405 IAC 5-30-1 - Reimbursement restrictions
Authority: IC 12-15-1-10; IC 12-15-6-5; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15-6
Sec. 1.
Medicaid reimbursement is available for emergency and nonemergency transportation, subject to the following restrictions:
(1) Except when additional trips are
medically necessary and the same is demonstrated and documented through the
prior authorization process, reimbursement is available for a maximum of twenty
(20) one-way trips per member, per rolling twelve (12) month period of time.
The following services are exempt from the numeric cap and do not require prior
authorization, except as specified in subdivision (2):
(A) Emergency ambulance services.
(B) Transportation to or from a hospital for
the purpose of an inpatient admission or discharge. This includes interhospital
transfers when the member has been discharged from one (1) hospital for the
purpose of admission to another hospital.
(C) Transportation for members on renal
dialysis or those residing in nursing homes.
(D) Accompanying parent or member attendant,
or both.
(E) Return trip from the
emergency room in an ambulance, if use of ambulance is medically necessary for
the transport.
(2) Prior
authorization is required for all trips of fifty (50) miles or more one (1)
way.
(3) Service must be for
transportation to or from an Indiana Medicaid covered service, or both. The
member being transported for treatment must be present in the vehicle in order
for Medicaid reimbursement to be available. Providers must comply with all
applicable Medicaid documentation requirements, as set forth in provider
manuals or bulletins, in effect on the date of service.
(4) Transportation must be unavailable from a
non-Medicaid reimbursed source, with the exception of Medicaid payments for
family member mileage. This source may include, but is not limited to, the
following:
(A) A member owned
vehicle.
(B) A volunteer
organization.
(C) Willing family or
friends.
(5)
Transportation must be the least expensive type of transportation available
that meets the medical needs of the member.
(6) The office must authorize all in-state
train, bus, or family member transportation services. The member or a party
acting on the member's behalf must make the request for any required
authorization to the office. For purposes of this rule, in-state includes
out-of-state designated areas.
(7)
When a member needs airline, air ambulance, interstate transportation, or
transportation services from a provider located out-of-state in a nondesignated
area, the office or the physician must forward the request for authorization by
telephone or in writing to the contractor. Telephone requests must be followed
up in writing. The request must include a description of the anticipated care
and a brief description of the clinical circumstances necessitating the need
for transportation by air or to another state, or both. The contractor will
review the request. If authorized, the transportation provider will receive the
authorization to arrange the transportation. Copies of the prior authorization
decision are sent to the member and the rendering provider.
(8) A provider is not entitled to Medicaid
reimbursement in any amount that exceeds what the provider accepts as payment
in full (including any coupon, cash discount, or other type of discount) for
the same or equivalent services provided to any non-Medicaid
customer.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.