Provider Notice issued 07/24/13

New Requirements Related to Prior Approval for Non-Emergency Ambulance Services

New Requirements Related to Prior Approval for Non-Emergency Ambulance Services

On July 1, 2013, the Illinois Department of Healthcare and Family Services (HFS) implemented new requirements related to prior approval for non-emergency ambulance services provided to Medicaid eligible patients being discharged from a hospital. The Department is committed to working closely with both hospital and ambulance providers to make this new mandate a success. During the implementation phase, the Department will hold weekly webinars with all stakeholders to discuss implementation issues and answer questions. The webinar schedule will be posted on www.NETSPAP.com. The first webinar will be held on Thursday, July 25, 2013, beginning at 9:30. We are confident that if all stakeholders work closely together, implementation issues will be minimized.

Phase 1 – Education and Proper Implementation

During the implementation phase (Phase 1), which ends September 30, 2013, the Department is making a concerted effort to educate hospitals that do not comply with the requirements for non-emergency ambulance transports outlined in the Informational Notice Regarding Prior Approval of Non-Emergency Ambulance Transports.

Ambulance services must only be requested if the patient’s condition warrants ambulance-level services. Information regarding the criteria for non-emergency ambulance transportation, including examples, can be found in administrative rule at: Criteria for Non-Emergency Ambulance.
During Phase 1, if a hospital requests non-emergency ambulance transportation for a Medicaid patient being discharged, and does not complete the Medical Certification for Non-Emergency Ambulance (MCA) form, the ambulance provider must request an MCA form from the hospital upon patient pick-up.

If the Hospital does not provide a completed MCA form at the time of transport, the Department will permit the hospital to fax the completed MCA form to First Transit and the ambulance provider after the transport. The Department will permit the ambulance provider to fax the completed MCA form obtained from the hospital after the transport along with the run report to First Transit within 20 business days of the service. This time frame may be extended 30 days for good cause during Phase 1 of the implementation if the delay is the result of hospital non-compliance, and is not the fault of the ambulance provider. Unsuccessful attempts by the ambulance provider to obtain a completed MCA form must be referred by the ambulance provider to the the HFS Office of Inspector General (OIG) by sending an email to hfs.mcaform@illinois.gov . The ambulance provider’s email must contain:

1)The hospital name and complete address;
2) The name, address, and fax number for the ambulance provider;
3) The trip date;
4) The contact person at the hospital.

The Inspector General will contact the hospital’s compliance department to educate the hospital about the requirement and obtain a corrective action plan. The hospital will be directed to:

5)Complete an MCA form for all non-emergency ambulance services the hospital requested, and an ambulance provided, on or after July 1, 2013; and,
6) Fax those completed MCA forms to First Transit and to the transportation provider that provided the service.

• Questions regarding form completion should be directed to First Transit.
• Questions regarding compliance and the corrective action plan should be directed to Mason Budelier at the Illinois Office of Counsel to the Inspector General.

During Phase 1, no non-emergency ambulance service provided to a hospital-discharged patient will be approved for payment without a hospital-completed MCA form. Any form that is submitted other than the MCA form will not be accepted. In order to be approved, the MCA form must completed by the authorized provider or designee and faxed by the hospital to First Transit at the fax number provided on the bottom of the MCA form. During Phase 1, the Department has directed First Transit to accept MCA forms faxed post-transport; and has extended the timeframe to accept run reports from ambulance providers to 20 business days from the date of service.

Phase 2 – Full Implementation

During Phase 2, which begins with dates of service October 1, 2013, the hospital must fax the MCA form to First Transit prior to transport, and must provide a copy of the MCA form to the ambulance crew at the time of transport. Beginning with dates of service October 1, 2013, the Department’s prior approval agent will not approve prior approval requests when an MCA form was not submitted by the hospital prior to transport.

Information regarding ‘authorized provider’ and ‘designee’ is provided in the Informational Notice for Non-Emergency Ambulance Services.

Common MCA Form Completion Problems

The form is divided into four parts: Trip information, Non‐Emergency Ambulance Transportation Criteria Medical Certification, Non‐Emergency Ambulance Transportation Criteria Certification, and Certification and Attestation. Below is a list of common errors that prevent processing of the MCA form. Please note:

1)The MCA form only applies to patients whose medical condition warrants an ambulance level transport and who receive medical benefits through Illinois Medicaid (primary or secondary) or are Medicaid pending.

2) It is the responsibility of the ‘authorized provider’ and/or ‘designee’ to know what constitutes an ambulance level transport. Guidance to inclusions and exclusions are listed at: Criteria for Non-Emergency Ambulance

3) Illegible or incomplete forms cannot be processed by First Transit.

4) A PDF-fillable version of the form is available at www.netspap.com. ‘Authorized Providers’ and ‘Designees’ are encouraged to type the form to assure legibility.

5) Do not place hospital stickers with patient information on the form in place of writing the information in the required fields.

6) Please do not use acronyms for the name of the hospital or transportation providers.

Part 1 - Trip Information

1)Recipient ID Number is the 9-digit Medicaid ID number.

2) ‘Reason for Trip’ is usually going to be ‘hospital discharge’.

3) Remember to put the ‘date of trip’ and ‘requested pick-up time’. ‘ASAP’ is not acceptable in place of a specific time.

4) ‘Location Name’ is the name of the hospital.

5) Don’t forget to list the name of the transportation provider that does the transport.

Part 2 – Non-Emergency Ambulance Transportation Criteria Medical Certification

1) This is a ‘read-only’ section that must apply to the medical necessity of the patient.

Part 3 - Non‐Emergency Ambulance Transportation Criteria Certification

1) At least one of the following must apply and be checked in order for the patient to be eligible for non-emergency ambulance transportation.

2) The ‘authorized provider’ or ‘designee’ must write the patient’s diagnosis that collaborates the criteria checked in the box under item eleven (11).

Part 4 – Certification and Attestation

1) Box A, B, or C must be checked.

2) The name and title of the ‘authorizing provider’ authorizing the transport must be printed in the appropriate box. 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. The ‘authorizing provider’ must be listed even when a ‘designee’ completes the form.

3) In cases where the ‘authorizing provider’ appoints a ‘designee’ to complete the form, the name and title of the ‘designee’ must be provided. 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 medical certification form for non‐emergency ambulance transportation.