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-30 July 2008 TO: Transportation Providers Participating in MassHealth FROM: Tom Dehner, Medicaid Director RE: Transportation Manual (New Service Code and Description) This letter transmits information related to transportation and introduces a new service code in Subchapter 6 (service codes and descriptions) of the Transportation Manual. New Service Code Effective for dates of service on or after September 1, 2005, MassHealth is paying for specialty care transport in an ambulance (Service Code A0434). Specialty care transport is defined as 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. This 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). For all specialty care transports, providers must keep trip log documentation in their files. * When the transport does not include additional staff from the originating facility, the ambulance provider must include in the trip logs and notes the appropriate paramedic level credentials as identified in the Department of Public Health’s Office of Emergency Medical Services regulations. * When the transport includes additional staff from the originating facility, the ambulance provider must include in the trip logs and notes the names, titles, and signatures of the additional staff. The following policies apply to prior denied specialty care transport claims and claims billed under a different ambulance code. * MassHealth will reprocess all claims that were previously denied for Service Code A0434. * All paid claims that were billed under a different ambulance service code and that occur within the one-year billing deadline, can be adjusted and resubmitted by providers. * For all paid claims that were billed under a different ambulance service code and are beyond the one-year billing deadline, the provider needs to file an appeal to MassHealth’s Final Deadline Appeal Board in accordance with 130 CMR 450.323. These regulations are effective August 1, 2008. 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, 4-3, 4-4, 4-19, 4-20, 6-1, and 6-2 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Transportation Manual Pages vi, 6-1, and 6-2 — transmitted by Transmittal Letter TRN-28 Pages 4-3 and 4-4 — transmitted by Transmittal Letter TRN-29 Pages 4-19 and 4-20 — transmitted by Transmittal Letter TRN-27 Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page vi Transportation Manual Transmittal Letter TRN-30 Date 08/01/08 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 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/PPHSD Screening Services Codes Z-1 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-30 Date 08/01/08 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) 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-30 Date 08/01/08 407.405: 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, prior to 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 the CORI must be conducted annually thereafter. (C) Except where the MassHealth agency 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 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 in order 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) Members in regions where selective contracts are in effect are notified by the MassHealth agency of the transportation available to them under the terms of such contracts. (130 CMR 407.408 through 407.410 Reserved) 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-30 Date 08/01/08 (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-30 Date 08/01/08 407.491: 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. 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 MassHealth agency. REGULATORY AUTHORITY 130 CMR 407.000: M.G.L. c. 118E, §§ 7 and 12. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-1 Transportation Manual Transmittal Letter TRN-30 Date 08/01/08 601 Service Codes and Descriptions: Dial-a-Ride Services Service Code Modifier Service Description A0120 Nonemergency transportation: mini-bus, mountain area transports, or other transportation systems (I.C.) A0120 TS Nonemergency transportation: mini-bus, mountain area transports, or other transportation systems (I.C.) (when more than two one-way trips are being billed for the same member on the same date of service) 602 Service Codes and Descriptions: Taxi Services Service Code Modifier Service Description A0100 Nonemergency transportation; taxi (Use for one passenger, intra-city transportation.) A0100 TS Nonemergency transportation; taxi (Use for one passenger, intra-city transportation.) (when more than two one-way trips are being billed for the same member on the same date of service) 603 Service Codes and Descriptions: Wheelchair Van Services Service Code Modifier Service Description A0130 Nonemergency transportation: wheelchair van A0130 TS Nonemergency transportation: wheelchair van (when more than two one-way trips are being billed for the same member on the same date of service) S0215 Nonemergency transportation; mileage, per mile (Wheelchair vans must use this code for mileage. Do not use A0425.) S0215 TS Nonemergency transportation; mileage, per mile (when more than two one-way trips are being billed for the same member on the same date of service) (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.) A0130 TK-TS Nonemergency transportation; wheelchair van (when more than two one-way trips are being billed for the same member on the same date of service) (extra patient or passenger, non-ambulance) (No mileage fee allowed.) T2001 Nonemergency transportation; patient attendant/escort (Use for second attendant.) T2001 TS Nonemergency transportation; patient attendant/escort (when more than two one- way trips are being billed for the same member on the same date of service) (Use for second attendant.) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-2 Transportation Manual Transmittal Letter TRN-30 Date 08/01/08 604 Service Codes and Descriptions: Ambulance Services Service Code Modifier Service Description Ground Mileage A0425 Ground mileage, per statute mile (Ambulances must use this code for mileage. Do not use S0215.) Ambulance Service, Specialty Care Transport A0434 specialty care transport Ambulance Service, Advanced Life Support A0426 Ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1) A0426 TS Ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1) (when more than two one-way trips are being billed for the same member on the same date of service) A0427 Ambulance service, advanced life support, emergency transport, level 1 (ALS 1 – emergency) A0427 TS Ambulance service, advanced life support, emergency transport, level 1 (ALS 1 – emergency) (when more than two one-way trips are being billed for the same member on the same date of service) A0428 Ambulance service, basic life support, nonemergency transport (BLS) A0428 TS Ambulance service, basic life support, nonemergency transport (BLS) (when more than two one-way trips are being billed for the same member on the same date of service) A0429 Ambulance service, basic life support, emergency transport (BLS – emergency) A0429 TS Ambulance service, basic life support, emergency transport (BLS – emergency) (when more than two one-way trips are being billed for the same member on the same date of service) A0433 Advanced life support, level 2 (ALS 2) A0433 TS Advanced life support, level 2 (ALS 2) (when more than two one-way trips are being billed for the same member on the same date of service) Ambulance Service, Basic Life Support 605 Service Codes and Descriptions: Other Licensed Carriers Service Code Modifier Service Description A0140 Nonemergency transportation and air travel (private or commercial), intra- or interstate A0140 TS Nonemergency transportation and air travel (private or commercial), intra- or interstate (when more than two one-way trips are being billed for the same member on the same date of service) MassHealth Transmittal Letter TRN-30 July 2008 Page 2