Section 69-10.12 - Prior Approval Requests for Certain Transportation for Medical Care and Services

69-10.12 Prior Approval Requests for Certain Transportation for Medical Care and Services.

(a) Requests for prior approval for transportation for medical care and services may be made by the enrollee or a person authorized to act on the enrollee's behalf. Such a request may be made for a one-time appointment or for multiple appointments during a specific period of time. A request for prior approval for non-emergency ambulance transportation or transportation by ambulette must be accompanied by the order of the practitioner who is the enrollee's attending physician, nurse practitioner, or physician assistant.

(b) Payments will only be made to commercial providers of transportation that met all applicable requirements for providing the transportation services requested on the date(s) that the transportation is provided.

(c) The following criteria will be used in determining whether to approve a transportation prior approval request:

(1) whether the nature and/or severity of the enrollee's condition necessitates a mode of transportation other than that ordinarily used by the enrollee or the transportation requested is the only mode of transportation that can safely be used by the enrollee;

(2) whether the enrollee needs multiple treatments or visits over a short period of time that would cause an undue financial hardship to the enrollee or the enrollee's family if required to pay for the transportation for such visits even though the transportation being used is the same transportation used by the enrollee for other activities in his or her community;

(3) whether the geographic location of the enrollee and the provider of medical care and/or services are such that the usual mode of transportation would be inappropriate;

(4) whether the distance to be traveled for the medical care and/or services would require a large transportation expense that would result in an undue financial hardship for the enrollee or the enrollee's family;

(5) whether the need to continue a regimen of medical care or services with a specific provider requires travel outside of the geographic region in which the enrollee's community customarily obtains its medical care and services; and

(6) whether there are any other circumstances that are unique to the enrollee and support the payment of the transportation expenses requested.

Effective Date: 
Wednesday, June 18, 2014
Doc Status: 
Complete