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    OpenPayerPolicy UpdatesAdministrative/Operational PolicyLouisiana Medicaid NEAT Prior Auth | OpenPayer
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    CurrentLouisiana Department of HealthPolicy 15-20

    Non-Emergency Ambulance Transportation (NEAT) for Nursing Home Residents

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    This bulletin governs medical necessity, prior authorization, scheduling, payment, and billing responsibilities for non-emergency ambulance transportation for Medicaid recipients residing in nursing facilities. It distinguishes responsibilities among Healthy Louisiana managed care plans, Legacy/Fee-for-Service Medicaid, Medicare, nursing facilities, and ambulance providers.

    Policy Summary
    PayerLouisiana Department of Health
    PolicyNon-Emergency Ambulance Transportation (NEAT) for Nursing Home Residents
    Policy CodePolicy 15-20
    Change TypeRevised informational bulletin
    Effective DateDecember 1, 2015
    Next Review DateN/A
    Key ActionFor standard NEAT services, nursing facilities must request prior authorization and schedule transportation at least 48 hours before the trip.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    5Healthy Louisiana managed care plans addressed
    48 hoursStandard notice and determination timeframe
    24 hoursUrgent determination timeframe
    1 hour

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    Emergency-department determination timeframe
    30 daysTransition payment protection
    3Bed-confined definition elements

    Coverage and Medical Necessity

    LDH Medical-Necessity Standard

    LDH medical necessity for non-emergency ambulance transportation (NEAT) is established when the beneficiary's condition makes every other transportation method contraindicated. No ambulance payment is allowed when another transportation method could be used without endangering the beneficiary's health.

    ONE of the following establishes medical necessity

    • The beneficiary's condition is such that use of any other method of transportation is contraindicated.

    • The beneficiary is bed-confined before the trip and is expected to remain bed-confined after the trip.

      • Unable to get up from a bed without assistance.
      • Unable to ambulate.
      • Unable to sit in a chair or wheelchair.

    Payer and Transportation-Type Coverage Rules

    Nursing facilities must arrange all medically necessary transportation for Medicaid recipients residing in the facility. Authorization and payment responsibility depends on the transportation type and whether Medicaid or Medicare is primary.

    Apply the coverage and payment rule that matches the beneficiary and transportation type.

    • ALL of the following

      • The transportation is non-emergency and non-ambulance.
      • The resident is a Medicaid recipient residing in a nursing facility.

    • ALL of the following

      • The transportation is non-emergency ambulance transportation (NEAT).
      • The resident is enrolled in Healthy Louisiana, including a Medicaid-only resident or a Medicare dual eligible without Medicare Part B.

    Medicare-Statutorily Non-Covered NEAT Categories

    For Medicare dual eligibles with Medicare Part B and Medicaid as secondary payer, Healthy Louisiana covers medically necessary NEAT services that Medicare is statutorily prohibited from covering.

    The service qualifies for Healthy Louisiana coverage when ALL of the following apply.

    • The beneficiary is a Medicare dual eligible with Medicare Part B coverage and Medicaid as secondary payer.
    • The NEAT service is medically necessary under the LDH ambulance standard.

    • The service is one of the following Medicare-statutorily non-covered NEAT categories.

      • Transportation to or from a physician's office or clinic.
      • Transportation to or from a diagnostic center.

    Authorization Timeframes and Transition Rules

    Standard request advance notice
    Advance noticeAt least 48 hours before the trip
    Applies toStandard non-emergency ambulance transportation (NEAT) services
    Late regular requestsManaged care plans may deny regular NEAT requests submitted less than 48 hours in advance
    Standard prior-authorization determination
    Request typeStandard NEAT prior-authorization request
    Determination timeframeWithin 48 hours of the request
    Responsible entity

    Nursing Facility and Ambulance Provider Responsibilities

    Note

    Arrange Transportation Through the Responsible Payer

    Nursing facilities must arrange all medically necessary transportation for Medicaid recipients residing in the facility. Authorization and payment depend on whether the service is non-emergency, ambulance, or emergency transportation.

    • Non-emergency, non-ambulance transportation: nursing home responsibility.
    • Non-emergency ambulance transportation: Managed Care Plan responsibility.
    • Emergency ambulance transportation: Legacy Medicaid/Molina responsibility.
    Prior Authorization

    Submit Standard NEAT Requests 48 Hours in Advance

    For standard NEAT services, the nursing facility must request prior authorization and schedule the service at least 48 hours before the trip. Managed Care Plans must make standard determinations within 48 hours and may deny regular requests submitted less than 48 hours in advance.

    • Submit the request at least 48 hours before the scheduled trip.

    Key NEAT Definitions

    Medical necessity for ambulance service
    When ambulance service is medically necessaryThe patient's condition makes use of any other method of transportation contraindicated
    Alternative transportationIf another transportation method could be used without endangering the individual's health, ambulance payment may not be made
    LDH standardMedical necessity is met when the beneficiary is bed-confined before the trip and expected to remain bed-confined after the trip
    Bed-confined
    Getting up from bedThe beneficiary is unable to get up from bed without assistance
    AmbulationThe beneficiary is unable to ambulate
    Policy Summary
    PayerLouisiana Department of Health
    PolicyNon-Emergency Ambulance Transportation (NEAT) for Nursing Home Residents
    Policy CodePolicy 15-20
    Change TypeRevised informational bulletin
    Effective DateDecember 1, 2015
    Next Review DateN/A
    Key ActionFor standard NEAT services, nursing facilities must request prior authorization and schedule transportation at least 48 hours before the trip.
    SourceLink
    On This Page
    Coverage and Medical NecessityAuthorization Timeframes and Transition RulesNursing Facility and Ambulance Provider ResponsibilitiesKey NEAT Definitions

  1. ALL of the following

    • The transportation is emergency ambulance transportation.
    • The resident is a Medicaid recipient residing in a nursing facility.

  2. ALL of the following

    • The resident is a Medicare dual eligible with Medicare Part B and Medicaid is secondary.
    • The NEAT service is covered by Medicare.

  3. ALL of the following

    • The resident is a Medicare dual eligible with Medicare Part B and Medicaid is secondary.
    • The medically necessary NEAT service is statutorily non-covered by Medicare.
    4. Transportation to or from a non-hospital-based clinic.
  4. Residence-to-residence transportation.
  5. Nursing-home-to-nursing-home transportation.
  6. Residence-to-nursing-home transportation, unless the beneficiary is admitted to a skilled bed.
  7. Nursing-home-to-residence transportation, unless the beneficiary is being discharged from a skilled bed.
    8. Managed care plans
    Urgent request determination
    Request typeUrgent NEAT request when the need was unknown and could not have been anticipated 48 hours in advance
    Determination timeframeWithin 24 hours of the request
    Earlier schedulingManaged care plans will make reasonable efforts to schedule approved urgent trips sooner when warranted and appropriate transportation is available
    Emergency-department discharge determination
    ServiceMedically necessary NEAT transportation after emergency-department release and stabilization
    Determination timeframeWithin one hour of the request for approval
    Failure to respondThe managed care plan is responsible for payment if it does not respond within one hour or cannot be contacted for approval
    Transition grace period
    Effective dateDecember 1, 2015
    Transition-period duration30 days
    Payment protectionManaged care organizations may not deny payment solely for lack of prior authorization or because the provider is out of network during the grace period
  8. The plan may deny a regular NEAT request submitted less than 48 hours in advance.
    9. Prior Authorization

    Use the Urgent Pathway for Unforeseeable Needs

    Use the urgent NEAT pathway when the transportation need was unknown and could not reasonably have been anticipated at least 48 hours in advance. The Managed Care Plan must determine authorization within 24 hours and will make reasonable efforts to schedule an approved trip sooner when appropriate transportation is available.

    • Urgent requests are for unforeseeable needs that could not have been anticipated 48 hours in advance.
    • The plan may deny trips requested less than 24 hours in advance.
    • Request urgent handling and explain the circumstances supporting the urgent need.
    Prior Authorization

    Escalate Emergency-Department Discharge Transportation

    For medically necessary NEAT transportation following emergency-department discharge after stabilization, request plan authorization as early as possible. The plan must decide within one hour; if it does not respond or cannot be contacted, the plan is responsible for payment of the post-stabilization NEAT service.

    • The plan may require authorization to determine whether ambulance transport is medically necessary.
    • In an inpatient hospitalization, begin preparing for the return trip and submit supporting documentation as soon as possible.

    Unsupported block type: prior_auth

    Unsupported block type: billing_rule

    Unsupported block type: prior_auth

    Unsupported block type: documentation

    Note

    Schedule the Approved Trip Through the Plan-Designated Process

    After approval, schedule the trip using the process designated for the resident's plan. Do not assume that plan approval alone completes scheduling: some plans notify the nursing facility, while others or their transportation intermediaries arrange the ride directly with the ambulance provider.

    • Aetna: the health plan sends approval to the nursing home; the nursing home schedules directly with the ambulance provider.
    • Amerigroup: Southeastrans notifies the requestor and sets up the trip with the ambulance provider.
    • AmeriHealth Caritas: Logisticare notifies the requestor and sets up the trip with the ambulance provider.
    • Louisiana Healthcare Connections: LHC sets up the trip and supplies the ambulance provider with the prior-authorization number.
    • UnitedHealthcare Community Plan: Logisticare notifies the requestor and sets up the trip with the ambulance provider.

    Unsupported block type: billing_rule

    Denial Risk

    Follow the Plan-Specific Denial and Reconsideration Process

    When a trip is denied, follow the applicable plan's notification and reconsideration or appeal process. Obtain the denial information and letter when issued, document the reason for denial, and submit any dispute through the plan or intermediary within the applicable deadline.

    • Aetna: denial by phone and letter; providers may file a payment dispute within 90 days, with processing within 30 days.
    • Amerigroup: urgent reconsideration through 1-877-440-4065, extension 35792, within one business day; standard reconsideration through 1-800-600-4441 or the specified appeal form, generally within 30 days.
    • AmeriHealth Caritas: no denial process applies when prior authorization is not required.
    • Louisiana Healthcare Connections: submit reconsideration verbally at 1-866-595-8133 or by fax at 1-877-401-8170; standard appeals are resolved within 30 days and expedited appeals within 72 hours.
    • UnitedHealthcare Community Plan: request reconsideration through Logisticare at 1-866-886-4081 and request a telephone conference with UHC clinical staff; determination is within one business day.

    Unsupported block type: denial_risk

    Sitting position
    The beneficiary is unable to sit in a chair or wheelchair
    Bed rest
    Bed-confined statusThe beneficiary must be bed-confined before the trip and expected to remain bed-confined after the trip
    Bed restBed-confined is not synonymous with bed rest
    Non-ambulatory statusBed-confined is not synonymous with merely being non-ambulatory
    Standard NEAT service
    Trip typeA planned, non-emergency ambulance trip
    Facility responsibilityThe nursing facility is expected to request authorization and schedule the trip
    Advance schedulingAuthorization and scheduling must be requested at least 48 hours in advance
    Urgent NEAT service
    Trip typeA non-emergency ambulance trip
    Unforeseeable needThe need was unknown and could not have been anticipated 48 hours in advance
    Authorization pathwayThe request follows the urgent NEAT prior-authorization pathway