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HEALTHCARE

CARTA CIRCULAR PR PROV18-002-004

16 de febrero de 2018.

A : TODOS LOS HOSPITALES, COMPANIAS DE AMBULANCIAS Y TRANSPORTE PARTICIPANTES DE MOLINA HEALTHCARE OF PR

RE : CAMBIOS A LA POLITICA DE TRANSPORTACION NO EMERGENTE

Reciba un cordial saludo de parte de la familia de Molina Healthcare de Puerto Rico (MHPR). En Molina Healthcare de PR estamos comprometidos con la salud de nuestros afiliados asf como tambien con el servicio a nuestros proveedores participantes para el Plan de Salud de Gobierno.

Desde el inicio, MHPR ha aprobado los servicios de la transportacion no emergente a beneficiarios de Plan de Salud de Gobierno, esto, para facilitar y asegurar el cuidado medico de sus beneficiarios.

Recientemente hemos revisado y actualizado la Polftica de Transporte No Emergente. La revision responde al interes de MHPR en proveer y asegurar la alta calidad de servicios medicos manteniendo un control de costos.

La revision de esta Polftica es efectiva al 1 de febrero de 2018. La misma define:

• l Quienes son los proveedores autorizados a solicitar/ ordenar servicio de transporte?

• Define y describe las condiciones para que un beneficiarios de PSG que pueda cualificar para la autorizacion de este servicio.

• lntegra la administracion del Grupo Medico Primario (GMP) como parte del proceso de aprobacion.

• Establece el proceso a seguir y requisitos para autorizar el servicio.

• Describe un proceso de evaluacion al beneficiario y/o familiares para definir y cualificar el grado de necesidad del servicio.

• Establece los codigos de servicios aprobados para la facturacion.

P.O. Box 364988 SAN JUAN, P.R. 009364988

PH: 087) 200-3300 - FAX: 087) 200-3251 WWW.MOUNAHEALTHCARE.COM

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Le lncluimos copia de la polftica y documento para la certificaci6n del servicio, para su revision.

Recuerde que tambien puede acceder nuestro manual de proveedores en el portal de MHPR en: http://www.molinahealthcare.com/providers

Para mas informaci6n puede comunicarse con nuestro Centro de llamadas al Proveedor al (888) 558-5501 de lunes a viernes de 7:00am a 7:00pm. Personas audio impedidas pueden comunicarse al TIY(787) 522-8281.

Edna Marfn. MA Dr. gustf n Fernandez VP Providers Network VP- Clinical Operations Molina HealthCare Puerto Rico Molina HealthCare Puerto Rico

Anejos

P.O. Box 364988 SAN JUAN, P.R. 009364988

PH: (787) 200-3300 - FAX: (787) 200-3251 WWW.MOUNAHEALTHCARE.COM

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HEALTHCARE

CERTIFICADO DE NECESIDAD MEDI CAPARA TRANSPORTE NO EMERGENTE Fax Number: (855) 378-3641

Nombre del Afiliado: ____________________Fecha de Nacimiento: __/__/__ Edad:

Numero de Ariliado: ____________Telefono: _____Diagnostico ICD-10: ___________

Fecha de Servicio: Desde ___/___/___ Basta ___/___/___ Hora del Servicio: ____

D Total de Ida ____ D Total de Vuelta Total de servicios ____

Raz6n de transporte LJ Tratamiento de Dialisis LJ Traslado a Institucion Hospitalaria de mayor nivel de cuidado LJ Alta Hospital o Skill Nursing Facility D Servicio fuera del hogar Justificaci6n

Condicion o situacion actual del afiliado (Marque todos los que apliquen) D Ningun recurso de Transporte Disponible (personal, familiar, custodio, vecino o municipio) D Confinado a la Cama D Obesidad Morbida BMI 2:: 50 D Dependiente de Oxigeno D Ventilador mecanico D Fallo Renal en Estadio Final en Hemodialisis D Silla de ruedas D Remplazo de Cadera (flu post operatorio) D Legalmente Ciego D Otro:

-Nivel de Servicio

D Automovil AO110, AO 100 D Guagua con rampa A0130 D Ambulacia basica A0428 D Ambulacia avanzada A0426

Origen D (D) Centro de Diagnostico y/o Tratamento D (E) Hagar Custodio D (G)Dialisis en Hospital D (H) Hospital 0 (J) Dialisis en Centro fuera de Hospital D (N) Skill Nursing Facility D (P) Oficina medica D (R) Residencia Direccion:

Destino

D (D)Centro de Diagnostico y/o Tratamento D (E) Hagar Custodio D (G) Dialisis en Hospital D (H) Hospital D (J) Dialisis en Centro fuera de Hospital D (N) Skill Nursing Facility D (P) Oficina medica D (R) Residencia

Direccion:

Certificaci6n del medico que solicita Nombre y especialidad:

NPI: ITelefono: IFax:

CERTIFICO que el servicio solicitado es medicamente necesario de acuerdo al diagnostico y condicion medica y entiendo que no existe otra forma de transporte no emergente disponible para el bienestar del afiliado durante este periodo.

Fecha: Firma del Medico: Licencia:

Certificacion del Grupo Medico Primario

Nombre y Titulo

GMP: ITelefono: j Fax:

CERTIFICO que el servicio solicitado es medicamente necesario de acuerdo al diagnostico y condicion medica y entiendo que no existe otra forma de transporte no emergente disponible para el bienestar del afiliado durante este periodo.

Fecha: Firma del representamte del GMP: Titulo/Puesto:

2016 Non Emergent Transportation Certification Form 12012016 Rev. 11/08/2017

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Policy Health Plan: Molina Healthcare ofPuerto Rico

Approver Name: Dr. Agustin Fernandez-Cabrero Title: VP C · · al O ations Signaturc~:::l!Dli Approval e: Enter date here

,~ t8/'ll1r

Policy No. MHPR-HCS-CAM-372 Policy Title: Non- Emergency Medical Transportation Pre Authorization Process Department Name: Clinical Operations

Effective Date: 11/8/17 IfRequired: Approver Name: Enter text here Title: Enter text here Signature: Approval Date: Enter date here

Reviewed and Revised Date: 12/05/17 Review Onl Date: Supersedes and replaces: MHPR-HCS­CAM-372 - Medical Transportadon Services. MHPR-MA-BH-022 - BHNon­Emergency Transportadon

Enter text here

Line of Business: (Please click all that apply)

D All 181 Medicaid

D Medicare-Medicaid Programs (Duals) D Health Insurance Marketplace

D Medicare D Other:

References (s): ASES - "Exclusions from Basic Coverage -Travel expenses, even when ordered by the Primary Care Physician" (secdon 7.5.2.1.14) "Behavioral Health Services- Escort/professional assistance and ambulance services when needed (7.5.11.1.9) Departments identified in the policy: Healthcare Services - Medical Affairs - Behavioral Health - Providers Oversight Committee: NIA

I. PURPOSE Non-emergency medical transportation (NEMT) is by contract a non-covered service. The purpose of this policy is to outline the exception process for responding on a case by case to prior authorization requests for non-emergent medical transportation for members. Refer to the Member's Benefit Plan under the GHP Contract approved by ASES, for the scope of coverage limitations and exclusions. Please refer to contract: see "Exclusions from Basic Coverage ­Travel expenses, even when ordered by the Primary Care Physician" (section 7.5.2.1.14)

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Il. POLICY Non-emergency medical transportation refers to transportation by ambulance, car or van when the member has no other transportation resources or when medical conditions require medical transportation services but do not require emergency services. It is not a covered benefit under the Molina Healthcare ofPuerto Rico (MHPR) Medicaid Plan. Prior authorization will be required for a non-emergent medical transportation from any point to point. For cases with no other transportation resources, only members certified by nephrologist with the diagnosis of End Stage Renal Disease (ESRD) on hemodialysis, with special coverage certification and evidence of social needs will be considered. Approval will be only for transportation to or from dialysis center. Request must come as a written medical order from the attending nephrologist and the complete pre authorization form in order to be considered. The evidence of social need must be from the nephrologist, hospital discharge planning staff and/or dialysis social worker. Social necessity for transportation must be confirmed by primary care physician o PMG's designee such as case manager or social worker. This service is limited for the member and not for the companion except for members under 21 years old and legally blind members. Recertification will be required for subsequent services.

Other medical conditions that are considered to require medical transportation services are bed confinement, mechanical ventilator dependency, and morbid obesity with BMI >50. Approval will be only to receive services that cannot be received at home.

Requests for non-emergent transportation from hospital to hospital will be considered as per hospital contract with MHPR and approved only after consultation with HCS Supervisor.

NEMT will be also considered for members enrolled in a behavioral health case management program for members with no other transportation resources certified by the MHPR behavioral health case manager and evidence of three (3) or more mental health hospital admissions or three (3) or more visits to mental health stabilization units in the previous 6 months. Approval will be only for transportation to or from a mental health provider facility. Request must come from the behavioral health case managers with the pre authorization form in order to be considered. An escort/companion will be approved as needed.

The Care Review Clinician (CRC) staff is responsible for the review and determination ofthe requests. For all cases, the level ofNEMT service that will be considered for approval and the service provider will be the most cost effective that meets the member's medical conditions. Reconsiderations will be determined by a medical director.

ID. DEFINITIONS • Non-Emergency Medical Transportation ("NEMT"): Transportation by ambulance,

car or van for a ride, provided so that an Enrollee with no other transportation resources can receive when medical conditions require medical transportation services but do not require emergency services or equipment during transport. NEMT does not include transportation provided on an emergency basis, such as trips to the emergency room in life threatening situations.

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• Bed confmed: is defined as the inability to get up from bed without assistance, the inability to ambulate and the inability to sit in a chair, including a wheelchair. All three components must be met in order for the patient to meet the requirements ofthe definition of ''bed confined". Bed confined is not synonymous with bed rest or non­ambulatory.

• Mechanical ventilator: is a machine that supports breathing. The ventilator helps get oxygen into the lungs and removes carbon dioxide.

• Morbid Obesity: diagnosis provided by a body mass index ( defined by the ratio of an individual's height to his or her weight)of 40 or more

• Legally Blind: A person with a visual acuity of 20/200 in better-seeing eye with conventional correction or a visual field ( total area an individual can see without moving eyes from side to side) of20 degrees or less in better-seeing eye.

• Level of care: The intensity ofmedical care being provided by the physician or health care facility.

• Secondary: medical care available in the community hospital; secondary care centers are equipped to provide all but the most specialized ofcare, surgery and diagnostic modalities.

• Tertiary: highly specialized medical care that consists in subspecialty expertise in surgery, internal medicine, diagnostic and/or therapeutic modalities.

• AOlOO Nonemergency transportation; taxi: These codes provide for reporting nonemergency transportation and related ancillary services. Different types ofvehicles used and/or the areas traveled, as well as additional fees are specified in these codes. This range reports nonemergency transport services such as a vehicle provided by a volunteer or family member; wheelchair van, taxi, bus, or air transport (private or commercial); mountainous area transport, or transportation outside the state. Examples ofancillary services include parking ,fees and tolls, lodging or meals for the recipient or for the escort, and per mile transportation ofa caseworker or social worker.

• AOllO Nonemergency transportation and bus, intra- or interstate carrier: These codes provide for reporting nonemergency transportation and related ancillary services. Different types ofvehicles used and/or the areas traveled, as well as additional fees are specified in these codes. This range reports nonemergency transport services such as a vehicle provided by a volunteer or family member; wheelchair van, taxi, bus, or air transport (private or commercial); mountainous area transport, or transportation outside the state. Examples ofancillary services include parking fees and tolls, lodging or meals for the recipient or for the escort, and per mile transportation ofa caseworker or social worker.

• A0130 Nonemergency transportation: wheelchair van: These codes provide for reporting nonemergency transportation and related ancillary services. Different types ofvehicles used and/or the areas traveled, as well as additional fees are specified in these codes. This range reports nonemergency transport services such as a vehicle provided by a volunteer or family member; wheelchair van, taxi, bus, or air transport (private or commercial); mountainous area transport, or transportation outside the state. Examples of ancillary services include parking fees and tolls, lodging or meals for the recipient or for the escort, and per mile transportation ofa caseworker or social worker.

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• A0428 Ambulance service, basic life support, nonemerge~cy transport, (BLS): Basic life support, non-emergency transport (BLS) is transportation by ground ambulance vehicle and the provision ofmedically necessary supplies and services, including BLS ambulance services as defined by state laws. The ambulance must be staffed by an individual who is qualified in accordance with state and local laws as an emergency medical technician-basic (EMT-basic). These laws may vary from state to state or within a state. For example, only in some jurisdictions is an EMT-basic permitted to operate limited equipment on board the vehicle, assist more qualified personnel in performing assessments and interventions, and establish a peripheral intravenous (iV) line.

• A0426 Ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1): Advanced life support, non-emergency transport, level 1 (ALS 1) is the transportation by ground ambulance vehicle and the provision ofmedically necessary supplies and services. Report these codes for advanced life support, emergency ambulance transport, level 1 (ALS I-emergency), which includes the provision ofan ALS assessment or at least one ALS intervention. Advanced life support intervention means a procedure that is in accordance with state and local laws, beyond the scope of authority ofan emergency medical technician-basic (EMT-basic).

• A0425 Ground Mileage: Mileage and reimbursement rates are generally defined by and under the jurisdiction ofstate statutes.

• A0200 Nonemergency transportation ancillary: lodging, escort .Nonemergency transport services such as a vehicle provided by a volunteer or family member; wheelchair van, taxi, bus, or air transport (private or commercial); mountainous area transport, or transportation outside the state.

General Criteria I. The pre authorization request for non-emergent transportation service for

physical health cases must meet all criteria mentioned below in order to be considered

i. Transportation Certification Form completed in all parts with treating physician and Primary Medical Group (PMG) representative signatures. Treating Physician must be

• Primary Care Physician for members with morbid obesity BMI >50, bed confined, and ventilator dependent)

• Nephrologist for members with end stage renal disease • Admitting Physician for members pending for discharge

ii. This form certifies the medical and/or social need that justifies the service and/or the level of the service requested. The treating physician, primary care physician, hospital discharge planning, PMG's case manager and/ or social worker must provide evidence that other transportation alternatives are not available for the requested period oftime due to lack of social support, private or public transportation or community resources. Exception to these criteria will be discharge planning cases that might not have (PMG) representative signature.

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II. The pre authorization request for non-emergent transportation service for behavioral health cases must meet all criteria mentioned below in order to be considered

• Transportation Certification Form completed by behavioral case manager. Last sections pertaining to physicians and PMG do not apply.

• Brief summary from the behavioral case manager with case specifics providing evidence that other transportation alternatives are not available for the requested period of time due to lack ofsocial support, private or public transportation or community resources.

• Evidence ofthree (3) or more mental health hospital admissions and/or three (3) or more visits to mental health stabilization units in the last 6 months.

• Evidence that member is committed with treatment from social worker, psychologist and/or psychiatrist recent evaluation

• Behavioral Health Case Management Manager approval of total of trips one way and need for escort

III. The service level requested must meet the following criteria. a. AOUO- taxi

i. Member must be ESRD receiving ambulatory hemodialysis and under special coverage registry

ii. Lack of transportation alternatives for the period requested iii. Lack ofsocial support for driving member back home after the

dialysis for members with access to a vehicle (for the period requested).

iv. Pick up place and drop offplace are either residence or residential address or hemodialysis certified center.

v. Maximum of80 trips one way in a 3 month period 1. 40 trips from residence to hemodialysis certified center 2. 40 trips from hemodialysis certified center to residence

vi. Members with ESRD pending for AV fistula insertion with lack of transportation alternatives will be considered also for these level of service only for the procedure (AV insertion)

I. Maximum of2 trips (to and from procedure)

b. AOlOO- taxi i. Member must be admitted to a hospital or skill nursing facility.

pending for discharge home ii. Lack of transportation alternatives to be discharged

iii. Pick up place is the hospital or skill nursing facility and drop off place is either residence or residential address.

iv. Maximum of 1 trip one way

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v. Member must be active in a behavioral health case management program and request has MHPR behavioral health case management Manager approval

vi. Pick up place and drop offplace are either residence or residential address or mental health facility

vii. Maximum of 6 trips one way in a 3 month period

c. A0130- wheelchair van i. Member must be wheelchair bound (unable to walk through injury or

illness and relying on a wheelchair to move ,around). ii. Ifmember is ESRD must meet also criteria for AO110

iii. Ifmember is pending for discharge home must meet also criteria for AOlOO

iv. Lack oftransportation alternatives to receive a service that can't be received at home

v. Pick up place and drop offplace are either residence or residential address or treatment center,

vi. Maximum of2 trips one way ( except for ESRD, discharge planning) d. A0428-ambulance BLS

i. Member must be bed confined (must meet the three components: inability to get up from bed without assistance, inability to ambulate and inability to sit in a chair, including a wheelchair).

1. Ifmember is ESRD must meet also criteria for AO110 2. Ifmember is pending for discharge home must meet also

criteria for AOl 00 3. Maximum of2 trips one way ( except for ESRD, discharge

planning) 4. Pick up place and drop offplace are either residence or

residential address, or treatment center. 5. Service that can't be received at home

ii. Members that require non-emergent transportation from hospital to hospital ifdischarged to be admitted in a higher level ofservice hospital

1. Maximum of 1 trip one way iii. Members that require non-emergent transportation from hospital to

skill nursing facility 1. Maximum of 1 trip one way

e. A0426-ambulance ALS i. Member must be mechanical ventilator dependent

1. Ifmember is ESRD must meet also criteria for AO110 2. Ifmember is pending for discharge home must meet also

criteria for AOlOO 3. Maximum of2 trips one way (except for ESRD, discharge

planning)

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4. Pick up place and drop offplace are either residence or residential address, or treatment center.

5. Service that can't be received at home ii. Members that require non-emergent transportation from hospital to

hospital ifdischarged to be admitted in a higher level ofservice hospital

1. Maximum of 1 trip one way iii. Members that require non-emergent transportation from hospital to

skill nursing facility 1. Maximum of 1 trip one way

f. A0425 ground mileage i. Must meet criteria for one ofthe following codes Code

AOl lO,AOlOO, A0130, A0426, or A0428 g. A0200

i. Member must be active in behavioral health care management program, legally blind or less than 21 years ofage

ii. Must meet criteria for one of the following codes Code AOl 10, AOlOO, A0130, A0426, or A0428

SLT Signature (ifexpedited):____________ Date:-----­

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