Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Transmittal Letter TRN-32 June 2010 TO: Transportation Providers Participating in MassHealth FROM: Terence G. Dougherty, Medicaid Director RE: Transportation Manual (Revised Transportation Regulations) This letter transmits revised transportation regulations. The revised regulations eliminate most personal reimbursements to members for transportation expenses incurred when traveling to MassHealth-covered medical services. The regulations continue to provide for transportation arranged through EOHHS’s vendors, as well as personal reimbursement for public transportation, and for direct transportation expenses in exceptional circumstances where MassHealth determines public transportation and transportation provided through the MassHealth agency is not available. These regulations are effective July 1, 2010. If you have any questions about the information in this transmittal letter, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. NEW MATERIAL (The pages listed here contain new or revised language.) Transportation Manual Pages vi, vii, 4-1 through 4-16, 4-19, and 4-20 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Transportation Manual Pages vi and 4-1 through 4-14 — transmitted by Transmittal Letter TRN-31 Page vii — transmitted by Transmittal Letter TRN-28 Pages 4-15 and 4-16 — transmitted by Transmittal Letter TRN-27 Pages 4-19 and 4-20 — transmitted by Transmittal Letter TRN-30 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Transportation Manual Transmittal Letter TRN-32 Date 07/01/10 6. Service Codes and Descriptions Dial-a-Ride Services ................................................................................ ....................................... 6-1 Taxi Services ................................................................................ ................................................... 6-1 Wheelchair Van Services ................................................................................ ................................ 6-1 Ambulance Services ................................................................................ ........................................ 6-2 Other Licensed Carriers........................................................................ ........................................... 6-2 Appendix A. Directory ................................................................................ ........................................ A-1 Appendix B. Enrollment Centers ................................................................................ ........................ B-1 Appendix C. Third-Party Liability Codes ................................................................................ ........... C-1 Appendix W. EPSDT Services: Medical and Dental Protocols and Periodicity Schedules............... W-1 Appendix X. Family Assistance Copayments and Deductibles........................................................... X-1 Appendix Y. EVS Codes/Messages ................................................................................ .................... Y-1 Appendix Z. EPSDT/PPHSD Screening Services Codes ................................................................... Z-1 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Preface Page vii Transportation Manual Transmittal Letter TRN-32 Date 07/01/10 The regulations and instructions governing provider participation in MassHealth are published in the Provider Manual Series. MassHealth publishes a separate manual for each provider type. Manuals in the series contain administrative regulations, billing regulations, program regulations, service codes, administrative and billing instructions, and general information. MassHealth regulations are incorporated into the Code of Massachusetts Regulations (CMR), a collection of regulations promulgated by state agencies within the Commonwealth and by the Secretary of State. MassHealth regulations are assigned Title 130 of the Code. Pages that contain regulatory material have a CMR chapter number in the banner beneath the subchapter number and title. Administrative regulations and billing regulations apply to all providers and are contained in 130 CMR Chapter 450.000. These regulations are reproduced as Subchapters 1, 2, and 3 in this and all other manuals. Program regulations cover matters that apply specifically to the type of provider for which the manual was prepared. For transportation providers, those matters are covered in 130 CMR Chapter 407.000, reproduced as Subchapter 4 in the Transportation Manual. Revisions and additions to the manual are made as needed by means of transmittal letters, which furnish instructions for substituting, adding, or removing pages. Some transmittal letters will be directed to all providers; others will be addressed to providers in specific provider types. In this way, a provider will receive all those transmittal letters that affect its manual, but no others. The Provider Manual Series is intended for the convenience of providers. Neither this nor any other manual can or should contain every federal and state law and regulation that might affect a provider's participation in MassHealth. The provider manuals represent instead MassHealth’s effort to give each provider a single convenient source for the essential information providers need in their routine interaction with MassHealth and its members. Commonwealth of Massachusetts MassHealth Provider Manual Series Transportation Manual Subchapter Number and Title 4 Program Regulations (130 CMR 407.000) Page 4-1 Transmittal Letter TRN-32 Date 07/01/10 407.401: Introduction All transportation providers participating in MassHealth must comply with the regulations governing the MassHealth agency, including but not limited to MassHealth 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, or 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 (DPH) as set forth in DPH regulations that implement M.G.L. c. 111C, regulating Ambulances and Ambulance Services. 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 MassHealth Provider Manual Series Transportation Manual Subchapter Number and Title 4 Program Regulations (130 CMR 407.000) Page 4-2 Transmittal Letter TRN- 32 Date 07/01/10 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. 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. 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 escort can be a parent, guardian of a child, a caretaker, a guardian of a mentally incompetent member, or an individual who physically assists a member with ambulating to and from a medical appointment. 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 or nurse practitioner; or a registered nurse, licensed practical nurse, or 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 MassHealth agency to determine the necessity of nonemergency medical transportation that is provided through selective contracts. 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, and the communication of information about illness prevention, health maintenance, and referral services. Public Transportation — mass fixed-route transportation services, including bus service, subway trains, trolleys, and commuter rail service provided to the public in the Commonwealth of Massachusetts pursuant to the authority granted to the Massachusetts Bay Transportation Authority (MBTA) and regional transit authorities established under M.G.L. 161A and 161B, respectively. Transportation services provided by MassHealth through selective contracts with regional transit authorities are not included in the definition of public transportation. Commonwealth of Massachusetts MassHealth Provider Manual Series Transportation Manual Subchapter Number and Title 4 Program Regulations (130 CMR 407.000) Page 4-3 Transmittal Letter TRN- 32 Date 07/01/10 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. Specialty Care Transport — a medically necessary ambulance transport, for a critically injured or ill person, to provide a level of interhospital transportation service that exceeds the scope of the ambulance paramedic’s clinical expertise as defined in the National EMS Education and Practice Blueprint. Such transportation is necessary when a person’s condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area (for example, nursing, emergency medicine, respiratory care, cardiovascular care) or a paramedic with additional training. 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 MassHealth agency when a Prescription for Transportation (PT-1) form has been signed by the prescriber but has not been received by the MassHealth agency 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 MassHealth agency covers transportation services only when provided to eligible MassHealth members, subject to the restrictions and limitations described in MassHealth regulations. MassHealth 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 MassHealth agency pays for all medically necessary transportation services for EPSDT- eligible members in accordance with 130 CMR 450.140 et seq., without regard to service limitations described in 130 CMR 407.000, and with prior authorization. Commonwealth of Massachusetts MassHealth Provider Manual Series Transportation Manual Subchapter Number and Title 4 Program Regulations (130 CMR 407.000) Page 4-4 Transmittal Letter TRN- 32 Date 07/01/10 407.405: 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 MassHealth agency. (B) The provider must ensure that drivers and attendants, before any contact with a MassHealth member, provide written references and undergo a Criminal Offender Record Information (CORI) check. The CORI must be in compliance with guidelines that the Executive Office of Health and Human Services may issue. The CORI must remain on file at the transportation provider’s place of business and must be conducted annually thereafter. (C) Except where the MassHealth agency elects to limit or terminate provider agreements in accordance with 130 CMR 407.407 and 450.108 in areas of the state where a selective contract with a transportation broker is in effect, the MassHealth agency 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 MassHealth agency, 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 MassHealth agency 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 MassHealth agency. An out-of-state provider must have a valid license issued by the appropriate regulatory agency within its state to be approved as a MassHealth provider. 407.407: Selective Contracting (A) In some regions, the MassHealth agency 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 MassHealth agency 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 MassHealth agency 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) The MassHealth agency informs eligible members of the availability of transportation services through all applicable member handbooks. Additional information about eligibility and the process for accessing transportation services can be obtained by contacting MassHealth Customer Service. (130 CMR 407.408 through 407.410 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Transportation Manual Subchapter Number and Title 4 Program Regulations (130 CMR 407.000) Page 4-5 Transmittal Letter TRN- 32 Date 07/01/10 407.411: Transportation Utilization Restrictions (A) Covered Services. The MassHealth agency pays for transportation services that meet the requirements of 130 CMR 407.000 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 MassHealth agency 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 MassHealth agency. (3) In the case of taxi, dial-a-ride, and wheelchair van transportation provided through a selective contract with a transportation broker, the MassHealth agency 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 0.75 miles of the member’s home or other MassHealth agency-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 MassHealth agency pays for an eligible member to be transported to sources of medical care only within the member's locality, unless otherwise authorized by the MassHealth agency. 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 MassHealth agency. Commonwealth of Massachusetts MassHealth Provider Manual Series Transportation Manual Subchapter Number and Title 4 Program Regulations (130 CMR 407.000) Page 4-6 Transmittal Letter TRN-32 Date 07/01/10 (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) Nonemergency Community-Based Transportation. (1) Members should use public or personal transportation resources, including family or friends, whenever possible. (2) Subject to meeting the requirements of 130 CMR 407.000, the MassHealth agency pays transportation brokers or fee-for-service transportation providers to furnish transportation services to eligible MassHealth members only when public transportation is not available as determined in accordance with 130 CMR 407.411(E)(3). (3) Public transportation is considered available if all of the following criteria are met. (a) Public transportation is accessible and suitable to the member’s medical condition and circumstances as determined by the MassHealth agency. (b) Public transportation is operated in the member’s locality on a regularly scheduled basis. A wait of up to one hour for a regularly scheduled ride and up to two transfers in transit is considered reasonable. (c) The public transportation stop (i.e., bus or trolley stop, subway or commuter rail station) is (i) within 0.75 mile from the member’s residence or other authorized point of origin; and (ii) within 0.75 mile from the destination address. (4) Public transportation information may be obtained by contacting the local public transit authority in the member’s community. (F) Shared Ride. 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 MassHealth agency, transportation provider, transportation broker, or medical provider. (130 CMR 407.412 through 407.420 Reserved.) Commonwealth of Massachusetts MassHealth Provider Manual Series Transportation Manual Subchapter Number and Title 4 Program Regulations (130 CMR 407.000) Page 4-7 Transmittal Letter TRN-32 Date 07/01/10 407.421: Authorization for Transportation (A) Types of Authorization. (1) All forms of transportation except public transportation require prior authorization from the MassHealth agency. 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 or dental third-party administrator, nurse practitioner, psychologist, or managed-care representative; (c) a completed Medical Necessity Form or, only for members transported for hospitalization under M.G.L. c. 123, § 12, a completed and signed Department of Mental Health Application for and Authorization of Temporary Involuntary Hospitalization. (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 MassHealth agency. Transportation to these out-of-state medical services must be the least costly mode suitable to the member's condition. (C) Prescription for Transportation. (1) The Prescription for Transportation Form (PT-1) is used for authorizing transportation that is provided through the selective contracts. (2) A prescription for transportation must be written by a physician, physician assistant, nurse midwife, dentist or dental third-party administrator, nurse practitioner, psychologist, or managed-care representative on a Prescription for Transportation (PT-1) form. (3) 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 care that will be received; (d) how often transportation is needed (specific dates or specified number of trips per week for the duration of treatment); (e) the destination of the trip (the name and address of the location of the service covered by MassHealth); (f) 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); (g) the date on which the prescription is written; (h) the signature of the physician, physician assistant, nurse midwife, dentist or dental third-party administrator, nurse practitioner, psychologist, or managed-care representative; (i) 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 (j) 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 MassHealth Provider Manual Series Transportation Manual Subchapter Number and Title 4 Program Regulations (130 CMR 407.000) Page 4-8 Transmittal Letter TRN-32 Date 07/01/10 (D) Medical Necessity Form. (1) Purpose. The Medical Necessity Form is used to authorize medical necessity for wheelchair van trips for members residing in an institutionalized setting and for nonemergency ambulance service for all eligible members. The member’s medical record must support the information given on the Medical Necessity Form. For members transported for hospitalization under M.G.L. c. 123, § 12, a completed and signed Department of Mental Health Application for and Authorization of Temporary Involuntary Hospitalization may be accepted in place of the Medical Necessity Form. (2) Required Signature. Only a physician, physician assistant, nurse midwife, dentist or dental third-party administrator, nurse practitioner, psychologist, or managed-care representative may sign a Medical Necessity Form. The Medical Necessity Form may be signed at either the trip’s origin or destination. (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 six 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 an escort whose mobility is limited, the escort's medical condition determines the appropriate mode of transportation. (130 CMR 407.422 through 407.430 Reserved.) Commonwealth of Massachusetts MassHealth Provider Manual Series Transportation Manual Subchapter Number and Title 4 Program Regulations (130 CMR 407.000) Page 4-9 Transmittal Letter TRN-32 Date 07/01/10 407.431: Reimbursement to Members for Transportation Expenses (A) Reimbursable Expenses. Members may obtain direct reimbursement from the MassHealth agency in accordance with 130 CMR 407.431(B) for public transportation expenses that the member incurred when traveling to services covered by MassHealth. (B) Method and Amount of Reimbursement. (1) In order to obtain reimbursement for public transportation expenses, a member must obtain documentation from his or her physician, registered nurse, physician assistant, licensed practical nurse, nurse midwife, dentist or dental third-party administrator, nurse practitioner, medical-facility social worker, psychologist, or managed-care representative that medical services covered by MassHealth were received. The documentation must give the date on which medical services were received and 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 MassHealth agency and request reimbursement for public 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. (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 unless authorized by the MassHealth agency. (C) Exceptional Circumstances. The MassHealth agency may authorize reimbursement to a member for direct transportation expenses not described in 130 CMR 407.431(A) which the member incurred when traveling to services covered by MassHealth, when the MassHealth agency determines that transportation is not otherwise available through MassHealth-contracted providers or selective broker contracts, and public transportation is not available as determined in accordance with 130 CMR 407.411(E)(3). The MassHealth agency may require the member to submit such documentation as it determines necessary to support a request for reimbursement under 130 CMR 407.431. Commonwealth of Massachusetts MassHealth Provider Manual Series Transportation Manual Subchapter Number and Title 4 Program Regulations (130 CMR 407.000) Page 4-10 Transmittal Letter TRN-32 Date 07/01/10 407.432: 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 407.432(C). 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 or an escort 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 MassHealth agency, 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 MassHealth agency will establish a rate under individual consideration, that will be deemed to be the provider's usual and customary charge for the purpose of payment by the MassHealth agency. In no event will this established rate exceed either the maximum fee established by DHCFP or the actual cost of the service. (C) Payment Limitations. The MassHealth agency does not pay a provider of transportation services other than a transportation broker for taxi or wheelchair van services provided to MassHealth members who reside in community- based settings in an area of the state where a selective contract with a transportation broker is in effect, unless the MassHealth agency determines that (1) the transportation service is not available through the selective contract; or (2) the transportation service available through the provider is more appropriate for the particular member than the transportation service available through the transportation broker. (130 CMR 407.433 through 407.440 Reserved) Commonwealth of Massachusetts MassHealth Provider Manual Series Transportation Manual Subchapter Number and Title 4 Program Regulations (130 CMR 407.000) Page 4-11 Transmittal Letter TRN-32 Date 07/01/10 407.441: Dial-a-Ride (A) Criteria for Use. (1) Dial-a-ride service is not appropriate when public transportation is available as determined in accordance with 130 CMR 407.411(E)(3). (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 MassHealth agency, verbal authorization may be granted by the MassHealth agency without a PT-1 with the provision that the member obtain a prescription from his or her physician, physician assistant, nurse midwife, dentist or dental third-party administrator, nurse practitioner, or managed-care representative verifying the urgent medical need for dial-a-ride transportation. Such a prescription must be submitted to the MassHealth agency 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 MassHealth agency. The MassHealth agency 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 MassHealth, 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 MassHealth agency. 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 MassHealth Provider Manual Series Transportation Manual Subchapter Number and Title 4 Program Regulations (130 CMR 407.000) Page 4-12 Transmittal Letter TRN-32 Date 07/01/10 (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 MassHealth agency 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. (130 CMR 407.442 through 407.450 Reserved.) Commonwealth of Massachusetts MassHealth Provider Manual Series Transportation Manual Subchapter Number and Title 4 Program Regulations (130 CMR 407.000) Page 4-13 Transmittal Letter TRN-32 Date 07/01/10 407.451: 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 MassHealth agency 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 MassHealth agency will review the information submitted, and may make an onsite review or request a meeting with a representative of the taxi company. In addition, the MassHealth agency 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 approval by the MassHealth agency. Commonwealth of Massachusetts MassHealth Provider Manual Series Transportation Manual Subchapter Number and Title 4 Program Regulations (130 CMR 407.000) Page 4-14 Transmittal Letter TRN-32 Date 07/01/10 (D) Criteria for Use. (1) Taxi service is not appropriate when public transportation is available as determined in accordance with 130 CMR 407.411(E)(3). (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) form completed by a physician, physician assistant, nurse midwife, dentist or dental third-party administrator, nurse practitioner, psychologist, 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 MassHealth agency, verbal authorization may be granted by the MassHealth agency without a prescription with the provision that the member obtain a prescription from his or her physician, physician assistant, nurse midwife, dentist or dental third- party administrator, nurse practitioner, psychologist, or managed-care representative verifying the urgent medical need for taxi transportation. Such prescriptions must be submitted to the MassHealth agency 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 MassHealth agency. The MassHealth agency grants authorization only when the request is accompanied by a completed PT-1 form, if required. Payment is subject to all general conditions of MassHealth, including member eligibility, third- party resources, and program restrictions. (G) Recordkeeping Requirement. (1) Providers of taxi services must keep records of all services billed to the MassHealth agency. 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. Commonwealth of Massachusetts MassHealth Provider Manual Series Transportation Manual Subchapter Number and Title 4 Program Regulations (130 CMR 407.000) Page 4-15 Transmittal Letter TRN-32 Date 07/01/10 (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 MassHealth agency and approved by the MassHealth agency. 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 MassHealth agency. 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. (130 CMR 407.452 through 407.470 Reserved.) Commonwealth of Massachusetts MassHealth Provider Manual Series Transportation Manual Subchapter Number and Title 4 Program Regulations (130 CMR 407.000) Page 4-16 Transmittal Letter TRN-32 Date 07/01/10 407.471: 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 MassHealth agency. Prior authorization from the MassHealth agency 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 are provided to the member in the same day; (2) transportation to a medical provider is needed outside the member's locality; and (3) transportation is provided to or from an out-of-state provider, 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 MassHealth agency. 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 MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations 130 CMR 407.000 Page 4-19 Transportation Manual Transmittal Letter TRN-32 Date 07/01/10 (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 MassHealth agency 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 MassHealth agency. Such records must be maintained in accordance with 130 CMR 450.205 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. For specialty care transport, such records must include the appropriate paramedic level credentials of the ambulance staff or, if originating facility staff is on the vehicle, then such records must include staff names, titles, and signatures. (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 MassHealth agency 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 MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations 130 CMR 407.000 Page 4-20 Transportation Manual Transmittal Letter TRN-32 Date 07/01/10 407.491: Other Licensed Carriers (A) Criteria for Use. The MassHealth agency 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 MassHealth agency; 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 MassHealth agency. (2) All train, boat, or private bus transportation requires prior authorization from the MassHealth agency. (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 MassHealth agency. REGULATORY AUTHORITY 130 CMR 407.000: M.G.L. c. 118E, §§ 7 and 12.