Washington Apple Health (Medicaid) Ambulance and ITA Transportation Billing Guide January 1, 2017 Every effort has been made to ensure this guide’s accuracy. If an actual or apparent conflict between this document and an agency rule arises, the agency rules apply. About this guide∗ This publication takes effect January 1, 2017 and supersedes earlier guides to this program. HCA is committed to providing equal access to our services. If you need an accommodation or require documents in another format, please call 1-800-562-3022. People who have hearing or speech disabilities, please call 711 for relay services. Washington Apple Health means the public health insurance programs for eligible Washington residents. Washington Apple Health is the name used in Washington State for Medicaid, the children's health insurance program (CHIP), and state- only funded health care programs. Washington Apple Health is administered by the Washington State Health Care Authority. This guide is designed to help ambulance providers and their staff to understand agency regulations and requirements necessary for reporting accurate and complete claim information for ambulance transportation and transportation under the Involuntary Treatment Act (ITA). ∗ This publication is a billing instruction. 2 What has changed? Subject Change Reason for Change Nonemergency Providers offering nonemergency Process change ground ambulance ambulance transportation services for transportation certain services are now required to use expedited prior authorization (EPA) number 870001404. *Announced in GovDelivery message sent February 14, 2017. Where can I Added a new section to help providers more Clarification download agency easily find the agency’s forms on the new forms? web page. Fee-for-service Added new section regarding changes for Policy change clients with other some fee-for-service clients. primary health insurance to be enrolled into managed care What is the Clarified the age of adults and minors. Clarification involuntary treatment act? Documenting Added information on documenting Clarification services specialty transportation. billed/provided Payment for Added “and the provider must bill their Clarification mileage usual and customary rate per unit” Payments by Deleted blue box regarding how the agency Funding is no longer DBHR processes ITA claims, but the Department this specific. of Social and Health Services Division of Behavioral Health and Recovery (DBHR) pays the claims. Which form must Added information on using the Clarification be completed when Authorization for Transportation to an transport to an Evaluation and Treatment Facility form alternative (also referred to as Alternative Destination destination is form). required? Alternative Added section on alternative destination Clarification, program destination transportation, including expedited prior updates transportation authorization Involuntary Added notebox about Designated Mental 71.05 RCW and 71.34 Treatment Act Health Professionals (DMHP) and RCW. Transportation Designated Chemical Dependency Specialist (DCDS) in preparation for April 2018 change 3 How can I get agency provider documents? To access provider alerts, go to the agency’s provider alerts web page. To access provider documents, go to the agency’s provider billing guides and fee schedules web page. Where can I download agency forms? To download an agency provider form, go to HCA’s Billers and providers web page, select Forms & publications. Type the HCA form number into the Search box as shown below (Example: 13-835). 4 Copyright disclosure Current Procedural Terminology (CPT) copyright 2016 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the American Medical Association. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. 5 Ambulance and ITA Transportation Table of Contents Which form must be completed when transport to an alternative destination is required? ..............................................................................................................................3 Added information on using the Authorization for Transportation to an Evaluation and Treatment Facility form (also referred to as Alternative Destination form). ................3 How can I get agency provider documents? ..............................................................................4 Where can I download agency forms? .......................................................................................4 Resources Available .....................................................................................................................11 Definitions .....................................................................................................................................12 About the Program ......................................................................................................................16 What is the ambulance transportation program? .....................................................................16 When does the agency pay for ambulance transportation? ......................................................17 What are the guidelines for emergency medical transportation? .............................................17 What about scheduled or “brokered” (nonemergency) medical transportation? .....................18 Client Eligibility ...........................................................................................................................19 What ambulance services are clients in fee-for-service programs eligible for? ......................19 How can I verify a patient’s eligibility? ..................................................................................19 What ambulance services are clients enrolled in an agency-contracted managed care organization (MCO) eligible for? ......................................................................................20 Effective January 1, 2017, some fee-for-service clients who have other primary health insurance will be enrolled into managed care ....................................................................21 Effective April 1, 2016, important changes to Apple Health ..................................................22 New MCO enrollment policy – earlier enrollment ............................................................22 How does this policy affect providers? ..............................................................................22 Behavioral Health Organization (BHO) ............................................................................23 Fully Integrated Managed Care (FIMC) ............................................................................23 Apple Health Core Connections (AHCC)..........................................................................24 AHCC complex mental health and substance use disorder services .................................24 Contact Information for Southwest Washington ...............................................................25 What ambulance services are clients enrolled in Primary Care Case Management (PCCM) eligible for? .........................................................................................................26 What ambulance services are clients under the Involuntary Treatment Act (ITA) eligible for? ........................................................................................................................26 Who is responsible for payment of ambulance services for incarcerated people? ..................27 Provider Responsibilities .............................................................................................................28 What are the general requirements for ambulance providers? .................................................28 Licensing ............................................................................................................................28 Staffing/training .................................................................................................................28 Verifying client eligibility..................................................................................................28 Billing in a timely manner .................................................................................................28 Alert! This Table of Contents is automated. Click on a page number to go directly to the page. 6 Ambulance and ITA Transportation Documenting services billed/provided ..............................................................................29 Record keeping and retention ............................................................................................30 Reporting material changes in provider status ...................................................................30 Knowing health care resources in service area ........................................................................31 Coverage .......................................................................................................................................32 What ambulance services does the agency cover? ..................................................................32 When ambulance transportation services are covered? ...........................................................32 When does the agency pay for nonemergency ground ambulance services? ..........................33 When are ambulance services not separately payable? ...........................................................33 Transporting an inpatient client to and from other diagnostic or treatment facilities ........34 When does the agency not pay for ambulance services? .........................................................35 What are examples of noncovered ambulance services? .........................................................36 “Treat but no transport” service calls.................................................................................36 ALS assessment only, no transport ....................................................................................37 Back door to front door transports (or vice versa) within the same hospital complex ........................................................................................................................37 Some nonemergency hospital transfers .............................................................................37 What ambulance coverage is available for interfacility transfers? ..........................................37 Transfer to a higher level of care .......................................................................................37 Transfer to an equivalent or lower level of care ................................................................38 Is out-of-state ambulance transportation covered? ..................................................................39 Is out-of-country ambulance transportation covered? .............................................................39 What if a client has third-party coverage for ambulance transportation? ................................40 How do providers submit institutional services on a crossover claim? .............................40 What is required from the provider-generated EOMB when processing a crossover claim?...........................................................................................................41 Frequently asked questions (FAQ) about ambulance transportation coverage .......................41 Does the agency pay for ambulance transportation home? ...............................................41 Does the agency pay for ambulance transportation to a kidney dialysis center?...............42 Does the agency pay for ambulance transportation to a free-standing emergency department? ..................................................................................................................42 Does the agency pay for nonemergency ambulance transportation to a physician’s office? ..........................................................................................................................42 Does the agency pay for ambulance transportation resulting from a 911 or emergency call center request? ....................................................................................43 Does the agency pay for ambulance transportation to an urgent care/24-hour walk-in clinic? ..............................................................................................................43 Does the agency pay for ambulance transportation based on a patient’s expressed preference to be transported by ambulance? ................................................................43 Coverage Table.............................................................................................................................44 Air ambulance ..........................................................................................................................44 Ground ambulance ...................................................................................................................45 Authorization................................................................................................................................47 Alert! 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Click on a page number to go directly to the page. 7 Ambulance and ITA Transportation What requires prior authorization (PA)? ..................................................................................47 Who can authorize ambulance services? .................................................................................47 What form(s) should be used to request PA?...........................................................................48 Which form must be completed for a transport to an alternative destination? ........................48 When is Non-Emergency Transfer Request form, HCA 13-950, required? ............................49 When is the Out-of-State Medical Services request form, HCA 13-787 and companion General Information for Authorization form, HCA 13-835, required? ..........50 When is the Involuntary Treatment Act (ITA) form, HCA 14-002 required? ..........................51 When is a physician certification statement (PCS) appropriate to use? ..................................51 Who can sign a PCS? .........................................................................................................52 What must a PCS include? .................................................................................................52 Reimbursement ............................................................................................................................53 What are the limitations on ambulance payment? ...................................................................53 What is the importance of origin and destination modifiers? ..................................................54 Origin/Destination Modifiers .............................................................................................55 Other Modifiers ..................................................................................................................56 When does the agency pay for air ambulance services? ..........................................................57 Payable circumstances for air ambulance services ............................................................57 Prior authorization (PA) requirement for nonemergency air ambulance transportation ...............................................................................................................57 Components of air ambulance payment .............................................................................58 Special circumstances involving air ambulance transportation .........................................58 When does the agency pay for ground ambulance services? ...................................................60 Levels of ground ambulance service..................................................................................60 Factors affecting ALS or BLS classification .....................................................................61 Payment for ground ambulance base rate ..........................................................................62 Payment for mileage ..........................................................................................................62 Payment for extra attendant ...............................................................................................63 Payment for ferry and bridge tolls .....................................................................................63 Payment for waiting time ...................................................................................................63 Payment in special circumstances involving ground ambulance transportation ...............64 When does the agency pay for out-of-state emergency ambulance services? .........................66 When does the agency pay for prior authorized ambulance services to or from and out-of-state facilities?.........................................................................................................66 When does the agency pay for ambulance services provided to qualified Medicare beneficiaries? .....................................................................................................................67 When does the agency pay for ambulance transportation of qualified trauma cases? .............67 When does the agency pay for ITA transportation? ................................................................68 ITA transportation - general ...............................................................................................68 ITA ambulance transportation ...........................................................................................68 ITA non-ambulance transportation ....................................................................................68 Where is the ambulance fee schedule? ....................................................................................69 Ambulance Services Provided Out-of-State ..............................................................................70 Does the agency cover emergency ambulance transportation provided out-of-state? .............70 Alert! 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Click on a page number to go directly to the page. 8 Ambulance and ITA Transportation Does the agency coordinate benefits for ambulance services provided out-of-state? .............70 Does the agency authorize nonemergency air ambulance transportation to out-of-state treatment facilities? ............................................................................................................71 Does the agency authorize nonemergency air ambulance transportation from out-of- state to in-state treatment facilities? ...................................................................................72 What does the agency pay for nonemergency air ambulance transportation to or from out-of-state treatment facilities? ........................................................................................73 Does the agency pay for out-of-country ambulance services? ................................................73 Alternative Destination Transports for Mental Health or Substance Use Disorder People ................................................................................................................................74 Expedited prior authorization ............................................................................................74 Screening Criteria for Alternative Destination Transportation Services (RCW 71.05.153 and RCW 70.96A) ......................................................................................75 The following inclusion criteria must be met in order for the transport to qualify as an alternative destination transport. .........................................................................76 If any of the following exclusion criteria occur, the transport does not qualify as an alternative destination transport. .............................................................................77 Involuntary Treatment Act Transportation ..............................................................................78 What is the involuntary treatment act (ITA)? ..........................................................................78 Who is eligible for ITA services? ............................................................................................78 Who decides what transportation is necessary under ITA? .....................................................79 Who pays for ITA services? ....................................................................................................80 Who pays for ITA transportation of managed care enrollees? ................................................80 When are transportation services covered under ITA? ............................................................81 When are transportation services not covered under ITA? ......................................................81 Who pays for transportation to and from court hearings? .......................................................82 What is the children's long term inpatient program (CLIP)? ...................................................82 What is the parent initiated treatment (PIT) program? ............................................................83 Laws pertaining to PIT: .....................................................................................................83 Are non-ambulance providers eligible to receive payment for ITA transportation services? .............................................................................................................................84 What are the requirements for non-ambulance ITA transportation providers? .......................84 Vehicle standards and maintenance ...................................................................................84 Driver requirements ...........................................................................................................85 Driver training ....................................................................................................................85 Transportation for Involuntary Substance Use Disorder Treatment .....................................86 What is the Ricky Garcia Act?.................................................................................................86 Who is eligible for substance use disorder services? ...............................................................86 Who decides what transportation is necessary under the Ricky Garcia Act? ..........................87 Who authorizes and pays for substance use disorder services? ...............................................88 Who pays for substance use disorder transportation of managed care enrollees? ...................88 When are transportation services covered under the Ricky Garcia Act? .................................89 When are transportation services not covered under the Ricky Garcia Act? ..........................89 Alert! 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Click on a page number to go directly to the page. 9 Ambulance and ITA Transportation Who pays for transportation to and from court hearings? .......................................................90 Audits 91 Post-payment reviews ..............................................................................................................91 Recoupment of improper payments .........................................................................................91 Quality of care audits and reviews ...........................................................................................92 Billing 93 How can I submit ITA claims electronically? .........................................................................93 ITA electronic claims 3-step process: ................................................................................93 How do providers bill for mileage? .........................................................................................95 Alert! 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