Prior Approval for Non-Emergency Ambulance Services
||Participating Medical Assistance Providers|
||July 1, 2013|
||Prior Approval for Non-Emergency Ambulance Services|
As a result of Public Act 097-0689(pdf)
, referred to as the Save Medicaid Access and Resources Together (SMART) Act, and subsequent changes to 89 Ill. Adm. Code Section 140.491
, the department is implementing new requirements for prior approval of non-emergency ambulance services.
Effective with dates of service on and after, July 1, 2013, the following requirements will apply to non-emergency ambulance services:
When any patient covered by the Department’s medical assistance programs is being discharged from a facility, an Authorized Provider of medical services, or an authorized provider’s Designee, must complete and fax to the department’s Prior Approval Vendor, currently First Transit, a completed Medical Certification for Non-Emergency Ambulance (MCA) form for each patient whose discharge requires medically supervised ground ambulance services. For purposes of this policy, an Authorized Provider is a provider who has the legal ability to order medical services for patients. An Authorized Provider includes a physician and, in some situations, an advanced practice nurse or a physician’s assistant acting within his or her scope of practice and in accordance with the privileges granted by his or her employer. For purposes of this policy, a Designee is a licensed or other healthcare professional, such as a nurse or a discharge planner not employed by a non-emergency transportation provider, specifically designated to complete a MCA form for non-emergency ambulance transportation.
The Designee may complete and fax the MCA form. The Provider remains responsible for the accuracy of the medical certification, the authentication of the discharge order, and any determination that the patient’s condition meets the requirements for the department’s criteria for non-emergency ambulance transports.
The MCA form must specify the level of ground ambulance services needed, and establish that the patient's condition meets the department's criteria for approval of non-emergency ambulance service. The department has developed criteria for approval of all non-emergency ambulance transportation which will be applied in completing a Medical Certification for Non-Emergency Ambulance (MCA) (pdf). The criteria and form can be found on the Non-emergency Transportation Services Prior Approval Program (NETSPAP) website.
An order is not required to meet the department’s criteria as long as the criteria selected on the MCA form is otherwise supported by the patient's diagnosis, condition or treatment, as documented in the patient's medical record.
For purposes of the department’s policy with regard to requiring the MCA form, the department will accept the MCA form as the “discharge order” referred to in Public Act 097-0689(pdf).
To be eligible for non-emergency ambulance transport, the service must meet the department’s non-emergency ambulance criteria.
The medical certification form, non-emergency ambulance transport criteria and instructions are available on the department’s Non-Emergency Transportation Services Prior Approval Program (NETSPAP) website. A copy of the MCA form can be found on the Non-Emergency Transportation Services Prior Approval Program (NETSPAP) website.
The department is entitled to recover overpayments paid to a provider or vendor, including, but not limited to, from the discharging physician or the discharging facility, in instances where a non-emergency ground ambulance service is rendered as the result of improper or false certification.
Questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565, option 3, and then option 3.
Theresa A. Eagleson, Administrator
Division of Medical Programs