CurrentArizona Health Care Cost Containment SystemPolicy 310-BB

Transportation

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Coverage and provider requirements for emergency, medically necessary non-emergency, maternal, newborn, and ET3 transportation; Federal Emergency Services populations are excluded.

Policy Summary

PayerArizona Health Care Cost Containment System

PolicyTransportation

Policy CodePolicy 310-BB

Change TypeNo material change

Effective DateJul 1, 2022

Next Review DateN/A

Key ActionObtain Contractor authorization for applicable compounding or specialty pharmacy trips exceeding 15 miles one way in Maricopa or Pima Counties.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Transportation service categories covered

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CurrentArizona Health Care Cost Containment SystemPolicy 310-BB

Transportation

Customize your policy alerts

Sign up for Arizona Health Care Cost Containment System Policy 310-BB alerts

Get alerted when Policy 310-BB changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Coverage and provider requirements for emergency, medically necessary non-emergency, maternal, newborn, and ET3 transportation; Federal Emergency Services populations are excluded.

Policy Summary

PayerArizona Health Care Cost Containment System

PolicyTransportation

Policy CodePolicy 310-BB

Change TypeNo material change

Effective DateJul 1, 2022

Next Review DateN/A

Key ActionObtain Contractor authorization for applicable compounding or specialty pharmacy trips exceeding 15 miles one way in Maricopa or Pima Counties.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Transportation service categories covered

Pharmacy-trip NEMT limit

6 yearsTNC record-retention period

Nearest appropriate facilityEmergency transport destination

NoneEmergency transport authorization

Covered Transportation Services

Covered transportation categories

AHCCCS covers transportation within specified limitations when one of the following covered service categories applies:

Covered transportation service

Emergency transportation: Specially staffed and equipped ambulance transportation is required to safely manage an emergent medical condition.
Medically necessary non-emergency transportation: Transportation is required to access a covered physical or behavioral health service under the policy's non-emergency transportation criteria.
Maternal or newborn transportation: Transportation is furnished through the Maternal Transport Program or Newborn Intensive Care Program.
Emergency Triage, Treat, and Transport transportation: Transportation or treatment is provided under the Emergency Triage, Treat, and Transport program.

Emergency transportation

Emergency transportation is covered when all of the following requirements are met:

ALL of the following

Emergency medical necessity: The member is in an emergent situation in which specially staffed and equipped ambulance transportation is required to safely manage the medical condition.
Appropriateness is assessed using whether a prudent layperson in a similar situation would have requested emergency services, based on the member's condition at the time of transport.
Appropriate destination: Transport is to the nearest appropriate facility capable of meeting the member's physical or behavioral health needs.
A Contractor-preferred hospital may be used without penalizing transport to the nearest appropriate facility.

Air ambulance

Air ambulance services are covered when both initiation and medical-necessity requirements are met:

ALL of the following

Authorized initiation: The air ambulance transport is initiated at the request of an emergency response unit, law enforcement official, clinic or hospital medical staff member, physician, or practitioner.
Air transport necessity
- Ground inaccessible: The pickup point is inaccessible by ground ambulance.
- Distance and ground insufficiency: The pickup point is a great distance from the nearest appropriate facility and ground ambulance will not suffice.
- Immediate intervention:

ET3 alternative destination or treatment on scene

ET3 services are covered when all provider and emergency-response requirements are met and one of the following ET3 services is provided:

ALL of the following

Provider and response requirements: The provider is an AHCCCS-registered Emergency Transportation Provider with an ADHS Certificate of Necessity, or a tribal provider with an AHCCCS attestation of CON equivalency, responding to a 9-1-1, fire, police, or locally established emergency call.
ET3 service
- Alternative Destination Partner transport: Field evaluation determines the service is medically necessary but not emergent; the alternative destination better matches the member's level of care than an emergency department; the destination is within or near the provider's service area; the provider has a pre-established arrangement; and the provider knows the destination's hours, clinical staff, services, and return-transport capability.
- Treatment on scene:

Medically necessary non-emergency transportation

Medically necessary non-emergency transportation is covered when all applicable criteria are met:

ALL of the following

General NEMT eligibility: The destination service is a covered AHCCCS physical or behavioral health service; the member cannot provide, secure, or pay for transportation; free transportation is unavailable; and transportation is to and from the nearest appropriate AHCCCS-registered provider.
Medicare Part D prescriptions: The member cannot provide, secure, or pay for transportation and free transportation is unavailable.
Transportation may be provided to obtain Medicare Part D-covered prescriptions.
Non-emergency ambulance: Other transportation methods are contraindicated and the member's medical condition requires medical treatment by qualified ambulance staff.

Public transportation option

Public transportation may be offered when available, provided that consideration of public transportation does not restrict access to other transportation services:

Appropriate public transportation consideration: The Contractor considers the member's distance from stops, provider distance from stops, schedule compatibility, ability to travel alone, and preference when offering public transportation.

Public transportation may be offered for travel to and from AHCCCS-approved services when available in the service area.

Maternal and newborn transportation

Specialized maternal and newborn transportation is covered when the designated program requirement is met:

Maternal Transport Program or Newborn Intensive Care Program transport: The high-risk transport team is dispatched after consultation with the Maternal Transport Program perinatologist or Newborn Intensive Care Program neonatologist.

Only contracted Maternal Transport Program or Newborn Intensive Care Program providers may provide air transport.

Federal Emergency Services (FES) populations are excluded from this transportation policy. Providers should refer to AMPM Chapter 1100 for FES requirements.

Emergency transportation is not covered when field evaluation determines that the member's condition is not medically necessary for transport. Emergency status is based on the member's medical condition at the time of transport and is assessed using the prudent-layperson standard.

For Contractor-enrolled members residing in Maricopa or Pima County, pharmacy NEMT trips are generally limited to 15 miles one way, measured from pickup to drop-off. Trips exceeding 15 miles to a compounding or specialty pharmacy require Contractor authorization to be covered. Trips to an MSIC or IHS/638 facility are exempt from this mileage limitation.

Transportation is not medically necessary when the member's condition at the time of transport does not warrant emergency or medically necessary transportation under the policy. Emergency transportation determinations are based on the member's condition at the time of transport.

Non-emergency ambulance transportation is not medically necessary when other transportation methods are not contraindicated or when the member's condition does not require medical treatment by qualified ambulance staff. Documentation must support both the need for ambulance-level care and the medical condition requiring it.

Authorization, Documentation, and Denial Risks

Prior Authorization

Authorization for Pharmacy Trips Over 15 Miles

Trips to compounding or specialty pharmacies that exceed the 15-mile one-way limit require authorization from the Contractor to be covered for applicable Contractor-enrolled members in Maricopa and Pima Counties.

Mileage is calculated one way from the pickup location to the pharmacy.
NEMT trips to an MSIC or IHS/638 facility are exempt from the 15-mile limitation.

Prior Authorization

Possible NEMT Ambulance Authorization Waiver

AHCCCS and the Contractor may waive prior-authorization and notification requirements for medically necessary non-emergency ambulance transportation. Waived claims remain subject to medical-necessity review based on the member’s condition at the time of transport.

Do not treat a waiver as an exemption from medical-necessity requirements.
Confirm applicable AHCCCS or Contractor waiver instructions before billing.

Transportation Coverage Framework

Transportation coverage is based on the member's medical condition and the level of care required at the time of transport. Emergency transportation supports immediate management of serious physical or behavioral health conditions, while medically necessary non-emergency transportation supports access to covered services when the member cannot independently obtain transportation.

Key Transportation Terms

Alternative Destination Partner

DefinitionAn AHCCCS-registered provider that may receive a member under the ET3 program.

Eligible provider exampleFederally Qualified Health Center or Rural Health Clinic (FQHC/RHC).

Other eligible provider typesPrimary care doctor, specialist, behavioral health center, or urgent care clinic.

Emergency Triage, Treat, and Transport (ET3)

Program purposeA program providing greater flexibility for AHCCCS-registered emergency transportation providers to address a member’s health care needs following a 9-1-1 call.

Alternative destinationThe emergency transportation provider may transport the member to an Alternative Destination Partner.

Policy Summary

PayerArizona Health Care Cost Containment System

PolicyTransportation

Policy CodePolicy 310-BB

Change TypeNo material change

Effective DateJul 1, 2022

Next Review DateN/A

Key ActionObtain Contractor authorization for applicable compounding or specialty pharmacy trips exceeding 15 miles one way in Maricopa or Pima Counties.

SourceLink

On This Page

The member's condition requires immediate intervention from emergency personnel or providers with appropriate facilities.

Field evaluation determines treatment is medically necessary but not emergent, and treatment is within the provider's scope of practice and medical direction.

Treatment may be delivered by telehealth when medically indicated and performed under AMPM Policy 320-I.

Non-ambulance air or equine NEMT: The service is used exclusively to connect the member to ground-accessible transportation; the pickup or return point is inaccessible by ground transportation; and ground access is unavailable because of the nature and extent of the surrounding Grand Canyon terrain.

Note

Program-Specific Authorization Guidance

Use the applicable program guidance when determining authorization requirements for transportation services and billing or documentation procedures.

For ALTCS authorization requirements, refer to AMPM Chapter 1200.
For non-ALTCS FFS members, refer to AMPM Chapter 800 for complete prior-authorization requirements.
For billing information, refer to the AHCCCS Fee-For-Service Provider Manual or AHCCCS IHS/Tribal Provider Billing Manual.
For reimbursement of non-contracted ground ambulance providers, refer to ACOM Policy 205.

Documentation Required

Emergency Transport Claim Support

Prior authorization and notification are not required for reimbursement of emergency transportation, but FFS providers must submit claim documentation that justifies the service.

Document the member’s condition and the medical need for specially staffed and equipped ambulance transportation.
Emergency transportation includes covered basic life support, advanced life support, and air ambulance services when supported by the member’s needs.

Unsupported block type: documentation

Unsupported block type: info

Unsupported block type: documentation

Unsupported block type: denial_risk

Unsupported block type: billing_rule

Unsupported block type: denial_risk

Denial Risk

Non-Ambulance Provider Requirements Not Met

Non-ambulance NEMT providers must meet all operational, vehicle, driver, and passenger-safety requirements for the trip to be covered.

The member must not require medical care en route.
Do not exceed manufacturer seating capacity; comply with passenger-restraint laws; use a licensed driver; and maintain insured, good-working-order vehicles.
Transport all passengers inside the vehicle. School-based providers must follow applicable school-based policies.
Non-ambulance air or equine NEMT is covered only for transport to ground-accessible transportation when the pickup or return point is inaccessible by ground because of the surrounding Grand Canyon terrain.

Treatment on sceneThe provider may initiate and facilitate medically necessary covered services at the scene, in person or through telehealth.

Medically Necessary Non-Emergency Transportation

DefinitionTransportation to and from a covered physical or behavioral health service when the member cannot provide, secure, or pay for transportation and free transportation is unavailable.

Covered service limitationThe destination must be a covered AHCCCS physical or behavioral health service.

Provider and destination limitationTransportation is provided to and from the nearest appropriate AHCCCS-registered provider.