ModifiedPositive HealthCare California (PHC-CA)Policy N/A

PHC-CA Transportation Benefit

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Governs emergency medical, non-emergency medical, and non-medical transportation benefits, including coverage, authorization, documentation, booking, reimbursement, and oversight for eligible PHC California enrollees.

Policy Summary

PayerPositive HealthCare California (PHC-CA)

PolicyPHC-CA Transportation Benefit

Policy CodePolicy N/A

Change TypeRevisedno material clinical or coverage change identified

Effective DateOctober 6, 2009

Next Review DateN/A

Key ActionFor NEMT requiring prior authorization, maintain a completed and executed DHCS-approved PCS form documenting functional limitations, service dates, transportation mode, and medical necessity.

SourceLink

POLICY UPDATE CHANGES

The policy is identified as revision 10 and supersedes prior versions CM 43.0 through CM 43.9.

3 hoursEmergency or post-acute transfer timeframe

12 monthsMaximum NEMT authorization period

300 milesTravel distance threshold

12 hoursTravel time threshold

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ModifiedPositive HealthCare California (PHC-CA)Policy N/A

PHC-CA Transportation Benefit

Customize your policy alerts

Sign up for all phccalifornia policy alerts

Know when phccalifornia releases new policies or updates existing guidance.

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

Policy Summary

PayerPositive HealthCare California (PHC-CA)

PolicyPHC-CA Transportation Benefit

Policy CodePolicy N/A

Change TypeRevisedno material clinical or coverage change identified

Effective DateOctober 6, 2009

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

The policy is identified as revision 10 and supersedes prior versions CM 43.0 through CM 43.9.

3 hoursEmergency or post-acute transfer timeframe

12 monthsMaximum NEMT authorization period

300 milesTravel distance threshold

12 hoursTravel time threshold

NEMT and NMT availability

1Covered NMT attendant

Transportation Coverage Criteria

EMT, NEMT, and NMT Coverage

The Health Plan covers transportation needed to access covered services, subject to the applicable eligibility, medical-necessity, prescription, authorization, and modality requirements below.

Covered transportation categories

At least one applicable category
- EMT services to provide access to all emergency-covered services.
- NEMT services for non-dual and dual enrollees who do not have NEMT coverage through their Medicare Advantage plan benefit package (PBP), to access covered services, subject to a prescription and prior authorization when required.
- NMT services for non-dual and dual enrollees who do not have NMT coverage through their Medicare Advantage PBP, to access covered services and Medi-Cal-covered services carved out of the Health Plan's contract with DHCS.
- NEMT and NMT for Medi-Cal-covered services carved out of the DHCS contract, including outpatient pharmacy, specialty mental health, substance use disorder, dental, and other services provided through the standard Medi-Cal fee-for-service delivery system.

NEMT Medical Necessity and Modality

NEMT is covered when the enrollee's medical or physical condition makes ordinary public or private transportation medically contraindicated and transportation is required to obtain needed medical care. Unlimited NEMT is available for medically necessary covered services prescribed in writing by an appropriate provider.

NEMT medical necessity and authorization

The transportation is required to obtain needed medical care and ordinary public or private conveyance is medically contraindicated.
The service is a medically necessary covered service prescribed in writing by a physician, specialist, mental health provider, substance use disorder provider, physician assistant, nurse practitioner, or other applicable physician extender.
The Health Plan authorizes, at minimum, the lowest-cost NEMT modality adequate for the enrollee's medical need, as determined by medical professionals.
A DHCS-approved Physician Certification Statement (PCS) form is completed and on file for all NEMT services requiring prior authorization.
PCS documentation

NMT Coverage Criteria

The Health Plan provides unlimited NMT when the enrollee can use ordinary transportation and the requested service is the least costly method that meets the enrollee's needs.

NMT coverage requirements

The enrollee is eligible for NMT and does not have NMT coverage through a Medicare Advantage plan benefit package, when applicable.
The transportation is for a medically necessary covered service, a prescription that cannot be mailed directly to the enrollee, medical supplies, prosthetics, orthotics, or other equipment.
The requested transportation is the least costly method that meets the enrollee's needs.
The service is provided in a form and manner accessible in terms of physical and geographic accessibility and consistent with applicable state and federal disability-rights laws.
Round-trip transportation is provided by passenger car, taxicab, public or private transportation, including mileage reimbursement for medical transportation arranged by the enrollee in a private vehicle, bus passes, taxi vouchers, and train tickets.

Special Populations and Exceptions

The following populations and circumstances qualify for transportation or receive specific exceptions when the applicable requirements are met.

Special populations and exceptions

A parent or guardian may receive NEMT or NMT when accompanying a minor enrollee. Written consent is requested to arrange NEMT or NMT for an unaccompanied minor.
Enrollees may obtain NEMT or NMT at no cost to access appropriate out-of-network providers, and the Health Plan provides transportation for out-of-network services as appropriate.
American Indian enrollees receive transportation as required by DHCS APL 24-002. An enrolled Medi-Cal Indian Health Care Provider (IHCP) is reimbursed for transporting an American Indian enrollee to an IHCP regardless of whether the IHCP is contracted with the Health Plan.
When an IHCP transports a non-American Indian enrollee, the IHCP must be enrolled in Medi-Cal as a transportation provider and contract with the Health Plan and/or its delegated transportation provider.

NEMT Prior Authorization Exception

Prior authorization is not required for NEMT in the following emergency or post-acute transfer circumstances.

Qualifying transfer

One qualifying setting
- The enrollee is transferred from an emergency room to an inpatient setting.
- The enrollee is transferred from an acute care hospital immediately following an inpatient stay at the acute level of care to a skilled nursing facility, intermediate care facility, embedded psychiatric unit, freestanding psychiatric inpatient hospital, psychiatric health facility, or other appropriate inpatient acute psychiatric facility.
The transfer is requested by the enrollee or provider.
NEMT is provided within three (3) hours of the request.<= 3 hours

NMT does not include transportation of sick, injured, invalid, convalescent, infirm, or otherwise incapacitated enrollees who need an ambulance, litter van, or wheelchair van licensed, operated, and equipped in accordance with applicable state and local requirements. Those enrollees require medically necessary NEMT at the appropriate level of service.

NMT is not covered to non-medical locations or for appointments that are not medically necessary.

NEMT and NMT are provided to non-dual and dual enrollees only when the applicable transportation benefit is not available through the enrollee's Medicare Advantage plan benefit package. The Health Plan coordinates with Medicare Advantage transportation benefits and provides covered services and applicable Medi-Cal-carved-out services when the Health Plan is responsible.

The requested NEMT modality is not medically necessary when the documented condition does not support that level or type of transportation. The PCS and supporting provider documentation must establish the enrollee's functional limitations, medical condition, requested mode, and certification of medical necessity; the Health Plan authorizes no more than the lowest-cost adequate modality.

Transportation to non-medical locations and transportation for appointments that are not medically necessary is excluded from NMT coverage.

Operational Time and Distance Parameters

Emergency or post-acute transfer response time

Emergency room transferTransfer from an emergency room to an inpatient setting

Post-acute transferTransfer from an acute care hospital, immediately following an acute inpatient stay, to a skilled nursing facility, intermediate care facility, embedded psychiatric unit, freestanding psychiatric inpatient hospital, psychiatric health facility, or other appropriate inpatient acute psychiatric facility

Required response timeTransportation must be provided within 3 hours of the enrollee's or provider's request

Maximum NEMT authorization duration

Maximum authorization periodNEMT authorizations may be issued for up to 12 months

Recurring appointmentsAuthorization for recurring covered-service appointments may cover the duration of the appointments, not to exceed 12 months

Authorization, Documentation, and Denial Risks

Prior Authorization

NEMT and NMT Authorization Requirements

NEMT is covered for eligible enrollees who lack NEMT coverage through a Medicare Advantage plan, to access covered services, subject to a provider prescription and prior authorization when required. NMT is covered for eligible enrollees who lack NMT coverage through a Medicare Advantage plan, including access to covered services and Medi-Cal-covered services carved out of the Health Plan’s DHCS contract; the Health Plan may require prior authorization for NMT.

No prior authorization is required for NEMT transfers from an emergency room to an inpatient setting or immediately after an acute inpatient stay to an appropriate skilled nursing, intermediate care, or psychiatric facility.
The transfer must be provided within three hours of the enrollee’s or provider’s request; if not, the acute care hospital may arrange out-of-network NEMT, which the Health Plan will cover.

Prior Authorization

Provider-Prescribed NEMT Mode

The treating physician, specialist, mental health or substance use disorder provider, or physician extender prescribes the NEMT mode on the DHCS-approved Physician Certification Statement (PCS). The Health Plan determines and authorizes the lowest-cost NEMT modality that adequately meets the enrollee’s documented medical need, but does not modify the provider-prescribed mode or delegate PCS review and approval to a transportation broker.

Transportation Benefit Context

NEMT supports access to needed medical care when ordinary transportation is medically contraindicated. It is intended for enrollees whose medical or physical condition prevents safe use of ordinary public or private conveyance. Depending on documented needs, covered transportation may include ambulance, litter van, wheelchair van, air transportation, or another appropriate modality, with authorization at a minimum for the lowest-cost adequate option. NMT is intended for enrollees who can travel without the medical transport capabilities required for ambulance, litter van, or wheelchair van services.

Transportation Terms

Transportation brokers

Administrative activitiesEntities that conduct administrative activities on behalf of the managed care plan

Call center supportMaintain a call center for enrollees to request NEMT or NMT rides

Ride coordinationSchedule and arrange rides for enrollees

Round trip

Outbound tripOne trip to the medical appointment for which the enrollee is seeking NEMT or NMT

Return tripOne trip back from the medical appointment

Flexible locations

Policy Summary

PayerPositive HealthCare California (PHC-CA)

PolicyPHC-CA Transportation Benefit

Policy CodePolicy N/A

Change TypeRevisedno material clinical or coverage change identified

Effective DateOctober 6, 2009

Next Review DateN/A

SourceLink

On This Page

Function limitations justification documents the specific physical and medical limitations that prevent the enrollee from reasonably ambulating with assistance or using public or private vehicles.
Dates of service include start and end dates; an authorization may not exceed twelve (12) months.<= 12 months
The requested mode is identified as ambulance/gurney van, litter van, wheelchair van, or air transport.
The certifying provider states that medical necessity was used to determine the requested transportation type.

Appropriate NEMT modality

Ambulance
- Transfer between facilities for an enrollee requiring continuous IV infusion, medical monitoring, or observation.
- Transfer from an acute care facility to another acute care facility.
- Transport for an enrollee recently placed on oxygen, excluding an enrollee with chronic emphysema who carries their own oxygen for continuous use.
- Transport for an enrollee with a chronic condition requiring oxygen when monitoring is required.
Litter van
- The enrollee does not meet the need for ambulance service.
- The enrollee must be transported in a prone or supine position because they cannot sit for the time needed for transport.
- The enrollee requires special safety equipment beyond what is available in passenger cars, taxicabs, or other public transportation.
Wheelchair van
- The enrollee cannot sit in a private vehicle, taxi, or other public transportation for the required travel time.
- The enrollee must be transported in a wheelchair or assisted to and from a residence, vehicle, and treatment location because of a disabling physical or mental limitation.
- The enrollee requires specialized safety equipment beyond that normally available in passenger cars, taxicabs, or other public conveyance.
- The enrollee has severe mental confusion, paraplegia, receives dialysis, or has a chronic condition requiring oxygen without monitoring, and the provider submits a signed PCS form.
Air transport is necessary because of the enrollee's medical condition or because practical considerations make ground transportation infeasible; necessity is substantiated by a written order from a physician, dentist, podiatrist, mental health provider, or substance use disorder provider.
The enrollee cannot reasonably ambulate or cannot walk or stand without assistance, including an enrollee using a walker or crutches.

Door-to-door assistance is provided for enrollees receiving NEMT services.

Wheelchair users and attendants

A physician may authorize NMT for an enrollee currently using a wheelchair when the enrollee can ambulate without assistance from the driver.
The Health Plan considers the enrollee's abilities when scheduling NMT.
Round-trip transportation for the enrollee and one attendant, including a parent, guardian, partner, or spouse, on public transportation, including ferry service, is covered subject to authorization at the initial NMT request.

Private conveyance

The enrollee attests in person, electronically in writing, or orally by telephone that all other transportation options have been reasonably exhausted, including at least one applicable statement: no valid driver's license; no working household vehicle; inability to travel or wait alone for medical or dental services; or a physical, cognitive, mental, or developmental limitation.
No other transportation method is reasonably available to the enrollee or provided by the Health Plan.
For mileage reimbursement, the driver has a valid driver's license, valid vehicle registration, and valid proof of vehicle insurance.
Mileage is reimbursed at the standard Internal Revenue Service medical-transportation mileage rate.

Transportation-related travel expenses are provided in accordance with 42 CFR 440.170(a)(1) and (3), DHCS APL 22-008, and subsequent updates.

Major Organ Transplant living donors and transplant recipients may request NEMT, NMT, and related travel expenses. A PCS is not required for an MOT donor requesting NEMT to ensure the donor can reach the transplant hospital.

The Health Plan may apply prior authorization and utilization management to MOT-related travel expenses and determine whether an attendant is necessary. An attendant for the donor is allowed when the Medical Director determines one is necessary.

If the three-hour standard is not met

The acute care hospital may arrange out-of-network NEMT, and the Health Plan covers that service.
The enrollee or provider is not required to obtain prior authorization for the qualifying NEMT transfer.

Authorization datesThe PCS must provide start and end dates for NEMT services

Travel time threshold

Travel-time conditionRound-trip travel to the service location cannot be completed within 12 hours

Covered expense contextThe threshold applies to transportation-related travel expenses for medically necessary, prior-authorized services

Approval requirementTravel-related expenses require approval by the Health Plan Medical Director

Travel distance threshold

Distance conditionRound-trip travel must exceed 300 miles from the enrollee's home

Covered expense contextThe threshold applies to transportation-related travel expenses for services authorized outside the Health Plan's service area

Combined qualificationThe trip must both exceed 300 miles round-trip and be unable to be completed within 12 hours

Appointment arrival expectation

Arrival expectationEnrollees must arrive within 15 minutes of their scheduled appointments

Booking communicationThe Transportation Coordinator informs the enrollee of the arrival expectation after the reservation is complete

Alternate transportationAn alternate NMT or NEMT transportation modality is provided if the transportation provider does not arrive at the scheduled pickup time

Providers must specify the required mode, such as ambulance, litter van, wheelchair van, or air transport, and provide the medical-necessity rationale.
When an executed PCS is on file, transportation is booked according to the mode and frequency specified by the provider.
If no PCS is on file, the UR Nurse or designee obtains the completed and executed form before the Transportation Coordinator books the appropriate mode, except when urgent telephone authorization applies.

Prior Authorization

Urgent Telephone Authorization

A Transportation Coordinator may approve telephone authorization when an enrollee requires an urgent, covered, medically necessary service and a PCS could not reasonably have been submitted in advance. The ordering provider must submit the PCS after the service for the telephone authorization to remain valid.

Urgent transportation may include transport to urgent care, emergency rooms, or appointments and procedures ordered as expedited or urgent.
The order’s severity level may be confirmed in the Health Plan’s Care Management System, eQ Health.

Unsupported block type: prior_auth

Prior Authorization

Travel Expense Prior Authorization

Travel expenses related to NEMT or NMT require prior authorization and approval by the Health Plan Medical Director. Providers and staff should ensure the service and travel meet the applicable medical-necessity, distance, and timing requirements before arranging or promising reimbursement.

The service must be medically necessary and authorized outside the Health Plan’s service area in Los Angeles County.
Round-trip travel must be more than 300 miles from the enrollee’s home and not reasonably completable within 12 hours.
A completed PCS is required for NEMT when applicable.

Unsupported block type: documentation

Documentation Required

Functional Limitation and Duration Documentation

The PCS must explain why the enrollee cannot reasonably ambulate with assistance or use public or private transportation. The provider must document specific physical and medical limitations and the period for which NEMT is needed.

Include service start and end dates; an authorization may not exceed 12 months.
State the transportation mode needed and certify that medical necessity supports the requested mode.

Documentation Required

Transportation Log Data

Transportation staff must maintain complete NEMT/NMT log records for each request and trip, including enrollee, trip, vendor, service, and authorization information. For NEMT bookings, verify and record that the PCS is on file.

Enrollee data: name, Client Index Number (CIN), date of birth, Medi-Cal Aid Code, and county when applicable.
Trip and vendor data: Trip ID, vendor name, date of service, call date, and trip status.
Service data: service type, reason for trip, pick-up address, and drop-off address.
Authorization data: PCS-on-file verification for NEMT bookings.

Documentation Required

Private Conveyance Attestation

NMT mileage reimbursement for a privately owned vehicle is available only when the enrollee attests that other transportation options have been reasonably exhausted. The attestation may be made in person, electronically in writing, or orally by telephone.

The attestation must identify at least one applicable reason: no valid driver’s license, no working household vehicle, inability to travel or wait for services alone, or a physical, cognitive, mental, or developmental limitation.
No other transportation method may be reasonably available to or provided by the Health Plan.
For mileage reimbursement, the driver must have a valid license, vehicle registration, and proof of insurance; reimbursement follows the standard IRS medical-transportation mileage rate.

Documentation Required

Travel Expense Documentation

The Health Plan covers necessary transportation-related expenses for medically necessary NEMT or NMT, including transportation, meals, lodging, and eligible attendant expenses, when the required authorization and Medical Director approval are obtained. Reimbursement documentation must support the medical necessity, authorization, approval, and amount of each expense.

Covered reimbursement categories may include food, lodging, parking, tolls, and the salary of a non-family accompanying attendant.
The enrollee may need to attest that they cannot pay related travel expenses in advance; case-by-case prepayment may be available at Health Plan discretion.
Follow SOP MS 505.0.0, AHF Direct Member Reimbursement Process, for enrollee reimbursement.

Denial Risk

Failure to Obtain Travel-Expense Authorization

If the enrollee does not follow the Health Plan’s required prior authorization process for NEMT or NMT travel expenses, the Health Plan is not required to cover those expenses.

Notify enrollees of the process for requesting travel-expense prior authorization before travel whenever reasonably possible.

Denial Risk

Missing NEMT PCS

NEMT services requiring prior authorization may be denied when the required PCS is absent, incomplete, or not executed. The PCS must be obtained from the ordering provider and maintained for the requested provider, service, mode, frequency, and authorization period.

A PCS is not required for an MOT donor requesting NEMT or for an urgent telephone authorization when advance submission was not reasonably possible, but the provider must submit a PCS post-service for urgent authorization.
Recurring NEMT authorizations may not exceed 12 months.

Denial Risk

Noncovered or Unnecessarily Costly NMT

NMT must be limited to medically necessary covered services and permitted Medi-Cal-covered carved-out services and must use the least costly method that meets the enrollee’s needs. NMT is not covered for nonmedical locations or appointments that are not medically necessary, and NMT does not replace NEMT for enrollees who require ambulance, litter-van, or wheelchair-van transport.

NMT may include transportation to covered services, non-mailable prescriptions, medical supplies, prosthetics, orthotics, and other equipment.
The Health Plan must not deny NMT for an out-of-network carved-out service when the service is otherwise covered.
A parent, guardian, partner, spouse, or other attendant may accompany the enrollee on public transportation when authorized.

Denial Risk

Private Conveyance Requirements Not Met

Private-conveyance mileage reimbursement may be denied when the enrollee has not exhausted other transportation options or fails to provide the required attestation. Reimbursement also requires a qualified driver and compliant vehicle documentation.

The driver must have a valid driver’s license, valid vehicle registration, and valid proof of vehicle insurance.
The private vehicle must be arranged by the enrollee, and no other reasonable transportation may be available or provided by the Health Plan.
Mileage is reimbursed at the applicable standard IRS medical-transportation rate.

Denial Risk

Inappropriate NEMT Modality

The requested NEMT modality must be supported by the enrollee’s documented medical and physical condition and the provider’s written prescription. Ambulance, litter van, wheelchair van, and air transport are reserved for the conditions described in the policy; unsupported higher-cost modalities may be denied or adjusted to the medically adequate lowest-cost option.

Ambulance may be appropriate for continuous IV infusion, medical monitoring or observation, acute-facility transfers, or qualifying oxygen needs.
Litter van requires transport in a prone or supine position and special safety equipment beyond ordinary vehicles or public transportation.
Wheelchair van requires inability to sit or ambulate for the required time, need for wheelchair or transfer assistance, or qualifying safety-equipment needs.
Air transport requires medical necessity or practical infeasibility of ground transport, substantiated by a written order from an authorized provider.

Reasonable round trips may begin or conclude at a location other than the enrollee's residence and may have different start and end points

NEMT

Medical contraindicationTransportation required because ordinary public or private conveyance is medically contraindicated

PurposeTransportation needed to obtain needed medical care

Covered modalitiesMay include ambulance, litter van, wheelchair van, air transportation, or another appropriate NEMT mode based on documented medical and functional needs

NMT

General definitionTransportation that does not include transport of sick, injured, invalid, convalescent, infirm, or otherwise incapacitated enrollees who require ambulance, litter van, or wheelchair van services

Enrollee limitationNMT is for enrollees who do not require ambulance, litter van, or wheelchair van transportation

Wheelchair usersA physician may authorize NMT for an enrollee using a wheelchair when the enrollee can ambulate without assistance from the driver