130 CMR 407.00 — Transportation Services

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents Page iv Transportation Manual Transmittal Letter TRN-39 Date 12/27/21

4. PROGRAM REGULATIONS

130 CMR 407.000: Transportation Services

130 CMR 407.00 Transportation Services

407.401 Introduction ....................................................................................................... 4-1

407.401: Introduction ....................................................................................................... 4-1

407.402 Definitions ........................................................................................................ 4-1

407.402: Definitions ........................................................................................................ 4-1

407.403 Eligible Members ............................................................................................... 4-4

407.403: Eligible Members ............................................................................................... 4-4

407.404 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services ... 4-4

407.404: Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services ... 4-4

407.405 Provider Eligibility: In-state ............................................................................ 4-4

407.405: Provider Eligibility: In-state ............................................................................ 4-4

407.406 Provider Eligibility: Out-of-state ..................................................................... 4-5

407.406: Provider Eligibility: Out-of-state ..................................................................... 4-5

407.407 Selective Contracting ........................................................................................ 4-6

407.407: Selective Contracting ........................................................................................ 4-6 (130 CMR 407.408 through 407.410 Reserved)

407.411 Transportation Utilization Requirements ........................................................... 4-7

407.411: Transportation Utilization Requirements ........................................................... 4-7 (130 CMR 407.412 through 407.420 Reserved)

407.421 Authorization for Transportation ...................................................................... 4-9

407.421: Authorization for Transportation ...................................................................... 4-9 (130 CMR 407.422 through 407.430 Reserved)

407.431 Reimbursement to Members for Transportation Expenses ............................... 4-11

407.431: Reimbursement to Members for Transportation Expenses ............................... 4-11

407.432 Payment to Providers for Transportation Services ............................................ 4-11

407.432: Payment to Providers for Transportation Services ............................................ 4-11 (130 CMR 407.433 through 407.470 Reserved)

407.471 Nonemergency Wheelchair Van ....................................................................... 4-13

407.471: Nonemergency Wheelchair Van ....................................................................... 4-13 (130 CMR 407.472 through 407.480 Reserved)

407.481 Ambulance ........................................................................................................ 4-14

407.481: Ambulance ........................................................................................................ 4-14 (130 CMR 407.482 through 407.490 Reserved)

407.491 Other Licensed Carriers .................................................................................... 4-16

407.491: Other Licensed Carriers .................................................................................... 4-16

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407.401 Introduction

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: Administrative and Billing Regulations.

407.402 Definitions

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: Administrative and Billing Regulations.

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 105 CMR 170.000: Emergency Medical Services System for the implementation of M.G.L. c. 111C, regulating Ambulances and Ambulance Services (Department of Public Health).

Authorized Provider — an individual authorized to sign medical necessity forms and PT-1 forms requesting transportation for MassHealth members. An authorized provider must: (1) be a physician (including an intern or resident), physician assistant, psychologist, dentist, nurse midwife, nurse practitioner enrolled in MassHealth; or (2) be a registered nurse designated and supervised by a physician enrolled in MassHealth.

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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.

Broker — an entity that, pursuant to a selective contract with Executive Office of Health and Human Services (EOHHS), procures and manages non-emergency transportation services for MassHealth members in a designated area.

Brokered Transportation — transportation services that are provided pursuant to a selective contract as described in 130 CMR 407.407.

Day Habilitation Program Representative — a health-care professional employed by a day habilitation provider who is authorized to complete and submit PT-1 forms for MassHealth members. A day habilitation program representative must be a registered nurse, a licensed practical nurse, a day habilitation service manager as described in 130 CMR 419.426(B), or a program director as described in 130 CMR 419.424: Staffing: Program Director.

Early Intervention Program Representative — a health-care professional employed by an early intervention program provider who is authorized to complete and submit PT-1 forms for MassHealth members. An early intervention program representative must (1) be a registered nurse, an occupational therapist, a physical therapist, a psychologist, a licensed clinical social worker, or a speech and language pathologist; and (2) satisfy the staff qualifications specific to his or her position as described in 130 CMR 440.411: Staff Qualifications.

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 § 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.

Fee-for-service Transportation — transportation services that are not provided pursuant to a selective contract.

Locality — the town or city in which a member resides and the surrounding communities within 25 miles of the town or city in which the member resides.

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Managed-care Representative — a clinical employee of a MassHealth managed-care organization (MCO) or other MassHealth managed-care entity 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 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, or a licensed clinical psychologist or a licensed, independent clinical social worker.

Medically Necessary — a service is “medically necessary” if: (1) it is reasonably calculated to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions in the member that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or to aggravate a handicap, or result in an illness or infirmity; and (2) there is no other medical service or site of service, comparable in effect, available and suitable for the member requesting the service, that is more conservative or less costly to the MassHealth agency. Services that are less costly to the MassHealth agency include, but are not limited to, health care reasonably known by the provider, or identified by the MassHealth agency pursuant to a prior authorization request, to be available to the member through sources described in 130 CMR 450.317(c), 503.007: Potential Sources of Health Care or 517.007: Utilization of Potential Benefits.

Medical Necessity Form (MNF) — a form designated by MassHealth documenting the medical necessity of fee-for-service transportation and its authorization by appropriate personnel.

Other Licensed Carrier — any carrier, including bus, train, plane, or boat, that is licensed by the appropriate licensing board or agency.

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.

Provider Request for Transportation (PT-1) — a form designated by and submitted to MassHealth, used to request brokered transportation for a member. The PT-1 form documents the medical necessity of the transportation requested and its authorization by appropriate personnel.

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. chs. 161A and 161B. Transportation services provided by MassHealth through selective contracts with regional transit authorities are not included in the definition of public transportation.

Shared Ride — transportation service provided to two or more members traveling in the same vehicle for the purpose of receiving medical services covered by MassHealth.

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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.

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 oral means obtained from the MassHealth agency when a Provider Request for Transportation (PT-1) form has been submitted but has not been received by the MassHealth agency or when urgent 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

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. The MassHealth regulations at 130 CMR 450.105: Coverage Types 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: Emergency Aid to the Elderly, Disabled and Children Program.

(B) For information on verifying member eligibility and coverage type, see 130 CMR 450.107: Eligible Members and the MassHealth Card.

407.404 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services

407.404: Early and Periodic Screening, Diagnostic 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: Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services: Introduction, without regard to service limitations described in 130 CMR 407.000, and with prior authorization.

407.405 Provider Eligibility: In-state

407.405: Provider Eligibility: In-state

(A) In order to be eligible to receive payment from MassHealth, a potential provider must complete and submit an application to become an approved MassHealth provider, own, lease, or otherwise control by means of a written agreement vehicles required for the transportation services it seeks to provide, be a Medicare provider of any Medicare-covered services it seeks to provide, and be assigned a MassHealth provider number by the MassHealth agency.

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(B) The provider must ensure that applicants and employees whose positions entail the potential for unsupervised contact with MassHealth members, including, but not limited to drivers and attendants, provide written references and undergo a Criminal Offender Record Information (CORI) check before any contact with a MassHealth member. The provider must ensure that all new employees whose positions entail the potential for unsupervised contact with MassHealth members including, but not limited to, drivers and attendants, undergo a CORI check prior to employment. The provider must ensure that all existing employees whose positions entail the potential for unsupervised contact with MassHealth members including, but not limited to, drivers and attendants, undergo a CORI check annually to recertify their eligibility for their position. 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.

(C) The provider must ensure that it and its employees and contractors, as applicable, meet each of the requirements listed below. Providers must demonstrate compliance with the following requirements through an attestation or other method identified by EOHHS, in such form and at such frequency as designated by EOHHS through provider bulletins or other written guidance. (1) The provider and its employees and contractors (including drivers and attendants) are not excluded from participation in any federal health care program (as defined in section 1128B(f) of the Social Security Act) and is not listed on the exclusion list of the Office of the Inspector General of the Department of Health and Human Services (OIG). The provider must use the OIG’s List of Excluded Individuals/Entities to screen all employees and contractors to determine if the OIG has excluded them from participation in federal health care programs, both upon initial hiring or contracting and on an ongoing monthly basis. (2) Each individual driver has a valid driver’s license. (3) The provider has in place a process to address any violation of a state drug law by its employees and contractors. (4) The provider has in place a process to disclose to MassHealth the driving history, including any traffic violations, of each individual driver employed or contracted with by such provider.

(D) Except where the MassHealth agency elects to limit or terminate provider agreements in accordance with 130 CMR 407.407 and 450.108: Selective Contracting in areas of the state or for modes of transportation for which 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: wheelchair van, ambulance, or other licensed carriers.

407.406 Provider Eligibility: Out-of-state

407.406: Provider Eligibility: Out-of-state

In order to be eligible to receive payment from MassHealth, an out-of-state transportation provider must complete and submit an application to become an approved MassHealth provider; own, lease, or otherwise control by means of a written agreement vehicles required for the transportation services it seeks to provide; be a Medicare provider of any Medicare-covered services it seeks to provide; and be 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.

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407.407 Selective Contracting

407.407: Selective Contracting

(A) In some regions, the MassHealth agency may provide some or all transportation services through selective contracts with brokers, such as 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, or otherwise limit existing provider agreements with transportation providers in those regions or for modes of transportation for which 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. MassHealth may issue provider bulletins to inform providers of services provided on a fee-for-service basis and those provided pursuant to selective contracts.

(130 CMR 407.408 through 407.410 Reserved)

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407.411 Transportation Utilization Requirements

407.411: Transportation Utilization Requirements

(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: Coverage Types). (1) In the case of public transportation, the MassHealth agency determines those medical services that are covered by MassHealth. (2) In the case of fee-for-service ambulance and wheelchair van transportation, 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 brokered transportation, the MassHealth agency determines those 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. 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 or other appropriate location, such as the office of another provider, and proceeds to the location of the medical appointment.

(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.

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(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

1. within 0.75 mile from the member’s residence or other authorized point of origin; and
2. 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.

(G) Members Traveling with Escorts. 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 407.412 through 407.420 Reserved.)

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407.421 Authorization for Transportation

407.421: Authorization for Transportation

(A) Types of Authorization. (1) All forms of transportation except public transportation require authorization consisting of one or more of the following: (a) verbal authorization for transportation following submission of a Provider Request for Transportation (PT-1) as described in 130 CMR 407.421(A)(1)(b) or when urgent care is needed; (b) a Provider Request for Transportation (PT-1) completed in accordance with 130 CMR 407.421 (C) submitted by an authorized provider, a day habilitation program representative, an early intervention program representative, or a managed-care representative, and approved by MassHealth; or (c) a Medical Necessity Form completed in accordance with 130 CMR 407.421(D) and signed by an authorized provider or a managed-care representative, 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 mode of transportation.

(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) Provider Request for Transportation. (1) The Provider Request for Transportation (PT-1) form must be used to request authorization for brokered transportation. (2) A Provider Request for Transportation (PT-1) form must be completed and submitted by an authorized provider, managed-care representative, day habilitation program representative, or early intervention program representative, and approved by MassHealth. (3) A completed PT-1 must contain: (a) adequate information to determine the need for the transportation requested and that the member will receive a medically necessary service covered by MassHealth at the trip’s destination; and (b) if recurring transportation is requested, the expected duration of the need for transportation (specific time period not to exceed six months for acute illness; one year for chronic illness; three years for early intervention and five years for day habilitation).

(D) Medical Necessity Form. (1) The Medical Necessity Form is used to document the medical necessity of fee-for-service transportation services. 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.

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(2) The transportation provider is responsible for ensuring that the Medical Necessity Form is signed by an authorized provider or managed-care representative and completed in accordance with 130 CMR 407.421(D). The completed Medical Necessity Form must be kept by the transportation provider as a record for six years from the date of service. (3) A completed Medical Necessity Form must contain adequate information to determine the need for the transportation requested and that the member will receive a medically necessary service covered by MassHealth at the trip’s destination. (4) 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.

(130 CMR 407.422 through 407.430 Reserved.)

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407.431 Reimbursement to Members for Transportation Expenses

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 an authorized provider, a day habilitation program representative, an early intervention program representative, a managed-care representative, a registered nurse, a licensed practical nurse, a social worker, a case manager, or another medical professional who provided services for which the member seeks reimbursement of public transportation costs. The documentation must demonstrate that medical services covered by MassHealth were received, identify the date on which medical services were received, and identify the specific address where medical services were received. In cases where urgent care is needed, 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, 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(C).

407.432 Payment to Providers for Transportation Services

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(B). Payment for brokered transportation is made in accordance with the terms of the selective contract. In all other cases, payment is made in accordance with 101 CMR 327.00: Rates of Payment for Ambulance and Wheelchair Van Services. 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.

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(B) Payment Limitations. The MassHealth agency does not pay a provider of transportation services other than a transportation broker for services other than those identified in 130 CMR 407.471(A)(2), 407.481(A), and 407.491(A), when provided to MassHealth members who reside 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 407.470 Reserved)

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407.471 Nonemergency Wheelchair Van

407.471: Nonemergency Wheelchair Van

(A) Criteria for Use. (1) Wheelchair van services may be provided only in nonemergencies to the following persons: (a) MassHealth members who use wheelchairs; (b) MassHealth members 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); (c) MassHealth members whose severe mobility handicaps prevent them from using public transportation or brokered transportation in a sedan; and (d) MassHealth members who are being transported by a fee-for-service provider, who are being discharged from inpatient psychiatric hospitals to community-based behavioral health programs, and who require supervision during transportation, when PT-1 transportation is unavailable or inappropriate. (2) Fee-for-service wheelchair van services may be provided only in nonemergencies to: (a) MassHealth members meeting the criteria in 130 CMR 407.471(A)(1)(a) through (c) who also reside in institutional settings; (b) MassHealth members meeting the criteria in 130 CMR 407.471(A)(1)(a) through (c) who also reside in the community and need mobility assistance from transportation provider personnel to exit their residences or to move from their residences to the vehicle; and (c) MassHealth members meeting the criteria in 130 CMR 407.471(A)(1)(d).

(B) Authorization. Fee-for-service wheelchair van transportation requires a Medical Necessity Form completed in accordance with 130 CMR 407.421(D). Brokered wheelchair van services require a Provider Request for Transportation (PT-1) form completed and approved in accordance with 130 CMR 407.421(C).

(C) Recordkeeping Requirement. (1) Providers of fee-for-service wheelchair van services must keep records of all services billed to the MassHealth agency. Such records must be maintained in accordance with 130 CMR 450.205: Recordkeeping and Disclosure 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 for brokered transportation.

(D) Rates of Payment. (1) Payment for fee-for-service wheelchair van service is made in accordance with 101 CMR 327.00: Rates of Payment for Ambulance and Wheelchair Van Services.. (2) The service codes that must be used when billing for wheelchair van services are listed in Subchapter 6 of the Transportation Manual. (3) Payment for brokered wheelchair van services will be made in accordance with the terms of the applicable selective contract.

(130 CMR 407.472 through 407.480 Reserved.)

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407.481 Ambulance

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.

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(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) 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: Recordkeeping and Disclosure 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.

(E) Rates of Payment. (1) Payment for ambulance services is made in accordance with 101 CMR 327.00: Rates of Payment for Ambulance and Wheelchair Van Services. (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.)

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407.491 Other Licensed Carriers

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 shall not exceed the carrier’s usual fee for patients other than MassHealth members and shall not 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.