Provider Notice issued 05/13/14

Retaining a Copy of the Medical Certification for Non Emergency Ambulance (MCA) Form

​To: ​Enrolled Hospitals and Ambulance Providers
​Date: ​May 13, 2014
​Re: ​Retaining a Copy of the Medical Certification for Non Emergency Ambulance (MCA) Form

The purpose of this notice is to remind hospitals of the requirement for an MCA form. In accordance with Public Act 97-0689 and 89 IL Admin Code 140.491(c), when a Medicaid eligible patient is discharged from a hospital, the treating provider (or their designee) must complete a medical certification justifying the medical necessity of the ambulance-level transport. The criteria selected on the MCA form must be supported by the patient's diagnosis, condition, or treatment as documented in the patient's medical record.

The hospital provider must determine that an ambulance level service is medically necessary prior to ordering an ambulance level service. Hospitals must complete the MCA form prior to transport, and must submit the form to the department's prior approval contractor, currently First Transit as well as the transportation provider prior to the transportation service being provided. Ambulance providers may choose not to transport a patient if the hospital does not provide a copy of the MCA form when the service is requested or when the ambulance provider presents to pick up the patient.

In conducting audits of hospitals to measure compliance with the requirement for an MCA form, the department's Office of Inspector General (OIG) found that some hospitals are not routinely maintaining a copy of the MCA form in their records. In those cases, the hospitals have been unable to provide the auditors with a copy of the MCA form.

In the future, when the OIG conducts an audit, the department may recover the payment for the ambulance service from the hospital provider if:

  • The hospital has not maintained a copy of the MCA form; or

  • The hospital maintained the MCA form, but the medical record does not support the criteria selected for prior approval.

The department is committed to assisting both ambulance and hospital providers in complying with this requirement. The department holds weekly conference calls on Thursdays at 9:30, and will continue to do so throughout implementation. The conference call number is 888-494-4032, passcode 7212487979#. In addition, a separate e-mail address has been established which is dedicated to questions relating to this requirement. The e-mail address is Questions regarding this notice may be directed to First Transit at 1-877-725-0569.

Theresa A. Eagleson, Administrator

Division of Medical Programs