical employee includes, in addition to those individuals listed above, a licensed clinical psychologist or a licensed, independent clinical social worker.
Other Licensed Carrier — any carrier, including bus, train, plane, or boat, that is licensed by the appropriate licensing board or agency.
Prescription for Transportation (PT-1) — a form developed by the Division of Medical Assistance to determine the necessity of nonemergency medical transportation.
Primary Care — the provision of coordinated, comprehensive medical services, on both a first-contact and a continuous basis, to members enrolled in managed care. Services include: an initial medical history intake, medical diagnosis and treatment, communication of information about illness prevention, health maintenance, and referral services.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 407.000)	PAGE
4-3	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
Private Transportation — transportation by a carrier of persons operated by an entity other than a state or a political subdivision thereof.
Public Transportation — transportation by a carrier of persons operated by a city, town, county, authority, or other political subdivision of a state.
Shared Ride — transportation service provided to two or more members traveling in the same vehicle (for example, taxi or dial-a-ride) for the purpose of receiving medical services covered by MassHealth.
Taxi — a motor vehicle for hire that is used to transport persons on an individual basis and is licensed by the city or town in which the business is located.
Urgent Care — medical services that are not primary care, and are needed to treat a medical condition that is not an emergency medical condition.
Verbal Authorization — authorization of transportation by telephone or other verbal means obtained from the Division when a Prescription for Transportation (PT-1) has been signed by the prescriber but has not been received by the Division or when urgent medical care is required.
Waiting Time — the time spent by a vehicle and its driver and attendants in waiting to return a member to the point of trip origin. Waiting time applies only when the member is not in the vehicle.
Wheelchair Van — a motor vehicle that is specifically equipped to carry one or more persons who are mobility-handicapped or using a wheelchair.
407.403: Eligible Members
(A)	(1) MassHealth Members. The Division covers transportation services only when provided
to eligible MassHealth members, subject to the restrictions and limitations described in the
Division’s regulations. The Division’s regulations at 130 CMR 450.105 specifically state, for
each MassHealth coverage type, which services are covered and which members are eligible
to receive those services.
(2) Recipients of the Emergency Aid to the Elderly, Disabled and Children Program. For information on covered services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program, see 130 CMR 450.106.
(B)	For information on verifying member eligibility and coverage type, see 130 CMR 450.107.
407.404: Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services
The Division offers and provides, when appropriate under policy provisions, transportation services to all MassHealth members under 21 years of age to facilitate their access to comprehensive health care. See 130 CMR 450.140 et seq. for regulations about Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 407.000)	PAGE
4-4	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
407.405: Provider Eligibility: In State
 (A)	In order to be eligible to receive payment from MassHealth, a potential provider must be a Medicare provider, complete a provider application form, and be assigned a MassHealth provider number by the Division.
 (B)	Except where the Division elects to limit and/or terminate provider agreements in accordance with 130 CMR 407.407 and 450.109 in areas of the state where a selective contract with a transportation broker is in effect, the Division accepts and approves applications from providers that qualify and meet given regulations or licensure requirements as are adopted by the Massachusetts Department of Public Health, the Division, or the Massachusetts Registry of Motor Vehicles for one or more of the following modes of transportation: dial-a-ride, taxi, wheelchair van, ambulance, or other licensed carriers.
407.406: Provider Eligibility: Out-of-State Emergency Services
An out-of-state transportation provider may be paid by the Division for transportation services provided in accordance with 130 CMR 407.000 only if the provider is a Medicare provider, submits an application to become an approved MassHealth provider, and is assigned a MassHealth provider number by the Division. An out-of-state provider must have a valid license issued by the appropriate regulatory agency within its state in order to be approved as a MassHealth provider.
407.407: Selective Contracting
 (A)	In some regions the Division may provide transportation services through selective contracts with regional transit authorities or other transportation entities. In areas of the state where a selective contract with a transportation broker is in effect, services are provided in accordance with all applicable MassHealth regulations and the terms of the contract.
 (B)	The Division may terminate, in whole or in part, existing provider agreements with transportation providers in those regions where selective contracts are in effect. In the event of any such termination, the Division notifies the affected providers in writing, at least 30 days before termination. Such termination will not affect payments to providers for services provided before the date of termination.
 (C)	Members in regions where selective contracts are in effect are notified by the Division of the transportation available to them under the terms of such contracts.
(130 CMR 407.408 through 407.410 Reserved)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 407.000)	PAGE
4-5	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
407.411: Transportation Utilization Restrictions
(A)	Covered Services. The Division pays for transportation services only when such services are
covered under the member’s MassHealth coverage type and only when members are traveling to
obtain medical services covered under the member’s coverage type (see 130 CMR 450.105).
 (1)	In the case of taxi, dial-a-ride, bus, and public transportation, the Division determines those medical services that are covered by MassHealth.
 (2)	In the case of ambulance and wheelchair van transportation not provided through a selective contract with a transportation broker, it is the responsibility of the transportation provider to judge which medical services are covered by MassHealth and to advise the member in cases where transportation is requested to a service that, in the provider's judgment, may not be or is not covered by MassHealth. If a member is in doubt as to whether or not a medical service is covered by MassHealth, the member should contact the Division.
 (3)	In the case of taxi, dial-a-ride, and wheelchair van transportation provided through a selective contract with a transportation broker, the Division determines those medical services that are covered by MassHealth.
(B)	Noncovered Services. The following are examples of transportation services that are not
covered by MassHealth:
 (1)	transportation to child day-care centers and nurseries;
 (2)	transportation of persons who are elderly or disabled to adult day health programs, except when arranged by special contract with the MassHealth Adult Day Health Program;
 (3)	transportation to schools, summer camps, and recreational programs (for example, swimming classes);
 (4)	transportation of family members to visit a hospitalized or institutionalized member;
 (5)	transportation to a medical facility or physician's office for the sole purpose of obtaining a medical recommendation for homemaker/chore services;
 (6)	transportation to government-agency offices;
 (7)	transportation to visit a child in foster-care placement or in group-care placement;
 (8)	transportation to a medical service that is within .75 miles of the member’s home or other Division-approved point of origin, when the member is able to ambulate freely with or without an escort;
 (9)	transportation to pharmacies to obtain medications; and
(10)	transportation to obtain computerized axial tomography (CAT) scans at a facility other
than one that has been issued a Certificate of Need by the Massachusetts Department of Public
Health.
(C)	Locality Restrictions. The Division pays for an eligible member to be transported to sources
of medical care only within the member's locality, unless otherwise authorized by the Division.
Locality refers to the town or city in which the member resides and to immediately adjacent
communities. However, when necessary medical services are unavailable in the member's
locality, transportation to the nearest medical facility in which treatment is available is covered by
MassHealth. Medical transportation originates from the member's home and proceeds to the
location of the medical appointment. Other points of origin, such as from one doctor's office to
another, require approval from the Division.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 407.000)	PAGE
4-6	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
(D) Institutionalized Members. When specialized equipment required for medical treatment for an institutionalized member is not available at a facility, the member may be transported to the site of such specialized equipment. Medical services that may require specialized equipment include X-ray services, cast removal, fitting for artificial limbs, and radiation therapy.
(E)	Types of Transportation. Members must use personal transportation resources such as family
or friends whenever possible. When personal transportation resources are unavailable, a member
must use public transportation, if available in the member's locality and suitable to his or her
medical condition. Private transportation is covered by MassHealth only when public
transportation suitable to the member's medical condition is unavailable.
(F)	Emergency Ambulance Only. For MassHealth Basic and MassHealth Limited members, and
for MassHealth Family Assistance members not receiving premium assistance pursuant to 130
CMR 450.105(H)(1), the Division pays for emergency ambulance services only.
(G)	Shared Ride.
 (1)	When two or more members are traveling to the same locality at the same time, they must share transportation when such arrangements are made by the Division, transportation provider, transportation broker, or medical provider.
 (2)	When two or more members are traveling together to the same locality, only one member may obtain reimbursement for use of a private automobile.
(130 CMR 407.412 through 407.420 Reserved.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 407.000)	PAGE
4-7	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
407.421: Authorization for Transportation
(A)	Types of Authorization.
(1)	All forms of transportation except public transportation require prior authorization from
the Division. The authorization must consist of one or more of the following:
 (a)	verbal authorization for transportation;
 (b)	a Prescription for Transportation (PT-1) completed by a physician, physician assistant, nurse midwife, dentist, nurse practitioner, or managed-care representative; or
 (c)	a completed Medical Necessity Form.
(2)	Specific authorization requirements for each mode of transportation are provided in the
sections of regulations for each type of vehicle.
(B)	Authorization for Out-of-State Transportation. Transportation to specially approved out-of-
state medical services requires prior authorization from the Division's Prior Authorization Unit.
Transportation to these out-of-state medical services must be the least costly mode suitable to the
patient's condition.
(C) Prescription for Transportation.
 (1)	A prescription for dial-a-ride or taxi transportation must be written by a physician, physician assistant, nurse midwife, dentist, nurse practitioner, or managed-care representative on a Prescription for Transportation (PT-1) form.
 (2)	A completed PT-1 must contain the following information:

 (a)	the member's social security number, name, and address;
 (b)	the specific physical or mental disability that prohibits the use of public transportation;
 (c)	the medical condition for which treatment is sought;
 (d)	the medical care that will be received;
 (e)	how often transportation is needed (specific dates or specified number of trips per week for the duration of treatment);
 (f)	destination of the trip (the name and address of the location of the service covered by MassHealth);
 (g)	the expected duration of the need for transportation (specific time period not to exceed six months for acute illness and one year for chronic illness); (h) the date on which the prescription is written;
(i) the signature of the physician, physician assistant, nurse midwife, dentist, nurse practitioner, or managed-care representative;
(j) if the member is residing in a nursing facility, the medical services or equipment that are needed and cannot be obtained in the facility; and
(k) if the treatment destination is outside the member's locality, the medical services or equipment that are needed and cannot be obtained locally.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 407.000)	PAGE
4-8	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
(D) Medical Necessity Form.
 (1)	Purpose. The Medical Necessity Form is used to authorize medical necessity for nonemergency ambulance and wheelchair van trips. The member’s medical record must support the information given on the Medical Necessity Form.
 (2)	Required Signature. Only a physician, physician’s designee, physician assistant, nurse midwife, dentist, nurse practitioner, or managed-care representative may sign a Medical Necessity Form. The Medical Necessity Form may be signed either at the trip’s origin or destination. If the Medical Necessity Form is signed by a physician’s designee, the physician’s name and the authority of the designee must be noted on the Medical Necessity Form where designated.
 (3)	Transportation Provider's Responsibility.

 (a)	The transportation provider must obtain a signature on the Medical Necessity Form from one of the individuals specified in 130 CMR 407.421(D)(2).
 (b)	Transportation providers are responsible for completeness of Medical Necessity Forms. The completed Medical Necessity Form must be kept by the transportation provider as a record for four years from the date of service.

 (4)	Recurring Need. When a member must travel more than once to the same destination in a 30-day period, all trips for the 30-day period may be authorized on one Medical Necessity Form. The anticipated dates of each trip and the anticipated total number of trips must be entered on the form.
 (5)	Special Circumstances. If a member is ambulatory but must be accompanied by a caregiver whose mobility is limited, the caregiver's medical condition determines the appropriate mode of transportation.
(130 CMR 407.422 through 407.430 Reserved.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 407.000)	PAGE
4-9	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
407.431: Reimbursement to Members for Transportation Expenses
(A)	Reimbursable Expenses. Members may obtain direct reimbursement from the Division for
expenses incurred in traveling to services covered by MassHealth. Members who receive
brokered transportation services from the Division are not eligible for reimbursement.
Reimbursement for transportation is limited to the following expenses:
 (1)	private automobile costs, when the use of a private automobile is less expensive than other available transportation;
 (2)	public transportation costs (MBTA, local buses);
 (3)	any licensed carrier costs, when there is no transportation provider in the member's locality enrolled in MassHealth and when documentation of medical necessity for the mode of transportation used can be provided by a physician, physician assistant, nurse midwife, dentist, nurse practitioner, or managed-care representative; and
 (4)	dial-a-ride, taxi, or wheelchair van transportation costs in cases of urgent medical need when the need occurs outside of regular business hours.
(B)	Method and Amount of Reimbursement.
 (1)	In order to obtain reimbursement for transportation expenses, a member must obtain documentation from his or her physician, registered nurse, licensed practical nurse, nurse practitioner, medical-facility social worker, or managed-care representative that medical services covered by MassHealth were received. The documentation must give the date on which medical services were received as well as the specific address where medical services were received. In cases of urgent medical need, the documentation must also state the time medical services were received. Transportation receipts are also required when available. The member must submit documentation and receipts to the Division and request reimbursement for transportation expenses.
 (2)	Transportation costs must total $5.00 or more in order for the member to request reimbursement. The member must submit a request for reimbursement no later than 90 days after the earliest date on which transportation costs in excess of $5.00 occurred. The amount of reimbursement for private automobile costs is the lesser of either the automobile mileage cost as calculated from the Division's mileage manual using the reimbursement rate currently authorized for Division employees and recognized mileage technology, or the cost of other available transportation.
 (3)	If a member traveled outside his or her locality, as defined in 130 CMR 407.411(C), the documentation must state the medical services that were needed and that could not be obtained locally. If a member traveled outside his or her locality when necessary medical services were available locally, transportation costs incurred are not reimbursable.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 407.000)	PAGE
4-10	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
407.432:  Payment to Providers for Transportation Services
 (A)	Amount of Payment. Payment for transportation is made directly to providers of services except in the circumstances specified in 130 CMR 407.431, or in areas of the state where a selective contract with a transportation broker is in effect. Where such a contract is in effect, payment is made in accordance with the terms of the contract. In all other cases, the maximum allowable fee for transportation services provided to members is either the fee established for the service by the Massachusetts Division of Health Care Finance and Policy (DHCFP) or the provider's usual and customary charge, whichever is lower. When a member and an individual who is not a member are transported together, the member is considered the "additional person" for billing purposes.
 (B)	Usual and Customary Charge Definition. The term "usual and customary charge" means the amount a provider would charge for substantially the same service to an individual who is not eligible for direct public assistance for that service. However, a special rule may apply to certain providers that operate low-cost transportation systems intended to benefit classes of individuals for whom no direct public assistance, insurance coverage, or other sources of third-party payment are available, where the amount charged to such individuals is less than the actual cost of providing the service, and when the operation of the system depends upon higher charges for services to individuals who have third-party sources of payment. In such cases, if the provider can demonstrate, by evidence satisfactory to the Division, that its charges for services to individuals who are not eligible for direct public assistance are significantly less than the cost of providing the services, the Division will establish a rate under individual consideration, which will be deemed to be the provider's usual and customary charge for the purpose of payment by the Division. In no event will this established rate exceed either the maximum fee established by DHCFP or the actual cost of the service.
(130 CMR 407.433 through 407.440 Reserved)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 407.000)	PAGE
4-11	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
407.441: Dial-a-Ride
(A)	Criteria for Use.
 (1)	Dial-a-ride service is not appropriate when public transportation is available. Availability of public transportation means that a public system is operated in the area on a regularly scheduled basis. A wait of up to one hour for a regularly scheduled ride or up to two transfers in transit is considered reasonable.
 (2)	Dial-a-ride service is appropriate for persons who are unable to use public transportation because of physical or mental disabilities. Dial-a-ride service is also appropriate to ensure necessary transportation in instances where no public transportation is available. The following criteria apply to the use of dial-a-ride transportation.

 (a)	Physical inability to use public transportation means that a person needs assistance to walk or is unable to climb bus steps.
 (b)	Mental inability to use public transportation means that a person has crowd phobias, dementia, or violent or assaultive behavior, or is seriously confused and disoriented.
(3)	Lack of escort for a young child is not an appropriate criterion for the use of dial-a-ride
transportation.
 (B)	Prescription Requirement. All dial-a-ride transportation requires a signed and completed PT-1 detailing the member's condition that prohibits the use of public transportation, with the following exception. When urgent medical need necessitates immediate dial-a-ride transportation to a medical service or to a hospital, and when there is no PT-1 on file with the Division, verbal authorization may be granted by the Division without a PT-1 with the provision that the member obtain a prescription from his or her physician, physician assistant, nurse midwife, dentist, nurse practitioner, or managed-care representative verifying the urgent medical need for dial-a-ride transportation. Such a prescription must be submitted to the Division within two business days after the day on which the authorization was granted.
 (C)	Authorization Requirement. Except as otherwise provided in a selective contract with a transportation broker in an area of the state where such a contract is in effect, all dial-a-ride transportation requires prior authorization from the Division. The Division grants authorization only when the request is accompanied by a completed PT-1, if required. Prior authorization is for health-care necessity only. Payment is still subject to all general conditions of the Division, including current member eligibility, third-party resources, and program restrictions.
 (D)	Recordkeeping Requirement.

 (1)	Providers of dial-a-ride services must keep records of all services billed to the Division. Such records must be maintained for a period of at least four years and must include a log or trip sheet, separate from the claim form, containing the name of the member transported, the date of service, and the origin and destination of the trip.
 (2)	In areas of the state where a selective contract with a transportation broker is in effect, the recordkeeping requirements in the contract apply.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 407.000)	PAGE
4-12	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
(E) Rates of Payment.
 (1)	Except in areas of the state where a selective contract with a transportation broker is in effect, rates of payment for dial-a-ride services must be established by the Division under individual consideration at the time the dial-a-ride company applies to become a provider. Rates must be based on actual cost data.
 (2)	The service codes that must be used when billing for dial-a-ride services are listed in Subchapter 6 of the Transportation Manual.
 (3)	In areas of the state where a selective contract with a transportation broker is in effect, payment for dial-a-ride services is made in accordance with the terms of the contract or pursuant to 130 CMR 407.431.
(130 CMR 407.442 through 407.450 Reserved.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 407.000)	PAGE
4-13	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
407.451: Taxi
(A)	Vehicle Standards.
 (1)	Every vehicle used by taxi providers must be maintained in such a manner as to ensure the safety and comfort of the passengers being transported. Such vehicles must be clean, sanitary, vermin-free, and protected against motor-exhaust fumes. The vehicle must carry no more than the number of passengers for which it was designed, in accordance with local town or city licensing regulations. The provider must maintain a system of regular vehicle inspection in accordance with the rules and regulations set by the local city or town licensing authority.
 (2)	Every vehicle used by taxi providers must be duly registered with the Massachusetts Registry of Motor Vehicles and must meet all safety and inspection requirements of the Registry.
(B)	Personnel Qualifications.
 (1)	Every taxi driver providing transportation services under MassHealth must possess a valid Massachusetts driver's license.
 (2)	Every taxi provider must ascertain that each operator employed in the operation of the vehicle is fit and proper to operate the vehicle and is fully instructed about the motor-vehicle laws of Massachusetts.
(C)	Application for Participation.
(1)	Except in areas of the state where a selective contract with a transportation broker is in
effect, every taxi company requesting to participate in MassHealth must submit the following
information to the Division for review:
 (a)	a completed Transportation Services Questionnaire;
 (b)	a copy of the license issued by the appropriate legal authority in the city or town where the taxi company is located; and
 (c)	a copy of the company's certificate of insurance.

 (2)	The Division will review the information submitted, and may make an on-site review or request a meeting with a representative of the taxi company. In addition, the Division may request information from other agencies about the services provided by the taxi company.
 (3)	In areas of the state where a selective contract with a transportation broker is in effect, the transportation broker selects taxi companies as their subcontractors in accordance with the requirements of the contract. All such subcontracts are subject to the Division's approval.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 407.000)	PAGE
4-14	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
(D)	Criteria for Use.
 (1)	Taxi service is not appropriate when public transportation is available. Availability of public transportation means that a public system is operated in the area on a regularly scheduled basis. A wait of up to one hour for a regularly scheduled ride or up to two transfers in transit is considered reasonable.
 (2)	Taxi service is appropriate for persons who are unable to use public transportation because of physical or mental disabilities. Taxi services are also appropriate to ensure necessary transportation in instances where no dial-a-ride or public transportation is available.

 (a)	Physical inability to use public transportation means that a person needs assistance to walk or is unable to climb bus steps.
 (b)	Mental inability to use public transportation means that a person has crowd phobias, dementia, or violent or assaultive behavior, or is seriously confused and disoriented.
(3)	Lack of an escort for a young child is not an appropriate criterion for the use of a taxi.
(E)	Prescription Requirement.
 (1)	All taxi transportation requires a Prescription for Transportation (PT-1) completed by a physician, physician assistant. nurse midwife, dentist, nurse practitioner, or managed-care representative detailing the member's physical condition that prohibits the use of rapid transit or bus service.
 (2)	When urgent medical need necessitates immediate taxi transportation to medical services, and when there is no prescription on file with the Division, verbal authorization may be granted by the Division without a prescription with the provision that the member obtain a prescription from his or her physician, physician assistant. nurse midwife, dentist, nurse practitioner, or managed-care representative verifying the urgent medical need for taxi transportation. Such prescription must be submitted to the Division within two business days after the day on which the prior authorization was granted.
(F)	Authorization Requirement. Except as otherwise provided in a selective contract with a
transportation broker in an area of the state where such a contract is in effect, all taxi
transportation requires prior authorization from the Division. The Division grants authorization
only when the request is accompanied by a completed PT-1, if required. Payment is subject to all
general conditions of the Division, including member eligibility, third-party resources, and
program restrictions.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 407.000)	PAGE
4-15	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
(G) Recordkeeping Requirement.
 (1)	Providers of taxi services must keep records of all services billed to the Division. Such records must be maintained for a period of at least four years and must include a log or trip sheet, separate from the claim form, containing the name of the member transported, the date of service, and the origin and destination of the trip. If two or more persons are transported together, the provider must record the names of all passengers on the log or trip sheet.
 (2)	In areas of the state where a selective contract with a transportation broker is in effect, the recordkeeping requirements in the contract apply.
(H) Rates of Payment.
 (1)	Except in areas of the state where a selective contract with a transportation broker is in effect, payment for taxi transportation is the provider's usual and customary charge, not to exceed the established legal rate as recorded on the taxi meter. Taxi companies that do not use a meter system must charge according to the exact fee schedule submitted by them to the Division and approved by the Division. Taxi charges may be applied only for loaded miles.
 (2)	For two or more passengers carried on the same trip, the usual and customary charge must not exceed the established legal rate as recorded on the taxi meter from the point of the first pickup to the destination or the fee schedule approved by the Division. The total fare is split equally among the passengers carried, unless one passenger is required as an assistant for the member. In such a case, the member and his or her assistant is considered to be one passenger for billing purposes.
 (3)	The service codes that must be used when billing for taxi services are listed in Subchapter 6 of the Transportation Manual.
 (4)	In areas of the state where a selective contract with a transportation broker is in effect, payment for taxi services is made in accordance with the terms of the contract or pursuant to 130 CMR 407.431.
(130 CMR 407.452 through 407.470 Reserved.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 407.000)	PAGE
4-16	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
407.471: Nonemergency Wheelchair Van
(A)	Criteria for Use. Wheelchair van services may be provided only in nonemergencies to the
following persons:
 (1)	those who use wheelchairs;
 (2)	those who need to be carried up or down stairs (because they are unable to walk up or down stairs or cannot walk without the assistance of two persons); and
 (3)	those whose severe mobility handicaps prevent them from using public, dial-a-ride, or taxi transportation.

 (B)	Medical Necessity Form Requirement. Wheelchair van transportation requires a Medical Necessity Form completed in accordance with 130 CMR 407.421(D). Where wheelchair van services are provided through a selective contract with a transportation broker, only a Prescription for Transportation (PT-1) completed in accordance with 130 CMR 407.421(C) is required.
 (C)	Authorization Requirement. A Medical Necessity Form, where required, serves as authorization for wheelchair van transportation except in the following cases, which require authorization from the Division. Prior authorization from the Division is required only in the following cases where the wheelchair van services are provided through a selective contract with a transportation broker:

 (1)	the second and succeeding round trips provided to the member in the same day;
 (2)	transportation to a medical provider outside the member's locality; and
 (3)	all out-of-state transportation, except when the destination is a town or city within the member's locality.
(D)	Recordkeeping Requirement.
 (1)	Providers of wheelchair van services must keep records of all services billed to the Division. Such records must be maintained for a period of at least four years and must include a log or trip sheet, separate from the claim form, containing the name of the member transported, the date of service, the origin and destination of the trip, and the vehicle identification number. If two or more persons are transported together, the provider must record the names of all passengers on the log or trip sheet.
 (2)	In areas of the state where a selective contract with a transportation broker is in effect, the recordkeeping requirements in the contract apply.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 407.000)	PAGE
4-17	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
(E) Rates of Payment.
(1)	Except where wheelchair van services are delivered pursuant to a selective contract with a
transportation broker, the rate of payment for a wheelchair van service is the lowest of the
following:
 (a)	the provider's usual and customary fee;
 (b)	the provider's actual charge; or
 (c)	the fee set by the Division of Health Care Finance and Policy.

 (2)	The service codes that must be used when billing for wheelchair van services are listed in Subchapter 6 of the Transportation Manual.
 (3)	Where wheelchair van services are delivered pursuant to a selective contract with a transportation broker, payment for such services will be made in accordance with the terms of the contract.
(130 CMR 407.472 through 407.480 Reserved.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 407.000)	PAGE
4-18	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
407.481: Ambulance
(A)	Criteria for Use.
 (1)	Emergency Situations. Ambulance services are always covered in emergency situations. An emergency situation is defined as one in which the member has a critical or unknown illness or injury that apparently demands immediate medical attention at a hospital to prevent permanent injury or loss of life. Emergency cases must be transported to the nearest medical facility equipped for and capable of treating such emergency cases.
 (2)	Nonemergency Situations. In nonemergency situations, ambulance services are covered when medically necessary as set forth in 130 CMR 407.481(B). The return trip of an emergency transport is considered to be a nonemergency situation.
(B)	Conditions Always Requiring Transportation by Ambulance.
(1)	Medical Conditions. A member who has any of the following medical conditions always
requires transportation by ambulance:
 (a)	continuous dependence on oxygen;
 (b)	continuous confinement to bed;
 (c)	classification as an American Heart Association Class IV patient with a disease of the heart: members with cardiac disease resulting in the inability to perform any physical activity without discomfort. Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased;
 (d)	receiving intravenous treatment;
 (e)	after cardiac catheterization; or
 (f)	having uncontrolled seizure disorders.
(2)	Orthopedic Conditions. A member who has either of the following orthopedic conditions
always requires transportation by ambulance:
 (a)	total body cast; or
 (b)	hip spicas or other casts that prevent flexion at the hip.

 (3)	Pediatric Conditions. A member who is in an isolette (incubator) always requires transportation by ambulance.
 (4)	Psychiatric Conditions. A member who has either of the following psychiatric conditions always requires transportation by ambulance:

 (a)	in need of restraints (possibly harmful to himself or herself or others, including persons transported under M.G.L. c. 123, § 12 for temporary hospitalization by reason of mental illness). As defined in M.G.L. c. 123, § 1, "likelihood of serious harm" is: "(1) substantial risk of physical harm to the person himself or herself as manifested by evidence of threats of, or attempts at, suicide or serious bodily harm; (2) a substantial risk of physical harm to other persons as manifested by evidence of homicidal or other violent behavior or evidence that others are placed in reasonable fear of violent behavior and serious physical harm to them; or (3) a very substantial risk of physical impairment or injury to the person himself or herself as manifested by evidence that such person's judgment is so affected that he or she is unable to protect himself or herself in the community and that reasonable provision for his or her protection is not available in the community."; or
 (b)	heavily sedated.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 407.000)	PAGE
4-19	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
(5) Neurological Conditions. A member who has any of the following neurological conditions always requires transportation by ambulance:
 (a)	continual confinement to bed (because of severe brain damage, for example); or
 (b)	comatose.
(C)	Medical Necessity Form Requirement.
 (1)	Emergency ambulance trips do not require a Medical Necessity Form. However, the nature of the emergency must be supported by medical records at the hospital to which the member was transported.
 (2)	Nonemergency ambulance transportation requires a Medical Necessity Form completed in accordance with 130 CMR 407.421(D).
(D)	Prior-Authorization Requirement. In addition to a Medical Necessity Form, the Division
requires prior authorization for all out-of-state nonemergency transportation by an ambulance.
(E)	Recordkeeping Requirement. Providers of ambulance services must keep records of all
services billed to the Division. Such records must be maintained for a period of at least four years
and must include a log or trip sheet, separate from the claim form, containing the vehicle number,
the time of the trip, the driver's name, the name of the member transported, the date of service, the
origin and destination of the trip, and the nature of the ambulance service provided. For
emergency trips, the nature of the emergency must be recorded in detail, including referring
source. If two or more persons are transported together, the provider must record the name of all
passengers on the log or trip sheet.
(F)	Rates of Payment.
(1)	The rate of payment for a Class I and Class II Ambulance Service is the lowest of the
following:
 (a)	the provider's usual and customary fee;
 (b)	the provider's actual charge; or
 (c)	the fee set by the Division of Health Care Finance and Policy.

 (2)	An ambulance trip may be considered to be a round trip if the waiting time exceeds one hour. Payment for such trips is double the base fee, plus mileage per loaded mile after 20 miles each way.
 (3)	When two patients are transported in the same vehicle, payment for the MassHealth member is one-half the base fee. In such instances, the mileage fee applies only once.
 (4)	The Division does not pay for additional or supplemental fees for oxygen service, for a nurse or extra attendant, or for waiting time.
(5)	The service codes that must be used when billing for ambulance services are listed in
Subchapter 6 of the Transportation Manual.
(130 CMR 407.482 through 407.490 Reserved.)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
4 PROGRAM REGULATIONS (130 CMR 407.000)	PAGE
4-20	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
407.491: Other Licensed Carriers
(A)	Criteria for Use. The Division pays for services provided by a licensed carrier in the
following circumstances:
 (1)	when there is no transportation provider in the member's locality or when it is less expensive to use a licensed carrier (for example, train) than a transportation provider;
 (2)	when the member is traveling to specialized medical care that is a great distance from home and has obtained approval from the Division; or
 (3)	when the member lives on an island accessible only by boat or airplane.
(B)	Authorization Requirement.
 (1)	All airplane transportation requires prior authorization from the Division.
 (2)	All train, boat, or private bus transportation requires prior authorization from the Division. If the licensed carrier is not a MassHealth provider, the member may pay for services directly and request reimbursement as set forth in 130 CMR 407.431.
 (3)	If the member is traveling outside his or her locality, documentation from a physician is required to verify that the necessary medical services cannot be obtained locally.
(C)	Consultation with the Prior Authorization Unit. The following situations require consultation
with the Prior Authorization Unit before granting prior authorization for private bus, train, or boat:
 (1)	when the member is traveling outside his or her locality to obtain medical care; and
 (2)	when a member is traveling out of state to obtain medical care, except when the destination is a town or city within the member's locality.
(D)	Rates of Payment. Rates of payment for licensed carriers is the carrier's usual and customary
charge, not to exceed established legal rates, if any. The service codes that must be used when
billing are listed in Subchapter 6 of the Transportation Manual.
(E)	Billing Procedures. Billing procedures for other licensed carriers who have provided
transportation in special circumstances for which they have received prior authorization requires
consultation with the Division of Medical Assistance.
REGULATORY AUTHORITY
130 CMR 407.000: M.G.L. c. 118E, §§ 7 and 12.

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-1	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
601 Service Codes and Descriptions: Dial-a-Ride Services

Service
Code	Service Description
A0120	Nonemergency transportation: mini-bus, mountain area transports, or other transportation
systems (I.C.)
602	Service Codes and Descriptions: Taxi Services
Service
Code	Service Description
A0100	Nonemergency transportation; taxi (Use for one passenger, intra-city transportation.)
603	Service Codes and Descriptions: Wheelchair Van Services
Service
Code	Service Description
A0130	Nonemergency transportation: wheelchair van
S0215	Nonemergency transportation; mileage, per mile (Wheelchair vans must use this code for
mileage. Do not use A0425.) A0130-TK    Nonemergency transportation; wheelchair van (extra patient or passenger, non-ambulance)
(No mileage fee allowed.)
T2001	Nonemergency transportation; patient attendant/escort (Use for second attendant.)
604	Service Codes and Descriptions: Ambulance Services
Service
Code	Service Description
Ground Mileage
A0425	Ground mileage, per statute mile (Ambulances must use this code for mileage. Do not use
S0215.)
Ambulance Service, Advanced Life Support
A0426	Ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1)
A0427	Ambulance service, advanced life support, emergency transport, level 1 (ALS 1 – emergency)
A0433	Advanced life support, level 2 (ALS 2)
Ambulance Service, Basic Life Support
A0428 A0429
Ambulance service, basic life support, nonemergency transport (BLS) Ambulance service, basic life support, emergency transport (BLS – emergency)

Commonwealth of Massachusetts
Division of Medical Assistance
Provider Manual Series
TRANSPORTATION MANUAL	SUBCHAPTER NUMBER AND TITLE
6 SERVICE CODES AND DESCRIPTIONS	PAGE
6-2	

	TRANSMITTAL LETTER
TRN-27	DATE
10/01/03	
605 Service Codes and Descriptions: Other Licensed Carriers
Service
Code	Service Description
A0140	Nonemergency transportation and air travel (private or commercial), intra- or interstate