Provider Notice issued 12/01/14

Medical Certification for Non Emergency Ambulance (MCA) Form

This notice informs ambulance providers of the process HFS will use to handle the payment of non-emergent ambulance transports provided when a MCA form has not been submitted by the hospital to First Transit, and the policy HFS will follow in the future when a MCA form has not been completed.

Not all hospitals are complying with Public Act 097-0689 (pdf) and 89 IL Admin Code 140.491(c), when a Medicaid eligible patient is discharged from a hospital. As a result, ambulance providers are transporting patients after a hospital discharge and the ambulance provider is not being reimbursed for these transports because no MCA form has been submitted.

In an effort to reimburse ambulance providers for trips provided, HFS has implemented the following:

• For dates of service through July 31, 2014, First Transit will approve trips that age to 90 days regardless of whether an MCA Form was completed.

• For dates of service, August 1, 2014 through December 31, 2014, First Transit will approve trips that have a MCA Form. If the hospital provider does not submit the form at the time of service, ambulance providers have 90 days from the date of service to submit the MCA Form to First Transit.

• After January 1, 2015, ambulance providers should not render a non-emergency ambulance transport of a hospital discharge without a completed MCA Form. Any ambulance that renders a trip without a properly completed MCA form documenting medical necessity risks non-payment for the service. Ambulance providers will have 20 business days from the date of service to submit the form to First Transit or the transport will be denied by First Transit and the claim cannot be submitted to the department for reimbursement.

Information regarding the prior approval process can be found in the February 21, 2014 informational notice, PassPORT Requirements for Non Emergency Ambulance Hospital Discharges (pdf). Providers may appeal any decision per 89 IL Admin Code, Section 104.205.

Special Information Regarding Care Coordination Billing and Eligibility

The information in this notice applies to patients enrolled in traditional fee-for-service, Accountable Care Entities (ACEs) and Care Coordination Entities (CCEs) and do not apply to patients enrolled in Managed Care Organizations (MCOs) and Managed Care Community Networks (MCCNs). Should a participant become enrolled in an MCO or MCCN during a period of time for which a prior approval has been previously granted, the prior approval will no longer be applicable effective with the participant’s managed care enrollment date.

It is imperative that providers check HFS electronic eligibility systems regularly to determine beneficiaries’ enrollment in a plan. Electronic Data Interchange vendors (formerly the Recipient Eligibility Verification (REV) System), the Automated Voice Response System (AVRS) at 1-800-842-1461, and the Medical Electronic Data Interchange (MEDI) system will identify any managed care plan in which the beneficiary is enrolled. Plan contact information for questions related to coverage and billing requirements as well as information regarding the way each plan is displayed in the department’s electronic eligibility systems may be located in the June 24, 2014 informational notice titled, Revised - Care Coordination Enrollment for Children, Families and ACA Adults (pdf).

Questions regarding prior approval should be directed to First Transit at 877-725-0569. Questions regarding billing should be directed to the Bureau of Professional and Ancillary Services at 877-782-5565, option 3, option 3.

Theresa A. Eagleson, Administrator

Division of Medical Programs