CurrentNew Mexico Health Care AuthorityPolicy N/A
Provider responsibilities and requirements for transportation services and lodging (MAD)
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Governs provider responsibilities, eligible providers, covered transportation, lodging, meal and attendant services, prior authorization, utilization review, and reimbursement rules for New Mexico medical assistance (MAD) transportation and related services; applies to providers furnishing services to MAP eligible recipients.
Policy Summary
PayerNew Mexico Health Care Authority
PolicyProvider responsibilities and requirements for transportation services and lodging (MAD)
Policy CodePolicy N/A
Change TypeNo material change
Effective DateJan 1, 2014
Last ReviewJul 1, 2024
Next Review DateN/A
Key ActionObtain prior authorization and required documentation for out-of-state transportation and for lodging/meals when applicable.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
4 hrsthreshold for lodging coverage
8 hrsmeal coverage threshold
15 mimileage included (ambulance)
120 mireferral distance for verification
1 attendantattendant coverage
MAD Transportation and Related Expense Coverage
MAD transportation and related expense coverage criteria
MAD covers transportation and related travel expenses when necessary to secure covered medical or behavioral health services, subject to the conditions and limits below:
ALL of the following
- Provider must be enrolled with MAD and comply with the MAD Provider Participation Agreement (PPA) and applicable rules
Providers must be enrolled before submitting claims and must follow MAD/contractor authorization and UR instructions.
- Covered transport must be for a MAP eligible recipient and for medically or program-covered services
ALL of the following
- Free alternatives must be used when available (volunteers, relatives, NF/residential center transportation).
- Least costly appropriate transportation must be used; private vehicle or public transit must be used before more expensive alternatives when suitable for the recipient's condition.
Covered provider types (one or more)
- Air ambulances certified by NM DOH EMS bureau.
- Ground ambulances certified by NMPRC or appropriate out-of-state licensing body for authorized regions.
- NMPRC-certified non-emergency transportation vendors (taxicab, vans) and certain bus services.
- Transportation network companies with a DOT-issued permit operating in NM under the Transportation Network Company Services Act.
- Long distance common carriers (buses, trains, airplanes) for recipients who must leave their home community.
- Lodging and meal providers when authorization criteria are met.
ALL of the following
Ground ambulance covered when
- An emergency requiring ambulance service is certified by a physician or documented in provider records as meeting emergency medical necessity criteria (emergency defined by acute severe symptoms a prudent layperson would consider requiring immediate attention).
- Scheduled non-emergency ambulance is ordered by a PCP who certifies that other transportation is contraindicated by the recipient's physical or behavioral condition (medical necessity for ambulance).
- Air ambulance covered when an emergency exists and PCP certifies medical necessity; emergency criteria include risk of death, serious jeopardy to health, serious impairment of bodily functions, or serious organ dysfunction.
- Base rate reimbursement for ground and air ambulance includes non-reusable items, oxygen, required professional attendants, detention/standby time, equipment, and mileage for first 15 miles (ground ambulance).
ALL of the following
- Covered when recipient has no primary transportation and cannot access a less costly form of public transportation; subject to non-covered service rules and limitations on additional passenger transports.
- When multiple MAP recipients are picked up at the same location for the same provider appointment, MAD will allow coverage for one recipient (additional passenger transports not covered).
ALL of the following
- Lodging is covered if recipient must travel more than four hours one way and an overnight stay is required for medical necessity or cost considerations.> 4 hours one way
- If medically justified and approved, lodging initially authorized for up to 5 continuous days; re-evaluation required by the fifth day to authorize up to an additional 15 days and every 15 days thereafter for extensions.
- Meals are covered if recipient must leave their home community for eight hours or more to receive medical or behavioral health services.>= 8 hours
- Out-of-state lodging and meal authorizations can be granted up to 30 days with re-evaluation every 30 days; out-of-state transportation and related expenses require prior authorization and documentation verifying service is not available in New Mexico.
ALL of the following
- MAD covers transportation, meals and lodging for one attendant when the attendant is medically necessary and certified in writing by the recipient's medical provider, or when the recipient is under 18 years of age; the attendant for a child under 18 should be the parent or legal guardian.
- MAD does not cover transportation or related expenses of children under 18 traveling with an adult recipient for adult appointments (subject to age and additional passenger rules).
- For ongoing need where attestation is unlikely to change, attestation must be renewed every six months unless the recipient is under 18; special rules apply for children 10 and under regarding attendant coverage for non-emergency transport.
ALL of the following
- Out-of-state transportation and related expenses require prior authorization by MAD or its designee and documentation that the out-of-state service is approved and unavailable in New Mexico.
- If a recipient must travel over 120 miles from their home community, the transportation provider must obtain and retain written verification from the referring provider or service provider in billing records that includes recipient identification, the service for which referred, the out-of-community provider name, and justification that care is not available in the home community.> 120 miles
- For continued out-of-community non-emergency transportation, required referral information must be obtained every 12 months.
- Transportation to border cities within 100 miles of the New Mexico border (Mexico excluded) is treated as in-state and follows in-state rules; requests for out-of-state transport must be coordinated through MAD.
ALL of the following
- All MAD services are subject to utilization review (UR) for medical necessity and program compliance; reviews may occur before or after services or payment.
- Certain procedures or services may require prior authorization; prior authorization does not guarantee recipient eligibility—providers must verify eligibility at time services are furnished.
ALL of the following
- Providers must submit claims on CMS-1500 or its successor for transportation, meal, or lodging reimbursement.
- MAD reimburses at the lesser of provider's billed charge (usual and customary or tariff-limited) or the MAD fee schedule/maximum allowed amount; for ground ambulance the base rate includes oxygen, disposable supplies, medications and mileage for the first 15 miles.
ALL of the following
- MAD does not pay to transport recipients to non-covered medical or behavioral health services or to pharmacies (except certain justice-involved recipients released within 7 days of incarceration), and will not pay when other alternatives (e.g., mail delivery) exist.
- Payments for transportation for any non-covered service are subject to retroactive recoupment; providers who fail to notify recipients that a service is not covered may not seek reimbursement from the recipient.
ALL of the following
- Authorization forms for direct payment to long distance common carriers, lodging and meal providers are available through local county ISD offices; transportation providers must retain required documentation in billing records for audits and UR.
- Re-evaluations: lodging re-evaluation by day 5 for extensions; out-of-state lodging and meals re-evaluated every 30 days; continued out-of-community non-emergency transport referrals renewed every 12 months; attendant attestations renewed every 6 months when applicable.
Claim Form and Reimbursement Coding Rules
Claim form requirementmixed
| CMS-1500 | Claim form required for transportation provider reimbursement |
Reimbursement rule
Reimbursement methodPayment is the lesser of the provider's billed charge (usual and customary or tariff-limited) or the MAD fee schedule / MAD maximum allowed amount.
Ground ambulance base rateBase rate (ALS or BLS) includes the equipped service, oxygen, disposable supplies and medications used in transport; base rate reimbursement includes mileage for the first 15 miles.
Scheduled non-emergency transportsAllowable base rate for scheduled non-emergency transport includes reimbursement for oxygen, disposable supplies and medications and mileage for the first 15 miles.
Non-emergency transportation providersReimbursed at the lesser of their approved tariff or the MAD rate; reimbursement limited to MAD one-way trip limits and does not cover portions when recipient not in vehicle.
Claims formTransportation providers must submit claims on the CMS-1500 form or its successor.
Prior Authorization, Documentation, and Out-of-Community Travel
Prior Authorization
Prior authorization required for out-of-state transport; written verification for long-distance travel
Out-of-state transportation and related expenses require prior authorization from MAD or its designee. Authorization is permitted only if the out-of-state medical or behavioral health service itself is approved by MAD or its designated contractor; documentation must be available to justify travel and verify that the treatment is not available in New Mexico. For lodging and meal services by an out-of-state provider, MAD may authorize up to 30 days with re-evaluation prior to expiration and every 30 days thereafter. All MAD services remain subject to utilization review for medical necessity and program compliance; providers must contact HCA or its authorized agents for UR/prior authorization instructions and follow any fee-for-service coordinated services contractor authorization procedures.
- Prior authorization required for out-of-state transportation and related expenses; out-of-state services must be approved by MAD or its designee (8.324.7.14).
- Documentation to justify out-of-state travel and verify lack of in-state treatment availability must be available to the reviewer (8.324.7.14).
- Requests for out-of-state transportation must be coordinated through MAD (8.324.7.14.A).
- Lodging and meal authorization for out-of-state providers may be granted up to 30 days; re-evaluate prior to expiration and every 30 days thereafter (8.324.7.14.B).
- All MAD services are subject to utilization review; certain procedures/services may also require prior authorization and remain subject to UR at any time (8.324.7.15).
- Providers must contact HCA or its authorized agents to request UR/prior authorization instructions and follow contractor-specific authorization procedures when applicable (8.324.7.15).
- For travel over 120 miles from the recipient's home community, the transportation provider must obtain and retain written verification from a MAD referring provider or service provider that includes recipient identification, the service being provided, the out-of-community provider name, and justification that the care is not available in the home community; for continued out-of-community non-emergency transport, this information must be obtained every 12 months (8.324.7.15.B).
Key Definitions
Emergency — definition
Definition (layperson standard)An 'emergency' is a condition with acute symptoms of sufficient severity that a prudent layperson could reasonably expect serious jeopardy or impairment without immediate attention.
Certification/documentationAn emergency requiring ambulance service must be certified by a physician or documented in the provider's records as meeting emergency medical necessity criteria.
ScopeEmergency criteria apply to ground and air ambulance coverage determinations under MAD.
Medical necessity — ambulance services
Medical necessity for ambulanceMedical necessity for ambulance services exists when the recipient's condition contraindicates use of any other transportation method and would endanger the recipient's health if other methods were used.
Provider rolePhysician certification or provider documentation may be required to establish that other transport methods are contraindicated for the recipient's condition.
Related coverage decisionGround and air ambulance coverage is allowed when emergency criteria are met or when a PCP certifies that other transport is contraindicated.
Transportation network company — definition
DefinitionA 'transportation network company' is a corporation, partnership, sole proprietorship or other entity that holds a permit issued pursuant to the Transportation Network Company Services Act and lawfully operates in New Mexico and that uses a digital network to enable prearranged transportation.
Driver relationshipThe transportation network company is not deemed to control, direct or manage the personal vehicles or drivers that connect to its digital network except where agreed by written contract (NM Stat section 65-7-2).
Digital network meaning'Digital network' means an internet-supported application, software, program, website or system that enables prearrangement of transportation between passengers and transportation network company drivers.
Policy Summary
PayerNew Mexico Health Care Authority
PolicyProvider responsibilities and requirements for transportation services and lodging (MAD)
Policy CodePolicy N/A
Change TypeNo material change
Effective DateJan 1, 2014
Last ReviewJul 1, 2024
Next Review DateN/A
Key ActionObtain prior authorization and required documentation for out-of-state transportation and for lodging/meals when applicable.
SourceLink
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