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KS Protocols - ATTACHMENT 1 TO THE KS Protocols - ATTACHMENT 1 TO THE Document Transcript

  • ATTACHMENT 1 TO THE<br />MEDICAL TRANSPORTATION SERVICES AGREEMENT BETWEEN <br />Kansas Health Policy Authority (KHPA)<br />AND MEDICAL TRANSPORTATION MANAGEMENT, INC.<br />Effective: July 7, 2010<br />Transportation Protocols<br />CATEGORYSERVICE ITEMCLIENT SPECIFICATIONSA. Customer Service Center RequirementsA.1.Hours of operation for routine transportation requestsOpen Mon through Fri 8:00 am to 5:00 pm (CT). Call Center will be closed for routine transportation scheduling for the following holidays: New Year’s Day, Martin Luther King Day, Memorial Day, Independence Day, Labor Day, Veteran’s Day, Thanksgiving Day, Christmas Day.A.2.After HoursOpen 24/7 for same day/next day, urgent trip requests, hospital discharges, and/or arrange transportation when a beneficiary has been stranded.A.3.GreetingThank you for calling Kansas Medicaid Transportation Services, this is (name) may I have your ID #?B. SERVICE AREAB.1.Service Area by CountyEntire State of Kansas including communities on the Border-City List on page 9; these cities were exempted by the State since they are within 50 miles of the Kansas border.B.2.Transport outside of service area These trips must be medically necessary and to nearest provider. These requests are escalated to Care Management. Trips outside of the service area (B.1) must be prior authorized by MTM Care Management and by the State’s Prior Authorization Unit. B.3.How should MTM handle requests for transportation out of state and meals and lodging?These requests must be medically necessary and to the nearest provider. All meals and lodging requests, both in-state and out-of-state, are escalated to Care Management for prior authorization.All travel requests outside of the service area (B.1) are escalated to MTM Care Management for prior authorization through the State’s Medical Necessity PA unit. C. SCREENING CRITERIAC.1.Who can request transportation?Beneficiaries who are at least 16 years of age.Beneficiary’s parent, legal guardian, or authorized representative.Plan Case Manager or other plan representative.C.2.Notice for Routine Medical Appointment48 hoursC.3.Instructions if Beneficiary calls less than required days of noticeEducate Beneficiary, schedule trip and note in file.If third or more attempt in calendar year, educate Beneficiary, note in file and ask Beneficiary to reschedule their appointment to be within days of notice requirements.C.4.Must MTM Verify Appointments for same day and urgent trip requests?Yes, follow the urgency guidelines.C.5.Instructions if Beneficiary is not EligibleIf beneficiary does not show up in MTM’s Trip Intake system, MTM must access the Beneficiary Eligibility Verification window via the secure KMAP website to confirm eligibility status. If the beneficiary has eligibility questions, educate them to contact their EES worker at SRS. Note: Prison and jail inmates are not eligible. C.6.Modes of Transportation CoveredPublic transitMileage Reimbursement ($0.30 per mile) Sedan, taxiWheelchair equipped vehicleStretcher Van C.7.Criteria for walkingIf an appointment is within ¾ of a mile from member’s originating address, then the member must walk unless certified for sedan or wheelchair equipped vehicle.C.8Criteria for use of public transportationPick up and drop off sites are ¾ of a mile from bus line.Follow MTM criteria for use of public transit (page 9).C.9Criteria for use of mileage reimbursementIf the member or member’s friend/family has a vehicle and can meet the enrollment requirements of a valid driver’s license and proof of insurance, then mileage reimbursement must be offered at $.30 per mile.<br />C. SCREENING CRITERIAC.10Transport of a minorBeneficiaries 16 years of age or older may travel aloneBeneficiaries younger than 16 years of age must have an adult 16 years old or older escort them. Exception: If the beneficiary is between the ages of 5 and 15, he/she may ride without an adult present if his/her parent or guardian signs a waiver and provides it to MTM to keep on file.All beneficiaries younger than 5 must have a parent/guardian or attendant (16+) travel with them, no exceptions.For beneficiaries who are 16 years of age or older and single caregivers with more than one minor child in his/her care, MTM will transport the additional minor children.C.11Transport of children 20 years old or youngerMTM must provide for transportation, and meals and lodging when appropriate, for an attendant to accompany a child 20 years old or younger who has a cognitive/mental/physical condition that warrants supervision and/or assistance to and from Medicaid covered services when a parent or guardian is unavailable. If the attendant is not a family member or paid personnel such as an assigned social worker, salary for the attendant must also be considered. These requests must be escalated to Care Management.C.12Transport of “at-risk” adultMTM must provide for transportation, and meals and lodging when appropriate, for an attendant to accompany an “at risk” adult to and from Medicaid covered services, when deemed medically necessary. These requests must be escalated to Care Management.C.13Transportation to/from ERNOT Allowed to ER for emergencies; Allowed to and from ER for non-emergent situations, i.e. when doctor’s office closed.Allowed from ER (Hospital Discharges)Allowed between ERsC.14Trips greater than 50 milesUrban: Trips must be Prior Authorized if the distance of the one-way trip is 50 miles or more and the beneficiary lives in one of the following urban counties: Butler, Douglas, Johnson, Leavenworth, Sedgwick, Shawnee, and Wyandotte. These requests must be escalated to Care Management.Rural: Trips must be Prior Authorize if the one-way trip is at least 100 miles and the beneficiary does not live in one of the urban counties listed above. These requests must be escalated to Care Management.<br />C. SCREENING CRITERIAC.15Trips to the pharmacy NOT Allowed as pharmacy only trip. Allowed as an emergency trip to the pharmacy when it is deemed medically necessary by the health care provider and only in areas where the provider does not deliver or cannot deliver within 24 hours. Allowed to the nearest pharmacy as a 3rd leg of a round trip to a Medicaid covered appointment.C.16Trips for Durable Medical EquipmentAllowed if deemed medically necessary by the health care provider and only in areas where the provider does not deliver or cannot deliver within 24 hours. Escalate to Care Management.C.17Trips for HCBS Waivered Services (not covered)Home and Community Based Services (HCBS) waivered services are not coveredTypes of waivers: Technology Assistance (TA); Traumatic Brain Injury (TBI); Frail Elderly (FE), Physically Disabled (PD); Mentally Retarded or Developmentally Disabled (MR/DD); & Seriously Emotionally Disturbed (SED)Examples of HCBS services, which are not covered:Adult Day CareDD Day ServicesSupported Employment Oral Health Services.C.18Additional PassengersBeneficiary and one additional passenger allowed. Allow more passengers than the one additional passenger if the passengers are minors (C.10) or have a medical condition that warrants supervision.C.19Car Seat UseTransportation Providers are required to comply with the state law on Car Seat usage. C.20Beneficiary Disagreement with mode of transportation authorized If MTM cannot resolve with its Grievance Process, the Beneficiary will be able to request a Fair Hearing with the State after that process is completed.C.21Presumptive Medical DisabilityPMD requests are handled by Care Management.C.22Meals and LodgingAll Meals and Lodging requests must be escalated to Care Management.C.23Spend downIf Beneficiary calls and states they are on spenddown for Medicaid: educate on the spenddown process/receipts, mail out the Transportation Spend Down form, and offer transportation provider if one is requested.Refer the beneficiary to SRS EES worker for Medicaid eligibility questions.<br />Summary of Transportation Services and <br />Benefits Covered and Not Covered List<br />Note: This is a list of transportation services and not medical benefits. Trips requests that are “Covered” can be scheduled by a CSR without further justification. Trip requests that are “Excluded” but have “Special Instructions” require follow-up either by the CSR Team Lead or Case Management. All trips request that require Prior Authorization must be escalated to Care Management. <br />ServiceCodeCoveredExcludedSpecial InstructionsAbortion50XCovered in cases of rape, incest, or potential life threatening situations. CSR to follow up by asking if the trip request is a result of rape, incest or potential life threatening situation.Adult Day Care-medical/behavorial80XAlcohol Abuse Evaluation to Enter Treatment 01XAlcoholics Anonymous Meetings82XAlcohol Rehabilitation 81XCardiac Rehab35XChemotherapy/Radiation34XChiropractor83XCommunity Psych Rehab84XIncludes, but not limited to, these mental health services: Community Psychiatric Support & Treatment, Psycho Social Rehab, Peer Support, and Crisis InterventionCounselor, Psychologist, Social Worker 29XIncludes, but not limited to, these mental health services:Evaluation & Assessment, Testing, Individual/Family/ Group Therapy, Medication Management and Medication Administration (include IM Injections), and Case ConsultationIncludes Targeted Case ManagementCourt Ordered Exams or appointments52XCovered if one of the other Medicaid covered servicesDay Treatment Program-medical/behavioral64XCovered as (84) Community Psych Rehab or (29) Counselor, Psychologist, Social WorkerDental Services 03XCovered service for KAN Be Healthy program birth to age 20; and Covered for members over age 20 if for medically necessary extractionsDiabetic Supplies and Education33XDialysis 04XServiceCodeCoveredExcludedSpecial InstructionsDrug Abuse Evaluation to Enter Treatment 05XDrug Rehabilitation /Therapy53XDrug counseling IS coveredDrug dosing is NOT covered- Thus if trip is only to receive a dosage it is not covered.Durable Medical Equipment06XCovered if deemed medically necessary by health care provider and DME provider does not deliver. Escalate to Care Management.Education/Outreach Programs70XEmergency Room-TO71XCovered if for a non-emergent, non-life threatening trip that does not require an ambulance. Emergency Room-FROM72XHearing Aids 08XCovered for exam and fitting.Not covered to pickup supplies only.Hospital – Inpatient Services/Admission 09XNot Covered: Larned, Oswatomie, and Rainbow State Mental Heath Hospitals and Psychiatric Residential Treatment Facility (PRTF). Once discharged, can be transported to covered service.Hospital - Discharge 10XNot Covered: Larned, Oswatomie, and Rainbow State Mental Heath Hospitals and Psychiatric Residential Treatment Facility (PRTF). Once discharged, can be transported to covered service.Hospital - Outpatient services12XNot Covered: Larned, Oswatomie, and Rainbow State Mental Heath Hospitals and Psychiatric Residential Treatment Facility (PRTF). Once discharged, can be transported to covered service.Hospital to Hospital 11XNot Covered: Larned, Oswatomie, and Rainbow State Mental Heath Hospitals and Psychiatric Residential Treatment Facility (PRTF). Once discharged, can be transported to covered service.Hospital Visitation 36XNot Covered: This includes parental visits and education since the member receiving Medicaid covered service is not in the vehicle Immunizations13XLaboratory Services14XLamaze Classes 56XLead Screening/Testing37XMammogram38XNon Medical Trip57XServiceCodeCoveredExcludedSpecial InstructionsNursing Home to Nursing Home39XOB/GYN services40XOccupational Therapy 15XPrior Auth by MTM required. Escalate trip to Care ManagementOptical Services-eye glasses/eye exams17XCovered for exam and fitting for Kan-Be-Healthy birth to 20.Covered non Kan-Be-Healthy (21+) for 1 exam and fitting every 4 years.Not covered to pickup supplies only.Opthamologist58XOrthotics18XPain Management20XPharmacy 21XCovered to nearest pharmacy as a 3rd leg to a round trip; or Covered when deemed medically necessary by health care provider and pharmacy does not deliver. CSR confirm with health care provider.Physical Exam46XPhysical Therapy 22XPrior Authorization by MTM required. Escalate trip to Care ManagementPodiatry24XPrenatal Services25XPrimary Care Physician 23XProsthetic 27XCovered for exam and fitting.Not covered to pickup supplies only.Psychiatrist 28XRadiology Services (X-rays, MRI)42XSpecialist 68X Speech Therapy 94XPrior Authorization by MTM Required. Escalate to Care ManagementSSI Determination Medical Appointment96XTransplant Services43XUrgent Care Facility-TO61XUrgent Care Facility-FROM60XVision/Hearing Screenings47XCovered service for KAN Be Healthy program birth to age 20Vocational Rehabilitation98X<br />ServiceCodeCoveredExcludedSpecial InstructionsWeight Control Programs66XBariatric surgery including gastric by-pass and lap band surgeries are not covered. WIC Appointments99X<br />Kansas Health Policy Authority (KHPA)<br />Criteria for Use of Public Transportation<br />MTM is commissioned by KHPA to select the most appropriate, most cost-effective mode of transportation when scheduling trips for beneficiaries. Public transportation must always be the first selection when scheduling transportation. However, there are extenuating circumstances that warrant the use of alternative, non public modes of transportation. These circumstances would include the health condition or age of the beneficiary and the availability of public transportation services within a particular geographic region. The list below outlines the criteria for use of an alternative, non public mode of transportation.<br />Criteria for Use of Public Transportation<br />Passenger lives and the appointment site are within 3/4 of a mile of a bus line.<br />If Level of Need (LON) verifies and/or passenger states they are physically and mentally able to be transported via bus or other public transit vehicle.<br />Passenger is 16 years of age or older if traveling alone (or per protocols).<br />Criteria for Use of Non Public Modes of Transportation<br />If current Level of Need (LON) verifies that passenger is physically and/or mentally unable to be transported via bus or other public transit vehicle<br />If more than one transfer is needed using public transit, then may not be suitable<br />Passenger is traveling with an infant under six (6) months old.<br />An adult or individual 16 years of age or older is traveling with more than 2 children under the age of 5.<br />Passenger is in her third trimester of pregnancy.<br />Passenger has a high risk pregnancy<br />Passenger does not speak English and does not have a passenger to assist that speaks English. NOTE: CSR must ask the caller if they have someone that can accompany them to interpret.  This info must be documented in trip notes before this will be considered an exclusion.  <br />Bus line is not operational on day and/or time of appointment.<br />Passenger is undergoing chemotherapy/radiation (any appointments due to weakened state)<br />Passenger is a transplant patient<br />Passenger is going to kidney dialysis appointments (non dialysis-related appointments not included)<br />Passenger is age 70 or older and uses walker, crutches and/or cane.<br />Sickle Cell Anemia (child)<br />Sickle Cell Crisis (adult)<br />BORDER CITY LIST<br />When a provider is located in a state other than Kansas, and services are rendered in that state, the provider must be licensed and otherwise certified by the proper agencies in his/her state of residence as qualified to render the services for which the charge is made. Certain cities, within 50 miles of the Kansas border, may be closer for Kansas residents than major cities in Kansas, and therefore these cities are considered Border Cities (see list below). This list is not all inclusive. All others are considered out-of-state and require Prior Authorization from the State of Kansas.<br />ARKANSAS<br />Bentonville<br />Gateway<br />Gravette<br />Rogers<br />COLORADO<br />Arapahoe<br />Burlington<br />Campo<br />Cheyenne Wells<br />Eads<br />Eckley<br />Idalic<br />Joes<br />Kirk<br />Lamar<br />Lycan<br />Springfield<br />Stonington<br />Stratton<br />Vilas<br />Vona<br />Walsh<br />Wiley<br />Wray<br />Yuma<br />MISSOURI<br />Anderson<br />Appleton City<br />Asbury<br />Belton<br />Blue Springs<br />Burlington Junction<br />Butler<br />Carthage<br />Claycomo<br />Craig<br />El Dorado Springs<br />MISSOURI(cont.)<br />Excelsior Springs<br />Gladstone<br />Golden<br />Gower<br />Grandview<br />Harrisonville<br />Independence<br />Jasper<br />Joplin<br />Kansas City Metro<br />King City<br />Lamar<br />Lee's Summit<br />Liberty<br />Maryville<br />Monett<br />Mound City<br />Mt. Vernon<br />Nevada<br />Noel<br />North Kansas City<br />Oregon<br />Parkville<br />Platte City<br />Plattewoods<br />Pleasanton<br />Raytown<br />Rich Hill<br />Rockport<br />St. Joseph<br />Sarcoxie<br />Savannah<br />Seligman<br />Seneca<br />Sheldon<br />Smithville<br />Stanberry<br />Tarkio<br />Urich<br />MISSOURI(cont.)<br />Warrensburg<br />Webb City<br />NEBRASKA<br />Alma<br />Araphoe<br />Auburn<br />Axtell<br />Ayr<br />Beatrice<br />Beaver City<br />Benkelman<br />Bertrand<br />Blue Hill<br />Cambridge<br />Chester<br />Clay Center<br />Cortland<br />Curtis<br />Deshler<br />Elwood<br />Fairbury<br />Falls City<br />Franklin<br />Geneva<br />Hastings<br />Hayes Center<br />Hebron<br />Holdrege<br />Humboldt<br />Indianola<br />Kearney<br />Maywood<br />McCook<br />Minden<br />Nelson<br />Oxford<br />Pawnee City<br />NEBRASKA(cont)<br />Red Cloud<br />Sterling<br />Stockville<br />Superior<br />Sutton<br />Table Rock<br />Tecumseh<br />Wilsonville<br />Wymore<br />OKLAHOMA<br />Afton<br />Alva<br />Bartlesville<br />Beaver<br />Blackwell<br />Boise City<br />Buffalo<br />Cherokee<br />Cleveland<br />Collinsville<br />Commerce<br />Dewey<br />Enid<br />Grainola<br />Grove<br />Guymon<br />Hooker<br />Laverne<br />Medford<br />Miami<br />Nowata<br />Pawnee<br />Ponca City<br />Vinita<br />Wakita<br />Waynoka<br />Woodward<br />